The Anxiety and Worry Workbook: The Cognitive Behavioral Solution [2 ed.] 1462551920, 9781462551927

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the anxiety and worry workbook

Also Available FOR GENERAL READERS

The Mood Repair Toolkit: Proven Strategies to Prevent the Blues from Turning into Depression David A. Clark FOR PROFESSIONALS

Assessment in Cognitive Therapy Edited by Gary P. Brown and David A. Clark Cognitive-Behavioral Therapy for OCD and Its Subtypes, Second Edition David A. Clark Cognitive-Behavioral Therapy of Addictive Disorders Bruce S. Liese and Aaron T. Beck Cognitive Therapy for Adolescents in School Settings Torrey A. Creed, Jarrod Reisweber, and Aaron T. Beck Cognitive Therapy of Anxiety Disorders: Science and Practice David A. Clark and Aaron T. Beck Cognitive Therapy of Depression Aaron T. Beck, A. John Rush, Brian F. Shaw, and Gary Emery Cognitive Therapy of Personality Disorders, Third Edition Edited by Aaron T. Beck, Denise D. Davis, and Arthur Freeman Group Cognitive Therapy for Addictions Amy Wenzel, Bruce S. Liese, Aaron T. Beck, and Dara G. Friedman-Wheeler Intrusive Thoughts in Clinical Disorders: Theory, Research, and Treatment Edited by David A. Clark Recovery-Oriented Cognitive Therapy for Serious Mental Health Conditions Aaron T. Beck, Paul Grant, Ellen Inverso, Aaron P. Brinen, and Dimitri Perivoliotis Schizophrenia: Cognitive Theory, Research, and Therapy Aaron T. Beck, Neil A. Rector, Neal Stolar, and Paul Grant

the

anxiety and worry workbook

The Cognitive Behavioral Solution second edition

David A. Clark, PhD  |  Aaron T. Beck, MD

The Guilford Press New York  London

Copyright © 2023 The Guilford Press A Division of Guilford Publications, Inc. 370 Seventh Avenue, Suite 1200, New York, NY 10001 www.guilford.com All rights reserved The information in this volume is not intended as a substitute for consultation with healthcare professionals. Each individual’s health concerns should be evaluated by a qualified professional. Purchasers of this book have permission to copy worksheets, where indicated by footnotes, for personal use or use with clients. These worksheets may be copied from the book or accessed directly from the publisher’s website, but may not be stored on or distributed from intranet sites, internet sites, or file-­sharing sites, or made available for resale. No other part of this book may be reproduced, translated, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the publisher. Printed in the United States of America Last digit is print number:  9 8 7 6 5 4 3 2 1 Library of Congress Cataloging-in-­Publication Data is available from the publisher. ISBN 978-1-4625-4616-9 (paperback) — ISBN 978-1-4625-5192-7 (hardcover)

contents

a tribute to Aaron T. Beck

vii



preface

ix

 1 a new beginning

1

 2 getting started

19

 3 when anxiety is helpful

34

 4 when anxiety becomes a problem

61

 5 living with anxiety symptoms

84

 6 transform your anxious mind

110

 7 curb anxious behavior

141

 8 take control of your worried mind

185

 9 defeat the fear of panic

240

10 conquer social anxiety

271



resources

331



references

337



index

341



about the authors

355

Purchasers of this book can download and print worksheets at www.guilford.com/clark6-forms for personal use or use with clients (see copyright page for details). v

a tribute to Aaron T. Beck (1921–2021)

V

ery few in the medical profession can be said to have changed the course of mental health treatment. Aaron T. Beck is one of those rare individuals. His six decades of research, clinical practice, teaching, and training resulted in a new school of psychotherapy called cognitive therapy. His cognitive theory and therapy of psychological disorders was one of the first systematic, empirically verifiable forms of psychotherapy. As a result Beck’s work has been thoroughly researched to the point where it is an established, evidence-based form of treatment for a wide variety of psychological problems even beyond anxiety and depression. The success of cognitive therapy is not attributable solely to the unusual genius of the man. Dr. Beck had an enthusiasm and passion for expanding our understanding of the human mind. He had a deep compassion for those struggling with mental health problems. He was truly inspiring in his vision to raise the quality and effectiveness of mental health treatment on a global scale. It has been a great honor and privilege to have learned from and collaborated with one of the giants of contemporary psychiatry. The personal loss I felt at the death of my mentor, friend, and collaborator on November 1, 2021, cannot be overstated. He was in the midst of providing his latest input for the first complete draft of our second edition of The Anxiety and Worry Workbook just one week before his death. Despite being deprived of his latest insights, this workbook is infused with the knowledge and clinical wisdom of probably the most consequential psychiatrist in modern times. It is my hope that individuals will glimpse the unique wisdom of Aaron T. Beck through the pages of this workbook. DAVID A. CLARK

vii

preface

A

nxiety continues to be one of the world’s greatest mental health problems. Since writing the first edition of this workbook 10 years ago we’ve seen a surge in anxiety related to the global upheaval caused by the COVID-19 pandemic and its consequences. The disease itself as well as the various mitigation efforts have directly impacted the lives of billions around the world. It is within this backdrop of a rising tide of anxiety that we offer this revised and expanded second edition of The Anxiety and Worry Workbook. Like its predecessor, this is a workbook about cognitive behavior therapy (CBT) for anxiety and its disorders. It is a self-help workbook that shows you how to use the insights, interventions, and resources of CBT to quell severe and uncontrollable anxiety. Its more than 70 worksheets offer step-by-step guidance in how to apply highly effective CBT strategies to generalized anxiety, worry, panic, and social anxiety. It is packed full of case illustrations and examples drawn from our decades of experience in CBT treatment, research, and teaching. Dr. Aaron T. Beck, my coauthor, is the originator of cognitive therapy for anxiety. The entire workbook is filled with his unique and innovative understanding of anxiety and its treatment. Our second edition is a complete revision and expansion of our original workbook. There are several changes and upgrades that are noteworthy. We have incorporated ideas and interventions of recovery-­oriented cognitive therapy (CT-R), a modification of standard cognitive therapy that Dr. Beck developed for treatment of severe mental disorders. This perspective was not available when the first edition was published. We’ve adapted the CT-R perspective to treatment of problematic anxiety. To our knowledge this is the first publication of CT-R for anxiety written for the general public. Based on the CT-R approach, there is a new chapter on helpful forms of anxiety that provides a starting point for revamping one’s approach to more severe, problematic anxiety. We have reorganized the workbook so that readers are first introduced to the basic CBT interventions used in strategies for difficult anxiety problems like worry, panic, and social anxiety. Interventions have been broken down into more ix

x preface

specific, practical steps that make it easier to acquire treatment skills necessary for genuine anxiety reduction. We have expanded the chapter on behavioral interventions and introduced more recent innovations in exposure therapy like inhibited learning theory and behavioral experimentation. A new chapter on anxiety sensitivity has been added, which is especially important for individuals with panic attacks. Other concepts such as mental control, intolerance of uncertainty, fear of embarrassment, and postevent processing have been included or expanded to provide a more robust treatment protocol for the various anxiety problems covered in the workbook. Based on reader feedback, the second edition contains more case examples, illustrations, and worksheet samples—all based on composites of real people, thoroughly disguised to protect privacy—so individuals can see how our CBT strategies are applied to realworld anxiety problems. The chapters on worry and social anxiety provide additional material that boosts the effectiveness of CBT for anxiety. This revision would not have been possible without the assistance and encouragement of a host of individuals. Over the years we have learned much about anxiety, worry, and their treatment from the experiences our patients have shared with us. Their wisdom and courage in facing such a daunting adversary as anxiety has been truly inspiring. In addition, numerous researchers, clinicians, and students have contributed to the development of CBT for anxiety. Many we have known personally, and to them we are grateful for the knowledge and clinical acumen they have brought to the pages of this workbook. But there are specific individuals who’ve played a critical role in this revision process. We are especially grateful to Chris Benton for her insights, energy, practicality, and close attention to details that improved our ability to communicate ideas and strategies. As in the past we appreciate the positive collaboration of our editor, Kitty Moore, who provided support and encouragement for this project to move forward. Robert Diforio, our literary agent, is a welcome addition to the team since our first edition. His deep understanding of the publishing world combined with an enthusiasm for and dedication to this project has been inspirational. There are also others at The Guilford Press who made a valuable contribution to this publication: Art Director Paul Gordon, Editorial Project Manager Anna Brackett, and copy editor Deborah Heimann. Finally, I am grateful for my spouse of 45 years, Nancy Nason-Clark, who continues to provide unfailing encouragement, advice, and emotional support in my efforts to communicate through the written word.

the anxiety and worry workbook

1 a new beginning

A

nxiety is not your enemy! This may sound like an unusual way to begin an anxiety workbook. No doubt you’ve been drawn to this workbook because anxiety and worry feel like uncontrollable forces in your life. Maybe you can think back to a time when feeling anxious was no different than any other fleeting emotion, like feeling sad, angry, or frustrated. But anxiety has come to play a much bigger role in your life than you’d like. It now causes you considerable personal distress and it’s interfering in your daily life. It’s taken the joy out of living and your self-­confidence has been shattered. Your world may be shrinking, as you avoid more and more places, people, and experiences because of anxiety. Clearly, anxiety and worry are a serious problem and you’re searching for answers. Whether your problem with anxiety and worry occurred recently or has been present for years, you’ll find in this workbook step-by-step instruction in how to use the cognitive behavior therapy approach to lighten the burden of your emotional distress. Cognitive behavior therapy (CBT) is a scientifically supported treatment that is effective in reducing a variety of anxiety problems. CBT was founded by Dr. Aaron T. Beck (second author), and The Anxiety and Worry Workbook is based on our collective research and clinical experience in offering CBT to hundreds of individuals. You’ll find in its pages numerous exercises and worksheets that present the most potent and innovative treatment strategies for anxiety and worry based on the fundamental tenets of CBT. Our approach in this workbook differs from other CBT resources in two fundamental ways. First, we spend considerable time explaining how the anxious mind operates and what you’ll want to work on to achieve lasting change. We believe it’s important to understand the psychology of anxiety to get maximum benefit from CBT interventions. And second, we introduce a new form of CBT called recovery-­ oriented cognitive therapy (CT-R). This approach recognizes that negative emotions like anxiety can be helpful in reaching cherished goals and aspirations. It assumes that everyone has strengths that can be harnessed to deal with problems like anxiety 1

2

The Anxie t y and Worry Workbook

and worry. Several exercises in the workbook focus on discovering your strengths and abilities when feeling anxious. Maybe you’ve been focused on eliminating your anxiety and worry by reading self-help books and inspirational material, taking motivational seminars, trying medication, and the like, but the harder you try, the more anxious and worried you feel. Have you considered whether you’re focusing on the wrong outcome? The truth is we can’t eliminate anxiety or worry by trying harder. Wouldn’t it be wonderful if we could abolish all distress and be calm and confident all the time? But this isn’t possible because negative and positive emotions are an intrinsic part of our psychological makeup. In fact, negative emotions, including anxiety, are necessary for our very survival. When they’re tolerable, they motivate us to deal with problems in our life and to prepare for the future. But anxiety and worry are not always tolerable. They can become very uncomfortable, disrupting important aspects of our life. This workbook is about dialing back problematic anxiety so you can live a happy and productive life. There are many ways that our experiences with anxiety differ from one another. Anxiety can vary from a slight, barely noticeable feeling of being keyed up to an intense surge of apprehension. Panic attacks and elevated generalized anxiety are examples of severe anxiety experiences. The intensity of our anxious feelings can change quickly or remain elevated for hours, depending on the situation. A little anxiety can be healthy. But when anxiety becomes too severe, persistent, and out of proportion to the situation, it becomes unhealthy. It is this type of anxiety that causes us to seek relief from its distressing and disruptive qualities. Anxiety can be measured on an emotional gauge as illustrated in Figure 1.1. We can use numbers ranging from 0 to 100 to represent various levels of anxiety. When anxiety is mild to moderately intense (0–50), we feel physically aroused, tense, alert, focused, and concerned. This is a healthy level of anxiety that can help us deal with life’s challenges. When anxious feelings become more intense (50–100), we feel agitated, nervous, frightened, hyperaroused, and out of control. Anxiety has now

50 25

75

0

10 0

F I G U RE 1.1.  

The anxiety gauge.



a new beginning 3

become severe. It’s a highly distressing state that interferes in our ability to function. It’s difficult to tolerate anxiety in this range, so we seek immediate relief. This workbook introduces you to interventions shown to increase anxiety tolerance, which has the effect of dialing down its intensity. But before delving into severe anxiety, take a moment to consider your experience of mild anxiety.

Mild Anxiety In your struggle with severe anxiety and worry, you may have forgotten that many times your anxiety experiences are brief, mild, and even helpful in specific situations. Mild anxiety involves: „ A

noticeable feeling of apprehension and unease

„ An

increase in physical arousal and tension

„ Thoughts

of a possible negative outcome for you or your loved ones

Mild anxiety is often triggered by anticipating specific situations, such as taking an important exam, attending a social event involving unfamiliar people, speaking up at a meeting, performing in front of others, going to an impending job interview, raising an important issue with your partner, or traveling alone to an unfamiliar place. Hardly a day goes by without each of us experiencing some mild anxiety or apprehension. It’s usually brief and reasonably well tolerated or managed. Even if you have many episodes of severe anxiety, you, like others, probably handle these mild incidents well. In fact, you probably harness that anxiety, so you cope with the situation much better than if you were too relaxed and overly confident. Have you forgotten all the times you tolerated milder anxiety and used it to your advantage? Throughout this workbook we’ll show you how you can take what you do with mild anxiety and apply it to more severe episodes. To get started we encourage you to take a few minutes to complete the following exercise. E VA L U AT ION EXER C I S E 

Remembering Mild Anxiety

Here is an opportunity to take a closer look at your strengths and abilities to deal with mild to moderately intense anxiety. You might even discover that you’re able to tolerate a greater range of anxiety than you realized. In Worksheet 1.1 you’re asked to recall situations that caused only mild anxiety. Think about how your response to these situations kept your anxiety low.

W ORK SHEE T 1.1

My Mild Anxiety Experiences Instructions: Think back to three or four experiences of mild anxiety (from 0 to 50 on the anxiety gauge). In the first column, note the situation that triggered your anxiety, and in the second column, describe how the anxiety felt (physical sensations, emotions, thoughts). In the third column, briefly describe how you reacted to the anxiety and how feeling a little anxious or worried might have been beneficial. Did the anxiety/worry help you deal with a difficult problem? The first row provides an example that illustrates how to complete the worksheet. Situation (trigger)

How the mild anxiety felt

Example:

I felt a knot in my stomach; tense; I had difficulty I have an older car, and while driving to work I hear sleeping; I kept thinking about an expensive car a knocking sound in the repair and how would I pay engine. for it.

How the anxiety helped

I did a review of my finances before I heard back from the dealer and came up with a limit on what I’d spend in repairing my old car. I made an appointment with the dealer. I thought of ways to deal with my transportation needs other than owning a car.

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

4



a new beginning 5

 Troubleshooting Tips: Recording Mild Anxiety

If you’re having difficulty recalling past experiences of mild anxiety, ask your partner or family member for help. Also, you could use the worksheet to write down your mild anxiety experiences over the next two weeks.

Were you surprised to learn that you can use mild anxiety to deal with problems? Looking back at your entries, is there anything you did in these situations that you could apply to times of severe anxiety? Keep this worksheet handy because we’ll come back to it in Chapter 3. For now let’s consider your experience of severe anxiety.

Severe Anxiety Episodes of severe anxiety feel much different than their milder form. When the anxiety dial is turned up into the 80–100 range, the anxiety becomes much harder to manage. There are several features of severe anxiety that make it especially difficult to tolerate. „ We

experience more symptoms with greater intensity and persistence.

„ Our

feelings are disproportionate (excessive) to the everyday situations that trigger them.

„ Our

thinking becomes more extreme by focusing on the worst possible outcome (catastrophe).

„ We’re more narrowly focused on danger and threat as well as personal helpless-

ness. „ We

hold strong beliefs that anxious feelings are intolerable and must be eliminated.

„ Escape

and avoidance become our modus operandi.

Chapter 4 explains how these features are related to each other, making severe anxiety a problem that interferes in daily living. In the meantime, consider the following three illustrations of people who experience various forms of problematic anxiety.

Rebekah’s Story: Haunted by What-Ifs Rebekah can’t sleep. In the past five years since being promoted to store manager, this 38-year-old mother of two school-age daughters has been fraught with apprehen-

6

The Anxie t y and Worry Workbook

sion, nervousness, and worries over her work, her children’s safety, her aging parents’ health, personal finances, and her husband’s job insecurities. Her mind generates an endless list of possible catastrophes—she won’t be an effective manager at work, she’ll fail to meet monthly sales projections, her younger daughter will get injured at school or her older daughter will be teased by friends, her parents will be disappointed if she doesn’t visit regularly, she won’t have enough money left over after paying bills to contribute to their retirement savings plan, her husband could lose his job any day . . . the list goes on. Rebekah has always been a worrier, but it has become almost unbearable in the last few years. In addition to sleepless nights, Rebekah is almost constantly agitated, shaky, “rattled,” unable to relax, and irritable, with occasional anger outbursts. She breaks down in tears for no apparent reason. The worries are relentless and impossible to control. Despite her best efforts at distraction and reassuring herself that everything will be fine, she has a sick feeling in her stomach that “trouble is just around the corner.”

Todd’s Story: A Body of Fears Todd is losing control—at least that’s what it feels like. As a recent college graduate starting a new sales job, Todd had just moved to a new city and for the first time had his own apartment. He was making friends; he had a steady girlfriend, and he was making great progress in his new occupation. His initial performance evaluations were extremely positive. Life was good; but all this suddenly changed on a cool November day while he was driving home from work. His job had been somewhat stressful, with Todd working extra hours to finish a large client project on time. He had gone to the gym afterward to do his cardio routine and work off the day’s stress. On his way home a strange and unexpected feeling overtook Todd. Suddenly his chest tightened, and his heart started pounding rapidly. He felt lightheaded, almost dizzy, as if he was about to faint. He pulled off to the side of the road, turned off the car, and gripped the wheel. By now he was feeling tense and started to shake and tremble. He felt extremely hot and started gasping for breath, convinced he was suffocating. Instantly, Todd wondered whether he was having a heart attack, just like his uncle had had three years earlier. He waited a few minutes until the symptoms settled down and then drove to the hospital emergency department. A thorough examination and medical tests revealed no physical problems. The attending physician called it a panic attack, gave Todd medication, and told him to see his family doctor. That first attack happened nine months ago, and since then Todd’s life has changed dramatically. He now has frequent panic attacks and is almost constantly worried about his health. Any unexpected physical sensation can trigger a cycle of severe anxiety. He’s cut back on social activities and now finds he’s afraid to go places



a new beginning 7

for fear of having another attack. He restricts himself to work, his girlfriend’s apartment, and his own place, afraid to venture into new or unfamiliar territory. Todd’s world has shrunk, dominated by fear and avoidance.

Isabella’s Story: Dying of Embarrassment Isabella is a shy single woman in her mid-40s. Since childhood she’s felt anxious around other people and so avoids social interaction as much as possible. It seems like just about everything to do with people makes her anxious—­carrying on a conversation, answering the phone, speaking up in a meeting, asking a store clerk for assistance, even eating in a restaurant or walking up the aisle of a movie theater. All these situations make her feel tense, anxious, and self-­conscious as she worries about blushing and coming across as awkward. She’s convinced that people are looking at her and wondering what’s wrong with her. On several occasions she has had panic attacks and felt incredibly embarrassed by her behavior in social settings. As a result, Isabella avoids social and public situations as much as possible. She has only one close friend and spends most weekends with her parents. Although very competent in her job as an office clerk, she has been overlooked for promotion because of her awkwardness around others. Isabella is caught in her own little world, feeling depressed, lonely, and unloved—­trapped by her fears and anxiety over people. Rebekah, Todd, and Isabella have considerable personal distress and limitations in their daily living because of severe and persistent anxiety. Do any of these stories sound familiar? Are you struggling with severe anxiety that is like Rebekah’s worry, Todd’s panic attacks, or Isabella’s self-­consciousness around others? The next exercise gives you an opportunity to write about your experience of severe anxiety. E VA L U AT ION EXER C I S E 

Remembering Severe Anxiety

You can probably remember several instances of severe anxiety or worry. It’s important that you take a look at these past experiences because they have likely had a big influence on your present tolerance for anxious feelings. Worksheet 1.2 will be an important resource for you throughout the remainder of the workbook.

Was it easier to recall occasions when anxiety was severe than when it was mild? Compare your entries on Worksheets 1.1 and 1.2. Do you notice any similarities between your mild and severe anxiety? Are there specific symptoms of severe anxiety that make it intolerable? Are there coping strategies you use with mild anxiety that could reduce the harmful effects of severe anxiousness? We believe there is much you

W ORK SHEE T 1. 2

My Severe Anxiety Experiences Instructions: Think back to three or four experiences of intense and persistent anxiety that felt intolerable at the time (anxiety gauge 80–100). In the first column, note the situation that triggered your anxiety. It could be a situation, a physical sensation, or an unwanted thought. Describe how the anxiety felt in the second column (physical sensations, emotions, thoughts), and in the third column briefly describe how you reacted to the anxiety and any consequences or problems caused by the anxiety. The first row provides an example that illustrates how to complete the worksheet. Situation (trigger) Example:

I feel nauseous, tired, and generally unwell

How the severe anxiety felt

How you reacted/its consequences

I feel weak, unsteady, lightheaded; my breathing becomes more rapid and shallow; my heart rate increases. I can’t explain why I feel so bad; I wonder if I should call the doctor; I think about the people I know who’ve had cancer and wonder if I could have stomach cancer.

I called my mother to seek reassurance that I’m not seriously ill. I stayed home from work and didn’t leave the house because I didn’t feel well. The anxiety was so severe; I couldn’t stand it any longer, so I took my medication. I lay down and tried to rest to see if I could calm down.

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

8



a new beginning 9

You’re Not Alone You’re not alone in your struggle against severe anxiety. Globally, 1 in 9 people experience an anxiety disorder in any given year,1 and approximately 65 million U.S. adults will experience a clinically significant anxiety condition sometime in their life, making it the most common mental health problem.2 Think of it this way. Over one-­quarter of your friends, colleagues, and neighbors will experience severe anxiety, even if the majority don’t seek professional help. Some well-known and successful people have struggled with anxiety, including Selena Gomez, Lady Gaga, Nicolas Cage, Kim Kardashian, and Marcus Morris,3 as well as historical figures like Winston Churchill and Abraham Lincoln. So, there is no reason to be embarrassed or to blame yourself for your fears and anxiety. Many people have lived very successful lives despite their bouts of severe anxiety. The good news is you don’t have to struggle alone. Research over the last several decades has taught us a lot about anxiety and the most effective way to treat it.

can learn from how you deal with mild anxiety. We’ll be returning to this theme time and again throughout the workbook, showing you how to learn from your experiences of tolerable anxiety. But for now, let’s put aside your experience with anxiety and introduce you to our approach to anxiety.

What’s Different about This Workbook? Hundreds of self-help books, as well as numerous internet gurus, life coaches, motivational speakers, and mental health professionals, offer insights and approaches that they claim produce breakthroughs in dealing with anxiety. For many of you this is not your first workbook on anxiety. Possibly your therapist has recommended other resource materials, but they’ve failed to live up to their promise. So why should you invest more time and effort in this workbook? What makes our approach different from others? The Anxiety and Worry Workbook drills deep into the CBT approach to anxiety. It doesn’t mix in other interventions with less proven effectiveness. It teaches the CBT understanding of anxiety and shows what needs to change in our thinking and behavior to reduce anxiety. The first seven chapters teach the fundamental skills of CBT, which are then tailored and refined in later chapters to deal with specific anxiety problems like worry, panic attacks, and social anxiety. This is also the first workbook on anxiety to include elements of CT-R. Throughout you will find case examples, illustrations, exercises, and worksheets that enhance the workbook’s practical utility. To give you a better idea of what to expect, we start with a brief overview of CBT and CT-R.

10

The Anxie t y and Worry Workbook

Cognitive Behavior Therapy Cognitive behavior therapy (CBT) asserts that the way we think and how we act has a significant effect on how we feel. If we think an impending event might result in a negative outcome, we’ll consider it threatening. Anticipated threat often leads to escape and avoidance actions because we are seeking safety and comfort. The thoughts of threat and avoidance behavior have the unintended effect of raising the intensity of anxious feelings. In CBT changing the way we think about threat and danger is considered critical to anxiety reduction. It’s an organized, systematic psychological treatment that teaches people how to dial down their anxiety by changing their thoughts, beliefs, and behavior. Figure 1.2 illustrates the basic CBT model. One of us (Aaron T. Beck) pioneered CBT in the late 1960s and 1970s for depression and then anxiety. Together we published an updated and comprehensive treatment manual of CBT for anxiety in 2010 called Cognitive Therapy of Anxiety Disorders: Science and Practice.4 The first edition of The Anxiety and Worry Workbook was a client version based on that manual. Readers can find a more detailed explanation of the CBT perspective on anxiety, its research support, and treatment strategies in the 2010 clinician manual. Today CBT is practiced by mental health practitioners worldwide. Hundreds of research studies demonstrate the effectiveness of CBT for anxiety.5,6 Sixty to eighty percent of people with an anxiety problem who complete a course of CBT (10–20 sessions) will experience a significant reduction in their anxiety, although only a minority (25–40%) will be completely symptom-free.7,8 This is equivalent to or better than the effectiveness of medication alone, with some studies showing that CBT produced longer-­lasting improvement than was produced by medication only.9 At the very least, CBT is substantially more effective than doing nothing or getting basic supportive

Trigger (trigger)

+

Thought (perception, interpretation)

+

Behavior (coping response)

=

Feeling (tense, anxious)

Waiting for job interview

“I have no clue what to say; they’ll think I’m an idiot.”

Pace around the room; drink coffee

Feel nervous, tense, butterflies in stomach

Waiting for job interview

“I’m well prepared for this interview; I should be able to make a good impression.”

Relax while sitting; read Facebook postings

Feel calm, confident, and safe

F I G U RE 1. 2 .  

The basic cognitive behavioral model of anxiety.



a new beginning 11

counseling. It’s now a recommended first-­choice treatment for anxiety by many psychiatric and mental health provider organizations worldwide.10,11

Recovery-­Oriented Cognitive Therapy CT-R is a new perspective in CBT that views human change in terms of recovery and not simply the alleviation of personal distress. A recovery approach focuses on strategies that help people capitalize on their interests, capabilities, aspirations, problem-­ solving ability, effective communication, and resilience over stress.12 CT-R recognizes that we all have “at our best” moments when our thoughts, emotions, and actions work together in pursuit of cherished goals, values, and aspirations. Beck and colleagues refer to this as the adaptive mode. A mode is a tendency or way of acting that involves beliefs, attitudes, feelings, motivation, and behavior.13 In CT-R we consider any response adaptive if it helps you reach important personal goals and values. We usually experience positive feelings when we respond adaptively. When you manage anxiety and, on occasion, turn it into a sense of accomplishment, you are operating in the adaptive mode. In CT-R we don’t simply work on negative thoughts and beliefs that cause distress, we also help individuals discover more positive ways of thinking that promote a more meaningful life.14 So the CT-R therapist and client work together on ways of thinking that might interfere in the person’s ability to achieve a goal. For example, imagine you’re coming to the end of a medical leave from work due to anxiety and stress. You’re very anxious and worried about the return-to-work plan created by HR. You’re convinced you’re going to fail and your anxiety will return with a vengeance. The traditional CBT therapist would focus on your anxious thoughts and how you could reduce your work anxiety. The CT-R therapist would also target anxiety reduction but would go beyond this focus to include discovering how you could promote a greater sense of fulfillment and goal attainment at work. If you’re maximizing your capabilities at work, progressing toward cherished goals, and developing greater resilience to stress, your work anxiety will be more tolerable, even adaptive, rather than severe and debilitating. Throughout this workbook we emphasize what you can learn from your experiences of mild anxiety and worry that helps you attain greater life satisfaction.

What to Expect The first seven chapters of The Anxiety and Worry Workbook delve into core psychological processes responsible for making anxiety a problem. In these chapters we tackle the nuts and bolts of the anxious mind, such as threat interpretation bias, underlying beliefs about anxiety, heightened anxiety sensitivity, avoidance and safety-­

12

The Anxie t y and Worry Workbook

seeking behavior, and intolerance of uncertainty. Psychologists often call these processes transdiagnostic because they are found in different types of anxiety problems. You’ll learn how to use specific treatment strategies designed to alter these core features of the anxious mind. The remaining three chapters focus on three anxiety problems: worry, panic attacks, and social-­evaluative anxiety. You’ll find CBT treatment protocols tailored to the unique features of each anxiety problem. Even if your anxiety fits closely with one of these problems, we recommend that you work through the first seven chapters before focusing on one of the specific later chapters. The early chapters provide foundational skills necessary to get the most from the later chapters. Table 1.1 presents an overview of the skills you’ll learn in each chapter. We wrote this workbook with you in mind. Its organization, style, and content are intended for individuals like you who desire a better life, a life of tolerable anxiety experienced in a way that enriches life rather than threatens your joy, peace, and comfort. No one who picks up a self-help workbook is looking for the easy way out. You know it will take commitment, time, and effort to overcome your usual ways of dealing with anxiety. It is our desire to work with you, providing a new way to understand your anxiety and more effective strategies so you can better tolerate and cope with a range of anxiety experiences.

How to Use the Workbook There may be unique aspects to your anxiety, but if you can see elements of your anxiety in the case examples of Rebekah, Todd, and Isabella, then this workbook is for you. It’s been written as a stand-alone self-help resource. This means you can use it on your own, regardless of the level or type of anxiety you experience. Others might find it more helpful to use the workbook as a companion to treatment, with a therapist assigning specific chapters, special sections, or certain exercises. This will be true if your anxiety is severe, you’re avoiding activities that are important to daily living because they make you anxious, or you’re having difficulty identifying your anxious thinking. A therapist can also advise you on which CBT skills to emphasize and how they might be modified to address unique features of your anxiety, and can assign workbook exercises in a more strategic fashion. Often people find they need the accountability of structured therapy to encourage commitment to the change process. If you’ve worked with a CBT therapist in the past and found the treatment helpful, you’ll be able to use the workbook to sharpen your CBT skills. Dropping old habits, learning new strategies, and practicing greater tolerance for fear, anxiety, and uncertainty takes courage and determination. Even if your anxiety is in the moderate range, using the workbook on your own may be too demanding.



a new beginning 13 TA B L E 1.1.  

What You’ll Learn from This Workbook

Chapters

What you’ll learn

Key exercises

Chapter 2, Getting Started

• That practice is key to treatment effectiveness • What beliefs undermine motivation and how to correct them • How to get the most benefit from the workbook

• Complete the Beliefs about Practice Assignments worksheet • Evaluate whether you’re getting the most from your practice experiences

Chapter 3, When Anxiety Is Helpful

• How anxiety can be helpful • How to recognize how anxiety helps you cope • Your level of anxiety resilience

• Track mild, helpful anxiety • Discover your Adaptive Anxiety Profile

Chapter 4, When Anxiety Becomes a Problem

• How to identify problematic anxiety • What an anxious mind is • How to develop an individualized treatment plan for your anxiety problem.

• Catch anxious thoughts • Keep an anxiety log • Create an Anxiety Symptom Profile

Chapter 5, Living with Anxiety Symptoms

• Whether anxiety sensitivity (AS) is driving your problematic anxiety • Your tolerance for specific anxiety symptoms • How to use CBT interventions to increase your anxiety tolerance and lower AS

• Evaluate your symptom sensitivity • Complete the Anxiety Sensitivity Beliefs worksheet • Practice detached observation and other CBT interventions

Chapter 6, Transform Your Anxious Mind

• How erroneous threat predictions drive anxiety • How to create a unique map of your anxious mind • How to use evidence gathering and other CBT interventions to reduce anxiety • How to conduct a mental audit to discover less anxious ways of thinking

• Discover your threat predictions • Create your anxious mind map • Use evidence gathering and cost/ benefit forms to practice CBT skills • Use the Alternative Perspective Form to generate healthier ways of thinking

Chapter 7, Curb Anxious Behavior

• How to rediscover your courage over anxiety • How to recognize the effects of the self-­protective mode on anxiety • Which anxiety beliefs are responsible for its persistence • How safety-­seeking can be self-­ defeating • How to use systematic exposure to overcome anxiety

• Complete the Self-­Protective Response worksheet • Fill-in the Beliefs about Anxiety Scale • Discover problematic safety-­seeking with the Safety-­Seeking Response Form • Use the Recovery-­Oriented Exposure Plan to enhance treatment effectiveness           (continued )

14

The Anxie t y and Worry Workbook

Chapters

What you’ll learn

Key exercises

Chapter 8, Take Control of Your Worried Mind

• How to distinguish harmful from helpful worry • The mental processes that drive the worried mind • How to determine your worry profile • How to use problem solving, de-­ catastrophizing, directed worry exposure, and other interventions to overcome harmful worry • How to build worry resilience through heightened tolerance of uncertainty

• Identify unhelpful ways of thinking that create harmful worry • Complete the Worry Beliefs Checklist • Track your worry with the Worry Diary • Construct your individualized Worry Profile • Evaluate control and responsibility with the Control Pie Chart • Record your interventions with the Worry Exposure Form, Daily Uncertainty Record, and Tolerance Fitness Form

Chapter 9, Defeat the Fear of Panic

• How to know what makes panic and its fear a problem • How to identify hypersensitivity and catastrophic misinterpretations of physical symptoms • How the panic-­stricken mind operates • How to assess your panic episode • How to use CBT strategies like panic reappraisal, panic rescripting, symptom induction, and safety-­seeking removal to counter panic attacks

• Complete the Panic Self-­Diagnostic Checklist • Self-­monitor your anxiety with the Weekly Panic Log • Create your unique Panic Profile • Use the Antipanic Symptom Interpretation Record to counter catastrophic misinterpretations

Chapter 10, Conquer Social Anxiety

• How to recognize the three pillars of social anxiety • How to break down your anxiety into the three phases of social anxiety • The CBT way to assess and conceptualize your social anxiety • How to use CBT interventions to reduce debilitating anticipatory anxiety • Strategies that promote better management of anxiety and improve social skills • How to stop anxious rumination and postevent processing of recent social interactions

• Complete the Social Anxiety Checklist • Identify your social change goals • Maintain a social anxiety log • Create your Social Anxiety Profile • Construct a social exposure plan • Strengthen social skills with the Prosocial Cognitive Skills Form and the Behavioral Retraining Guide • Confront a fear of embarrassment with the Cost of Embarrassment Form • Practice reevaluation of past social performance to reduce rumination

You may make better progress if you receive professional treatment, because genuine change depends on knowing what to do and then applying this knowledge to your everyday experience of anxiety. Whether using the workbook alone or with a therapist, you’ll only get as much from the workbook as you put into it. We suggest you schedule 20 minutes each day to read The Anxiety and Worry Workbook and plan on which exercises and worksheets you’ll complete next.



a new beginning 15

As you read through the workbook, keep asking yourself “How does this apply to my anxiety?” Take your time and do as many exercises as possible. Don’t get too hung up on trying to do all the exercises and worksheets perfectly. You’ll find some more helpful than others, and so you’ll want to spend more time on the helpful worksheets. Remember, the workbook is meant to be a practical guide, not a textbook. You’ll gain new insights into your anxiety, but more importantly, we’re hoping you’ll learn new skills that you can apply to your everyday experience of anxiety. Before we get started, take a few moments to consider what you’d like to achieve from spending time with The Anxiety and Worry Workbook.

My Anxiety-­Reduction Goals What do you want to get from the workbook? What are your goals when it comes to dealing with anxiety? This next exercise gives you an opportunity to think more deeply about your anxiety and how better coping skills might contribute to a more fulfilling life.

E VA L U AT ION EXER C I S E 

Stating Your Workbook Goals

Like most people, you’ve probably tried to make improvements in some area of your life, like physical exercise, diet, time management, sleep, and the like. You know that having a goal is critical to maintaining your motivation and commitment. The same is true for The Anxiety and Worry Workbook. You need specific goals to keep yourself motivated to apply the knowledge and do the workbook exercises. Worksheet 1.3 presents a process you can use to discover specific ways that your life would be improved if your anxiety was less intense and more tolerable. You’re asked to come up with specific goals that refer to practical ways your life would be better if your anxiety was more manageable. Â Troubleshooting Tips: Other Ways to Establish Anxiety-­Reduction Goals

In CBT, therapists work closely with clients to help them create reasonable and effective treatment goals. Most people need some help with this task. If you’re doing this exercise alone, setting goals for change can be especially difficult. We’ve listed some additional strategies you can follow when creating your anxiety-­reduction goals. „ Think of some specific ways your performance would improve in each life domain if

you had little or no anxiety. „ Consider how you functioned in each domain before anxiety became a problem. Your

goal might be to get back to that same way of functioning.

W ORK SHEE T 1.3

My Anxiety-­Reduction Goals Instructions: Daily living involves several primary concerns that are listed below. Review your entries in Worksheet 1.2 and consider how anxiety is having a negative effect in each life concern. Next, imagine specific ways you’d be more successful or effective in each life domain if your anxiety was mild (tolerable) rather than severe (intolerable). In the right-hand column, list specific ways in which you would function better within that domain if you were less anxious. These will become your anxiety-­reduction goals; that is, what you’d like to achieve by improving your tolerability and management of anxiety. An example is provided for each life concern. Life domains Work (How would mild, tolerable anxiety make me more successful at work?)

Specific anxiety-­reduction goals or targets Example: I’d express my opinion more often in the weekly department meetings. 1.                                   2.                                   3.                                  

Family/partner (How would I be a better parent, spouse, sibling, or son/ daughter if my anxiety was milder, more tolerable?)

Example: I’d take trips with my family and attend family gatherings rather than use my anxiety as an excuse to stay home alone. 1.                                   2.                                   3.                                  

Friendships (How would milder anxiety affect my social life?)

Example: I’d go out more with friends rather than make up excuses for turning them down. 1.                                   2.                                   3.                                   (continued)

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

16

W ORK SHEE T 1.3 (continued)

Life domains Health/physical fitness (How could more tolerable anxiety improve my health?)

Specific anxiety-­reduction goals or targets Example: I’d take a reasonable wait-and-see approach when I have an unexpected ache or pain rather than immediately googling the symptoms or making a doctor’s appointment. 1.                                   2.                                   3.                                  

Leisure/recreation (How could milder anxiety lead to more fun in my life?)

Example: I’d engage in more hobbies, sports, arts, or other enjoyable activities rather than wait until I felt like it. 1.                                   2.                                   3.                                  

Community/citizenship (How might tolerable anxiety increase my level of community engagement?)

Example: I’d read more about important political/social issues and seek ways to become more politically engaged in my community. 1.                                   2.                                   3.                                  

Spirituality (How would better anxiety tolerance enhance my spiritual awareness?)

Example: Be more present minded and grateful; that is, more aware of the blessings in my life. 1.                                   2.                                   3.                                  

17

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The Anxie t y and Worry Workbook

„ Do you have a friend or family member who you think is a great parent, has a suc-

cessful career, maintains their physical fitness, or in some other way seems successful? Anxiety doesn’t interfere in their life. What do you admire about them? Could that characteristic or quality become your anxiety-­reduction goal? „ Make sure your goal refers to a specific way of thinking or responding. It should be

a way of thinking or responding that is consistent with your personality and skills. For example, a goal like “be the life of the party” would be inappropriate if you are a more serious introvert by nature.

Were you able to list specific ways you’d act, think, or feel better with less anxiety? You can think of these as goals or aspirations for how you’d like to function if you had better management of your anxiety. Maybe these are ways you used to be when anxiety was less intense, and now you’d like to get back to your previous way of being. If you can see how your life would be better with milder anxiety, this can motivate you to do the work presented in the following chapters. As you work your way through the chapters, you may want to come back to Worksheet 1.3 and revise your goals. Also, you can use your goals to evaluate how the CBT approach to anxiety has improved your quality of life. We all need encouragement to keep going, and if you can see progress through the goals you’ve achieved, you’ll be motivated to keep working on your anxiety.

The Next Chapter This chapter is all about determining whether the workbook is right for you. If you completed Worksheets 1.1 and 1.2, you may have already decided the workbook is relevant for your distress. At the very least you have enough curiosity to read on. You may be wondering what CT-R can add to the standard CBT approach to anxiety. The next chapter shows you how to get started with the workbook. You’ll learn about the importance of practice assignments in CBT and how to improve your engagement with the workbook.

2 getting started

W

hen you think about fitness and staying healthy, no doubt diet and physical exercise come to mind. You try your best to eat well and get regular exercise because you know they’re important to life satisfaction and well-being. But it’s hard to “stay the course.” Our busy schedules and the pressing demands of daily living easily knock us off our healthy routines. When this happens, it’s important to take stock and renew our commitment to healthy living. Mental health is a lot like physical health. In fact the term mental fitness has been used in reference to a healthy mind. Psychologists define mental fitness as thriving in this life by using our skills and resources to flexibly adapt to the challenges and advantages that come our way.15 Excessive anxiety and worry undermine mental fitness. They interfere in our ability to deal with challenges and reach our potential. If problematic anxiety and worry are blocking your path to mental fitness and wholeness, we’ll show you how to use CBT to clear the path for better mental fitness. It’s well known that physical fitness can be achieved only through a regular exercise program that keeps our bodies strong, agile, and resilient. The same is true for the mind. We can become psychologically and emotionally stronger by engaging in daily cognitive (thinking) and behavioral exercises. These exercises are designed to reduce the damaging impact of anxiety on our lives just as physical exercises counteract the modern sedentary lifestyle. But the benefits of all exercise, whether physical or mental, depend on regular practice. And that’s the rub for most of us! Maintaining regular exercise and eating a balanced diet is challenging. You may start out strong, but soon your enthusiasm wanes, schedules collapse, resolve crumbles, and excuses start to sound more and more reasonable. Even the most die-hard fitness enthusiasts find regular exercise tough. Fortunately, those who make some effort to stick with it find that the benefits—both short- and long-term—become so important that they miss exercising when they let their regimen lapse. We believe you’ll discover the same when you devote your energy to the exercises in this work 19

20

The Anxie t y and Worry Workbook

book. That’s why this chapter is important: Arming yourself with the mental tools you’ll need to keep working at reducing your anxiety will give you a chance to make the CBT approach work for you.

Different Starting Points Each of us starts at a different point on the pathway to mental fitness and wholeness. Because of previous life adversities, childhood difficulties, family history, biological predispositions, and other factors, some people may have to work harder at mental fitness than others. But everyone can improve their emotional health. The fact that you’re reading this workbook is the first step toward committing yourself to better mental health. First steps are a critical part of change, so we commend you for starting this journey with us. We’ve designed exercises to help you make long-term changes, just as CBT has been shown to have long-term beneficial effects on anxiety. Are you ready to take the next step by practicing the CBT skills explained in this workbook? Before you begin, consider the following ways you can make the workbook a more positive, satisfying experience. „ Keep

your expectations realistic. We all have different starting points for anxiety and worry that affect how much we can lower our anxiety. For example, in Chapter 5 you’ll learn that we have different sensitivities to anxiety symptoms. If you’re highly reactive to anxious feelings, you may not get your anxiety down to the same level as a person less sensitive to anxiousness. „ Make

time for yourself. If you ever start questioning whether you can afford to take the time to do CBT, stop and consider how much time you are wasting now because of anxiety. Have you ever sat down and figured out how much time you spend each day worrying, feeling tired because of insomnia, being stressed out, or being unproductive because of avoidance? Now compare this to how much time you’ll need with the workbook. Would an investment in anxiety reduction now cause a net loss or gain in time and productivity in the coming months? „ Start

low and work up. You’ve heard the saying “Rome wasn’t built in a day.” This certainly applies to CBT for anxiety. If you are very sensitive to anxiety symptoms (see Chapter 5), it’s important not to overwhelm yourself by trying to do too much. It’s much better to start with something that causes only mild or moderate anxiety and then gradually work up to more severe anxiety situations. „ Pace

yourself. If you’ve ever done a road race, you’ll know that keeping a good steady pace is key to finishing the race. The same is true for your CBT program. It’s



getting started 21

better to do a little each day and every day than to do nothing for a few days and then do something for a couple of hours on the weekend. Read a little of the workbook each day and make sure you are spending some time on the exercises. „ Catch

the thoughts. When doing CBT exercises, focus your attention on how you are thinking. If you’re feeling anxious, write down thoughts of exaggerated threat and danger (catastrophic thinking). Are there errors or distortions in your thinking? Are you convinced you’re helpless or can’t stand the anxiety? Are you thinking about escape or relying on a false sense of safety? Becoming more aware of your anxious thinking and learning to correct it (see Chapter 6) is an important strategy for reducing anxiety. „ Be patient and don’t run. When anxiety is building and the anxious mind takes

over, our instinct is to run! Although this is entirely understandable, it’s important to stick with the exercise. Don’t leave the situation or give up. Break time into small units and focus on reaching the next goal (“I’ll stay for 10 more minutes, and once that is reached, I’ll stay for another 10 minutes, and so on”). This is how runners finish a race when they are tired, aching, and want to give up. „ Celebrate

success and problem-solve barriers. Many people who begin a CBT program see improvements in their anxiety right away. It is important to recognize your achievements and celebrate the progress you’ve made in overcoming anxiety. After all, you’re the one who is making the changes, and so you need to encourage yourself. At the same time, expect setbacks and disappointments. Instead of giving up, take a close look at why the assignment did not go well. Take a problem-­oriented approach and see what changes you can make to break through the failed attempt. „ Don’t

fight anxiety; let it flow. Anxiety is like being entangled in a net; the more you fight it, the worse the entanglement. Take note of whether you are trying to control your anxiety when doing the practice exercises. Fighting for control will make your anxiety worse. Instead, focus on accepting your anxious state and allowing the anxiety to decline naturally. „ Be

kind to yourself. Changing how we think and react to strong emotions like anxiety is difficult. You’ll get a lot further with the workbook if you exercise self-­ compassion rather than self-­criticism.

How Our Approach Can Work for You There are three types of exercises and associated worksheets in this workbook. Approximately half of the exercises are evaluative. They are designed to give you new

22

The Anxie t y and Worry Workbook

insight into your anxiety and worry. They provide assessment information that shows you how to apply intervention strategies to reduce your anxiety. Most of the remaining exercises present CBT intervention strategies. These are the therapeutic exercises designed to reduce your anxiety and worry. They will help you progress toward the anxiety reduction goals you listed in the first chapter. It’s important that you complete both types of exercises because they build on each other. Occasionally you’ll encounter a quiz. This type of exercise helps you determine whether you understand a core tenet of the CBT approach to anxiety. Regardless of the type of exercise, you’ll find the worksheets more helpful in reducing your anxiety if you follow these tips. „ Always

fill out the worksheets on your own so that you’re capturing your perspective on anxiety and worry.

„ Follow

the exercise instructions that tell you how to complete the worksheet.

„ Don’t

spend a lot of time worrying about whether your entries on the worksheets are highly detailed and complete. You’ll get better at doing this type of work as time progresses.

„ Avoid

being a perfectionist. Your worksheets don’t have to be perfect, but always consider them a “work in progress”—an opportunity to learn.

„ Try

to complete the worksheets as close to an anxiety experience as possible. If you wait until hours or days later, you’ll forget a lot of valuable information about your experience.

„ Resist the temptation to go back and change your entries to worksheets already

completed. Your first, immediate response on a worksheet is probably the best. worksheets in this book are available to download and print from www. guilford.com/clark6-forms. If you choose to print out worksheets from the website, be sure to keep your completed forms handy; you’ll need to refer to many of them as you proceed through the book.

„ The

What Have You Heard about CBT? You probably wouldn’t have gotten this far in the book if you had serious doubts about the CBT approach to anxiety. But if you’ve been exposed to the following misconceptions, they could weaken your confidence in CBT and undermine your motivation to do the workbook exercises. Let’s put them to rest once and for all:



getting started 23

M Y T H : CBT is overly intellectual and does not deal with feelings. : F A C T: It is true that CBT focuses a lot on how we think and behave. But the ; thoughts and beliefs important in CBT are emotional—they deal with our emotions and not our intellect. CBT is all about changing emotions, and in this workbook we continually ask people to observe, record, and understand “how they feel.” M Y T H : Only well-­educated or highly intelligent people can benefit from CBT. : F A C T: The ability to observe your thinking, evaluate it, and consider alterna; tive ways of thinking is more important to the success of CBT than how far you went in school or your IQ. M Y T H : Because it’s very rigid, CBT can’t take into account the unique needs : and circumstances of individuals. F A C T: CBT is always applied to the unique features of your anxious experi; ence. M Y T H : CBT is superficial, dealing only with symptoms and not addressing the : root cause of anxiety. F A C T: CBT considers automatic thoughts and beliefs about threat and helpless; ness, basic elements of anxiety. By addressing these cognitive “root causes,” CBT has often shown enduring benefits for reducing anxiety. M Y T H : You can’t benefit from CBT if you’re taking medication for anxiety. : F A C T: Research studies and our own clinical experience have shown that peo; ple on medication for anxiety can benefit significantly from CBT. M Y T H : You have to be well organized and disciplined to benefit from CBT. : F A C T: There is no research evidence that a well-­organized and disciplined per; sonality type benefits more from CBT than anyone else. M Y T H : CBT completely ignores the influence of a person’s past. : F A C T: CBT does focus on the present, but past difficult experiences and child; hood adversities may be considered when they have an important influence on your anxiety and worry.

24

The Anxie t y and Worry Workbook

M Y T H : CBT is effective only with mild or moderate anxiety. : F A C T: Research studies that formally evaluated CBT have shown that individu; als with severe anxiety symptoms can achieve significant symptom improvement. M Y T H : CBT is only “talk therapy” in which people “talk themselves out of : being anxious.” F A C T: Behavior change is a very important part of CBT. Although changing ; how you think about anxiety is critical, it is just as important to change your behavior in response to your anxiety problem. M Y T H : CBT emphasizes the “power of positive thinking” to trick people into : being less anxious. F A C T: CBT emphasizes the importance of “realistic thinking” and not “posi; tive thinking.” You’ll learn to replace unrealistic, exaggerated thinking with more accurate, realistic evaluations of threat in ordinary daily activities. This is a core skill you’ll use repeatedly to reduce the intensity of your anxiety. M Y T H : Cognitive behavior treatment for anxiety is slow and can take many : weeks before real benefits are seen. F A C T: Many of the significant effects of CBT are seen in the first few sessions. ; You can expect to see some improvement within the first four to six weeks of therapy. M Y T H : It is rare to see sudden anxiety reductions in CBT. : F A C T: People in formal CBT can experience a sudden reduction in anxiety ; from one week to the next. It is unknown whether these sudden changes occur when using CBT workbooks alone. Â Tips for Success: Staying Motivated for Change

If you hit a point in this workbook where you feel stalled or unmotivated, come back to this list and see if you’re still subscribing to any of these myths. If so, remind yourself of the facts. Or maybe you believe one of these myths and it’s preventing you from committing to the workbook program. If this is the case, consider whether you can suspend judgment about the CBT approach until you’ve given it a try. You could select some aspect of your anxiety experiences and use one or two exercises in Chapter 6 or 7 over a two- to three-



getting started 25

week period. Observe what effect it’s had on your anxiety. Is it worth continuing? The best way to stay motivated is to experience some progress in reducing your anxiety or worry. If you’re working with a CBT therapist, discuss your concerns about slow treatment progress.

Practice Makes “Perfect” The phrase “practice makes perfect” may not quite apply to anxiety reduction, but its basic message is relevant. The more you practice CBT skills, the better you’ll get at applying them to your anxiety and worry problems. You may never reach perfection, but the more you use the workbook exercises and worksheets, the greater their anxiety-­reducing effects. Research has shown that individuals who engage in practice assignments between therapy sessions experience greater improvements in anxiety and depression than do individuals who don’t engage.16,17 In CBT, practice exercises are tailored to address unique aspects of your anxiIn this workbook, practice exercises are ety experience. Here are some examples. defined as any specific, clearly defined Darrell avoids public places because he structured activity that is carried out in believes being in them causes his panic a person’s home, work, or community to attacks. His practice exercises focused observe, evaluate, or modify the faulty on demonstrating to him that it is not the cognitions and maladaptive behaviors places that triggered anxiety but his tenthat characterize anxiety. dency to misinterpret his increased heart rate as a sign of a possible heart attack. Aaliyah constantly worries about almost every aspect of her life—the health of her daughters, the viability of her marriage, the future of her aging mother, and so on. Her exercises tested her beliefs that worrying prepared her for the worst. Phoebe felt extremely anxious in anticipation of all social situations because she was convinced she was the only person who felt this level of anxiety and that embarrassing herself was inevitable. Her exercises focused on showing her not only that many people felt some level of social anxiety but also that they performed well even while anxious.

Do You Have Doubts about Doing CBT Exercises? Maybe you’re thinking that this sounds good but it’s a lot easier said than done. You may bring to this book (or to therapy) a lot of preconceived notions about the effectiveness of practice exercises and about CBT strategies in general. By doing the

26

The Anxie t y and Worry Workbook

exercises you’ll see that CBT tools and techniques have been crafted meticulously to anticipate stumbling blocks and help you chip away at the negative effects of anxiety in your life. But if you’ve got doubts that keep you from diving in, now is the time to clear away any preconceived notions that are standing in your way. We’ve found that when people have trouble completing practice exercises, either as self-help or with a therapist’s guidance, the problem often lies in preconceived ideas about this work. You might feel eager to tackle your anxiety and believe you’re entering this program with an open mind, but little doubts and questions often lurk in the back of people’s minds, ready to pop up and sabotage their efforts when they least expect it. Exposing these hobgoblins to the light of day and addressing them now will help you get the most out of the work you do in this book and/or in therapy. The bottom line: You’ll get a lot more from this workbook if you have an open mind about doing the exercises and filling out the worksheets. E VA L U AT ION EXER C I S E 

Problematic Beliefs about Practice

Are you fully aware of the beliefs you hold about CBT practice exercises? Take a few minutes and rate yourself on the belief statements in Worksheet 2.1. How did you do? We don’t have data that will tell you reliably what ratings indicate being ready for CBT. But you can use the checklist more informally by looking over the belief statements for which you checked off “Agree” or “Strongly agree.” All of these statements reflect ideas that might interfere with your ability to commit to this program.

IN T ER V EN T ION EXER C I S E 

Challenge Unhelpful Practice Beliefs

You don’t have to remain stuck in your negative beliefs and biases against practicing CBT strategies. You can use the CBT approach to evaluate your beliefs about practice assignments and adopt a more positive perspective that will boost your engagement in the workbook. Review your answers to Worksheet 2.1 and write down statements that you marked “Agree” and “Strongly agree” on a piece of paper. For each statement you listed, evaluate the accuracy of that belief statement by doing the following: „ Question the accuracy of these beliefs. Does the belief apply to all your experiences

of doing physical or mental exercises to improve yourself? Have you had any experiences that contradict the belief? What are the consequences for you of holding these beliefs? „ Substitute the term physical fitness or lack of physical fitness for anxiety in your

belief statement (for example, “I can overcome my lack of physical unfitness without practice”). Would you believe this statement if it referred to getting physically fit? If it is untrue for physical fitness, how can it be true for mental fitness? You could

W ORK SHEE T 2.1

My Beliefs about Practice Assignments Instructions: Please read each statement and circle the number that best corresponds with how much you agree or disagree with each belief about self-help exercises.

Belief statement

Strongly disagree Disagree

Agree

Strongly agree

  1. Doing these assignments will make my anxiety worse.

1

2

3

4

  2.  There is no point in trying; nothing can help me.

1

2

3

4

  3. I should not have to practice skills to overcome my anxiety.

1

2

3

4

  4. I am too anxious to do homework tasks right now.

1

2

3

4

  5.  My anxiety has been pretty good; I don’t want to risk making things worse by doing self-help exercises.

1

2

3

4

  6. I don’t believe these exercises are an effective approach for reducing anxiety.

1

2

3

4

  7. I am a procrastinator; I’ve always had trouble motivating myself to do extra work.

1

2

3

4

  8. I’m not getting any better, so why bother doing these exercises?

1

2

3

4

  9. I’m too tired or stressed to do self-help exercises.

1

2

3

4

10.  These tasks are trivial; I don’t see how this will help me beat anxiety.

1

2

3

4

11. I’m too busy and don’t have time for daily mental self-help exercises.

1

2

3

4

12.  Anxiety is a medical condition; I shouldn’t have to go to all this effort to get rid of it.

1

2

3

4 (continued)

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

27

W ORK SHEE T 2.1 (continued)

Belief statement

Strongly disagree Disagree

Agree

Strongly agree

13. Other people overcome anxiety without putting this much work into it.

1

2

3

4

14.  There is a deep-­seated root to my anxiety that needs to be discovered; I don’t see how these exercises can be effective.

1

2

3

4

15.  What if I don’t do these exercises correctly and they make my anxiety worse?

1

2

3

4

16. I hate writing things down; I’ve never been a person to keep records.

1

2

3

4

17. I lack the motivation and discipline to do this kind of therapy.

1

2

3

4

18.  This is too hard; there must be an easier way to overcome anxiety.

1

2

3

4

19. Doing even a little homework is better than doing nothing at all.

1

2

3

4

20. Even if I don’t do the self-help exercises, going to therapy sessions or reading about anxiety should be somewhat helpful.

1

2

3

4

21. I’ve always hated doing homework, even as a child.

1

2

3

4

22. I don’t like following rigid programs; I prefer to do things my own way.

1

2

3

4

23. I can overcome my anxiety without practice.

1

2

3

4

24. I’ve made progress on my anxiety in the past without doing self-help exercises; therefore I shouldn’t need to do them now.

1

2

3

4

25.  These exercises are too demanding; I just don’t see how they are going to help me overcome anxiety.

1

2

3

4

28



getting started 29

discuss with friends how they overcame the same negative beliefs about physical fitness training. „ Take action by doing something small that might test or correct the belief (if you

believe you lack the discipline to do self-help assignments [item 17], you could start by engaging in a brief, limited self-help exercise that takes only a few minutes each day). Â Troubleshooting Tips: Still Skeptical about Practice Exercises

If you still have some doubts about your readiness to do the exercises in this workbook, and you are in therapy, you should discuss these doubts with your therapist, because they could also be a roadblock to your therapy progress. If you are reading the workbook on your own, talk to others who overcame anxiety through therapy. What role did exercises play in their recovery? Also, we are not asking you to do all the exercises all the time. Instead we are asking you to set aside 30 minutes on most days and focus on one exercise at a time. Do you recall the old Chinese saying “Every journey begins with the first step”? That’s our outlook in CBT. You have already taken the first step by getting this far in the workbook. Are you ready to continue the journey toward recovery?

Maximizing Your Workbook Success CBT is most effective when people practice anxiety-­reduction strategies rather than just read about them. You’ve been introduced to barriers that can hinder your engagement with this workbook. It’s also important to remember that our practice exercises are generic so they can be applied to a wide range of anxiety experiences. Even with instructions and recommendations, it is up to you to decide how to use the exercises and apply CBT strategies to your anxiety experiences. It is possible to use these exercises in an effective manner or an ineffective manner. Consider the following examples. For many years Sebastian, age 44, had severe anxiety caused by upsetting, intrusive thoughts of harm or injury to loved ones. For example, he had thoughts of a friend being in a car accident and then became anxious that this might really happen, or he would think of a family member having a serious illness and then worry that his relative might actually become seriously sick. Sebastian experienced these terrible thoughts many times throughout the day and tried to distract himself from the thoughts or reassure himself that everything would be all right. To overcome the anxiety caused by these worrisome thoughts, it was important for Sebastian to engage in exercises that exposed him to situations that trigger the worry, practice correcting his automatic thoughts of danger (such as “if I have this worry about harm, maybe something bad will happen to people”), and prevent efforts

30

The Anxie t y and Worry Workbook

to control the worry. Sebastian, however, was never very keen on doing these homework tasks. He was quite happy to attend therapy sessions and talk about his anxiety, but he had great difficulty finding the time to apply the therapy. Sebastian tried to do some of the things his cognitive behavior therapist recommended, but they never worked for him. He was afraid the exercises would make him feel more anxious. He was impatient with the pace of therapy and felt like the exercises were trivial and unimportant. He refused to keep a written account of the exercises and would do them only once or twice a week for a few minutes. He said he was too busy and didn’t have enough time. When he did an exercise, he would stop it as soon as he felt a little anxious. In the end, the whole process was frustrating and unproductive for Sebastian. Despite faithfully attending his therapy sessions, Sebastian was unable to overcome his anxious, worrisome thoughts. What went wrong? Sebastian wasn’t sure of the benefits he stood to gain from doing the exercises assigned by his therapist, he didn’t stick with the tasks and work his way up gradually, he refused to keep a written record of his exercise experiences, he didn’t practice regularly, and he never tried to determine what had gone wrong and how he might rectify the problems. There were many problems with Sebastian’s approach to practice assignments. To turn his therapy around and make it effective, he’d need to truly believe in the benefits of practice exercises. He would need to be more systematic in how he did the exercises, keep a written record of his experiences, and practice the exercises repeatedly over several days. Belinda, age 32, who wanted to address intense social anxiety, took advantage of all the arrows in the CBT quiver. Belinda felt conspicuous when around others and believed that people could see she was anxious and therefore would conclude that she must have an emotional problem. Her practice exercises exposed her to increasingly more severe anxiety-­provoking social situations. She practiced these exercises on a daily basis and recorded her progress in structured diaries and rating forms. If she had trouble with a particular exercise, she wrote the challenges down on her evaluation form and then problem-­solved the issues. She also used the exercises as an opportunity to practice correcting her exaggerated thoughts of fear and danger and to refine her coping responses to anxiety. After several weeks of daily structured exercises, Belinda found she was much less anxious in a variety of common social situations, and she felt much more confident in her social skills. The people you met at the beginning of this chapter—­Darrell, Aaliyah, and Phoebe—used exercises that helped them too. Darrell’s exercises involved going into the supermarket in the morning when only a few people were shopping. He would stay close to the front of the store, near the exit, and monitor his anxiety level, note any physical symptoms, and identify any anxious thoughts or interpretations of the symptoms. He then generated alternative,



getting started 31

less frightening interpretations of his physical symptoms. Darrell did not leave the store until his anxiety level had declined to 50% of its highest level when he entered the store. Also, Darrell practiced going to the store every day until he gained mental fitness in that situation—that is, he could enter the front of the store without feeling problematic anxiety. Once this situation was conquered, he proceeded to a new anxiety situation, such as shopping for prolonged periods throughout the store. In therapy, Aaliyah learned the difference between productive and unproductive worry (you’ll learn more about this distinction in Chapter 8). She was given a sheet that listed the characteristics of both types of worry. Over the next week, Aaliyah was asked to record several worry episodes each day and to indicate whether the worry met the criteria of productive or unproductive worry. She was amazed to learn that two-­thirds of her worry was unproductive and had little to do with preparing her for future negative events. This information was then used to evaluate some of her faulty beliefs about worry and to structure various strategies she could use in response to unproductive worry. For Aaliyah, mental fitness involved actively monitoring her worry and learning to view it from this new perspective. As noted earlier, Phoebe had a core belief that she was the only person who gets anxious and that anxiety always leads to embarrassment. To test out this belief, Phoebe’s therapist asked her to observe and rate other people’s anxiety level at the next department meeting. Phoebe wrote down any outward signs of anxiety she observed in others and rated their probable level of anxiety on a 0–100 scale. She also recorded how well they performed at the meeting in spite of their anxiety. This practice assignment played a critical role in Phoebe’s learning that anxiety is common and does not always lead to a disastrous outcome, that a person can perform quite well even when anxious. By changing some old attitudes about anxiety, Phoebe was gaining strength to try expressing her opinion despite feeling very anxious. These three people improved through practice exercises by working on their anxieties one at a time, by addressing each anxiety gradually, and by sticking with the exercise even though their anxiety rose initially. This is like what happens with physical fitness: You establish a baseline as your starting point, you build strength gradually, and you subscribe to the “no pain, no gain” principle if you want to get physically stronger. E VA L U AT ION EXER C I S E 

Is Your Practice Effective?

The next worksheet lists seven characteristics needed to make an exercise effective. If you’re ever concerned that you might not be doing an exercise correctly, you can use Worksheet 2.2 to determine whether your exercise experience contains the critical elements for success. For now, take a moment to familiarize yourself with this list.

W ORK SHEE T 2. 2

Seven Characteristics of Effective Assignments Instructions: Read through the questions below and check either Yes or No to answer each one. A brief explanation is provided for each characteristic of an effective practice exercise. There is sufficient space in the yes/no columns for multiple checkmarks so you can use this exercise repeatedly as you progress through the workbook. Question 1.  Clear rationale Do you understand why you are doing the practice exercise? 2.  Cost–­benefit Do you know what you’ll gain from doing the exercise? 3.  Precise instructions Do you know how to do the exercise? 4.  Graduated steps Are you doing the exercise by following specific steps? 5.  Record keeping Are you keeping a record of your practice sessions? 6.  Repeated practice Are you practicing the exercise again and again over several days?

Explanation

Yes

No

The exercise must address an important aspect of severe anxiety and must contribute to your goal of anxiety reduction. You should be clear about the costs and benefits associated with investing your time in doing the exercise.

The exercise should be clearly specified so you know exactly what to do, when, and for how long.

Practice assignments need to be done systemically, where you start with something at a lower anxiety level and work up to situations or tasks that involve more severe anxiety. A brief written description of your behavior, thinking, and anxiety level is essential each time you engage in a practice exercise. Do each exercise frequently, possibly even daily, before proceeding to the next chapter assignment. When CBT fails, it’s often because of insufficient time doing a practice exercise.

7.  Problem-solve disappointments

If you’re disappointed with the outcome of a practice exercise, take time to evaluate If there’s a problem with an exercise, what went wrong. Consider how you what can you do to make the could improve on the exercise the next exercise work for you? time you do it. From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

32



getting started 33

 Troubleshooting Tips: Tweaking Your Practice Exercises

Have you concluded that you’re not getting the most from your practice exercises? There are several ways you can improve how you use the workbook exercises. „ If an exercise is too difficult, break it down into smaller steps that allow you to work

to full completion. „ If your anxiety is intolerable when starting a new practice assignment, consider

seeking the support of a close friend or confidant. However, this needs to be faded out quickly so you don’t develop a dependency on another person. „ Seek advice from a person knowledgeable about CBT on how to modify a practice

assignment so it is most relevant to your anxiety experience. „ Do the practice assignment in a variety of anxiety-­producing situations to increase

its effectiveness and generalizability. Avoid unnecessary redundancy in your practice exercises. „ Practice exercises should elicit some anxiety. Stop doing an exercise when it is no

longer anxiety-­provoking.

The Next Chapter Now that you’ve read through these two introductory chapters, you’re ready to begin building your CBT skills for anxiety and worry. In this chapter we’ve been emphasizing the importance of doing the work of CBT, that is, practicing the anxiety-­reduction strategies that are explained in this workbook. You’ll learn lots about your anxious mind and the CBT approach in subsequent chapters. But to achieve genuine reduction in anxiety and worry, you’ll need to put these skills into practice. Without that “hands on” experience of wrestling with your anxiety, CBT will be little more than an interesting way to understand anxiety. So let’s get started working on your CBT anxiety-­reduction program. In the next chapter we begin at a most unusual place. Based on the CT-R perspective, we start with your strengths and how you use anxiety to deal with difficult situations in your life.

3 when anxiety is helpful

A

nxiety can be mysterious, hitting us in ways that are hard to understand. Maybe you remember a time when anxiety and worry were not major issues for you. There were times when you felt anxious, or you worried about some upcoming event, but it was no big deal. You understood why you felt tense or nervous, and you dealt with it just like all the other negative emotions that ebb and flow throughout the day. Feeling anxious before making a presentation, meeting an important person for the first time, or awaiting the results of a medical test—we expect to feel anxious under these circumstances. In fact the anxiety we feel in these circumstances can actually help us perform better by focusing our attention on the importance of the event. But your experience of anxiety has changed, and it now dominates your day. You feel anxious and worried about things that never bothered you in the past—­grocery shopping, medical appointments, your partner’s fidelity, going to a restaurant, or thinking about your future. You’ve noticed changes in your emotions and not for the better. You’ve become anxious and worried, and you don’t know why. Or maybe you know why you’re so anxious and worried, but the things that make you severely anxious don’t always make sense. Have you noticed that you get anxious about daily activities that everyone faces, and yet you’re remarkably calm and level-­headed about major problems with serious implications? Often anxiety is not triggered by the greatest threats to our physical safety or well-being. You might feel stress and frustration but no anxiety when driving in heavy traffic. And yet, you could feel nervous and hesitant to turn down an unreasonable request even from a total stranger. Clearly, the heavy traffic is more life-­threatening than being assertive with the stranger. A client once reported feeling highly anxious about swallowing solid food but had no problem doing stand-up comedy. Most people would agree that the latter is especially terrifying given the high probability of flubbing. A pilot had severe anxiety when traveling as a commercial airline passenger but had no difficulty flying a small single-­engine plane. A financially secure person worried about money but was less worried about his health despite having a recent heart attack. What makes us 34



when anxiety is helpful 35

most anxious can be a mystery; it’s often the routine, mundane aspects of life rather than the most significant personal threats. When anxiety threatens our emotional health, we naturally focus on the occasions when it’s severe and seemingly out of control. It’s easy to overlook all the times you dealt successfully with anxious feelings and didn’t let them interfere with daily living. When anxiety symptoms are severe, they can be an unforgettable experience that grabs our attention and raises our level of insecurity and helplessness. We forget about all the times we tolerated our anxious feelings and considered them normal emotions. Do you have an anxiety bias? Have you become convinced you can’t handle anxiety because you remember only the severe episodes? Most of the individuals we’ve treated with an anxiety problem have this bias. They’ve lost confidence in their ability to deal with anxiety and worry. Is it possible you’re better at managing anxiety than you think? We believe it’s important to start your work on anxiety by rediscovering your natural strengths and abilities to deal with anxious feelings. This approach is entirely consistent with the recovery orientation to CBT introduced in Chapter 1. Is it possible that your way of thinking and behaving when adapting to anxiety might provide some insights on how to deal with anxiety when it becomes a problem? This chapter is framed within the CT-R perspective on anxiety. The exercises and worksheets provide you the opportunity to discover your adaptive skills with low to moderate levels of anxiety. You’ll learn why you’re able to tolerate anxiety at this level and how you use anxious feelings to your advantage. You may be surprised to learn that you’re emotionally stronger than you think and that you already possess skills you can use against your anxiety problems.

Alyssa: An Anxious Mother Alyssa, age 44, is smart, resourceful, and disciplined and has always been determined to make the most of her life. All was going well until she and Daniel decided it was time to start their family. After several years of consultation with reproductive endocrinologists and a fertility clinic, Alyssa finally gave birth to Brianna. She thought of Brianna as her “miracle baby,” but much to the couple’s surprise, three years later Alyssa was pregnant again, giving birth to a baby boy they named Caleb. Alyssa felt truly blessed and set about creating the secure, loving family that she never had as a child. Life was all she had dreamed except for one unexpected development. The birth of the children had brought with it fears, anxieties, and worries that were completely foreign to Alyssa. At first she thought her anxiety about harm, injury, and sickness affecting her children was typical of older first-time mothers. But the anxiety and worry grew over time. Alyssa was fearful the children might be abducted at school, be

36

The Anxie t y and Worry Workbook

injured on the playground or when playing sports, contract a serious disease, or that the parents of their children’s friends would be lax when taking the kids on outings. Also, Alyssa worried the after-­school caregiver was not paying enough attention to Brianna and Caleb. Whether she was the driver or a passenger, family driving was a nightmare because of Alyssa’s fear they’d be involved in an accident. With Brianna at age 8 and Caleb 5, Alyssa had become an overly anxious, controlling, and protective mother. She realized this was unhealthy for the children and it was putting strain on her marriage, but she couldn’t seem to stop herself. Alyssa was at a loss to understand her anxiety. At one level she blamed the anxiety on the difficulty of pregnancy and the circumstances around the children’s birth. But at another level the anxiety made no sense. She had had no anxiety issues before the children, and she could handle threats and challenges at work, about her health, and in family relationships with only minimal apprehension and nervousness. She realized that millions upon millions of women face the same degree of threats and dangers for their children with far less anxiety and worry. Furthermore, anxiety didn’t really run in her family, and she was creating a far safer environment for her children than she had had as a child. It was a mystery why she could control her anxiety at work but when it came to the children Alyssa fell victim to her runaway anxious mind. Are you, like Alyssa, surprised by your anxiety? Is it triggered by a specific concern like child-­rearing, health, job performance, travel, or relationships, while you’re able to function practically anxiety-free in other areas of your life? Can you remember a time when anxiety was not a concern? To understand how you became anxious, start by considering your experience of mild anxiety. For Alyssa this meant looking at how she normalizes the anxiety and worry she experiences at work.

Fear and Anxiety: What’s the Difference? Fear is a basic emotion that’s hardwired in our brain and is critical to survival. It’s one of the earliest emotions to arise in our development as a species and is found widely throughout the animal kingdom. Without fear, we would soon perish from all the dangers we encounter in this world. We might call someone “fearless” who is thrill-­ seeking and takes unnecessary risks, but even that person knows what it’s like to feel fear. If you had no fear, you’d be careless and indifferent, which could endanger you and those around you. We don’t have to remind ourselves to be afraid. Fear arises suddenly, often without warning. It’s an automatic emotional response to any object, situation, or circumstance we recognize (perceive) as an imminent danger to our personal well-being.4 It is the perception of danger. For example, people with arachnophobia know they have



when anxiety is helpful 37

a fear of spiders. But this fear is activated only in situations where they think a spider might be present, such as when they see a spider web, enter an older house, or walk in the forest. Even seeing a picture of a spider might activate fear. Whenever outside, the spider-­fearful person thinks, “I wonder if I will come across a spider,” “Spiders are dangerous because they can crawl into your mouth or ears and lay eggs,” or “If I see a spider, I’ll freak out.” The body kicks into high arousal when spider-­phobic individuals see anything that reminds them of a spider. They might feel tense, on edge, a churning stomach, chest tightness, or a racing heart. And the fear could cause a change in behavior, such as avoiding any place that seems to pose the risk of exposure to spiders. In CBT you work on reducing fear by changing how you think and act. Instead of thinking of the fear object (for example, a spider) as an imminent threat or danger, you’re taught to reevaluate the fear object as less threatening to your safety and wellbeing. Instead of avoiding or running from the fear, you’re encouraged to face the fear. Fear and anxiety are interconnected. We feel anxious when we anticipate that a future situation, event, or circumstance may involve significant distress due to an uncertain and uncontrollable threat to our vital interests.4 You could think of anxiety as an early warning system of the possibility that some threat to your well-being could occur in the future. For example, we talk about a “fear of death,” but for most people not facing imminent death, it would be more accurate to call it “feeling anxious about death.” In our spider phobia example, you’d feel anxious about going to visit friends because they live in an older home that might have spiders or anxious about going to the movies because the film might contain a scene with spiders. You have a basic fear of encountering spiders, but you live in a state of persistent anxiousness about the possibility of being exposed to a spider. When anxious we have a feeling of apprehension and physical arousal in which we believe we can’t predict, let alone control, potentially aversive future events. We feel nervous, on edge, and keyed up. We’re also thinking that something bad is about to happen. We don’t feel anxious or worried about the past. Instead anxiety is always about events in the future—a bad outcome or catastrophe we imagine “could happen.” The person with anxiety is dominated by “what if” thinking. Practically anything we encounter in life can trigger anxiety. Even anxiety itself can make us feel more anxious (“What if the anxiety never goes away?” or “What if the anxiety gets worse and I lose control?”). Other examples of imagined catastrophes are: „ “What

if my mind goes blank during the exam?”

„ “What

if I don’t get all my work done?”

„ “What

if I have a panic attack in the supermarket?”

„ “What

if I become seriously ill due to contact with other people?”

38

The Anxie t y and Worry Workbook

„ “What

if I encounter someone who reminds me of the assailant who attacked

me?” „ “What

if I lose my job?”

What Prompts Mild Anxiety? Rarely do our feelings occur without cause. There is usually a trigger that changes the way we feel, and anxiety is no different. We most often feel anxious because something has triggered a sense of threat. The trigger could be a situation or circumstance, an intrusive thought, image, or memory, an unexpected physical sensation, or some comment or action by another person. Being able to identify the most common triggers to your mild anxiety is an important part of learning how you handle anxiety in some situations but not others. E VA L U AT ION EXER C I S E 

Discover Your Triggers of Mild Anxiety

This exercise will help you discover situations, thoughts, physical sensations, and behaviors in your everyday life that may trigger feelings of anxiousness. Worksheet 3.1 is a selective list categorized under major aspects of living: work, finances, social relations, health, and family/intimate relationships.

How many situations caused you at least some anxiety (that is, the ones you checked as causing only a little anxiety)? Were most of these triggers associated with one category or another, such as work or intimate relationships? Were you surprised by the number of situations that make you feel anxious? The situations that triggered a lot of anxiety are the subject of the next chapter. For now we want to focus on the mildly anxiety-­inducing situations so you can discover why you’re able to tolerate anxiety in these situations but not others. Later we’ll compare how you respond to situations that cause you severe anxiety with how you respond to the ones that cause mild anxiety. In the meantime, keep Worksheet 3.1 handy so you can refer to it while completing the chapter.

Anxiety Can Feel Normal You probably don’t notice how you shift from calm and relaxed to stressed and anxious throughout the day. You tolerate mild levels of apprehension, tension, and nervousness so they don’t interfere in your daily living. Most of us would feel anxious

W ORK SHEE T 3.1

Anxiety Trigger Checklist Instructions: Place an X in the column that represents the amount of anxiety you associate with each situation. In the blank spaces, write any additional triggers to your anxious feelings that are not listed in the relevant category. Possible anxiety triggers

No A little A lot of anxiety anxiety anxiety

Work/school performance Being late for meeting, class, or appointment Losing my job; failing or quitting school Thinking I’m falling behind; not keeping up at work or school Not succeeding; failing to meet expectations, goals, or targets Possible negative work evaluation or poor marks Having unfinished work Making mistakes Not doing my best Other:              Other:              Social relationships Going to social event (such as a party) with a lot of unfamiliar people Making a telephone call to a stranger Walking into a theater, church, group setting late Being assertive Expressing my opinion, especially in a group Having friends over for dinner Working out in the gym Concern that others think I’m stupid, boring, or no fun Feeling of not knowing what to say Thought of not fitting in with these people (continued) From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

39

W ORK SHEE T 3.1 (continued)

Possible anxiety triggers

No A little A lot of anxiety anxiety anxiety

Social relationships (continued) Thought that I’ve made a bad impression or a fool of myself Concern that I’ve been rude or impolite Thought that I’m not accepted Giving a presentation Thought of looking nervous, uncomfortable Other:              Other:              Finances Difficulty paying bills Reminded of being in debt Concern I’ll not have enough money Overspending Not saving enough/investments underperforming Not meeting my budget Not having enough money; not making ends meet Need a better income Other:              Other:              Intimate/family relationships Argument with partner/child/parent Accident, injury to partner/child/parent Thought that I’m unattractive to intimate partner Thought that I’m not loved by intimate partner Thought that my intimate partner isn’t committed to me Thought that my intimate partner is not faithful (continued) 40

W ORK SHEE T 3.1 (continued)

Possible anxiety triggers Intimate/family relationships (continued) Currently having no intimate partner Beginning of a romantic relationship Experiencing a lack of intimacy Other:              Other:              Health Concerns about a chronic medical condition Chronic pain Waiting for the results of a medical test Sudden chest pains Being in public and getting an infectious illness Concern about being overweight or in poor health Going to the doctor or hospital Feeling nausea or upset stomach Headache Unexpected aches and pains Feeling dizzy, unsteady, or weak Feeling tired, lack of energy Poor sleep Concern of a possible heart attack, stroke, or aneurysm Concern about forgetting, confusion, or poor concentration Thoughts of death and dying Other:              Other:             

41

No A little A lot of anxiety anxiety anxiety

42

The Anxie t y and Worry Workbook

before giving a speech or performing in front of a large audience, meeting an important person for the first time, waiting for the results of a medical test, hearing that our partner has doubts about the relationship, and the like. What makes normal, mild anxiety different from its more severe counterpart is our ability to tolerate it and recover quickly. E VA L U AT ION EXER C I S E 

Rediscover Mild Anxiety

Maybe you’ve forgotten what a normal feeling of anxiety is like because you’ve been so focused on your anxiety problems. The exercise in Worksheet 3.2 will help you reconnect with your experiences of mild anxiety. You can use the experiences you marked as causing a little anxiety on the previous worksheet as typical triggers of mild anxiety. Â Troubleshooting Tips: Capturing Moments of Mild Anxiety

It can be difficult to think of anxiety as a normal, even helpful, emotion when you’re struggling with anxiety problems. If you couldn’t recall any experiences of mild anxiety for Worksheet 3.2, you can use the worksheet as a self-­monitoring form. Over the next week or two, write down times when you faced a difficult, stressful, or challenging problem. Use the symptom checklist (Step 2) to indicate how you felt physically, how it affected your thinking, how you behaved, and what you felt (subjective) when facing the problem. Complete the checklist as soon as possible while your memory is fresh. It’s hard to remember the symptoms of mild anxiety because the experience evaporates quickly. If the self-­monitoring strategy is not helpful, try completing Worksheet 3.2 when you and your partner or family member are dealing with the same problem. You can discuss how you each experienced the problem using Worksheet 3.2 as your guide.

When feeling anxious, were some of the physical, cognitive, behavioral, and subjective characteristics more prominent than others? Whatever your experience of mild anxiety, it’s clear you’re able to tolerate these symptoms. This is what keeps the anxious feelings brief and mild. Clearly, you’re able to deal effectively with anxiety when it involves the symptoms you checked off on this worksheet. Keep this worksheet handy so you can compare it with your experiences of problematic anxiety, the topic of the next chapter. If Alyssa completed Worksheet 3.2, her mild anxiety experiences might be having to pitch a new online advertising strategy to senior management and going to a parent–­teacher meeting. Anxiety in both situations was mild and manageable, but Alyssa might notice certain physical symptoms like upset stomach and tense muscles. Her cognitive concerns might be fear of negative evaluation and poor concentration. Behaviorally, she might show some signs of restlessness and difficulty speaking.

W ORK SHEE T 3. 2

Mild Anxiety Checklist Instructions: There are two parts to this worksheet. Step 1. In the space provided, briefly describe two experiences of normal, mild anxiety. On these occasions you felt slightly nervous, tense, or anxious, and you were thinking that something unfortunate could happen to you or a loved one. The anxiety may have occurred in a situation that would cause most people some anxiety.

1. Mild anxiety experience:





2. Mild anxiety experience:



Step 2.  Below you’ll find a checklist of features common to all levels of anxiety. Place a checkmark beside the symptoms you had during the mild anxiety experiences recorded in Step 1. Physical features † Increased heart rate, palpitations † Shortness of breath, rapid breathing † Chest pain or pressure † Choking sensation † Dizziness, lightheadedness † Sweating, hot flashes, chills † Nausea, upset stomach, diarrhea † Trembling, shaking † Tingling or numbness in arms, legs † Weakness, unsteadiness, faintness † Tense muscles, rigidity † Dry mouth Behavioral features † Avoidance of threat cues or situations † Escape, flight † Pursuit of safety, reassurance † Restlessness, agitation, pacing † Hyperventilation † Freezing, motionlessness † Difficulty speaking

Cognitive (thinking) features † Fear of losing control, being unable to cope † Fear of physical injury or death † Fear of going crazy † Fear of negative evaluation by others † Frightening thoughts, images, or memories † Perceptions of unreality or detachment † Poor concentration, confusion, distractibility † Narrowing of attention, hypervigilance for threat † Poor memory † Difficulty in reasoning, loss of objectivity Subjective features † Feeling nervous, tense, wound up † Feeling frightened, fearful, terrified † Being edgy, jumpy, jittery † Being impatient, frustrated

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

43

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The Anxie t y and Worry Workbook

Alyssa might also feel somewhat edgy and wound up. However, none of these symptoms are difficult to handle, and so she’d be able to function very well in these situations. Were your mild anxiety experiences like Alyssa’s, or did you check different symptoms? We don’t all experience anxiety the same way. It’s entirely possible that some symptoms are easier to tolerate than others, and that might be one reason your anxiety remains low in these situations. Later we’ll see how the features you experience with low anxiety compare with the symptoms you have when anxiety is severe.

The Making of Mild Anxiety There are certain ways we think, feel, and behave to keep our anxious feelings in check. Figure 3.1 on the facing page depicts three gears that keep your anxiety in the normal range of emotion.

The Cognition Gear We keep our anxious feelings mild by evaluating the threat or danger in realistic terms. We avoid thinking the worst or catastrophizing the situation. Realistic thinking about threat involves: „ Downgrading

the personal significance and intensity of the anxiety-­provoking

situation „ Assuming

a mild to moderate negative outcome is most likely

„ Thinking

that a seriously bad outcome is not immediate but a possibility in the distant future

Alyssa had to make an important presentation to her department, but she felt only mildly anxious. She kept her anxious feelings in check by telling herself there was nothing special about this presentation and even if she didn’t perform her best, nothing would happen. She believed it was highly unlikely that she’d do so poorly that it would ruin her reputation at work. Getting a poor performance evaluation that would threaten her job was not something Alyssa thought was imminent, although she did recognize her job security was not absolute by any means. We also keep our anxiousness to a minimum by believing we can deal with the demanding situation at hand. Anxiety rises when we believe we’re too weak, helpless, or vulnerable to deal with an anticipated negative outcome. So we keep our anxious feelings under control by:



when anxiety is helpful 45

Thoughts of threat and vulnerability Physical arousal

Coping responses

F I G U RE 3 .1.  

The basic cognitive behavioral model of anxiety.

„ Believing

we’re able to cope with the situation causing the anxiety

„ Focusing

on our problem-­solving skills

„ Tolerating

uncomfortable feelings

Alyssa believed in herself when it came to her work performance. She knew from experience that she was quite good at making presentations, so she treated the current assignment as a problem to be solved. She realized from personal experience that she could perform well even when a little anxious. In fact she believed a little anxiety kept her sharp and on her toes. So Alyssa was able to keep her work anxiety to a minimum by believing no threat was too great and her coping skills were ready and able to deal with any challenge that came her way. In CT-R the focus is on the pursuit of valued goals and aspirations for the future. A good way to keep anxiety low is to concentrate on the important goals in your life. This is more than just distracting yourself with “busy work.” It involves passionate engagement in what you consider most important that builds on your strengths and talents. It doesn’t have to be engagement in a big task. Rather it can be specific activities that are connected to a larger life goal. Being productive and successful were valued goals for Alyssa. She knew that making a good presentation was an important part of succeeding at work. When she started to feel nervous about a presentation, she was able to shift her attention to improving the presentation and away from how she felt. What’s important to you? Have you noticed you’re less anxious when you’re engaged in an important and interesting task? In mildly anxiety-­provoking situations you may be thinking more about what you have to do, what we call goal-­directed activity, rather than how you feel.

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The Physical Arousal Gear Even when our anxiety is mild, we can still feel it in our body. Look back at Worksheet 3.2. Which physical sensations did you check? Why do you think these symptoms remained relatively mild and eventually disappeared? There are probably two things you did when you had tense muscles, felt lightheaded, had an upset stomach, or some other symptom. 1. Generated a benign interpretation: You did not consider the physical sensation serious; you believed it was due to stress, feeling tired, or overwork and that it would eventually fade away. 2. Got distracted: Instead of focusing on the physical symptom and worrying about it, you focused your attention on something else, like an important task or a conversation with a friend. When Alyssa felt stressed and anxious at work, she noticed that her heart raced and she felt hot and sometimes lightheaded. She recently had a complete physical checkup, and given her age and low risk factors, she knew these symptoms were due to stress rather than a cardiovascular problem. So, rather than fear the symptoms, she took them as a sign to calm down and take a couple of deep breaths. Rather than trying to control the symptoms, she let them pass on their own. She was then able to get back into her work. The recovery orientation to CBT emphasizes what is “best about you.” In CT-R the therapist guides individuals in discovering positive beliefs about themselves, other people, and their future.12 What might be some positive beliefs about being physically aroused when anxious? When anxiety is mild, or even helpful, it’s likely you consider physical arousal an asset rather than a hindrance. For example, you might interpret your tension, increased heart rate, or tingling sensation as a sign that you’re attentive, “pumped,” or ready for action. This is the interpretation you make of these symptoms at the start of a sporting competition, a music recital, or when embarking on a dangerous military mission. You might call it “an adrenaline rush,” but what’s important is the belief that it’s a positive sign. When anxiety is helpful, we tend to see physical arousal as helpful, even a sign of strength. When anxious feelings are heightened, we’re more likely to believe physical arousal is a problem and that we need to calm down.

The Coping Response Gear When our anxiety is mild, we respond to our feelings differently than when it’s severe. You’re aware of the anxiety, but you continue to focus on whatever it is that you’re



when anxiety is helpful 47

doing. You follow through with the immediate goal that’s before you. When a difficulty arises, you take a problem-­solving approach and see the situation as a challenge. You might interpret the anxious feeling as a useful emotion that keeps you sharp and focused. Avoiding, delaying, or escaping from the thing that’s making you feel anxious is the furthest thing from your mind. This is the approach Alyssa took when feeling anxious about her presentations at work. From a CT-R perspective you could say that Alyssa’s positive beliefs and expectations about herself were foremost in her mind and that she capitalized on her strengths and talents when dealing with the presentation. She considered her mild anxiousness helpful because it motivated her to stay focused on preparing the presentation. When she thought about doing a poor job, she looked back at the parts of the presentation that she felt less certain about and spent extra time collecting information that supported her arguments. Since the presentation was scheduled for the end of the week, she set aside time to work on it. She kept it a high priority and refused to let other work crowd out her scheduled prep time. In this way Alyssa worked with the anxiety, allowing herself to experience the feelings while maintaining a focus on her work. E VA L U AT ION EXER C I S E 

Tracking Mild Anxiety

This exercise gives you an opportunity to better understand how the cognitive, physical, and coping gears operate to keep your anxiety at bay. All anxiety, whether mild or severe, can be broken down into triggers, thoughts, physical sensations, and coping responses. You’ll find the work you’ve done in the previous exercises helpful when completing Worksheet 3.3. The example on page 49 illustrates how Alyssa might complete this worksheet.

Were you surprised at the number of times you kept your anxious feelings in the low intensity range? Were there certain ways of thinking or coping with the anxiety that kept it at a minimum? You might want to highlight these key cognitions and coping responses because they might be especially potent in keeping your anxiety mild. If you take a look at Alyssa’s example, you’ll see two cognitions that were especially helpful in keeping her anxiety tolerable. The first was reminding herself she always was sufficiently prepared for past presentations no matter how little preparation time was available, and second, she could turn the presentation into a brainstorming session with her colleagues. In terms of behaviors, Alyssa’s assertiveness in dealing with audience questions and knowing what to do if she got stuck in certain details of the presentation were most helpful. Have you, like Alyssa, discovered ways of thinking and behaving when mildly anxious that might help you with episodes of problematic anxiety?

48

My Mild Anxiety Log

Anxiety situation/trigger Physical sensations

Cognition (What were you thinking when mildly anxious?)

Coping (How did you respond to your mild anxiety?)

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

2.

1.

Date and time

Instructions: When completing this worksheet, think broadly about your mild anxiety triggers. Any external situation, thought, image, memory, or physical sensation could trigger mild anxious feelings. It is likely that only a few physical arousal symptoms will be present with mild anxiety. The cognition and behavior columns are the most important. For the cognition column, consider how you’re thinking the situation is not that bad, that you’ll be able to cope with it, and everything will work out in the end. For the behavior column, briefly describe how you turned the anxiety-­provoking situation into a challenge, maintained a problem-­solving focus, and didn’t let anxiety derail your efforts.

W ORK SHEE T 3.3

49

Anxiety situation/trigger

2.

1.  Tues,

Sitting at my desk, Feb 18, trying to work on 2022, @ the presentation 2:30 p.m. for Friday, but I’m getting a constant flow of interruptions

Date and time

I feel tense and suddenly the room seems much hotter; I feel a pressure building in my chest, my mouth feels dry; when I stand up, I feel a little unsteady and lightheaded

Physical sensations

I’m never going to be ready with all these interruptions. Why can’t people leave me alone? I’ll have to work on the presentation at home, which is so difficult for the whole family. I always get the work done. I’ve even done some of my best work when in a crunch. This is not a major presentation; people realize I’ve had a lot of demands lately. If I’m not completely ready, I can devote more time to discussion and turn it into a brainstorming session.

Cognition (What were you thinking when mildly anxious?)

Alyssa’s Mild Anxiety Log

I put a sign on my office door that said “do not disturb” between 3:00 and 4:00. I did not look at texts or emails for one hour. I read a couple of key documents and then listed the main points I wanted to get across in the presentation. I acknowledged I was feeling anxious, so I took a five-­minute break to do controlled breathing and listen to some soothing music. If I got stuck on one part of the presentation, I skipped to another part so I could keep my work momentum for the full hour.

Coping (How did you respond to your mild anxiety?)

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The Anxie t y and Worry Workbook

Making Anxiety Helpful At the beginning of this chapter we discussed the survival value of fear and anxiety. Next, we want to consider whether anxiety might confer some personal benefits in daily living. Many of the threats we face today are more psychological or even existential in nature, and so is it possible that anxiety is helpful in these situations? Is there a type of anxiety that is part of your adaptive mode, enabling you to be your best when making decisions or taking action on an important issue? Let’s consider a few examples. Have you ever worried about something you said to a friend or family member? Maybe you made a hasty comment and now, as you reflect on what you said, you wonder if they took it the wrong way. Your concern (mild anxiety) persists, and finally you speak to your friend. You find out your friend was offended by your remark. Now you have a chance to make matters right. In this case your anxiety was adaptive; it made you aware of a possible ruptured friendship so you then took corrective action. This action is consistent with one of your core values, which is to live in harmony with others. Some people, though, are excessively worried about offending others. In this case the anxiety ceases to have any adaptive value. It’s like a faulty burglar alarm that is useless because most of the time it goes off when there’s no robbery in progress. We can all think of numerous times when we felt anxious about our work performance. A fear of failing, embarrassing yourself, or falling short of your standards caused some anxiety, which motivated you to work harder and perform better. Once again, a mild case of performance anxiety can be adaptive, but if it’s too intense, the anxiety undermines your confidence and ability to work. At other times, mild anxiety in social situations can increase your awareness of social cues so you act appropriately. But when social anxiety becomes too severe, we become awkward and self-­conscious around others. There is a host of other situations where some anxiety and worry can motivate us to deal with real-life problems. Some worry about finances could make us more responsible with our money, anxiety about harm to our children could help us take appropriate precautions, and some worry about the future could motivate us to create reasonable contingency plans. Of course, anxiety in each scenario ceases to be adaptive when it becomes exaggerated and disproportionate to the situation at hand. E VA L U AT ION EXER C I S E 

Leaning into Anxiety and Worry

This exercise will help you think about the possible advantages of mild anxiety in seven key areas of living. Not all of the life concerns listed in Worksheet 3.4 are equally relevant, so pick three or four that are most important to you. Think about a problem or challenge you faced in each of these areas and how some anxiety helped you deal with the difficulty. It’s

W ORK SHEE T 3.4

When My Anxiety Was Helpful Instructions: Select three or four life domains that are important to you. Think of an experience that caused you some nervousness, anxiety, worry, or stress, but your emotional state actually helped you deal successfully with the situation. After describing the situation in the first column, indicate in the second column how some anxiety or worry helped you perform better than if you had no anxiety.

Challenging/difficult situation, problem, or concern

How mild anxiety or worry helped me deal with the situation, problem, or concern

Work:

Family/intimate relationships:

Friendships/social sphere:

Health/physical fitness:

Leisure/recreation:

Community/citizenship:

Spirituality/religious faith:

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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The Anxie t y and Worry Workbook

important that you’re able to recall specific examples from your life when mild anxiety or worry was helpful. This will make the concept of helpful anxiety meaningful to you. Â Troubleshooting Tips: More Guidance in Discovering Helpful Anxiety

If you had difficulty thinking of anxiety or worry as helpful, make sure that: „ You choose areas of living that are associated with several important challenges or

problems that you remember experiencing. Most people can think of difficult situations in work/school or family/intimate relationships but would have greater difficulty with community/citizenship or spirituality/religious faith domains. You can also review your answers to Worksheets 3.1 and 3.3 to help you remember some relevant experiences. „ You’re not misinterpreting or ignoring experiences that are mild anxiety. Some peo-

ple don’t think of nervousness, tension, or butterflies in their stomach as anxiety. But these are symptoms of mild anxiety, so you may have had these symptoms but not called it anxiety. „ You think of helpful anxiety as increasing your motivation, making you more cre-

ative, or encouraging you to take initiative to deal with the situation. These are ways in which mild anxiety or worry help us deal with problems of daily living.

Were you surprised to discover specific examples of anxiety working to your advantage? Some anxiety and worry can make us better at our job, more sensitive and understanding in our relationships, more conscientious about healthy living, and more committed to building relaxation and enjoyment in our weekly schedule. Alyssa felt pulled between her job and family responsibilities. This was an ongoing difficulty that made her mildly anxious and worried. But she used this anxiety to her advantage by being more conscious of not letting work demands encroach on her family life. Another challenging experience in the friendship domain was her concern that she’d lose her close friends because of neglect due to her busy life. Again, the mild anxiety associated with this concern was adaptive because it motivated her to set aside time for her friends.

Play to Your Strengths In this chapter you’ve learned that in many situations you experience low levels of anxiousness. Maybe you’re surprised to learn you experience mild anxiety episodes more often than more severe episodes. We hope you’ve learned from this chapter that you’re stronger than you think. You’re much better at dealing with difficulties than



when anxiety is helpful 53

you may have realized. Possibly you’ve been so focused on your problems with anxiety, worry, and panic that you’ve forgotten how well you deal with anxiety in other situations. The recovery orientation to CBT begins with helping people discover what is best about them. This is why we started with a chapter on adaptive anxiety. We want you to rediscover your emotional strength and use this as a starting point for developing a CBT program to tackle your anxiety problems. Make no mistake about the goal, however: This is not just a “feel good” chapter. Have you discovered ways you think and act during mild anxiety that you can apply to occasions when anxiety becomes a problem? This next exercise is intended to help you pinpoint the strategies you use to manage anxiety in difficult situations. We call this My Adaptive Anxiety Profile because it represents what you do to keep anxiety tolerable, even helpful. E VA L U AT ION EXER C I S E 

The Adaptive Anxiety Profile

The work you’ve done in this chapter is summarized in Worksheet 3.5. The best way to discover your strengths in dealing with anxiety is to do a “postmortem” on past difficulties you handled well. You’re asked to take a closer look at some of your mild anxiety experiences and explain how you thought about the difficulty, your ability to deal with it, your tolerance for anxiety, and how you coped. Your answers to these questions will provide insight into how you turn down the anxiety dial in various situations. Â Troubleshooting Tips: Seeing Past Severe Anxiety

Everyone has their best moments when they use their anxiety and worry to some advantage in dealing with difficult situations or problems. But this can be hard to recognize when it seems like severe anxiety is unrelenting. It’s like a spark of anxious feeling ignites a firestorm of anxiety or panic. And it may be true that you feel your anxiety much more intensely most of the time, whereas others may have fewer bouts of severe anxiety. You might have to strain to see your moments of mild anxiety within a whirlwind of severe anxiety. But we encourage you to take some extra time to search for the few times you experience mild anxiety or worry and consider whether your adaptive way of thinking and coping during mild anxiety could be used when feeling severe anxiety.

If you are still having difficulty completing the Adaptive Anxiety Profile, we’ve written a couple of scenarios based on Alyssa’s story. What did you tell yourself about the outcome or consequences of the difficulty that made you feel a little anxious or worried? Were you able to think of ways the situation was not as dire as you may have first thought? Were you able to believe you could deal with the difficulty, that you were not a victim of bad circumstances? How

W ORK SHEE T 3.5

My Adaptive Anxiety Profile Instructions: Review your entries in Worksheet 3.4 and select two or three life experiences that were difficult but you managed the anxiety and worry so well that you were able to overcome the difficult circumstance. Next answer the four questions associated with each situation. Briefly explain what you thought and how you behaved in each situation that enabled you to keep your anxiety and worry low.

A. Challenging, difficult situation:

1. What I told myself that made me think the situation was not that serious: 2. What I told myself about my ability to deal with the situation: 3. What I told myself about my ability to tolerate or handle the anxiety caused by the situation: 4. How I responded to this situation that reduced the anxiety: (continued) From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

54

W ORK SHEE T 3.5 (continued)

B. Challenging, difficult situation:



1. What I told myself that made me think the situation was not that serious: 2. What I told myself about my ability to deal with the situation: 3. What I told myself about my ability to tolerate or handle the anxiety caused by the situation: 4. How I responded to this situation that reduced the anxiety: (continued) 55

W ORK SHEE T 3.5 (continued)

C. Challenging, difficult situation:



1. What I told myself that made me think the situation was not that serious: 2. What I told myself about my ability to deal with the situation: 3. What I told myself about my ability to tolerate or handle the anxiety caused by the situation: 4. How I responded to this situation that reduced the anxiety: 56



when anxiety is helpful 57

Alyssa’s Adaptive Anxiety Profile A. Challenging, difficult situation:   A few months ago Daniel heard that his company was downsizing and

his job could be terminated. 1. What I told myself that made me think the situation was not that serious:   At first I was worried and

anxious, but I reminded myself that I have a good job and we can survive on one salary for a while if needed. Daniel has had to look for work in the past, and he’s always found good employment because he has skills and an excellent employment record. No job is guaranteed for life, so one has to expect to change jobs several times during their working life. Anyway, he’s been unhappy in this job; he’ll get a good severance package that will give him time to look for more satisfying employment. 2. What I told myself about my ability to deal with the situation:   There’s nothing I can do to change the

situation. I have no influence over his company’s decision making. We’ve pulled together and managed past financial difficulties when we had much less money than we do now. Daniel’s good at dealing with difficulties like this. I focused on giving him emotional support and encouragement while he waited to hear about his employment. I told myself we could use a few weeks of him off work so he could take on more family responsibilities and attend to some much-­needed house repairs. 3. What I told myself about my ability to tolerate or handle the anxiety caused by the situation:

If Daniel got laid off, I’d feel more anxious and worried if it dragged on for months. At the time, I was able to deal with the anxiety of not knowing whether he’d keep his job. It’s only natural to have some worry and maybe lose a little sleep when waiting for possible “bad news.” If I felt some anxiety, I imagined how much greater it must be for him. I kept my focus on Daniel and didn’t become preoccupied with my feelings. 4. How I responded to this situation that reduced the anxiety:   I focused on my work and family life to

maintain a semblance of normality. I didn’t question Daniel about what’s happening with his job or the company’s downsizing because talking endlessly about it only increased our anxiety. I didn’t seek reassurance from him because he didn’t know what was going to happen. I was available when he wanted to talk, but I also wanted to give the appearance of personal strength and confidence in his ability to weather this storm. B. Challenging, difficult situation:   My mother has not been well. She saw her family doctor, who recently

booked a series of medical tests. This is worrying because cancer runs in my mother’s family. 1. What I told myself that made me think the situation was not that serious: I reminded myself that my

mother is getting older, so it’s normal that health issues will arise. Most older adults have health problems.

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Life is uncertain, so I have no choice but to live with the uncertainty of our health. I resisted jumping to conclusions and thinking the worst. Most medical conditions in older people are chronic and managed by medication and lifestyle changes. It’s the nature of modern medicine that we have no choice but to wait for test results. I kept thinking that I don’t want her to be treated without proper assessment and diagnosis. Like everyone in this situation, I could practice patience and wait, or I could fret but still have to wait. On many occasions I’ve had to wait for an outcome that could have been much worse than it was. 2. What I told myself about my ability to deal with the situation:   Whatever the outcome of the tests, I had

no choice but to deal with it. We are a close family, and my parents needed my support. When Daniel had a serious car accident several years ago, I rose to the occasion and provided the support he needed to get back on his feet. I did it then, and I told myself I can do it again for my mother. 3. What I told myself about my ability to tolerate or handle the anxiety caused by the situation:

I was worried and anxious until we got the test results back. I thought, “Well, everyone experiences some anxiety while waiting for results.” When I thought about my mother’s health problems, I said a prayer for her and then let my anxiety and worries ebb and flow naturally throughout the day. 4. How I responded to this situation that reduced the anxiety:   I kept focused on my work and family

responsibilities. I was in daily contact with my mother, but I didn’t keep asking whether she had heard anything. I asked how she was feeling but decided it was best to normalize life as much as possible. I resisted telling her “everything will be all right” because I knew it was useless reassurance. I can’t tell the future. Instead I had to live with the uncertainty of not knowing.

did you convince yourself that you could tolerate the anxiety—that it wouldn’t derail your efforts to deal with the problem? What coping strategies did you use to maintain a low level of anxiousness? We’ve treated many individuals with anxiety problems who reported that concerns about employment and the health of loved ones caused severe anxiety and worry. But like Alyssa, most people are able to identify times when they experienced lower, more manageable, levels of anxiety and worry. If we look at the first question in each scenario of Alyssa’s worksheet, you’ll notice she corrected her way of thinking about Daniel’s possibility of unemployment and her mother’s health. Instead of thinking of the worst possible outcome, she forced herself to think of less threatening outcomes to the situations. If Daniel was made redundant, he might have a short period of unemployment but then would probably find another



when anxiety is helpful 59

job. Alyssa gave herself permission to be anxious waiting for her mother’s medical test results, realizing this was a normal response that millions must endure. Alyssa also reminded herself she can deal with these family difficulties. She told herself to remain focused on providing emotional support to Daniel and that she had no choice but to wait for her mother’s test results. Based on past experience, she knew she could tolerate her anxious feelings, that the feeling of apprehension was temporary and would disappear once the situation changed. But changing the way you think is not enough to reduce anxiety. The way we act also affects our anxiety. As seen in Alyssa’s answers to the fourth question, she normalized her daily life as much as possible even though she was feeling anxious about Daniel’s possible dismissal and her mother’s test results. She stopped herself from seeking reassurance or avoiding any discussion with her husband or mother about their worries. She decided that if she acted strong and confident, it might undermine inner feelings of weakness and vulnerability.

The Next Chapter

• Exaggerate the bad outcome (catastrophize)

• Downgrade the severity of the outcome

• Consider the bad outcome imminent

• Consider a bad outcome less likely, more distant

• Ignore signs of safety, comfort, and wellness

• Seek evidence of safety, comfort, and wellness

• Believe you can't cope with the situation

• Believe you can deal with the situation

• Focus on your anxiety and its intolerability

• Focus on the problem, not your feelings

• Avoid, delay, and procrastinate

• Problem-solve the situation and tolerate anxious feelings

F I G U RE 3 . 2 .  

Key points about regulating anxious feelings.

How to lower anxiety

How to raise anxiety

This chapter focused on your experiences of mild, adaptive anxiety. Are you surprised to learn that you can manage anxiety quite well in many situations? When you minimize the negative consequences of difficult situations and take a problem-­solving approach, you can reduce the intensity of anxiety symptoms. Figure 3.2 provides a summary of the main psychological processes involved in the pathway of anxiety. The list on the left side highlights how certain ways of think-

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The Anxie t y and Worry Workbook

ing and coping will increase the severity of your anxiety symptoms. This is the topic of Chapter 4, on problematic anxiety. The list on the right summarizes the main points of this chapter. This way of thinking and coping will lower anxiety so it can help you deal with life’s challenges. As you read through the key processes involved in lowering anxiety, review the work you’ve done in this chapter. When you experienced mild anxiety because of the responses you employed in the right-hand column, you were tapping into your positive, adaptive way of thinking and behaving. Possibly a lot of your anxiety experiences fall somewhere in the middle range between mild, helpful nervousness at one end and severe, debilitating anxiety at the other. You may not be sure whether your feelings are normal or excessive. The next chapter explains how to assess your anxiety experiences to determine whether you might have an anxiety problem that would benefit from the CBT interventions presented in this workbook.

4 when anxiety becomes a problem

T

here is an inevitability to our emotions. We all know the feeling of “frayed nerves” as we prepare for an important interview, anticipate meeting someone personally significant for the first time, or think about performing before an audience. As you learned in the last chapter, anxiety is a normal emotion that can bring urgency in preparing for a difficult situation. It’s an emotional signal that says, “Get ready for challenges ahead.” But when anxiety and worry are disproportionate to real threat, they can feel more severe and interfere in our daily living. Take the three people introduced in Chapter 1. Rebekah’s worries about her work performance, finances, and her parents’ health caused chronic insomnia and disrupted her concentration at work. As a result, Rebekah felt she wasn’t at the top of her game, which in turn increased her worries about her annual performance review. Because of frequent panic attacks, Todd developed a fear of panic. To control his fear, he started avoiding any situation that might trigger another attack. This reduced the number of panic attacks, but it also greatly interfered in his daily functioning and quality of life. And Isabella’s social anxiety meant that she felt intensely nervous, appearing awkward and self-­conscious in her interactions with others. As a result, she spent a lot of time alone, which caused her to feel bored and depressed. In each of these examples, the anxiety or worry became a personal problem. Each person had an elevated feeling of anxiousness that lasted much of the day and had a negative impact on work and relationships. As well, happiness, life satisfaction, and the pursuit of cherished life goals plummeted in the presence of severe anxiety. In this chapter you’ll learn whether anxiety has become a problem in your life. You may feel like you already know the answer to this question. We still think you’ll find the explanation and resources in this chapter useful because they introduce you 61

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The Anxie t y and Worry Workbook

to some of the basic elements of CBT for anxiety and worry. Other readers may not be sure whether their anxiety experiences are sufficiently distressing to warrant use of this workbook. For you this chapter will be critical. It’ll give you a greater understanding of your anxiety and whether it’s a problem that could benefit from the CBT approach. To better understand what we mean by problematic anxiety, consider two different reactions to a common anxiety-­provoking experience—a job interview. Two people are interviewing for a position at a large multinational corporation. One person feels nervous several days before the interview. She’s thinking about the interview and how much she wants the job. She rehearses in her mind all the possible questions she might be asked and how to answer them. She experiences a couple of nights of poor sleep, and on the day of the interview she feels quite nervous. A few minutes into the interview, her nerves settle down and she gets through the ordeal. Now she must wait for the verdict. We would call this experience normal or “nonproblematic anxiety” because the anxiety didn’t stop her from doing the interview and performing reasonably well. The second candidate for the same job opening starts worrying about the interview a couple of weeks before the interview date. She focuses on how anxious she’ll feel, that her mind will go blank, and she’ll make a fool of herself. Although she wants the We reserve the term problematic job, she’s convinced she’ll fail miserably. She anxiety for heightened anxiety can’t stop thinking about the embarrassment in which symptoms are felt more she’ll feel from the whole ordeal. For a week intensely than would be expected she can’t eat, she barely sleeps, and she has to for a given situation and there is take a couple of sick days from her current job. significant personal distress and/ Finally, the anxiety is so great that she calls to or interference in daily functioning. cancel the interview. Clearly, anxiety for this second candidate is a problem. She’s experiencing more severe anxiety than one would expect for a job interview, and it’s causing significant interference in daily living. Because of the anxiety, she decided to cancel the interview even though it meant losing out on better employment. To help you understand whether you have problematic anxiety, we expand on the core features of severe anxiety listed in Chapter 1 and provide assessment tools so you can determine whether you’re experiencing an anxiety problem. You’ll learn how to use a symptom tracking form so you can be more aware of the ebb and flow of your anxious feelings. The chapter concludes with a symptom profile tool you can use to discover the connections between the various components of your anxiety. This will give you a “snapshot” of what you experience when feeling highly anxious. It’ll be one of the worksheets you’ll need to build your personal CBT treatment plan.



when anxiety becomes a problem 63

The Making of an Anxiety Problem Not all anxiety is created equal. People differ in how they experience anxiety, its triggers, and their response. You know from the last chapter that it’s perfectly normal to feel some anxiety and worry. We could even say most people can recall experiences of exceptionally severe anxiety. But there’s a difference between occasional severe anxiety and problematic anxiety. The latter occurs when we experience frequent, persistent, highly distressing, and poorly controlled anxiety that interferes in our relationships, work, and other significant daily activities. Anxiety problems often spring from the experiences of everyday life. You’ve gone to the grocery store hundreds of times, and yet this one time you have an intense surge of nervousness and a sense that you’re losing control. The experience leaves you bewildered and you wonder what’s wrong with you. The next time you go out, you remember the awful experience at the grocery store and are concerned it could happen again. So you start to cut back and decide to do your grocery shopping online. Can you see how an ordinary situation, like grocery shopping, could trigger an eventual anxiety problem? Figure 4.1 illustrates the critical components in the pathway to problematic anxiety. Let’s consider another example that demonstrates how this pathway led to Isabella’s social anxiety problem. If we consider some of her anxiety triggers, many will cause mild anxiety in most people, like public speaking or attending a party where you don’t know most people. However, Isabella felt significant anxiety when attending family gatherings, asking a store clerk for assistance, or eating in a restaurant. These are situations that most people would not find anxiety-­provoking. So the pathway to her social anxiety problem began with a heightened sensitivity to situations that cause at most mild apprehension in people without an anxiety problem. If we consider the second juncture in the anxiety pathway, Isabella’s way of think-

Faulty interpretation

Ineffective coping

Triggers

F I G U RE 4 .1.  

The upward spiral in the pathway to problematic anxiety.

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The Anxie t y and Worry Workbook

ing about social situations made her anxiousness much worse. She interpreted any feeling of anxiety as a sign of losing control. She expected everyone to see that she was anxious and wonder what was wrong with her. She considered herself shy and awkward around others and therefore likely to say something embarrassing that would cause feelings of shame. She believed anxiety had devastating effects, so she needed to be calm and self-­confident before she could venture into uncomfortable social settings. Isabella’s unhealthy way of thinking about her social skills and ability to handle anxiety led her to cope by avoiding social settings as much as possible. She felt safe and comfortable when alone, with her immediate family, or with her best friend. Isabella, like most people, preferred comfort over discomfort, so she learned to cope with her social anxiety by escape and avoidance. But the more she avoided social situations, the more anxious and awkward she felt around others. Unfortunately, Isabella’s social anxiety also spread to other situations that had not provoked much anxiety in the past. Does Isabella’s pathway to a problem with social anxiety sound familiar? Do you recognize similarities to how your anxiety has grown over time? To help you better understand whether your anxiety has become a significant personal problem, we provide several worksheets you can use to assess the three aspects of anxiety—­triggers, interpretation, and coping responses.

Anxiety Triggers Anxiety rarely pops up out of nowhere; it’s usually triggered by an external situation or a thought, image, memory, behavior, or physical sensation. Most people find it quite easy to identify their anxiety triggers, especially if it’s an external situation or circumstance. Other times the trigger may be less obvious. This is especially true when it’s a thought or physical sensation. Whether obvious or not, it’s important to know what triggers your anxiety. This is one of the first steps in CBT for anxiety. It’s hard to treat anxiety if you don’t know your triggers. To determine whether the anxiety you experience in the presence of certain triggers is more than you’d expect, ask yourself: „ Is

this trigger causing me more anxiety than it would for most people?

„ Are

my anxiety triggers unique or novel to me?

E VA L U AT ION EXER C I S E 

Anxiety Triggers

Worksheet 4.1 focuses on the types of triggers associated with your anxiety problem. Think back to your experiences of severe anxiety or worry (review Worksheet 1.2). What was happening at the onset of your anxiety? Did you find yourself in a situation or circumstance

W ORK SHEE T 4 .1

My Anxiety Trigger Evaluation Form Instructions: Three types of anxiety triggers are indicated in the first column of this worksheet. For each type, list the most common triggers associated with your experience of anxiety. In the next column rate the probability or likelihood (0–100%) that you’d feel at least some anxiety if exposed to each trigger you listed. In the third column rate from 0 (no anxiety) to 10 (extreme, panic-like anxiety) the average severity of your anxiety or worry when provoked by the trigger.

Anxiety triggers

Likelihood provoked (0–100%)

Severity of anxiety/ fear/worry (0–10)

External situations 1. 2. 3. 4. 5. Unwanted thoughts, images, or memories 1. 2. 3. Physical aches, pains, and other bodily sensations 1. 2. 3. From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

65

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The Anxie t y and Worry Workbook

that made you feel anxious? Did a thought, image, or memory suddenly pop into your mind that caused you to feel anxious or worried? These are called unwanted intrusive thoughts. Or did you feel some unexpected pain, ache, or other physical sensation that provoked your anxiety? You’re asked to think more deeply about your anxiety triggers in terms of their potency in eliciting severe anxiety. Â Troubleshooting Tips: Keep a Record of Your Triggers

If you had trouble recalling your anxiety triggers, Worksheet 4.1 can be used as a self-­ monitoring form. Pay close attention to your anxiety over the next week or two. When you experience significant anxiety, write down where it happened and what you were thinking or doing just before the anxiety hit you. This should give you a clue to its triggers. If you had difficulty completing Worksheet 4.1, you could ask a family member or close friend for their observations about your anxiety or complete the worksheet with your therapist.

Were you able to list several triggers that frequently provoke more anxiety than you would expect? If your triggers were mainly unwanted thoughts that suddenly pop into your mind, you probably experience a combination of anxiety and worry. If most of your triggers are unwanted physical symptoms, health anxiety or even panic attacks are the most likely associated states.

The Anxious Way of Thinking The way we think has a powerful influence on how we feel. If you’re feeling anxious in a situation, then you’re also having anxious thoughts whether you’re aware of them or not. Anxious thinking always centers on threat or danger to yourself or people important in your life. It’s a tendency to think of the worst and then to feel helpless to stop this from happening to you. You may be thinking about loss of control, how awful it feels to be in so much distress, or that you can no longer stand the distress. We also know that anxious thinking undermines our ability to adapt to difficult situations. Positive beliefs about yourself, like “I can deal with this situation” or “I’ve dealt with much worse in the past and got through it,” get drowned out by anxious beliefs about vulnerability and helplessness. In the CT-R approach to anxiety, we work on rediscovering your personal strengths and resilience so you’re able to overcome doubts you may have about yourself and your ability to cope. When Rebekah worried, she’d have a thought about work pop into her mind and then think about getting a poor work evaluation, making an inadequate presentation, or getting into a heated argument with her manager. Any adaptive thought about having gotten better work evaluations than she expected never even crossed her mind.



when anxiety becomes a problem 67

Todd’s anxious thinking was triggered by an unexpected tightness in his chest, and then he couldn’t stop thinking about having an impending panic attack. And Isabella could be reminded of a social event on the weekend and start thinking about how anxious she’d feel. Rebekah was convinced she’d feel better if she stopped worrying, whereas Todd tried to convince himself the chest tightness was simply due to activity. Isabella was convinced she’d feel more comfortable at the weekend party if she concealed her anxiety from others. What do you think about when feeling anxious? Is it hard to remember how you overcame more difficult situations in the past? Do the next exercise to discover how you think when you encounter situations, thoughts, or physical sensations that make you anxious. E VA L U AT ION EXER C I S E 

Catch Anxious Thinking

Review your experiences of anxiety and worry that you recorded on previous worksheets. Focus on what you were thinking about during these anxiety experiences rather than on what you were feeling. Ask yourself what was so upsetting or troubling about feeling anxious. What’s the bad outcome or consequence you were imagining? What were you afraid could happen? Use Worksheet 4.2 to begin the process of training yourself to be more aware of your anxious way of thinking. Â Tips for Success: Common Themes in Anxious Thinking

Identifying anxious thinking is one of the most difficult skills to learn in CBT for anxiety. This is because our feelings can be so overpowering when we’re anxious that it’s hard to pay attention to what we are thinking. All we know is that we’re feeling very upset and we need to get out of the situation as fast as possible. But it’s still important to know how you are thinking anxiously because this is the key to overcoming anxiety. You can improve your awareness of what’s going through your mind by looking for certain common themes in your thought process, like: „ Thinking you can’t stand feeling anxious „ Wondering if the anxiety will ever go away „ Questioning whether there is something wrong with you „ Believing you must be weak and helpless „ Making dire predictions about the future

Were you able to identify the threatening thoughts, images, or memories that pop into your mind when feeling highly anxious? Often our anxious thinking looks

W ORK SHEE T 4 . 2

My Anxious Thinking Form Instructions: In the first column, write down triggers that caused an anxiety severity rating of between 5 and 10 on the previous worksheet. In the second column, make note of any threatening, troubling, or uncomfortable thoughts, images, or memories that came to mind when you encountered the trigger. Anxiety triggers

What’s threatening, troubling, or uncomfortable?

External situations 1.

2.

3.

4.

5.

Unwanted thoughts, images, or memories 1.

2.

3.

Physical aches, pains, and other bodily sensations 1.

2.

3.

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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when anxiety becomes a problem 69

ridiculous when we’re calm or removed from the threatening situation. But it’s important to know how you’re thinking when feeling anxious or upset. Changing the way you think when anxious is a key component of CBT. This is easier said than done because when we are highly anxious all we can think about is how to get relief from the anxiety. If you’re having difficulty identifying how you think when anxious, take a look at Rebekah’s Anxious Thinking Form. You’ll recall from Chapter 1 that Rebekah’s anxiety focused on her work performance, safety of her children, personal finances, and her husband’s job security. Did you notice that Rebekah’s entries in the second column about her anxious thinking focused on an expectation that some negative outcome was likely to befall her? Sometimes the anxious thinking was extreme, even catastrophic, like having stomach cancer or Derek losing his job. At other times the anxious thinking was less extreme, but it always involved some degree of personal threat. In CT-R we also consider how anxious thinking can undermine confidence in our

Rebekah’s Anxious Thinking Form Anxiety triggers

What’s threatening, troubling, or uncomfortable?

External situations 1.  Driving to work; heavy traffic

2.  Open email and it’s overflowing

with new messages

I’ll be late, get behind in my work before I even start, and have an extremely stressful day. When I’m stressed, my anxiety is always so much worse. I can’t possibly work through all these emails. I’m going to miss something important and get in trouble with the head office.

Unwanted thoughts, images, or memories 1.  Sudden image of my daughter

g­ etting hurt on school playground 2.  Wonder what my husband is doing right now at his work

She’s seriously hurt and needs to be taken to the hospital. She’s crying for her mother and I’m not there. What will we ever do if he loses his job? We can’t possibly survive on my salary alone.

Physical aches, pains, and other bodily sensations 1.  Sudden feeling of nausea

This job is so stressful; I wonder if it’s destroying my health and I have some serious illness like stomach cancer.

2.  Can’t sleep

I’m going to be so tired tomorrow at work; I’ll drag myself through the day, and that will make things so much more stressful. When I’m tired, I’m more likely to have an anxiety attack.

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The Anxie t y and Worry Workbook

ability to deal with difficult thoughts, feelings, and situations. During your anxiety experiences, look for thoughts about weakness, helplessness, and vulnerability. Also, consider whether you have anxious thoughts that convince you there are too many barriers or difficulties preventing you from pursuing cherished goals and values.14 For example, when Rebekah had a sudden feeling of nausea and thought about the possibility of stomach cancer, she also questioned whether she could handle a job as stressful as the one she had. Questioning her ability to cope with stress was an important part of her anxious thinking: “Maybe I’ll have to settle for a less fulfilling and lower-­ paying job.” These self-­doubts not only fed her anxiety but were a barrier to finding more satisfying and fulfilling work. To overcome her work-­related anxiety, Rebekah’s treatment plan needed to include exercises that emphasized her talents and abilities so she had more confidence and less self-doubt about work. This illustrates how the CT-R orientation adds greater potency to conventional CBT for anxiety.

Ineffective Coping The third critical element in the pathway to anxiety problems is reliance on coping strategies that can provide only short-term relief at best. Unfortunately they have the unintended consequence of making anxiety worse in the long-term. That’s why we are calling them ineffective coping strategies. When anxious feelings are severe and it seems like you can’t take any more, is it possible your attempts to cope might be harming your chances of recovery from problematic anxiety? E VA L U AT ION EXER C I S E 

Discover Ineffective Coping

This exercise asks you to consider whether you might be relying on coping strategies that could make your anxiety more persistent. Think back to experiences when you felt highly anxious. Worksheet 4.3 lists 26 common coping responses that are ineffective for problematic anxiety. It also provides a rating scale you can use to estimate how often you might use each coping strategy. As you read through the list, what’s your general impression of how often you might be using each strategy when feeling severe anxiety? Â Troubleshooting Tips: Track Your Responses to Anxiety

If you’re not sure what you do when feeling highly anxious, you can use Worksheet 4.3 as a self-­monitoring form. Over the next couple of weeks, keep the Ineffective Coping Checklist handy. When you feel especially anxious, place a checkmark beside any of the coping responses you used to deal with your anxiety. Often people use more than one strategy when feeling anxious. For example, you might try to calm down by taking long, deep breaths. When this did not help, maybe you lay down, but the anxiety didn’t sub-

W ORK SHEE T 4 .3

Ineffective Coping Checklist Instructions: Using the 4-point rating scale, circle the number that best approximates how often you think you use each coping response when feeling highly anxious. Coping responses

Never

Occasionally

Often

Always

Leave situation when first feel anxious

0

1

2

3

Avoid anxious triggers

0

1

2

3

Seek reassurance that I’ll be okay

0

1

2

3

Become quiet, withdraw into myself

0

1

2

3

Take antianxiety medication

0

1

2

3

Call/ask for help

0

1

2

3

Try to calm down by focusing on my breath, relaxing, meditating

0

1

2

3

Distract myself with activities, music, and so forth

0

1

2

3

Lie down and try to rest

0

1

2

3

Steady myself by holding on to objects

0

1

2

3

Drink alcohol, use cannabis, CBD, or other substance

0

1

2

3

Procrastinate

0

1

2

3

Be overly cautious; slow down

0

1

2

3

Overprepare when anticipating an anxious situation

0

1

2

3

Overthink, analyze my feelings

0

1

2

3

Try to reason with myself

0

1

2

3

Worry

0

1

2

3

Speak or act more quickly to get through an anxiety experience

0

1

2

3

Seek medical/professional help

0

1

2

3

Seek a family member or friend who makes me feel safe, less anxious

0

1

2

3

Get angry, even aggressive; go on the attack

0

1

2

3

Get emotional, tearful to vent my feelings

0

1

2

3

Check and recheck something to reassure myself it’ll be okay

0

1

2

3

Engage in a pleasurable activity (like social media, eating, watching a movie or TV)

0

1

2

3

Pray or other religious activity

0

1

2

3

Sleep

0

1

2

3

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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side. So you finally took an antianxiety medication. In this example you’d place a checkmark beside all three coping responses. At the end of two weeks, count up the number of checkmarks beside each response. This will give you a good idea of how often you are using each of these coping responses.

How many coping responses did you rate as 2 or 3? These may be ineffective coping responses that you’ll want to target once you begin using the treatment strategies presented in later chapters. You’ll become better at catching these responses and replacing them with more effective coping behaviors. But for now, try to be more aware of how your behavior actually might make you feel more anxious than you’d like in a variety of situations. Not all the coping strategies listed in Worksheet 4.3 are equally ineffective. Some, like avoidance, leaving a situation at the first signs of anxiety, or using alcohol to calm down have a more negative impact than others, like seeking reassurance, trying to calm down, or praying. We consider the first three high-­impact coping strategies because they give you the false notion that you’re handling your anxiety when, in fact, they’re making it worse. The bottom line is this: All of the strategies will contribute to your problem with anxiety if used frequently. You can think of them as Band-Aid solutions for a much deeper wound! The CBT approach to anxiety and worry will introduce you to alternative coping strategies that are more effective in reducing your distress.

A Closer Look at Anxiety Problems You probably picked up this workbook because you suspected you have a problem with anxiety. In this chapter you’ve been assessing your experience of anxiety to get a more complete view of your anxiety problem. As we stated at the beginning of the chapter, knowing how problematic your anxiety is and viewing it in terms of the characteristics professionals use to identify anxiety problems can help you with the work in this book as well as motivate you to take action. Table 4.1 presents eight features that therapists use to determine the presence of anxiety problems. We’ve already covered some of these characteristics, but others may be new to you. Together they will shed some additional light so you’ll better understand your experience of anxiety problems. Are the eight characteristics of problematic anxiety relevant to your experience of severe anxiety? The next exercise is designed to help you think more deeply about whether you can see the core characteristics of problematic anxiety in your own experience.



when anxiety becomes a problem 73 TA B L E 4 .1.  

Characteristics of Problematic Anxiety

Characteristic

Explanation

Greater symptom severity

Anxiety symptoms are more severe than one would expect in a particular situation. For example, experiencing intense anxiousness when answering the phone, driving across a bridge, making a request of a store clerk, or touching a doorknob would suggest an exaggerated level of anxiety because these types of actions cause little or no anxiety for most people.

Persistence

Anxiety becomes a problem when it doesn’t fade quickly. For instance, we all worry from time to time, but people with problematic worry experience it for hours, day in and day out.

Interference

Problematic anxiety interferes with daily functioning. Its negative effects may be limited to certain life domains, but the impact is definitely noticeable. Some individuals with agoraphobia, for example, will do their grocery shopping at 3:00 a.m. to avoid other people, others will drive many extra miles in traffic to avoid crossing a certain bridge, and people with generalized anxiety can’t fall asleep because of worry.

Sudden anxiety or panic

Surges of anxiety or even panic attacks characterize many anxiety disorders. Spontaneous, out-of-the-blue panic and fear of panic are significant features of anxiety problems. See Chapter 9 for further discussion.

Generalization

When fear or anxiety becomes a problem, it often starts with a specific concern but then spreads to a broad range of situations, tasks, objects, or people. Mary, for example, had her first panic attack while in a crowded restaurant. It really scared her, so she started checking to make sure restaurants weren’t too crowded before entering. Soon she was selecting only less popular restaurants and going at off hours. Eventually Mary stopped going to all restaurants and other public places for fear that she might get that “trapped feeling” and begin to feel anxious. You can see how Mary’s anxiety spread, causing greater interference and limitations in her daily living.

Catastrophic thinking

People with anxiety problems tend to think about worst-case scenarios. Their thinking style is biased toward assuming that serious threats are much more likely than they actually are. For example, a person with panic might automatically think, “I’m having trouble catching my breath. What if I suffocate to death?” Someone with social anxiety might think, “What if people notice that I’m nervous and wonder if I am mentally ill?” In each example thinking is focused on the possibility of some catastrophe that is an exaggeration of the real danger. Chapter 6 focuses on how to “decatastrophize” anxious thinking.

Escape and avoidance

Escape and avoidance are common coping strategies when anxiety symptoms are severe. The natural tendency is to seek relief from anxiety as quickly as possible, leaving at the first signs of discomfort or avoiding anxious triggers altogether. But extensive avoidance comes at a high cost. It contributes to the persistence of anxiety, and it means you can’t do many of the ordinary things that other people do comfortably. You’ll learn in Chapter 7 how to break through the escape/avoidance cycle.

Loss of safety or ability to feel calm

Individuals with an anxiety problem often feel less safe or secure than others. They may go to great lengths to feel calm and comfortable, but any sense of security is short-lived and the feeling of apprehension returns. Relaxing or staying calm can be quite difficult. When anxiety becomes a problem, people often feel on edge, keyed up, and agitated. Sleep disturbance is another sign that anxiety has become a significant problem in your life.

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The Anxie t y and Worry Workbook

E VA L U AT ION EXER C I S E 

Has Anxiety Become a Problem for Me?

Worksheet 4.4 poses questions that help you look at your experience with anxiety so you can come to a firm conclusion about whether your anxiety is a true problem, one that you would like to solve. The questions are based on the eight characteristics listed in Table 4.1.

What’s your conclusion? Can you see now that what you’ve suspected is accurate—you are having a problem with anxiety? If so, this book is for you. Even if you’re not sure, you can use the workbook to keep your anxiety from gaining a more damaging hold on you. You’ll find our strategies useful in reducing the severity of your anxiety symptoms and their negative impact on your life. Did you find in completing the worksheet that some of the characteristics of problematic anxiety are more relevant to you than others? If so, these are the features of anxiety you’ll want to focus on throughout the workbook.

Tracking Your Anxiety Symptoms Many of the exercises you completed so far asked you to think back to past anxiety experiences. There is much you can learn by dissecting experiences in the past. But it is also true that our most accurate information on anxiety comes from tracking our symptoms in “real time.” Memory is selective, and there may be gaps in what you remember of an anxiety episode that occurred weeks or months ago. This is why writing down your current anxiety experiences is a core feature of CBT for anxiety. We call this self- ­monitoring, and it involves using structured forms to record various aspects of your anxiety experience as close to its actual occurrence as possible. If you stop and make a note of your experience minutes after it occurred, what you record will be less clouded by forgetfulness than if you waited until the end of the day or week to write about an anxiety experience. CBT therapists use many different types of self-­monitoring forms when treating anxiety. In fact you’ll find different self-­monitoring forms in later chapters, but they are narrower in scope, designed to answer specific questions about anxiety. Here we present the most basic type of anxiety self-­monitoring form. This is the starting point for anyone beginning a course of CBT for anxiety. You can’t proceed much farther in the workbook until you spend a couple of weeks completing Worksheet 4.5. E VA L U AT ION EXER C I S E 

Symptom Self-­Monitoring

A deeper understanding of anxiety is a critical treatment element in CBT. This begins with learning how to track the key symptom features of your anxiety. Worksheet 4.5 pro-

W ORK SHEE T 4 .4

Core Characteristics of My Problematic Anxiety Instructions: Recall your recent experiences of feeling severely anxious. Write a short answer to each question below to elaborate on your experience.

1. Do you experience more severe feelings of anxiety in common situations than most people? If yes, give some examples:





2. When you feel anxious, does it last longer than most people you know? If yes, what is the average length of your severe anxiety episodes?

3. Does anxiety prevent you from engaging in certain common activities? If yes, state what you can’t do because of anxiety:





4. Does your anxiety often hit you suddenly, like a panic attack? If yes, how often would you have a surge of anxiety in a typical week? 5. Do you find that more things now make you anxious than when you first started having problems with anxiety? Circle:   Yes or No  6. When you feel highly anxious, do you automatically think about the worst possible outcome? If yes, what’s a typical catastrophe (worst outcome) that pops into your mind when anxious?





7. When feeling anxious, do you often try to get out of the situation as quickly as possible or avoid it altogether? If yes, describe a common situation, object, or person you try to avoid because it makes you feel anxious:



8. Circle the statement that best describes how you feel most of the time. a. I feel calm, relaxed, and comfortable within myself. b. I feel tense, on edge, and uncomfortable within myself.

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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76

My Symptom Self-­Monitoring Form

Behavioral symptoms (How did you deal with the anxiety? What did you do to stop feeling anxious? What coping strategies did you use to feel safe and more comfortable?)

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

3.

2.

1.

Triggers (Where were you? Who was present? What happened just before the anxiety started?)

Anxious thoughts (What went through your mind during the episode? Were you thinking about being anxious? Were you worrying about something? Were you concerned Physical symptoms (What physical sensations did something bad could happen to you or loved ones?) you experience?)

Instructions: Complete this form by starting with the far left column and making your way across to the far right column. Use the questions in each column as prompts to help you write about your anxiety experience. Keep your entries brief, focusing on the main features of your anxiety.

W ORK SHEE T 4 .5



when anxiety becomes a problem 77

vides a breakdown of anxiety into four key elements: triggers, physical sensation, anxious thoughts, and behavioral responses. At first symptom self-­monitoring might increase your anxiety because it’s making you more aware of your anxious thinking and ineffective coping responses. But CBT does not stop at symptom self-­monitoring. You’ll be using the data you’ve collected to design your own anxiety-­reduction treatment plan. Â Tips for Success: Keeping an Anxiety Log Can Be Therapeutic

Writing down your anxiety experiences may seem like a tedious process. You might be wondering whether what you learn from doing this exercise is worth your time. As noted above, maximum success with CBT depends on having as complete an understanding of your anxiety as possible. But our clinical experience has shown another benefit of self-­monitoring: It’s called reactivity, and it happens when we become more aware of an experience. In the case of anxiety, you may experience a reduction of severe anxiety symptoms, or even panic attacks, simply by logging your experiences. So you can think of the Symptom Self-­Monitoring Form as a therapeutic intervention as well as an assessment tool. But remember, self-­monitoring is most potent when you complete the form minutes after an anxiety episode.

Make multiple copies of this worksheet (see www.guilford.com/clark6-forms to download and print). You’ll want to keep using the Symptom Self-­Monitoring Form as long as you’re working on your anxiety problem. It’s a good way to pick up changes in your anxiety and to track your treatment progress. Monitoring your symptoms will help you be precise about the anxiety and to think of its various elements rather than being overwhelmed by the emotion. If you’re unsure whether your symptom monitoring is adequate, consider Rebekah’s Symptom Self-­Monitoring Form. Notice that she included a little more detail on her anxious thinking because this is the key symptom that we target in CBT for anxiety.

Roadmap to Recovery It’s now time to construct your roadmap to anxiety reduction based on the work you’ve done in this chapter. We call this the Anxiety Symptom Profile, and it will be the foundation for the more specific profiles you’ll develop in later chapters. E VA L U AT ION EXER C I S E 

Anxiety Symptom Profile

Worksheet 4.6 is a way for you to summarize all the information you’ve gathered in this chapter. This means you’ll have to review the work you completed in previous exercises.

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Tight chest, lightheaded, How will we pay all these bills? Our weakness, tense muscles, a little spending is out of control; we’ll end shaky up having to declare bankruptcy. [I experience poor concentration, confusion, can’t think through to a solution.]

bills

I avoid opening the monthly bills, procrastinate making bill payments; continue to spend

I should take the time to visit them I avoid talking to my parents; make more. I’m such a bad daughter. What promises to visit them next week if one of them soon dies? Then I’ll be sorry I didn’t visit more. How can I find the time when I’m so busy at work and home? I can’t take the pressure.

3.  Looking over the monthly

being disappointed that I haven’t visited them recently

Behavioral symptoms (How did you deal with the anxiety? What did you do to stop feeling anxious? What coping strategies did you use to feel safe and more comfortable?)

What if the employee gets angry and I rehearse over and over what to say; we have a confrontation? What if he procrastinate, avoid the employee notices I’m anxious and thinks I’m weak? He’ll think I’m a pushover. What if he talks behind my back and the employees lose respect for me?

Tense muscles

Chest pressure, weakness, lightheaded, rapid heart rate, tension

2.  Thinking about my parents

confront a tardy employee

1.  Thinking about need to

Triggers (Where were you? Who was present? What happened just before the anxiety started?)

Anxious thoughts (What went through your mind during the episode? Were you thinking about being anxious? Were you worrying about something? Were you concerned Physical symptoms (What physical sensations did something bad could happen to you or loved ones?) you experience?)

Rebekah’s Symptom Self-­Monitoring Form

W ORK SHEE T 4 .6

My Anxiety Symptom Profile Instructions: „ Turn to your completed Worksheet 4.1 and, in the form below, list the external situations, unwanted

thoughts, and physical sensations that make you feel anxious.

„ Turn to your completed Worksheet 4.2 where you recorded the anxious thoughts, catastrophic

thinking, and worry that enter your mind when you are feeling anxious. List examples of anxious thinking in the second section of the profile form, below.

„ Review Worksheet 4.3 and in the third section below list the various ways that you tend to respond

when you feel highly anxious. In addition to the ineffective strategies you circled on Worksheet 4.3, list any responses you noted in Worksheet 4.5.

Anxiety Triggers (situations, thoughts, sensations, expectations) 1. 2. 3. 4. 5.



(continued) From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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W ORK SHEE T 4 .6 (continued)

Anxious Thinking (Cognitive Symptoms) (apprehensive thoughts, worries, worst possible outcome) 1. 2. 3. 4. 5.

 Coping Responses (Behavioral Symptoms) (situations, thoughts, sensations, expectations) 1. 2. 3. 4. 5.

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when anxiety becomes a problem 81

By completing the various components of the profile, you’ll develop a better understanding of the connections between thoughts, feelings, and behavior that drives up the intensity of your anxiety. After completing Worksheet 4.6, consider monitoring your anxiety symptoms for another week using Worksheet 4.5. Is the Anxiety Symptom Profile you completed correct, or do you need to make changes to your entries? Â Troubleshooting Tips: Identifying Anxious Thinking Is a Learned Skill

Often people find anxious thinking the most difficult component to identify. This is because we become so focused on the physical sensations of anxiety and our behavioral response that we often miss how our mind is operating when anxious. If you had difficulty identifying your anxious thoughts, you can still proceed to the next chapter. You’ll learn more about identifying anxious thoughts in Chapter 6, which has more exercises and worksheets that will increase your awareness of anxious thinking. You can always come back and revise your Anxiety Symptom Profile after gaining more understanding of anxiety from later chapters.

If you had some difficulty completing the Anxiety Symptom Profile, consider Beth’s profile. Beth is a 36-year-old mother who recently started having panic attacks with intermittent periods of generalized anxiety. She was able to identify social and public settings as the main triggers for her anxiety and panic. But she was employed in the retail industry, which meant that much of her workday involved interaction with people. So Beth started missing more and more days at work and isolating herself at home away from family and friends. Beth was able to identify the four main symptom components of her anxiety. Before leaving this chapter, compare what you wrote in your Adaptive Anxiety Profile (Worksheet 3.5) and your entries in the Anxiety Symptom Profile (Worksheet 4.6). Although the formats are different in the two worksheets, the first two statements in the Adaptive Anxiety Profile refer to how you thought about difficult situations when you experienced mild anxiety. How does this thinking compare to the cognitive symptoms (second box) you reported for severe anxiety? You can make the same comparison between statements 3 and 4 in Worksheet 3.5 and the behavioral symptoms you noted in Worksheet 4.6. Do you notice some obvious differences between the way you think and cope with difficult situations that lead to mild anxiety and the situations that cause more severe anxiety symptoms? Could you imagine thinking and behaving more like you do in mild anxiety situations at times when you experience your anxiety problem? We’ll come back to this in Chapters 6 and 7, but for now consider the possibility that you already have the personal strength and skills you need to manage severe anxiety more effectively.

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Beth’s Anxiety Symptom Profile Anxiety Triggers 1. 

Being in public places such as a supermarket, large restaurant, shopping mall, movie theater

2. 

Anticipating a social event like the end-of-week staff meeting

3.

Having a conversation with an unfamiliar person

4.

Feeling hot and uncomfortable, especially around other people

5.

Remembering a social interaction I had with a person at work last week

 Anxious Thinking (Cognitive Symptoms) 1.

Once anxiety starts, it’ll get so bad that I won’t be able to stand it.

2.

I can’t let people see that I’m anxious because they’ll think I’m weak or emotionally unstable.

3.

What if I lose control and do something embarrassing? I could never live with myself.

4.

I can’t let myself get stressed out; it’s bad for my health.

5.

I can’t let myself blush, because then people will know I’m anxious.

 Coping Responses (Behavioral Symptoms) 1.

Avoid situations, places that make me anxious.

2.

Say as little as possible in front of others.

3.

Leave at the first sign of anxiety.

4.

Take an antianxiety medication before engaging in a stressful task.

5.

Try to convince myself everything will be okay.





when anxiety becomes a problem 83

The Next Chapter This chapter focused on your experiences of heightened anxiety and whether this is a problem that could benefit from the CBT approach. By learning how to break down anxiety into its main symptom components, you’ve taken the first step in gaining better understanding and control of your anxiety problem. It’s clear from your work in the last chapter that many times you face difficult situations that elicit only mild feelings of anxiousness. But then other times, something familiar that never bothered you in the past now causes you an intensity of anxiety that you never expected. Maybe you’re feeling puzzled by your emotional reactions, wondering why you seem to be struggling with anxiety where others seem to be taking life in stride. The next three chapters focus on this question. Chapter 5 delves into the physical symptoms of anxiety. For many people anxiety becomes a problem because of the intolerable physical arousal they experience when anxious. Chapters 6 and 7 explain how an anxious mind and ineffective coping contribute to a problem with anxiety. All of this builds on the knowledge you gained in this chapter, because understanding your anxiety is half the battle.

5 living with anxiety symptoms

N

o doubt you’re familiar with the term pain threshold. This refers to the lowest point at which an aversive stimulus causes you to feel pain. Imagine you’re asked to put your hand in a bucket of ice water. As you know, ice water on bare skin is painful. Let’s say you can hold your hand in the ice water for 15 seconds. You feel pain in your hand, and so you remove it quickly. Your friend puts her hand in the ice water but doesn’t feel pain until 45 seconds, and then she continues to leave her hand in the ice water for a full two minutes. We would say she has a higher pain threshold and a higher tolerance for pain than you. We’ve all had lots of experience with pain, so you probably have a pretty good idea whether your pain threshold is low or high. Just like pain, we all have a threshold for anxiety and our tolerance for it. If your anxiety threshold is high, you might be able to stand a higher level of threat before you feel anxious. You might even be something of a risk-taker or daredevil. You’re the person who can walk close to the edge of a cliff. But even highly tolerant people can feel anxious. It’s just that you’re able to cope with more intense anxiety before it becomes a problem. But if you have a low anxiety threshold, it may not take much to make you feel anxious. If your tolerance is also low, you might have difficulty coping with even modest levels of anxiety. Figure 5.1 illustrates this relationship. It’s important to know your anxiety threshold because: „ It’ll

help you understand why anxiety has become a problem in your life.

„ You’ll

develop more realistic anxiety-­reduction goals that fit with your emotional makeup.

„ You’ll

see how the CBT focus on strengthening anxiety tolerance can improve your ability to cope with unwanted anxiety and possibly even increase your anxiety threshold.

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living with anxiety symptoms 85

High anxiety threshold and tolerance Reduced sensitivity to threat/danger

Greater tolerance for feeling anxious

Fewer experiences of problem anxiety

Low anxiety threshold and tolerance Heightened sensitivity to threat/danger

Reduced tolerance for feeling anxious

F I G U RE 5 .1.  

More experiences of problem anxiety

The anxiety threshold and tolerance relationship.

Consider Marissa and Martina, who both experienced anxiety but from different threshold and tolerance levels.

A Tale of Two Thresholds Marissa’s High Threshold Marissa’s life was full of stress and challenges that could derail her at any moment. She was a single parent with two school-age children, had a demanding job in advertising, was the only child of an aging mother, and had health problems that culminated in a series of medical tests for possible breast cancer. At home, work, and in her personal life Marissa faced many difficulties that threatened her health and well-being. At times she wondered if the burden was too great and whether she was destined for a life without love and companionship. At work she often felt tense, flustered, and testy when getting hit with multiple demands. Certain tasks like making a presentation, pushing hard against a deadline, or meeting with senior management caused a rise in anxiety. But these moments of anxiety and stress did not scare Marissa. She believed they were temporary, that she could power through them, and there would be no negative impact from feeling anxious. Anxiety would have to be more frequent, the symptoms more severe, and the consequences more impactful before Marissa would call it a problem.

Martina’s Low Threshold Martina’s life was much less turbulent than Marissa’s, yet anxiety had been a problem since childhood. She remembers feeling tense, nervous, and self-­conscious at school.

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She was painfully shy and had intense anxiety attacks if a peer spoke to her. She often had stomach pains so severe that her parents consulted several medical specialists, convinced she must have some serious disease. Now in adulthood Martina becomes anxious if she experiences any ache or pain that cannot be explained easily. She’s nervous and self-­conscious around others, so she avoids most social situations. She’s in a constant state of worry, thinking about all the things that could go wrong in her life. She has difficulty falling asleep because of her “racing mind.” She hates feeling anxious and so tries to cut back as much as possible to avoid triggering these negative feelings. For Martina anxiety has become a huge problem. It’s crept into every aspect of her life, and she’s losing patience with herself.

E VA L U AT ION EXER C I S E 

Find Your Threshold

As you read these case examples, who seemed more like you, Marissa or Martina? In the space below, write down which aspects of Marissa’s and Martina’s anxiety were like yours. Do you have more features of high (Marissa) or low (Martina) tolerance for anxiety? How my anxiety is like Marissa’s: 1. 2. 3. How my anxiety is like Martina’s: 1. 2. 3.

What’s your conclusion? Do you have a high or low threshold/tolerance for anxiety? If your anxiety threshold is low, this may explain why you are having problems with anxiety. But there’s good news; you can change your anxiety threshold so you’re more resilient to anxiety and worry. In this chapter we introduce you to a concept called anxiety sensitivity and show you how you can raise your anxiety threshold by altering your sensitivity to anxiety symptoms.



living with anxiety symptoms 87

What Is Anxiety Sensitivity? During times of severe anxiety most of us have thought “I can’t stand this any longer.” You’ve felt consumed by the anxiety, unable to focus on anything but how miserable you feel. In this moment nothing feels worse than anxiety and its symptoms. Martina quickly arrived at this “intolerable point” when she noticed a queasy feeling in her stomach. It was the first sign of anxiety, which she knew would only intensify unless she shut it down. So whenever she felt nausea or something not quite right with her stomach, Martina would leave a situation or avoid it altogether. Her heightened sensitivity to unwanted abdominal sensations was an important feature of her low anxiety threshold.

E VA L U AT ION EXER C I S E 

The First Symptom

In the space below, write down the first symptom you experience when feeling anxious. Next circle the number that best indicates how often you try to control, suppress, or reduce the symptom so it does not escalate into full-blown anxiety. My first anxious symptom: 0   1   2   3   4   5   6   7   8   9   10  Never             Often             All the time If you’re not sure of your first anxiety symptom because your episodes happen so quickly, look at some of the suggestions in the Tips for Success. It can be hard to dissect an anxiety episode if everything seems to hit you at once.  Tips for Success: How to Discover Your First Anxiety Symptom „ Review the symptoms you recorded on Worksheet 4.5, My Symptom Self-­Monitoring

Form, to determine which symptoms tend to occur early in your anxiety episodes. „ When writing down your anxiety experiences, be mindful of the sequence of physical

symptoms that occur when anxiety is building. „ When you think about the situations that trigger anxiety, what’s the first indication

that you’re not feeling right (see Worksheet 4.1)? „ What’s the first sign that makes you think you’re heading for a severe anxiety epi-

sode?

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Symptom Sensitivity: A Core Element of Anxiety Sensitivity Are you like Martina? Have you developed an intense reaction to the first symptoms of anxiety because of high anxiety sensitivity? Anxiety sensitivity is a tendency to feel anxious about being anxious. Numerous studies have found that Anxiety sensitivity is an intolerance people who have anxiety problems also (even fear) of the physical, behavioral, tend to have high anxiety sensitivity.19,20 and cognitive symptoms of anxiety When you repeatedly experience anxiety, because of beliefs that these symptoms you may develop a fear of the tension, heart have negative physical, social, or palpitations, and breathlessness experipsychological consequences.18,19,20 enced during anxiety episodes, believing these symptoms might have a serious negative impact. For instance, many people with anxiety come to dread the physiological arousal of anxiety and so respond quickly to avoid it at all costs. Depending on your anxiety concerns, you may have developed a heightened sensitivity to certain physical symptoms. If you experience anxiety or panic attacks, your anxiety sensitivity probably focuses on physical sensations related to the chest, heart, or respiration. If you get anxious in social situations, you might be particularly fearful of outward signs of anxiety like blushing or sweating. Individuals with generalized anxiety are often most concerned about symptoms of tension, or feeling keyed up and on edge, whereas individuals with health anxiety tend to focus on inexplicable body aches, pain, or skins rashes. How anxiety sensitivity expresses itself depends on the type of anxiety you experience.

E VA L U AT ION EXER C I S E 

Symptom Sensitivity

Use this exercise to determine whether you find some physical symptoms of anxiety more distressing than others. Worksheet 5.1 presents a list of common anxiety symptoms. Give an overall rating of how much these symptoms bothered you during episodes of severe anxiety. You are likely to have high sensitivity to symptoms that bothered you a lot. Which of these symptoms bother you most? If you’re not at all, or only slightly, bothered by these physical sensations of anxiety, you probably have low anxiety sensitivity. But if you rated one or more of these symptoms as moderately or greatly bothersome, your anxiety sensitivity level might be elevated. Remember anxiety sensitivity is an intolerance or fear of feeling anxious. The key thought in high anxiety sensitivity is “I can’t stand [fill in here your most bothersome symptom].” Martina might complete the statement with “I can’t stand that queasy feeling in my stomach, a churning, nauseating sensation that makes me wonder if I’m going to vomit.” It’s only natural to try to do something to extinguish the disturbing symptom before it makes your anxiety worse.

W ORK SHEE T 5.1

My Symptom Tolerance Scale Instructions: Circle the scale value that best describes how much each symptom bothers you on the 0–3 scale.

Not at all

Slightly bothered

Moderately bothered

Greatly bothered

Feeling discomfort, tightness, or pain in chest

0

1

2

3

Sudden increase in heart rate, heart palpitations

0

1

2

3

Trembling body, shaking hands

0

1

2

3

Feeling of suffocation, shortness of breath, or feeling like you’re not getting enough air, out of breath

0

1

2

3

Feeling of unreality, déjà vu, or feeling detached from your body

0

1

2

3

Feeling dizzy, lightheaded

0

1

2

3

Upset, queasy stomach, nausea, or cramps

0

1

2

3

Feeling faint, weak, or unsteady

0

1

2

3

Tense muscles, feeling stiff or achy

0

1

2

3

Blurred vision, feeling like you’re in a fog

0

1

2

3

Feeling hot, chills, or sweaty

0

1

2

3

Feeling restless, keyed up, agitated, or pacing

0

1

2

3

Blushing, feeling flushed, or hot flashes

0

1

2

3

Having unexpected pain, soreness, muscle spasms, or other symptom of a medical condition

0

1

2

3

Anxiety symptoms

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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Martina developed a heightened sensitivity to abdominal sensations and would immediately try to settle her stomach if something didn’t seem quite right. She knew that an upset stomach usually triggered a fresh round of severe anxiety. Even more horrifying was the possibility that she might be sick to her stomach. It’s no wonder that physical sensations associated with her gastrointestinal system became the focus of her high anxiety sensitivity. The first step in learning to manage high anxiety sensitivity more effectively is to know which anxiety symptoms bother you most.

Context and Consequence in Anxiety Sensitivity It’s not just our sensitivity to certain physical symptoms that determines our level of anxiety sensitivity. Two other factors, context and consequence, are important in understanding anxiety sensitivity. Whether a certain physical sensation causes us to be “anxious about being anxious” depends on the context of the symptom. If you’re in a situation that calls for increased physical arousal and it’s perfectly understandable why you’re aroused, your fear of the arousal will be low. But if the physical sensation arises spontaneously for no good reason, your fear of the physical arousal will be high. Let’s say you just climbed several flights of stairs and you notice your heart is racing. Assuming you don’t have a heart condition, you wouldn’t be anxious about the increased heart rate because it’s expected given your increased activity. But if you’re sitting at home, watching a movie, and suddenly you experience heart palpitations, your anxiety sensitivity would kick into action. You’d be thinking, “Why is my heart racing? I’m just sitting here, doing nothing. It shouldn’t be racing. There must be something wrong with me. Maybe this is the start of an anxiety attack, or worse, maybe I’m having a heart attack.” Whether or not your intolerance for anxiety gets activated depends on the circumstances surrounding your experience of the symptom. E VA L U AT ION EXER C I S E 

Catch the Context

Consider the times when you’ve experienced severe anxiety, focusing on the circumstances in which the anxiety happened. Think of situations in which you suddenly had anxiety symptoms but you should not have felt anxious. Having the anxiety symptom in this circumstance made no sense. These are situations with high anxiety sensitivity potential. Likewise, if you had the same symptom in a situation where you’d expect to feel this way, it would have low anxiety sensitivity potential. You’re unlikely to feel anxious about being anxious because you can explain why you’re feeling this way. Use Worksheet 5.2 to discover how context or circumstances affect whether or not you are anxious about being anxious. We’ve provided a couple of examples to illustrate how to complete this exercise.

W ORK SHEE T 5. 2

Discovering the Importance of Context Instructions: In the space below, write down some situations that trigger unwanted physical symptoms that make you anxious because you’re thinking I shouldn’t be feeling this way right now. These are high anxiety sensitivity situations. Next to each situation, think of a different situation in which you’d not feel anxious about the symptom because it would be appropriate in that situation (for example, I expect to have the physical sensation in this situation). These are low anxiety sensitivity situations.

Situations with high anxiety sensitivity potential

Situations with low anxiety sensitivity potential

1. You’re sitting in a chair, and you suddenly stand up and feel dizzy, lightheaded; like you’re going to faint.

1. You’ve been ice skating at a public rink going around and around in circles. After 20 minutes without a break you feel dizzy, lightheaded, like you’re going to faint.

2. You’re sitting in a board meeting. Suddenly you feel hot flashes, your face turns red, and you begin to sweat.

2. You’re in a crowded room with poor ventilation, and you begin to feel hot and start sweating.

3.

3.

4.

4.

5.

5.

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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The point of this exercise is to demonstrate the importance of context. The same physical sensation can elicit high anxiety sensitivity (fear of being anxious) if you think “I shouldn’t be feeling this way now.” It will elicit low anxiety sensitivity (acceptance of being anxious) if you think “I often have this physical sensation in this situation and its okay. It’s just a physical sensation.” Being aware of the context or situation that triggers a symptom can help you be less frightened of it. The second important factor in anxiety sensitivity is perceived consequence. If you think an anxious symptom could harm you in some way or lead to a serious consequence, your anxiety sensitivity will be high. If you think there is little or no consequence to having the symptom, your anxiety sensitivity will be low. You’re better able to accept the symptom and not feel frightened by it. There are three types of consequences associated with anxiety sensitivity:21 „ Physical

concerns: that anxiety-­related symptoms could cause physical harm (a heart attack, suffocation, vomiting)

„ Cognitive

concerns: that anxiety symptoms could cause serious problems in mental functioning (thinking, concentration, memory, mental control)

„ Social

concerns: that anxiety symptoms will elicit a negative evaluation in others (viewed as weak or abnormal, and so rejected, ridiculed by others)

Notice the consequences associated with anxiety sensitivity are beliefs about what might happen due to an anxiety symptom. These could be based on actual experience, but often they are based on what we fear could happen. For example, heart palpitations are often experienced when we’re anxious. The consequence you fear most about this symptom might be “Am I having a heart attack?” even though you’ve never had a heart attack. But you could also fear that your racing heart could lead to a panic attack, which you’ve experienced in the past. The important point is that an increased heart rate becomes the focus of your anxiety sensitivity because you associate it with a feared negative consequence.

E VA L U AT ION EXER C I S E 

What’s Your Fear?

It’s important to know what you fear about the physical symptoms of anxiety because CBT targets all aspects of fear of feeling anxious. The feared consequences of some anxiety symptoms are more obvious than others. This exercise will help you discover your feared consequences of the physical symptoms of anxiety, especially the ones that are less obvious. Worksheet 5.3 presents a list of common anxiety symptoms in the left column and a list of negative consequences in the right column. Recall some of your worst anxiety

W ORK SHEE T 5.3

Symptom–­Consequence Match-Up Instructions: Circle all the symptoms you experience when anxious. Then draw an arrow from each symptom to one or two consequences you believe are associated with that symptom. Draw a heavy arrow if you are very concerned that the negative consequence might arise and a light arrow if you’re only mildly concerned the consequence could arise. Note that any symptom can have more than one feared consequence, and any consequence could be associated with more than one symptom. Anxiety symptoms

Perceived consequences

Feeling discomfort, tightness, or pain in chest

Anxiety will build and continue most of the day

Sudden increase in heart rate, heart palpitations

Increased risk of a panic attack

Trembling body, shaking hands

Won’t be able to work or be productive due to anxiety

Feeling of suffocation, shortness of breath, or feeling like you’re not getting enough air

Symptom of a serious medical condition like heart attack, brain aneurysm, severe asthma attack, or the like

Feeling of unreality, déjà vu, or feeling detached from your body

Increased risk of feeling shame or embarrassment

Feeling dizzy, lightheaded

Cause disapproval, rejection, or criticism by others

Upset, queasy, or butterflies in stomach, nausea, or cramps Feeling faint, weak, tired, or unsteady Tense muscles, feeling stiff or achy Blurred vision, feeling like you’re in a fog Feeling hot, chills, or sweaty Feeling restless, keyed up, agitated, or pacing Blushing, feeling flushed, or hot flashes Having unexpected pain, soreness, muscle spasms, or other symptom of a medical condition Feeling confused, distracted, can’t concentrate Feeling frustrated, annoyed, or impatient

Experience uncontrollable worry or loss of mental control Trigger an anger outburst or intense irritability toward others Signals danger of imminent harm to self, family, or other valued people in my life Increase in physical symptoms of discomfort like muscle/stomach pain, tension headache, nausea Disruption of order, routine, or predictability in daily living Heightened fear and thoughts of death or dying Increase in chronic pain condition Disrupted sleep leading to increased fatigue throughout the day Feeling overwhelmed and highly stressed

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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episodes. What were you most frightened might happen because of a distressing physical sensation like heart palpitations, shortness of breath, dizziness, and the like? Â Tips for Success: How to Identify Your Symptom Fears

Here are some tactics you can use to discover what you fear most about the symptoms of anxiety. „ When writing down your anxiety episodes, be specific about the physical, cognitive,

or behavioral symptoms that bother you most. Then ask yourself “What’s my greatest fear of what might happen if I did nothing and let the anxiety run its course?” „ Is there some catastrophe or worst possible outcome associated with the symptom?

For example, if the feeling of unreality is your most upsetting anxiety symptom, are you afraid you could lose complete contact with reality and slip into a psychotic state? Even if you know the catastrophe is highly unlikely, it could be driving your intolerance for the symptom. „ Think back to your worst experience of anxiety. What was the most prominent anxi-

ety symptom, and what was its impact on you? This can give you a clue about what consequences you fear most with a particular symptom.

Did you notice any recurring themes in your anxiety symptoms and what you fear could happen because of your anxiety? The negative consequences you believe are associated with your anxiety symptoms tell you a great deal about your anxiety sensitivity. We are less able to tolerate anxiety symptoms when we believe they are harmful. The more serious the consequences, the greater the likelihood that high anxiety sensitivity is playing a role in your anxiety. For example, if you think your heart palpitations might be caused by a cardiac problem, you’ll be less tolerant of that physical sensation than if you think it’s an indication of increased stress. If you’re still unsure how to complete Worksheet 5.3, consider Martina’s example. You’ll recall that butterflies and upset stomach were her most prominent anxiety symptoms. From the arrows you can see that the greatest consequence she feared was an escalation in her anxiety. However, she also had some secondary concerns about the possibility of a panic attack and the sheer discomfort associated with her abdominal symptoms. It’s clear from Martina’s example that her high anxiety sensitivity focused on the belief that she could not stand feeling nauseous. Knowing the consequences you fear most from anxiety symptoms is important to rethinking the “dangers” of anxiety and improving your tolerance of these symptoms.

living with anxiety symptoms

95

Martina’s Symptom–Consequence Match-Up Anxiety symptoms

Perceived consequences

Feeling discomfort, tightness, or pain in chest

Anxiety will build and continue most of the day

Sudden increase in heart rate, heart palpitations

increased risk of a panic attack

Trembling body, shaking hands

Won’t be able to work or be productive due to anxiety

Feeling of suffocation, shortness of breath, or feeling like you’re not getting enough air

Symptom of a serious medical condition like heart attack, brain aneurysm, severe asthma attack, or the like

Feeling of unreality, déjà vu, or feeling detached from your body

increased risk of feeling shame or embarrassment

Feeling dizzy, lightheaded

Cause disapproval, rejection, or criticism by others

Upset, queasy, or butterflies in stomach, nausea, or cramps Feeling faint, weak, tired, or unsteady Tense muscles, feeling stiff or achy Blurred vision, feeling like you’re in a fog Feeling hot, chills, or sweaty Feeling restless, keyed up, agitated, or pacing Blushing, feeling flushed, or hot flashes having unexpected pain, soreness, muscle spasms, or other symptom of a medical condition Feeling confused, distracted, can’t concentrate Feeling frustrated, annoyed, or impatient

experience uncontrollable worry or loss of mental control Trigger an anger outburst or intense irritability toward others Signals danger of imminent harm to self, family, or other valued people in my life increase in physical symptoms of discomfort like muscle/stomach pain, tension headache, nausea disruption of order, routine, or predictability in daily living heightened fear and thoughts of death or dying increase in chronic pain condition disrupted sleep leading to increased fatigue throughout the day Feeling overwhelmed and highly stressed

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Anxiety Sensitivity Assessment By now you might be wondering if you have high anxiety sensitivity and if it’s a significant factor in your problem with anxiety. Possibly the work you’ve done in the previous exercises suggests that you lack tolerance for certain anxiety symptoms. You suspect you have high anxiety sensitivity, but you’d like a more definitive answer. Fortunately, there is a strong research base on anxiety sensitivity with several measures available that provide a reliable and valid assessment of anxiety sensitivity level.18,21,22 E VA L U AT ION EXER C I S E 

Measuring Anxiety Sensitivity

Take a few moments to complete our measure of anxiety sensitivity beliefs to see whether you might have reduced tolerance for anxiety symptoms. We focus on beliefs about symptom intolerance and their consequences because this is the most important part of anxiety sensitivity. Worksheet 5.4 presents 10 belief statements about anxiety symptoms. We don’t have research that establishes a cutoff score, but high anxiety sensitivity may be relevant if you circled “Much” or “Very much” to three or more items.

How to Strengthen Your Anxiety Tolerance Have you concluded that anxiety sensitivity is contributing to your problem with anxiety? It’s important to know your anxiety threshold and whether you have high anxiety sensitivity (fear of being anxious) because this will have an impact on how you work on reducing anxiety. There are several ways anxiety sensitivity has an influence on anxiety treatment. „ If

you have high anxiety sensitivity, you may need to lower your anxiety-­ reduction goals to take into account your heightened sensitivity to anxiety symptoms.

„ You’ll want to target the specific symptoms you fear most in your anxiety treat-

ment program. „ With

elevated anxiety sensitivity, anxiety treatment must include repeated activation of feared symptoms and prevention of escape and avoidance strategies.

In the remainder of this chapter we present four interventions that you’ll want to include in your anxiety treatment program if you have high anxiety sensitivity. These strategies will raise your anxiety threshold by making you more tolerant and less frightened of feeling anxious.

W ORK SHEE T 5.4

My Anxiety Sensitivity Beliefs Instructions: Below are 10 belief statements that represent perceived negative consequences of physical sensations relevant to anxiety. Circle how much each statement indicates what you believe about that physical sensation.

Statements

Very little

A Very little Some Much much

  1. I am afraid of my heart beating quickly because I tend to think something could be terribly wrong.

0

1

2

3

4

  2.  When my stomach feels queasy or upset, I start to worry that I might become sick.

0

1

2

3

4

  3.  When I feel unexpected chest tightness or pains, my initial fearful thought is whether this could be a sign or symptom of a heart attack.

0

1

2

3

4

  4.  When I feel like I am not breathing properly, I tend to think this is serious and could lead to suffocation.

0

1

2

3

4

  5.  When my throat feels tight, I seriously wonder if I could choke to death.

0

1

2

3

4

  6. It is important to keep myself calm and relaxed as much as possible.

0

1

2

3

4

  7. I try to control my anxiety so I don’t look nervous to other people.

0

1

2

3

4

  8. I don’t like feeling physically aroused or excited.

0

1

2

3

4

  9. I am concerned that physical arousal or stress could get out of hand and cause a panic attack.

0

1

2

3

4

10. I am quite preoccupied with how I am feeling physically and whether I am starting to feel anxious.

0

1

2

3

4

Note. These statements indicate whether or not a person has a tendency toward high anxiety sensitivity. An accurate assessment of anxiety sensitivity must be done by a qualified mental health professional using a standardized anxiety sensitivity measure.21

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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Build on Tolerance We start with one of the easiest ways to rethink your tolerance of anxiety symptoms. In Chapter 3 you learned that anxiety is not always a problem in your life. Often you manage anxiety quite well and can even use it to your advantage. It’s an example of your positive, adaptive mode kicking in so you’re using anxiety to enrich your life. The same is true for your tolerance of specific anxiety symptoms, even the ones that bother you most. There are times when you accept anxiety symptoms; let’s say a racing heart, shortness of breath, or a flushed feeling. You tolerate them, and so your anxiety level is kept low. Is there something you can learn from these experiences that you can apply to times when your anxiety gets out of hand?

IN T ER V EN T ION EXER C I S E 

Catch Symptoms during Low Threat

We start with an intervention exercise called focused symptom attention. Its aim is to help you gain a deeper understanding of why you can tolerate physical arousal symptoms in some situations but not others. You’ll learn that in many situations you normalize the same physical arousal symptoms you have when feeling highly anxious. Over the next week, write down times when you had a physical, cognitive, or behavioral symptom that you often experience when severely anxious but in this situation felt little or no threat (that is, anxiety). For example, if you find heart palpitations most frightening when anxious, are there times when your heart accelerates but you don’t feel fearful of the sensation? Those are the experiences that we’d like you to record on Worksheet 5.5. Â Tips for Success: Catching Symptoms When Not Anxious

It can be difficult to shift our attention to times when physical arousal sensations don’t bother us, because we pay more attention to the times of distress. The following are some strategies you can use to improve your awareness of physical sensations in nonanxious situations. „ Write down the physical sensations or other symptoms that occur when you’re highly

active, such as during exercise, sports, or dance. Often these arousal symptoms are like what we experience when highly anxious. The difference is that we don’t consider them threatening because we expect to feel this way when physically active. „ Be attentive to the arousal symptoms that happen when you’re stressed, frustrated,

or have multiple demands coming at you. Often the symptoms don’t bother us as much during these times because we think it’s normal to feel this way when stressed or frustrated.

W ORK SHEE T 5.5

Nonthreatening Symptom Diary Instructions: Pay attention to times when you had a physical sensation in a nonanxious situation. Follow these steps when completing the worksheet. „ Step 1.  State the specific symptom(s) you experienced in the first column. „ Step 2.  Then briefly describe the situation that triggered the symptom. „ Step 3. Next indicate how you interpreted or explained why the symptom occurred. What caused the symptom to occur in that situation? What effect or consequence did you think the symptom might have on you? „ Step 4. In the final column note the outcome of the whole experience. Did the symptom just disappear on its own? Did you do something to deal with the symptom? What effect did it have on your emotional state or on your actions? Symptom(s) I experienced Martina’s examples:

Stomach felt queasy, a little nauseated Felt very jittery, restless, couldn’t focus

Situation that triggered the symptom(s)

Your interpretation (understanding) of the symptom(s)

Outcome

Had just eaten some Mexican take-out at my desk because I was busy at work.

This is all due to the food; fast food always bothers my stomach; I don’t know why I keep eating this stuff.

Took an antacid and eventually my stomach settled down.

Again, at work; terribly busy; lots of interruptions and demands

I was feeling stressed and overwhelmed by the work; I drank more coffee than usual to stay alert; I was probably reacting to too much caffeine in my body plus all the stress.

I took a short break and went outside to clear my head; I decided to ignore my emails and focus on the most pressing task. It took an hour or so, but eventually I settled down.

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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„ Focus on the symptoms you experience when feeling unwell or when you’ve not had

enough sleep. „ Think about the symptoms you experience after consuming alcohol or other sub-

stances. Again, feeling lightheaded or keyed up, for example, is not threatening because you attribute these symptoms to the drug or alcohol you consumed.

The first two rows of Worksheet 5.5 present examples from Martina’s experience with anxiety symptoms. Often a queasy stomach or feeling jittery were prominent when anxiety was a problem for her, but in these examples Martina’s anxiety did not escalate. The reason can be found in her symptom interpretation. She told herself the symptoms were normal and not to be feared because there was a good explanation for her feeling this way. But more important, Martina learned that often she can tolerate anxiety symptoms better than she realized. The difference is found in how she explains the cause and consequence of the symptoms. What have you learned from your entries in Worksheet 5.5? Are you surprised that often you’re rather good at tolerating anxiety symptoms? How did you explain the cause and consequence of the symptoms that caused you to tolerate them? Because of your symptom tolerance, your anxiety was minimal in these situations. Is it possible that you could use these explanations to understand the anxiety symptoms when they frighten you? This would strengthen your tolerance and greatly reduce anxious feelings.

Confront Your Symptom Fear This next intervention is more challenging but has greater potential for changing how you think about the anxiety symptom(s) that bother you most. Its aim is to strengthen your tolerance of the feared symptom(s) when your anxiety is a problem. Our natural tendency when feeling severely anxious is to seek relief from anxiety symptoms. Martina tried various strategies to relieve her queasy stomach when her problematic anxiety about social situations escalated. In this next exercise you’re asked to do the exact opposite of seeking relief from the feared symptoms. Instead of trying to dampen the symptom by leaving a situation, distracting yourself, or trying to relax, the idea is to focus intently on the symptom for several minutes. For example, let’s say when anxiety is a problem you tend to feel short of breath. That feeling scares you because you’re afraid of suffocation. Instead of doing diaphragmatic breathing, stay with that feeling of being short of breath. What exactly does it feel like? Can you feel yourself inhale and exhale? Put your hand on your chest. Can you feel your lungs expand and contract? Imagine you’re standing outside your body and watching your lungs receive and expel air. In your mind’s eye,



living with anxiety symptoms 101

can you imagine them filling with and then emptying of air? Focus all your attention on the shortness of breath feeling but as a detached observer. You observe or watch your lungs fill and expel air in a rhythmic manner. Does the feeling remain constant, or does it ebb and flow? Does it fade with time? IN T ER V EN T ION EXER C I S E 

Detached Observation

Detached observation, the exercise in Worksheet 5.6, is an intervention you can use for any symptom you checked as moderately or greatly bothersome on Worksheet 5.1. The key to its effectiveness is repeated practice in shifting your attention toward the unwanted sensation rather than away from it by using distraction or trying to convince yourself the symptom doesn’t bother you. Observing your symptoms in a detached manner is a form of exposure to unwanted, distressing physical sensations. You’ll discover in Chapter 7 that exposure is a powerful treatment for fear and anxiety.

Worksheet 5.6 provides an example of detached attention to a feared symptom based on Martina’s social anxiety. Were you able to overcome your reluctance and focus on the symptom you fear most when highly anxious? Congratulations if you did the exercise several times! It takes courage and determination to do the opposite of the natural inclination to seek relief and safety from the things we fear most. What happened to the symptoms and the anxiety after you practiced detached observation? After repeating the exercise several times, did you notice that your tolerance for the feared symptom improved? Based on your work with the last two intervention exercises, try to come up with an alternative explanation for your most bothersome or feared symptom that would increase your tolerance for that symptom and raise your anxiety threshold. You can write this in the space provided. You’ll see an example of Martina’s alternative explanation, which improved her tolerance for queasy and nausea sensations in her stomach. My alternative explanation for my feared symptom(s):

My stomach is extremely sensitive to everything that happens in my life. I’ve had lots of medical tests, so I know there’s nothing wrong with it. It’s just the way it is. The sensations always disappear on their own. Nothing bad has ever happened other than feeling unwell. Lots of people feel unwell, and they can cope with life. I can Martina’s alternative explanation for the queasy symptom:

W ORK SHEE T 5.6

Focused Attention Symptom Diary Instructions: Over the next week, write down times when you practiced detached focus on the symptom(s) that you fear most. In the first column, note the situation and the feared or threatening symptoms you experienced. Then describe how you practiced detached focus toward the symptom. In the last column, state what eventually happened to the symptom after spending time engaged in focused attention. Occurrence of feared, threatening, or bothersome symptom(s)

Quality of detached observation of the symptom(s)

Martina’s example:

I was able to focus all my attention on the sensations in my Sitting at home and thinking about the dinner party invitation. stomach. I imagined that it was I feel butterflies in my stomach, a like a pot of stew boiling on the churning sensation as if I could be stove. I kept my attention focused on it, observing the ebb and flow sick to my stomach. of the sensations.

Symptom outcome

Eventually the sensations subsided. I got bored with thinking about my stomach and found myself mindlessly phone surfing. Any anxiety about anticipating the dinner party faded as well.

1.

2.

3.

4.

5.

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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living with anxiety symptoms 103

do the same; I’ll just carry on with my life as if having a highly sensitive stomach is more of an unfortunate inconvenience than anything else. Physical Exercise No doubt you’ve heard that physical exercise improves our ability to deal with stress and anxiety, but you may not have known that it’s also an excellent way to boost tolerance for anxiety symptoms. Research indicates that aerobic exercise can be as beneficial for lowering anxiety as other established treatments like medication or CBT.23 Other studies suggest that the anxiety-­reduction benefits of exercise might be due to its effect on anxiety sensitivity.24 In one study individuals with high anxiety sensitivity who participated in a running program showed more decrease in anxiety symptoms than did individuals with low anxiety sensitivity.25 This suggests that engaging in regular physical exercise that causes an increase in the same arousal symptoms you experience when severely anxious can help reduce how much these symptoms bother or frighten you.18 There is no agreement on the frequency, intensity, or type of physical exercise you might need to improve your tolerance of anxiety-­related arousal symptoms and raise your anxiety threshold. However, aerobic exercise (brisk walking, running, cycling, swimming, rowing, dancing, and the like) that increases your need for oxygen and accelerates your heart rate is best. Even if you’re physically fit or athletic, regular exercise can improve your tolerance for anxiety symptoms if you pay attention to the similarity between the arousal sensation/symptoms activated during exercise and the same sensations/symptoms triggered during severe anxiety. The following exercise will help you maximize the antianxiety effects of physical exercise. IN T ER V EN T ION EXER C I S E 

Symptom-­Focused Physical Exercise

There are several steps to follow when using physical exercise to improve your tolerance of anxiety. „ Step 1.  Consult with your family physician before starting an exercise program to

determine whether there are medical restrictions on increasing your physical activity. „ Step 2. Have a certified fitness trainer set up an exercise program that takes into

consideration your age, medical status, and fitness level. „ Step 3.  Choose an exercise activity that increases your respiration and cardiac out-

put. Make sure you start at a level that is consistent with your current fitness level. „ Step 4.  Make sure your exercise activity provokes the arousal symptoms you rated

as bothersome on the Symptom Tolerance Scale (Worksheet 5.1).

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„ Step 5.  When exercising, play close attention to how your body feels, especially the

feared physical sensations you identified in the previous worksheets. „ Step 6. Use Worksheet 5.7 to record your exercise activity.

 Tips for Success: Boost Motivation for Physical Exercise

Most people find it extremely difficult to stick with an exercise program over the long haul. We all “fall off the wagon” more than we’d like. Some of our excuses for not exercising can be quite creative. The following are some strategies that will help you stay true to your exercise regimen. „ Select a regular time for exercise that works best for you and stick to your schedule.

If you exercise only when you’re free, you’ll never be consistent enough, especially with a busy schedule. „ Establish realistic goals that take into account your daily commitments and fitness

level. Start low, increase gradually, and don’t take on more than you can handle over the long-term. „ Strengthen your commitment by exercising with a friend or organized group; this

will make you accountable to another person. Solitary exercise is harder to maintain. „ Establish goals that give you a sense of accomplishment at regular intervals. A

series of incremental fitness goals is better than a weight-­reduction goal. „ Use an app to keep track of your daily exercise level. Give yourself small rewards

when you’ve achieved an exercise milestone. Report on your exercise activities to friends and family as a way of boosting accountability.

Physical exercise is a less frightening intervention for high anxiety sensitivity than detached observation is. Were you able to tolerate physical arousal much better when exercising than when these symptoms occur during your problematic anxiety? Martina, for example, found that feeling tense and keyed up bothered her when she was feeling anxious because these initial symptoms often led to more severe anxiety. But she noticed that vigorous walking also caused her muscles to tense and to feel a little hyped up internally. And yet these symptoms didn’t scare her when she exercised because she expected to feel this way. By repeatedly exercising and paying attention to how her body felt, Martina gradually became less frightened about feeling tense and keyed up in nonexercise situations.

Symptom Provocation This final intervention for strengthening your tolerance for anxiety symptoms is the most difficult. It is like the second exercise, detached observation, except this time

W ORK SHEE T 5.7

Weekly Exercise Log Instructions: Keep track of your daily exercise using the weekly exercise log. Briefly state the exercise activity in the second column and its duration in the third column. Rate how much physical effort you put into the exercise from 0 = no effort, quite relaxed, to 10 = completely exhausted by the exercise. Use the last column to write comments on the physical symptoms/sensations you experienced while exercising.

Day

Exercise activity

Duration (minutes)

Degree of effort (0–10)

Physical symptoms/sensations experienced during exercise

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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you’re asked to intentionally provoke the feared symptom rather than simply observe it closely when it occurs naturally. This is a challenging exercise for people with high anxiety sensitivity because you’re intentionally making yourself anxious. “Why would I do this?” you might ask. It sounds like you’re deliberately poking yourself with needles just to feel pain! Isn’t the point of treatment to reduce anxiety, not intentionally produce anxious moments? It turns out that symptom provocation is a powerful intervention for raising our tolerance for anxiety symptoms because it’s a more intense form of exposure therapy. (As mentioned earlier, Chapter 7 explains exposure treatment in detail.) When we take control of an anxiety symptom that bothers us greatly and deliberately produce that symptom repeatedly, we eventually lose our fear of that symptom. We learn from experience that we can tolerate the symptom and that any catastrophic consequences we associate with the symptom don’t arise. What we’re doing with symptom provocation is normalizing the feared symptom. As an example, let’s say you have high anxiety sensitivity about heart palpitations. Whenever your anxiety becomes a problem, you focus on your heart rate and fear that you’re putting extra strain on it that could result in a heart attack. Even though you’ve had medical exams and you’ve been assured by your family physician that your heart is healthy, you still fear a heart attack when you have palpitations. To overcome this fear, you practice running on the spot or hyperventilate for two minutes a couple of times daily. Both exercises produce a sudden increase in your heart rate. Although you can easily explain that your heart is racing because of the increased physical activity, you are still learning: „ That

you can tolerate the physical symptom

„ That

nothing terrible happens by provoking the symptom

„ That

you can take control of the symptom

Each anxiety symptom requires a different provocation technique. These are listed in Table 5.1. IN T ER V EN T ION EXER C I S E 

Deliberate Symptom Exposure

Follow the steps below and plan to engage in symptom provocation daily, or at least several times a week. Vary the exercises so you’re doing different activities that provoke the anxiety symptom(s) that are most bothersome or frightening. Symptom Provocation Steps Step 1. Obtain medical clearance. Step 2. Identify your feared anxiety symptom(s) and comment on what bothers you most



living with anxiety symptoms 107 TA B L E 5 .1.  

Provocation Techniques for Raising Symptom Tolerance

Provocation technique

Provoked symptom(s)

Hyperventilate for one to two minutes

Breathlessness, smothering sensation, racing heart

Hold breath for 30 seconds

Breathlessness, smothering sensation

Place tongue depressor at back of tongue for 30 seconds

Choking sensation

Run on the spot for two minutes

Pounding, racing heart

Spin in a chair for approximately one minute

Dizzy, faint feeling

Tense all body muscles for one minute

Trembling, shaking

Breathe through narrow straw for two minutes

Breathlessness, smothering sensation

Shake head rapidly from side to side for 30 seconds

Dizzy, faint feeling

Stare continuously at yourself in the mirror for two minutes

Feeling unreal, dreamy; dizzy or faint

Sit facing a heater for two minutes

Feeling flushed, sweaty, blushing

about this symptom, its possible consequences, how it makes you feel, loss of control, and so forth. Record the symptom and why it bothers you on Worksheet 5.8. Step 3.  Select one or two provocation activities from Table 5.1 that increase the unwanted symptom(s). Step 4.  Begin in safety. Make sure you begin the provocation exercises in a safe, calm, and comfortable location. If you are in therapy, your therapist will likely introduce symptom provocation in the therapy session. Step 5.  Be courageous. Before you start, decide how long you will engage in the exercise. Don’t stop when you begin to feel anxious—you’re supposed to feel anxious. Keep going until you have reached the predetermined end (for example, two minutes). Step 6.  Take it gradually. Begin with exercises that make you moderately anxious. Gradually increase the length of the exercise until you are completing the full exercise. For example, if a few seconds of overbreathing makes you highly anxious, start with 20 seconds and then gradually increase the duration until you are doing the full two-­minute exercise. Step 7.  Take notice of the symptoms. During the exercise, notice how quickly the symptom(s)

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rise and fall when you begin and end the provocation exercise. What does this tell you about the feared symptom? Step 8.  Vary the situation. After you’ve succeeded in doing symptom provocation in nonanxious situations, practice producing the physical sensations in anxious or stressful situations. This is the best way to overcome your fear of the physical symptoms of anxiety. Step 9.  Practice daily and as often as possible. Step 10. Record your symptom provocation sessions on Worksheet 5.8.

Did you notice that the more you practiced provoking the feared symptom, the less it bothered or frightened you? Were you surprised to learn that you could tolerate these anxiety symptoms better than you expected when you intentionally exposed yourself to the symptom? For example, if breathlessness or the feeling that you’re not getting enough air makes you anxious, repeatedly hyperventilating for two minutes several times a day will build up your tolerance for this symptom. You’ll learn that feeling short of breath is uncomfortable but that the sensation quickly disappears and you don’t really end up suffocating. Once this fear of the sensation subsides, you’ll be better able to tolerate it during times of stress or anxiety. Symptom provocation is one of the most powerful interventions for lowering anxiety sensitivity because it’s based on repeated fear exposure to a specific symptom or sensation. As you learn to tolerate the anxiety symptoms, you are also raising your anxiety threshold. More of your anxiety experiences will be considered normal, leaving only a narrow band of very severe anxiety as problematic.

The Next Chapter You’ve been introduced to the concept of anxiety sensitivity and how it contributes to anxiety problems. Learning to lower your sensitivity to anxiety symptoms is an important element in CBT for anxiety. Confronting the specific symptoms or sensations that bother you most, or possibly even frighten you, and then learning that you can tolerate these uncomfortable sensations will raise your anxiety threshold. But there is much more to the CBT approach to anxiety than reducing your anxiety sensitivity. In the next chapter you’ll learn how to deal with another major contributor to problem anxiety, the anxious mind.

W ORK SHEE T 5.8

My Symptom Provocation Record Instructions: There are three parts to this worksheet. State the physical symptoms of anxiety that bother you most (see Worksheet 5.1) and then explain what frightens you about these symptoms. Next record the daily frequency of your symptom provocation sessions and rate your overall tolerance of the symptoms during these sessions. In the last question, summarize what you learned about tolerating anxiety symptoms from the provocation sessions. 1. In this space, write the anxiety symptom(s) that bother, frighten you most:



2. Briefly explain what bothers or frightens you about this symptom(s):



Days

Number of times you practiced symptom provocation

Rated ability to tolerate the symptom(s) on 0–10 scale*

Monday Tuesday Wednesday Thursday Friday Saturday Sunday *10-point rating scale where 0 = poor symptom tolerability, gave up doing the provocation exercise quickly; 5 = moderate symptom tolerability, completed the provocation exercise but felt quite anxious doing it; 10 = excellent symptom tolerability, completed the provocation exercise with minimal anxiety.

3. What did you learn about your ability to tolerate the physical symptoms of anxiety?



From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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6 transform your anxious mind

J

amal, an unemployed 24-year-old university graduate, was stuck in a rut and going nowhere because of unrelenting anxiety. He had big aspirations to attend law school, but things had not gone well, and now he’s back living with his parents. He hadn’t done well on the LSAT exam the first time and was now finding it extremely difficult to study for a second attempt. The pressure on him was enormous since he came from a long line of lawyers and doctors. Jamal felt keyed up and on edge more days than not. He woke up feeling uneasy, with a sense that the day would not go well. He felt exhausted because his anxiety and worry had kept him up most of the night. During the day he had a churning sensation in his stomach and had difficulty concentrating when he tried to study. Being around others made him more anxious, so he withdrew, preferring instead the safety and comfort of his bedroom. Despite an abundance of free time, Jamal was too restless and agitated to study, so he spent most of the day phone surfing or binge-­watching online content. Procrastination and avoidance had become a way of life. Jamal’s anxiety was now incapacitating and threatening to derail his future. Instead of focusing on what was needed to improve his application to law school, his mind was filled with anxious thoughts like: “I’m losing my focus; I can’t remember anything. I don’t understand what I’m studying. I’ll never do well on the LSAT. I’ll get another low score, which will torpedo my admission to a law school. I’m destined for a life of loneliness, to work at a menial job, and to barely be able to look after myself. I’ll be such a disappointment and embarrassment to my family. I’ll never be happy, ending up a pathetic loser that people look down on.” This negative thinking, with its focus on impending failure, was a driving force in Jamal’s anxiety and a type of self-­ fulfilling prophecy, causing him to act in a way that could eventually lead to his most feared outcome. For Jamal, his anxious mind had taken over every aspect of daily living, causing him to sink further and further into the hole of generalized anxiety. Does Jamal’s experience sound familiar? Is anxiety stalking you from the moment you awake in the morning to late evening when you’re trying to fall asleep? In Chapter 110



transform your anxious mind 111

3 you were reminded of the times when you think of anxiety as a normal emotion and can manage it quite well. But possibly you’re like Jamal, and your experience of anxiety has changed. The symptoms have become more severe, and now anxiety is a dominant force in your daily life. You may recall from Chapter 4 that the way we think about danger, threat, uncertainty, and our ability to cope determines whether our anxiety remains manageable or becomes intolerable. We now want to return to this theme and take a closer look at the anxious mind. You’ll learn how an anxious mind can “supercharge” emotions, driving the intensity of anxiety to such heights that we experience an inability to work productively, connect with others, maintain our health, or enjoy life. You’ll discover unique characteristics of your anxious mind and be introduced to intervention strategies that can transform the way you think about threat, danger, and uncertainty. You can change your anxious way of thinking by acquiring mental skills that can shrink anxiety to manageable levels. Before we get started, take a second look at Jamal’s anxious self-talk. Try answering the following questions about his anxious mindset. QUIZ 

Jamal’s Anxious Mind

1. When Jamal thought about his current level of functioning, it made him feel more anxious. What was he concerned he couldn’t do because he was feeling anxious?

2. When Jamal thought anxiously, he made negative predictions about an important task he faced in the future. What were his negative predictions? 3. Once he started thinking anxiously, Jamal ended up with a worst-case scenario, a catastrophe. What was Jamal’s catastrophe?

Were you able to identify the main concerns in Jamal’s anxious thinking? For the first question, it appears that Jamal is afraid there is something wrong with his intellectual ability, that he couldn’t concentrate, understand, or remember what he was studying. This concern led him to predict that he would perform poorly on the LSAT and never be successful in his law school application (second question). All of

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this would culminate in a terrible life of low employment, parental disappointment, and never-­ending loneliness and misery (third question). Can you see how Jamal’s anxious thinking starts with an observation in the present (“I don’t understand what I’m studying”) and then spirals toward a catastrophic ending? Does your mind work in a similar way when you feel severe anxiety? In this chapter you’ll learn how to pull yourself out of this “death spiral” of anxious thinking and transform how you deal with problematic anxiety.

What’s Bothering You? The quiz highlighted several issues that bothered Jamal when he was anxious. You can use the same process to discover the root of your problematic anxiety. When anxiety becomes a problem, people often lose sight of the specific threats, dangers, and uncertainties that make them anxious. Rediscovering these concerns is important to understanding how your mind gets pulled into the pit of anxiety. You can use the next exercise to uncover your most important anxious concerns. E VA L U AT ION EXER C I S E 

Catching Your Anxious Concerns

In the evening, find a quiet location with no distractions. Take a few minutes to think about everything that happened during the day. Did you experience times of heightened anxiety when you felt nervous, agitated, tense, or even panicky? If so, make note of these experiences in Worksheet 6.1. Then think about why your anxiety escalated in each situation. Ask yourself the following questions: „ Was I feeling threatened, diminished, attacked, or made to feel weak or inadequate?

If so, how? „ Was I concerned that something bad might happen to me? If so, what was it? „ Was I focused on being helpless and unable to cope? If so, what couldn’t I handle?

Your answers to these questions will help you discover the concerns that are causing you to have episodes of severe anxiety. The worksheet includes three examples that illustrate Jamal’s anxiety-­provoking concerns about his future. Â Tips for Success: What’s on Your Mind?

Pinpointing what it is that’s making you feel so anxious can be difficult because there’s a tendency to focus on the distress rather than on what’s causing the distress. The following are some additional strategies that can help you identify the concerns behind your anxiety.

W ORK SHEE T 6.1

My Daily Anxiety Record Instructions: Use this worksheet to record at least one time each day when you experienced more anxiety than you think was appropriate. When recording the anxiety experience in the first column, consider where you were, what you were doing, and whether something disturbing or unfortunate happened to you. Write down in the third column what you were thinking about, that is, what concerned you most about the anxious situation.

Briefly describe periods of moderate to severe anxiety during the day

Days Sunday (Jamal’s entries)

1.  After procrastinating several hours, I finally went online to work on

the LSAT study materials but had a wave of intense anxiousness.

2. 

What were you feeling anxious about? (What were your concerns at the time)

There’s way too much material; I’ll never retain all this information.

3.  Monday

1.  My father seemed embarrassed that a coworker had asked him what I’m so ashamed that I’m

I was doing. I could feel my face get flushed, and I wanted to run.

2.  3.  Tuesday

1.  Saw Facebook posting of friend in law school and felt panicky. 2.  3. 

still living at home and dependent on my parents. I need to leave home and be more independent. Everyone is getting ahead of me; I’m falling so far behind; I’ll never make up for all the time I’m losing.

Wednesday 1.  2.  3.  Thursday

1.  2.  3. 

Friday

1.  2.  3. 

Saturday

1.  2.  3. 

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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„ Review the situations you rated as causing a lot of anxiety on Worksheet 3.1. Did

you rate more situations in one category as highly anxiety-­provoking than in other categories? If so, this suggests the presence of an underlying concern. For example, if many of your high ratings fell into the social relationship category, this would suggest you have anxious concerns about the opinion or evaluation of others. „ Consider the situations, intrusive thoughts, or physical sensations that most often

trigger severe anxiety (see Worksheet 4.1). If the same or similar triggers are causing you to feel anxious, this suggests a common underlying concern. For example, if your anxiety is often triggered by intrusive thoughts of possibly angering someone, you might have an underlying fear of confrontation. „ Look for repetitions in the threatening thoughts that occur in anxious situations (see

Worksheet 4.2). For example, if you feel anxious whenever you think of the possibility of sickness or disease, then your anxious concern could be about loss of vitality, being dependent on others, or death itself. „ Finally, you can think of anxious concerns as your “hot buttons.” Is there a topic or

issue that you try to avoid because it bothers you? If so, it’s likely that issue is an anxious concern.

At the end of the week, review your entries in Worksheet 6.1. Do you notice any common themes in the incidents that provoked your anxiety? If you look at Jamal’s entries in the third column, you’ll notice that his anxiety was associated with concerns about his cognitive (thinking) ability, disappointing others, and the ultimate catastrophe, that he’s falling further behind others and will end up a total loser. Identifying your anxious concerns is the first step in gaining a better understanding of your anxious mind. You need to know what you’re thinking about before you can change how you think about it.

Threat Predictions At the time of writing this chapter the COVID-19 pandemic was ongoing. It was an unprecedented time when the entire world was facing a common danger, that of contracting the coronavirus and becoming seriously ill. When we thought about the pandemic, we were automatically making predictions about its danger in terms of the probability of contracting the virus and how sick we’d become if infected. These predictions affected how anxious we felt and whether we took preventive measures to reduce risk (got vaccinated, social distanced, wore a mask). If you predicted that your chances of contracting COVID-19 were low and if you thought that you would have only mild symptoms if you were infected, then your anxiety might have remained low. However, if you predicted the probability of contracting COVID-19 was quite



transform your anxious mind 115

high and you had a comorbid condition that made you expect serious illness if you got infected, then your anxiety might have been quite high. You might have been especially cautious, deciding to stay at home as much as possible. Research has shown that people become overly focused on threat and danger when feeling highly anxious.4,26 When anxiety becomes a problem, we tend to exaggerate the likelihood and the severity of the anticipated threat. Does this happen to you when you feel moderate to severe anxiety? Do you: think something bad is very likely to happen to you or loved ones (“I know I’ll mess up the interview,” “I will embarrass myself if I go to the party,” “I know there’s something wrong with my body, that I’m ill”)?

„ Automatically

assume the worst will happen (“I’ll never get a promotion and will be stuck at this entry-level job until I retire,” “Everyone will instantly dislike me,” “I can’t breathe and will suffocate”)?

„ Instantly

Our anxious mind can be so extreme in overestimating the likelihood and severity of threat that we call it catastrophic thinking. With problematic anxiety, we tend to catastrophize about the ordinary, everyday experiences of life; we think the worstcase scenario is much more likely to occur than it is. Catching and correcting our catastrophic thinking is an important CBT intervention for reducing anxiety and worry. Table 6.1 provides some examples of exaggerated threat predictions. Bad things happen in life, and because of this we often feel anxious. But you can see from the examples in Table 6.1 that the anxiety becomes problematic when we predict the threat is more likely than is realistic and we assume the worst possible outcome. Having unexpected chest pains may cause most of us a brief pang of anxiousness. But if we think there’s a high likelihood the chest pains mean there’s something wrong with our heart and then we start thinking of a heart attack, the intensity of our anxiety will increase dramatically. Learning to correct exaggerated predictions of the likelihood and severity of threat is an important part of transforming the anxious mind. To do this, you’ll need to become more aware of your threat predictions and how you exaggerate their probability and severity. E VA L U AT ION EXER C I S E 

Catching Anxious Predictions

Use the exercise in Worksheet 6.2 to practice catching your threat predictions when feeling anxious. From the work you’ve done so far in the workbook, you know what you are thinking when your anxiety problem occurs. Your anxious thoughts are about future threat, so consider them predictions about bad things that could happen to you or loved ones.

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 Troubleshooting Tips: Improving Awareness of Anxious Predictions

If you had difficulty identifying your anxious predictions and completing the estimates in Worksheet 6.2, try the following: „ Review your entries in Worksheets 4.2 and 4.6. In these worksheets you wrote about

what goes through your mind when you have high levels of anxiety. As well, look at the anxious thinking you listed in your Symptom Self-­Monitoring Form (Worksheet 4.5). Can you see examples of overestimated probability and severity predictions in this anxious thinking? „ When your problematic anxiety strikes, write down what you’re thinking is the worst

possible outcome for you or your loved ones. Think about what is scaring you most

TA B L E 6 .1.  

Feeling anxious about . . .

Examples of Catastrophic Anxious Thinking

Exaggerated predictions of threat likelihood

Exaggerated predictions of threat severity (imagining the worst possibility)

. . . going to movies with a friend

It will be crowded, we’ll have to sit in the center of the row, and I’ll be anxious.

I’ll have a panic attack in the middle of the movie; I won’t be able to get out, and I’ll be freaking out; it will be the worst panic I’ve had in a while.

. . . an unexpected interview with my manager

I’ll be told that my work is not satisfactory; I’ll probably be extremely nervous, hot, and uncomfortable.

I’ll lose my job; at the very least I’ll be so anxious and panicky that my boss will wonder what’s wrong with me.

. . . mailing my tax return

I’ll probably get audited and then have to pay a lot of extra income tax.

The audit will result in a substantial tax bill. I’m already maxed out on my line of credit and won’t be able to pay it. I’ll have to declare bankruptcy.

. . . the thought that I could die young

Having these disturbing thoughts is a bad omen; it means I’m likely to die young.

What a tragedy to die in my 20s and never get to live a full life; to miss out on all the things that other people experience.

. . . not being able to sleep due to worry

I’ll never get to sleep. I’ll never be able to control this worry and sleep normally again.

My life is completely ruined by not being able to sleep. My concentration at work is so poor, I’m sure I’ll be fired.

. . . sudden, unexpected chest pain

I shouldn’t be having these chest pains now. It means there’s a strong likelihood I’m at risk of having a heart attack.

I could be having a heart attack. I am too far from the hospital. Doctors will get to me too late, and so I’ll die from this heart attack.

W ORK SHEE T 6. 2

My Threat Estimations Instructions: Review the anxious thoughts and concerns you recorded on previous worksheets. What negative outcome(s) were you thinking could happen? These outcomes are your predictions of threat. Write down these predictions in the first column of the worksheet. (Take a look at Jamal’s anxious predictions as examples.) In the second column, provide an estimate of the likelihood the threat will happen in real life, from 0% (couldn’t possibly happen) to 100% (certain it will happen). In the third column, rate the severity of the predicted threat from 1 = mildly aversive experience to 10 = an absolute catastrophe, the worst that could happen to me. Complete the probability and severity estimates as if you were feeling severe anxiety when doing the exercise. Probability estimate (0–100%)

Severity estimate (1–10)

I’m going to do poorly on my second attempt at taking the LSAT exam.

85%

8/10

I’ll never get into law school and will end up in a menial job the rest of my life.

50%

10/10

My anxious predictions Jamal’s predictions

1.

2.

3.

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

about the situation or what is most upsetting about your experience. Then rate how intense this outcome would be on the 10-point scale. „ Next, while still anxious, rate the probability that the worst outcome would happen

in real life. This is based on how likely it feels when you’re anxious, not your rational, reasoned judgment once you feel safe and comfortable. „ If you’re still having trouble identifying your threat estimates, ask for help from your

partner, family member, close friend, or therapist. 117

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When Jamal felt moderate to severe anxiety, his thinking jumped to all the bad things that could happen. One of his threat predictions was about doing poorly on his retake of the LSAT exam. He was highly certain this would happen (85%), and he rated this outcome as very severe (8/10). The more distant but devastating prediction of career failure was deemed less likely but more severe. What do you notice about your estimates of threat? Are they quite extreme, indicating that your anxious mind is catastrophizing your life circumstances? Your mind generates these anxious predictions very quickly (in less than half a second!) and automatically so you’re not aware that your brain is locked onto threat and danger until you’re well into the process. If you repeatedly experience problematic anxiety, your brain becomes so attuned to threat that it automatically scans the environment for signs of risk and danger. Even our memory system and reasoning abilities become biased when highly anxious, so you may have better recall of past anxious or frightening experiences. In other words, the whole mental system becomes locked into an anxious mind-set. Earlier we referred to this as a “threat mode.” In anxiety problems the threat mode becomes more easily activated. One of its by-­products is this tendency to anticipate a greater likelihood of really bad things happening than is realistic. CBT strategies teach you how to detect and override exaggerated predictions of threat and danger.

Feeling Helpless It’s hard to believe in yourself—­believe you can handle a situation effectively—when you’re feeling anxious about it. When our anxious mind takes over, we tend to see ourselves as weak, vulnerable, and unable to cope. So along with your rapid predictions of threat or danger, when highly anxious you may feel helpless and unable to cope. This vulnerability thinking tends to be slower and more effortful, so you may have greater awareness of your thoughts about not coping than you do your threat predictions. You may feel helpless because you believe you lack the skills necessary to deal with the anxiety-­provoking situation. Self-doubt and a profound sense of uncertainty will intensify your sense of vulnerability. The problem with vulnerability thinking is that it usually involves a distortion of reality; you’re not as weak and unable to cope with the situation as you think. Anxiety becomes a problem when our predictions of threat combine with thinking we’re vulnerable. It can be expressed in the following equation: Overestimating threat  +  Underestimating personal coping  =  Problematic anxiety

You can see how this equation operates in the three examples presented in Chapter 1. When Rebekah worried about work, she thought about her employees losing



transform your anxious mind 119

respect for her (threat prediction) and about not being able to confront her employees effectively (helplessness thinking). Todd had unexpected heart palpitations and immediately thought it might be a heart attack (threat prediction) and that he wouldn’t get to the hospital in time (helplessness thinking). Isabella worried about embarrassing herself in front of other people (threat prediction) and not being able to carry on a coherent conversation (helplessness thinking). Like Rebekah, Todd, and Isabella, you may be convinced that you’re helpless in the face of anxiety. But there are different ways to think about helplessness. E VA L U AT ION EXER C I S E 

Helplessness Thinking

This exercise will give you greater insight into how you think of yourself as vulnerable during periods of problematic anxiety. Use Worksheet 6.3 to record how you’re thinking about your ability to cope when experiencing a problem with anxiety. After listing several experiences of severe anxiety, consider what made you think you couldn’t cope or that you were overwhelmed in these situations. What did you do that led you to conclude that you didn’t cope well? Did you make the anxiety worse rather than better? Did you end up evaluating yourself negatively or put yourself down because of your failed attempts to cope? Also, thinking about how you’d like to respond in these situations of severe anxiety will contribute to understanding how you view yourself as helpless in the anxiety-­provoking situation. Concerns about losing control often occur when we’re feeling moderate to severe anxiety. If you believe you have limited control over the outcome of a situation, this will contribute to a sense of helplessness. Are you concerned about losing control over your thoughts, feelings, bodily sensations, or behavior when confronted with an anxiety-­provoking situation? If you’re thinking there’s not much you can do, that you have little control over what’s happening to you, then you’ll experience a heightened sense of vulnerability. It’s important to ask yourself “Do I really have as little control or influence in this situation as I assume? How might I exercise more influence over what’s happening to me?”

One of Jamal’s most disturbing vulnerability thoughts concerned his reduced cognitive ability when feeling severe anxiety. He’d try to study for his law school entrance exam, but his anxiety was so great that he could barely understand what he was reading. This caused him to think, “What’s wrong with me? I’ve lost my ability to learn. I can’t seem to understand the most basic information. The anxiety has destroyed my intellectual ability, and I can’t do anything about it.” His desired coping response was to return to the days when he could be anxious about an exam but still study well enough to get a good mark. CBT for anxiety focuses on evaluating and correcting vulnerability thinking so individuals with problematic anxiety have greater confidence to deal with anxious

W ORK SHEE T 6.3

My Helplessness Thinking Record Instructions: In the first column, briefly describe the situation that triggered your anxiety. What caused you to feel anxious? Next write down the thoughts you had about being weak or helpless. In the final column, briefly describe what you think would be an effective response to this situation. How would a confident, self-­assured person deal with this situation? How would you like to cope with this anxious situation? Anxiety concern (triggers)

Thinking you are helpless

Desired way to cope

1.

2.

3.

4.

5.

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

concerns. But before you can learn that you’re more resourceful and resilient than you think, you need to be aware of how you view yourself as helpless and vulnerable.

Thinking Errors Recall the last time you experienced problematic anxiety. Did you notice a change in your thought process—that you became entirely focused on your anxiety and couldn’t seem to concentrate on anything else around you? Anxiety does this; it distorts our thinking so that we become narrowly focused on threat, danger, and helplessness. 120



transform your anxious mind 121

This narrowed thinking is extremely important to our survival when real danger exists. If someone approaches you on the street who looks threatening to you, your full attention needs to be on figuring out whether this person is going to mug you or is harmless. No time to be looking at store windows, checking your phone, or planning the evening meal. You need to make a very quick decision and identify a quick escape route. You need to exercise vigilance. But what happens when there is no external threat? When the threat is merely anticipated—a thought and not an actual event (such as “What if I am getting sick?” or “What if I have a panic attack?” or “What if I make a mistake?”)—your anxious thinking, unfortunately, is still selective. When feeling anxious, we’re not likely to be aware of this narrowing of our attention. Our perception of reality becomes biased or distorted. Table 6.2 lists several thinking “errors” that cause this distortion when people feel highly anxious. Read through the definitions and examples, checking off the ones that seem most relevant to you. You’ll be using this information later in the chapter. When these thinking errors focus your attention exclusively on threat and danger, they make it impossible for you to consider less threatening or benign interpretations of situations. This exclusion prolongs the experience of anxiety because it’s harder for you to think in a more realistic, balanced manner. Have you noticed how hard it is to focus on aspects of a situation that suggest it is safer and less threatening than you think? Whenever Jamal started worrying about not doing well on his second attempt at the LSAT exam, he couldn’t think of anything else, such as all the times in the past when he was anxious about exams but pulled through in the end. He jumped to the conclusion that it was different this time, that he’d never succeed in preparing for the LSAT. Jamal’s worry involved several thinking errors, like jumping to conclusions, tunnel vision, catastrophizing, and emotional reasoning. Knowing the cognitive (thinking) errors you make when you are anxious is an important component of CBT for anxiety. The anxious mind tends to make more of these errors when it’s trying to process threat and safety. Increasing your sensitivity to these errors will help you correct your anxious thinking and adopt a more balanced, realistic perspective on your anxious concerns.

Mapping Your Anxious Mind It’s time to integrate everything you’ve discovered about your anxious thinking to create a map of your anxious mind. You’ll be using this “mind map” to tailor your CBT interventions so they focus on the unique features of your problematic anxiety. Figure 6.1 presents the major components of the anxious mind map. As emphasized throughout the workbook, anxiety is most often triggered by an

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Thinking Errors in Anxiety

Thinking error

Definition

Examples

Catastrophizing (overestimating threat and danger)

Focusing on the worst possible outcome in an anxious situation

Thinking that chest tightness is sign of a heart attack Assuming friends think your comment is stupid and they’ll dump you Thinking you’ll be fired for making a mistake in your report

Jumping to conclusions

Tunnel vision

Nearsightedness

Expecting that a dreaded outcome is extremely likely based on minimal information

Being unsure of a question and assuming you’ll fail the exam

Focusing only on possible threat-­relevant information while ignoring evidence of safety

Noticing that a person looks bored while you’re speaking in a meeting

Tendency to assume that threat is imminent

Feeling anxious in a social setting and assuming you’ll say something awkward and embarrassing

Stumbling during a speech and thinking you’re blanking out Feeling tense while packing and thinking you’ll be too anxious to make the trip

Focusing exclusively on anxiety symptoms while in the grocery store Worrying about a medical test and only thinking it’ll be positive for cancer

Worrying about your work performance and being convinced this week you’ll be let go Fearing you will vomit; your stomach feels queasy and you’re convinced you’ll be sick Emotional reasoning

Assuming that the more intense the anxiety, the greater the actual threat

You have a fear of flying and are convinced flying is dangerous because of feeling anxious whenever you fly Having panic attacks and being convinced the likelihood of “losing control” is greater when you feel highly anxious Being convinced something bad will happen because you feel anxious

All-or-­nothing thinking

Viewing threat and safety in rigid, absolute terms as either present or absent

When feeling anxious, assuming it will escalate into a panic attack but when feeling calm, assuming it’s not possible to have a panic attack Having social anxiety and assuming your work colleagues will think you’re incompetent if you speak up but competent if you say nothing Assuming you’ll never find a job after being laid off from work if it doesn’t happen in the first month

From Cognitive Therapy of Anxiety Disorders by David A. Clark and Aaron T. Beck (p. 169). Copyright © 2010 The Guilford Press. Adapted by permission.



transform your anxious mind 123

Anxiety situations/triggers

Overestimated threat

THE ANXIOUS MIND

Underestimated safety

Helplessness thinking

Cognitive errors

F I G U RE 6 .1.  

The anxious mind map.

external situation, unwanted thought or memory, physical sensation, or experience with others (see Worksheet 4.1). We immediately interpret the experience as threatening by overestimating the likelihood and severity of a possible outcome. But our anxious mind doesn’t stop there. We also tend to see ourselves as incapable of handling this potential threat (that is, helpless). Several cognitive errors are present that contribute to a distortion in our thinking about the anxious concern. The fourth component of this anxious way of thinking is the tendency to downplay or even ignore safety information. E VA L U AT ION EXER C I S E 

The Anxious Mind Map

This exercise guides you through development of your anxious mind map. Worksheet 6.4 is based on the four components of the anxious mind. Think about the problematic anxious experiences you’ve recorded on previous worksheets. Based on these experiences, answer the six statements in this worksheet to develop an individualized profile of your anxious mind.

W ORK SHEE T 6.4

My Anxious Mind Map Instructions: Follow these steps to create a map of your anxious mind.

„ Step 1.  Begin by writing down a primary concern evident in many of these experiences. „ Step 2. Next, write down the various triggers of this anxiety in the second item. „ Step 3. Item 3 asks you to briefly describe the threat associated with the anxious concern. Make sure

your comment includes what you think is the likelihood and severity of the possible threat when you’re feeling anxious (see Worksheet 6.2). „ Step 4.  Use item 4 to describe how you feel helpless, vulnerable, and unable to cope should the dreaded threat occur in real life. You could also include whether you feel helpless to deal with the severe anxiety associated with these experiences (see Worksheet 6.3). „ Step 5.  List all the cognitive errors present in your anxious thinking (see Table 6.2). „ Step 6. In the final item, reflect on the possible safety information that may be present, but that you find it difficult to think about when experiencing your anxiety problem.

1. Briefly describe your primary anxious concern:



2. List situations, physical sensations, thoughts, memories that trigger the anxious concern:



3. Describe how you overestimate the likelihood and severity of the threat:



4. Describe how you think you’re helpless to deal with this threat:





5. List errors present in your anxious thinking:



6. Describe the safety information you are ignoring or minimizing:



From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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transform your anxious mind 125

 Troubleshooting Tips: Constructing the Anxious Mind Map

If you’re having any trouble with this exercise, try the following. „ Consult the worksheets you completed in earlier chapters. Three worksheets in par-

ticular (Worksheets 4.1, 4.2, and 4.5) focused on triggers and anxious thinking associated with periods of severe anxiety. „ Review the Anxiety Symptom Profile you completed in Chapter 4 (Worksheet 4.6).

What did you write down in the second box under “anxious thinking”? „ Consider how you think when anxiety is mild and a fairly normal emotional experi-

ence (see Worksheet 3.3) and how this could be turned into problem anxiety if your thinking was more extreme. Can you see how you think about threat, vulnerability, and safety differently when your anxiety is mild versus when anxiety becomes a problem in your life?

Constructing your anxious mind map is an important step in changing how you think about the things that make you highly anxious. It will be your guide, providing a step-by-step approach to using the cognitive treatment strategies in the remainder of this chapter. You’ll find it much easier to construct your mind map if you completed Worksheets 6.1 through 6.3. Also, we suggest you review our example of an anxious mind map. It is based on a young woman, Nadia, who had severe bouts of health anxiety that caused significant personal distress and interfered in her daily living.

Correct Anxious Thinking: Examine the Evidence Apprehension is at the heart of anxiety, so changing how you think about threat is an important part of CBT for anxiety. One of the most powerful anxiety-­reduction interventions in CBT is evidence gathering. This is where you take an investigative approach to your anxiety. If anxiety problems occur when we exaggerate the likelihood and severity of threat to our well-being, then discovering a more realistic, probable outcome will reduce anxiety. For example, if you have panic attacks, what’s the evidence that your heart palpitations could be a heart attack? If you have social anxiety, what’s the evidence that you’re an embarrassment to others? Taking the perspective of a detective by questioning your anxious thoughts and beliefs is extremely difficult. Most people get caught up in the emotion and abandon their reasoning skills. Evidence gathering is an important intervention that cognitive behavior therapists use to correct the exaggerated thoughts about threat and danger that are responsible for anxiety problems. Angela, for example, had intrusive anxious thoughts about death and dying.

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Nadia’s Anxious Mind Map 1. Briefly describe your primary anxious concern:   that I might have a serious life-­threatening illness like

cancer that has not been detected 2. List situations, physical sensations, thoughts, memories that trigger the anxious concern:   unexplained

aches and pain, skin rashes or acne, appearance of uncommon pimples, abdominal cramps 3. Describe how you overestimate the likelihood and severity of the threat:   I immediately think it might be

cancer or the first signs of cancer; I tend to think of cancer as quite common since I know several friends treated for cancer; I also tend to assume it will be terminal and I’ll be told I don’t have long to live. 4. Describe how you think you’re helpless to deal with this threat:   Well, what can you do if you have cancer?

You are totally helpless; you can’t prevent it, minimize it, or will it away; you are a complete victim to the disease. 5. List errors present in your anxious thinking:   I’m catastrophizing, jumping to conclusions, and having

tunnel vision (I only see disease and no other possibility for the symptoms). 6. Describe the safety information you are ignoring or minimizing:   I ignore the fact that all these

symptoms are extremely common and most often they are a sign of nothing; they just disappear. I forget that I’ve had these symptoms for years and I’ve never received a cancer diagnosis despite numerous medical investigations. Even if I had cancer, it would most likely be treatable and I could have a reasonably normal life for years afterward.

Whenever she had these thoughts, she would seek reassurance from her husband that she was healthy and not seriously ill. These thoughts caused so much anxiety that Angela started to believe maybe she was destined for an early death, that somehow being so preoccupied with death was a bad omen. She knew her thinking was illogical, but that didn’t seem to make her feel better. She became more and more anxious every time she experienced the “death and dying thoughts.” Angela’s therapist asked her to gather evidence for and against the belief that “thinking about death makes it more likely to happen.” You can use the same intervention for your anxious thoughts. Follow the instructions in the next exercise to train yourself in the evidence-­gathering approach. It’s the first step in transforming your anxious mind from an emphasis on personal threat and vulnerability to a greater appreciation of safety and your ability to deal with your anxious concerns.



transform your anxious mind 127 IN T ER V EN T ION EXER C I S E 

Launching a Cognitive Investigation

Evidence gathering is a core CBT intervention, so make multiple copies of the Evidence-­ Gathering Form (Worksheet 6.5; see www.guilford.com/clark6-forms to download and print). You’ll want to do this exercise frequently with different anxiety episodes. Start by completing the worksheet when you’re not feeling anxious. It’s easier to take a more balanced perspective on the anxiety experience. If you try evidence gathering when you’re severely anxious, you’ll have difficulty coming up with evidence against your anxious thinking. Â Troubleshooting Tips: Looking for Evidence

In our clinical experience working with hundreds of individuals with anxiety, most people have difficulty with the evidence-­gathering intervention. They may struggle to think of evidence against their exaggerated thinking of threat. If they can think of reasons that their anxious thoughts are not realistic, they may still have trouble believing them or the whole exercise may feel too academic and sterile. If you’re not finding evidence gathering helpful, we recommend the following guidelines. „ Make sure the anxious thought you’re testing is central to your anxiety concerns.

If in doubt, review the threat-­related thinking you listed in Worksheets 4.2 and 6.2. Also review the anxious thoughts you recorded on the Symptom Self-­Monitoring Form (Worksheet 4.5) and the anxious thoughts listed in your Anxious Mind Map (Worksheet 6.4). „ Evidence for and against the anxious thought will speak to your predictions about

the probability and severity of threat related to your anxiety problem. Evidence for will support your belief that the probability of a worst-case outcome is high, whereas evidence against will support a view that a less severe outcome is more likely. „ When you experience the problematic anxiety, ask yourself, “What’s the evidence

that I am exaggerating the probability and severity of the situation and underestimating my ability to cope or that I’m ignoring the safety elements in the situation?” „ Don’t expect to be convinced to abandon your anxious thinking that the worst is

likely to happen. Instead use evidence gathering to begin the process of nudging your mind away from dire threat and toward a greater appreciation of safety and your internal strength to cope with life’s difficulties.

Evidence gathering is an effective intervention for most anxiety problems, but it takes considerable practice before you’ll be skilled at using it to correct your anxious thinking, especially when you’re in the throes of severe anxiety. Most people don’t find the evidence against their anxious thinking convincing. If you found yourself still

W ORK SHEE T 6.5

My Evidence-­Gathering Form Instructions: There are 4 steps to completing this worksheet.

„ Step 1. On the first line, write down your primary anxious thought. You’ll find this in Questions 3 and 4 of

your Anxious Mind Map.

„ Step 2. Over the next week, write down the evidence or reasons why you should be concerned (or afraid)

of whatever it is that’s making you feel severe anxiety at that moment. Ask yourself, “What is the evidence that the threat is very likely to occur? What’s the evidence for the worst possible outcome happening? What’s the evidence (reasons) that I can’t cope with the negative outcome?” After you have generated all the evidence for the threat, circle the one you find most convincing. „ Step 3. Once your anxiety has subsided, take a few minutes to write down evidence (reasons) why you shouldn’t be afraid of the anxious concern. Ask yourself, “What’s the evidence that the threat is not as likely as I think? What’s the evidence that the outcome will be only mildly unpleasant? Is there any evidence I can cope better than I think? Is there evidence of safety that I’m overlooking?” Try to generate as much evidence as possible against the anxious thought. Circle the evidence or reasons you find most convincing. „ Step 4. Once you’ve listed evidence for and against your core anxious thought, rate the likelihood and severity of the outcome based on the realistic evidence you collected. Remember, these ratings are based on the evidence you gathered and not on how you feel. Write down the anxious thought about threat or danger you are testing: Evidence for anxious thought

Evidence against anxious thought

1.

1.

2.

2.

3.

3.

4.

4.

5.

5.

Based only on the gathered evidence (and not on how you feel), rate how likely it is that the threat will occur, from 0% (won’t happen) to 100% (certain):    % Based only on the gathered evidence (and not on how you feel), rate the severity of the most likely outcome, from 0% (not at all severe) to 100% (most severe I can imagine):    % From Cognitive Therapy of Anxiety Disorders (p. 228) by David A. Clark and Aaron T. Beck. Copyright © 2010 The Guilford Press. Adapted in The Anxiety and Worry Workbook, Second Edition (Guilford Press, 2023). Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/ clark6-forms for personal use or use with clients; see copyright page for details.

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transform your anxious mind 129

feeling anxious after doing evidence gathering, don’t give up on it. Consider Jamal’s approach to evidence gathering. If you look at Jamal’s example, you’ll see the evidence against his anxious thought was based on his real-life experience, not on wishful thinking or abstract arguments. Also, the “against” evidence didn’t invalidate the anxious thought. Clearly Jamal was struggling in his study efforts. But the evidence indicated he was exaggerating the threat; he was thinking his study ability was much worse than it was. This increased his anxiety, which in turn caused a further decline in concentration and memory. Evidence gathering does two things: „ It

brings to light how you’re exaggerating the threat. You’ll notice through evidence gathering Jamal recalibrated the probability of not remembering anything as low (25%). He realized the more realistic outcome was “not remembering as much as he wanted.” This was much less severe (20%) than remembering nothing.

„ It

starts the process of discovering a less anxious, alternative way to think of your anxious concern.

Correct Anxious Thinking: Consider the Consequences People who struggle with anxiety often develop ways of responding that worsen their anxiety in the long run. They come to believe that worry, avoidance, reassurance seeking, and the like are the only way to deal with anxiety. Or they accept their exaggerated beliefs in threat and danger as the only way to view a situation. One person automatically thinks about heart attacks whenever she has unexpected chest pain; another worries incessantly about finances. This investment in the “anxious mind-set” can be evaluated using another CBT strategy called cost– ­benefit analysis. This intervention focuses on the consequence of anxious thinking. If you’re not convinced by the evidence-­gathering exercise that your anxious thinking about threat is distorted, you still might conclude that this type of thinking is not worth it; that any benefits are outweighed by the costs. If you’ve been living with anxiety for a long time, your anxious way of seeing yourself and your world may have become an entrenched part of your life, and you may have forgotten the cost that it’s exacting. Doing a cost–­benefit analysis is a powerful way to increase your resolve to correct this faulty thinking. Reminding yourself of the heavy price you’re paying for continuing to listen to your exaggerated thoughts and beliefs about threat and danger will help weaken your investment in “assuming the worst.”

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Jamal’s Evidence-­Gathering Form Write down the anxious thought about threat or danger you are testing:   I can’t study for the LSAT because

I can’t concentrate or remember anything. Evidence for anxious thought 1.  I’ve not studied in the last several weeks. (evidence of worst outcome)

Evidence against anxious thought 1.  When I eventually take out the books and just read a few

pages of study material, I’m surprised that I can read a few pages when I don’t try to memorize the material.

(evidence against worst outcome) 2.  When I try hard to study, I become very

anxious.

(evidence of worst outcome)

2.  When I think back to past study periods, I get more

questions right than wrong when I quiz myself. This means that I’m remembering more information than I realize.

(evidence against worst outcome) 3.  I’m able to study for only 20 minutes at a

time even when I’m less anxious.

(evidence of not coping)

3.  I remember my undergraduate days, when I could cram

for exams and retain a large amount of material in a short period of time.

(evidence of ability to cope) 4.  Every time I quiz myself after studying

4.  I can study for the LSAT better if I keep my study time

(evidence of high likelihood of not remembering)

(evidence of safety, ability to cope)

5.  Every time I open the LSAT practice book

5.  Even when I’m highly anxious while studying, it’s not

(evidence of not coping)

(evidence against likelihood and severity of worst outcome)

even a little I get too many wrong answers.

I’m overcome with anxiety.

to 20-minute periods with plenty of breaks in between.

true that I remember absolutely nothing.

Based only on the gathered evidence (and not on how you feel), rate how likely it is that the threat [not remember any study material] will occur, from 0% (won’t happen) to 100% (certain):   25%  Based only on the gathered evidence (and not on how you feel), rate the severity of the most likely outcome [that I’ll remember less material than I’d like], from 0% (not at all severe) to 100% (most severe I can imagine):   20%  From Cognitive Therapy of Anxiety Disorders (p. 228) by David A. Clark and Aaron T. Beck. Copyright © 2010 The Guilford Press. Adapted by permission.



transform your anxious mind 131 IN T ER V EN T ION EXER C I S E 

Conduct a Mental Audit

This exercise provides instruction in doing a cost–­benefit audit of your anxious mind. Use Worksheet 6.6, My Cost–­Benefit Form, to list the advantages (benefits) and disadvantages (costs) of continuing to accept how you think about threat when you have a problem with anxiety. Follow the instructions for completing the worksheet. After you’ve listed several advantages/disadvantages of anxious thinking, think deeply about the costs you listed so they readily come to your mind when you feel anxiety build. Â Tips for Success: More on Consequences

If the cost–­benefit audit didn’t help you reduce anxious thinking, consider integrating it with the evidence-­gathering exercise. It’s important not to treat cost–­benefit analysis as an intellectual exercise but rather to deeply reflect on the disadvantages of exaggerating threat. It’s important to feel these disadvantages emotionally, not just intellectually. To achieve this level of effect you must spend time with your Cost–­Benefit Form. Add new disadvantages of your anxious thinking as they come to you, and review the worksheet frequently. Keep it handy and read it over when experiencing anxiety. Remind yourself, “I can choose to think about the possibility of future threat, about the worst outcome, or I can choose to think about the less threatening alternative. Is my tendency to always focus on the worst possibility working well for me, or is it associated with a lot of negative effects? What’s the cost of always assuming the worst, the most threatening or dangerous?”

Consider Emma, a 43-year-old government employee, who had a longstanding problem with generalized anxiety. Emma had many worries, but one of her most troubling anxious concerns was finances. There were several things about money that made her anxious, but one of her biggest concerns was not saving enough for an unforeseen emergency. More specifically, she often thought “I’m not saving enough money to protect myself from some future financial disaster.” Review Emma’s Cost–­ Benefit Form to see the advantages and disadvantages associated with her anxious thinking about saving. Although worrying about saving was not entirely futile, it’s obvious from Emma’s cost–­benefit analysis that her anxious thinking was exacting a huge cost on her quality of life. The disadvantages she circled—more anxiety, less sleep, conflict with her partner, and distraction from parenting—were robbing her of happiness and fulfillment. The audit showed Emma that she needed to change how she thought about saving.

W ORK SHEE T 6.6

My Cost–­Benefit Form Instructions: There are several steps to completing this worksheet.

„ Step 1. Begin by writing down a specific anxious thought or belief. You can use the anxious thought(s) you

worked on in the previous exercise.

„ Step 2. Next think hard about the direct and indirect advantages or benefits and disadvantages or costs

of the anxious thought when you’re not feeling anxious. Make sure you come up with specific pros and cons. Avoid general or vague reasons, which will not be helpful when you’re anxious. „ Step 3. Include both short-term and long-term consequences of assuming that the anxious thought is an accurate prediction of what could happen. „ Step 4. Circle the costs and benefits that are most important to you. „ Step 5. Try to review this form immediately after experiencing an episode of problematic anxiety, spending several days on this exercise to correct, add, and delete various benefits/costs to your thinking. There may be some reasons that you overlooked when you completed the form when not feeling anxious. Briefly state the anxious thought or belief: Immediate and long-term benefits

Immediate and long-term costs

1. 

1. 

2. 

2. 

3. 

3. 

4. 

4. 

5. 

5. 

6. 

6. 

7.

7.

Note. Circle the advantages and disadvantages that are most important to you. From Cognitive Therapy of Anxiety Disorders (p. 229) by David A. Clark and Aaron T. Beck. Copyright © 2010 The Guilford Press. Adapted in The Anxiety and Worry Workbook, Second Edition (Guilford Press, 2023). Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/ clark6-forms for personal use or use with clients; see copyright page for details.

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transform your anxious mind

133

Emma’s Cost–Benefit Analysis Briefly state the anxious thought or belief:

I’m not saving enough money to protect myself from some future

financial disaster. Immediate and long-term advantages

Immediate and long-term disadvantages

1.

It’s forcing me to save each month, and so my investments are slowly growing.

1.

The more I think about not saving enough, the more anxious and tense I feel. It can practically ruin my day. Once I start to worry about saving enough, I can’t seem to stop; it consumes me.

2.

Because I worry about saving, I’m watching my expenses more closely.

2.

3.

I’m now better prepared to absorb a financial loss.

3.

I don’t sleep well because of worry over my investments.

4.

I’m less likely to lose the house or go bankrupt if I lose my job.

4.

There is little enjoyment in my life because I’m constantly worried about finances.

5.

I feel better about myself when I’m saving.

5.

I frequently deprive myself of the little pleasures of life for fear of spending money.

6.

6.

7.

7.

I get into severe arguments with my partner over saving and spending money; she threatened to leave. I feel distant and uninvolved with my children because I’m so preoccupied with finances.

8.

8.

I spend long, frustrating hours each night monitoring my investments.

Note. Circle the advantages and disadvantages that are most important to you. From Cognitive Therapy of Anxiety Disorders (p. 229) by david A. Clark and Aaron T. Beck. Copyright © 2010 The Guilford Press. Adapted by permission.

Correct Anxious Thinking: Be Aware of Cognitive errors You were introduced to cognitive (thinking) errors in Table 6.2. These errors are particularly important in sustaining an anxious mind and driving up the intensity of anxiety problems. But you don’t have to be a slave to cognitive errors! No doubt you catch yourself making these errors when thinking about other issues in your life. Do you notice what you do when you catch yourself jumping to conclusions,

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for example? You automatically correct your thinking, maybe telling yourself to be patient and wait to see what really happens. In CBT for anxiety, therapists work on helping people become more aware of their cognitive errors. This is another intervention that cognitive behavior therapists use to correct the anxious thoughts and beliefs responsible for anxiety problems. IN T ER V EN T ION EXER C I S E 

Cognitive Error Awareness

This exercise is focused on increasing your awareness of the cognitive errors that have crept into how you think about threat, helpless, and safety during times of severe anxiety. Based on Table 6.2, Thinking Errors in Anxiety, review the anxious thoughts you recorded and write down the cognitive errors that are evident in each anxious thought. Then, over the next couple of weeks, work on being more aware of your anxious thinking errors. Whenever you feel anxious, stop yourself and ask: “What am I thinking right now?” “Are there any errors or mistakes in how I’m thinking at this moment?” “Am I catastrophizing, jumping to conclusions, having tunnel vision or nearsightedness, emotional reasoning, or all-or-­nothing thinking?” On a blank sheet of paper, write down some examples of common thinking errors that occurred during each anxiety episode. Within a few days you should have gathered many examples of anxious thinking errors. You can then be on the lookout for these errors whenever you feel anxious. Â Tips for Success: Increasing Your Sensitivity to Thinking Errors

It’s much easier to see the errors in other people’s thinking than in our own. This is true even for cognitive behavior therapists! A good way to build greater awareness of cognitive errors is to start by picking out cognitive errors in the thinking of your friends and family. Once you’ve done this a few times, try becoming aware of your errors with nonanxious concerns and then finally go back to identifying cognitive errors during your anxiety episodes. You can ask your partner or close friend who knows about your anxiety to help you identify the errors in your anxious thinking. Of course if you’re in therapy, you’ll be working on this skill with your therapist.

Jamal noticed that the evidence he gathered for his anxious thought “I’m losing focus when I study; I don’t understand anything” was loaded with cognitive errors. Tunnel vision (he focused only on what he didn’t know and ignored what he did understand), emotional reasoning (because he felt anxious, he assumed he must not be focusing), and all-or-­nothing thinking (if I can’t remember everything when I study, then I must be losing my focus) were rampant when he became anxious about studying.



transform your anxious mind 135

Correct Anxious Thinking: Discover the Alternative In previous exercises you discovered how exaggerated predictions about the likelihood and severity of threats to yourself or significant others create a problem with anxiety. Despite evidence to the contrary, many disadvantages, and several cognitive errors, your anxious mind kicks into gear before you know it. Maybe this has been happening for so long that you’re not sure how you could think differently about your anxious concern. Take Alexis’s struggle with commitment. Every time she started to get serious, she could feel anxiety build to an unbearable level. The only solution was to break off the relationship, which she ended up doing repeatedly. Several anxious thoughts were driving her relationship anxiety, including “What if this person’s not right for me, what if there’s someone better, what if I get trapped in a relationship that ruins my life, or how do I know I’m truly in love?” Alexis realized that most people make longterm commitments, so they must see it differently. What she discovered in therapy is that people accept the risk of commitment because it’s impossible to eliminate it entirely. Their alternative thinking goes like this: We can’t know the future, and with 7.8 billion people on this planet, there’s a good chance several people exist who’d be a better partner. How could we possibly know? Falling in love is risky because I could get hurt. I’m quite certain my partner loves me, but I have my times of doubt. If I fail to risk commitment, it means I live alone and alienated from others, which for me sounds truly depressing. As you consider Alexis’s dilemma, which way of thinking about commitment would cause less anxiety? Is it thinking that commitment is risky, it could ruin your life, and you need to be certain you’re making the right decision? Or alternatively, thinking that all relationship commitment is risky to a certain extent, we can’t know the future, and we can only make what appears to be a good decision in the present? If relationship problems arise in the future, there are options available to us. No doubt you’ll agree that the second way of thinking is associated with less anxiety. But notice it’s not an anxiety-free view of commitment. With the alternative, you may still feel some anxiety about committing yourself to another person, because there is a lot at stake. However, the anxiety is less intense, more tolerable. Is this not the way it is for most people who enter a long-term intimate relationship? How we think determines the intensity of our anxiety and how we cope with it. One problem with seeing things differently is not being able to think of an alternative explanation. If you have trouble coming up with different alternatives, consider the following questions:

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„ How

do people who feel less anxious understand your anxious concern when they experience it? What do they tell themselves about the concern?

„ What

is an alternative way of thinking that is more likely, that is a better approximation to reality than your more extreme, catastrophic thinking?

„ Is

the alternative somewhere between your ideal outcome and the catastrophic, worst-case scenario?

„ If

the alternative happened, could you cope with it better than if the anxious, catastrophic outcome happened?

Another problem is believing the alternative. Maybe you can think of a healthier perspective but you can’t seem to make yourself believe it, especially when you’re highly anxious. Before we get into issues of belief, let’s work on discovering an alternative, less anxious way of thinking about the concerns involved in your anxiety problem. IN T ER V EN T ION EXER C I S E 

Creating an Alternative Perspective

Step 1.  What I Think Begin Worksheet 6.7 by identifying a threatening thought that automatically enters your mind when you feel the distress associated with your anxiety problem. This could be an anxious thought you recorded on previous worksheets. Next, think creatively about an alternative, less anxious way to think about the situation or issue that’s causing you to feel anxious. Ask yourself the following questions as you work on constructing a less anxious, alternative way of thinking. „ Before I had problems with anxiety, how did I understand the anxious concern or

interpret the situations that trigger the anxiety? „ How do other people who don’t have severe anxiety think about the anxious concern

or the things that trigger my anxiety problem? „ Based solely on the evidence, what is the most likely interpretation or outcome of the

anxiety-­related situation? „ When I’m feeling calm and rational, how do I view the anxious concern or its trig-

gers? Step 2.  Believing the Alternative The second part of this exercise focuses on determining whether the alternative is believable. First consider evidence from your experience or any reasons you can think of for

W ORK SHEE T 6.7

My Alternative Perspective Form Instructions: Record an anxious, threatening thought that automatically enters your mind during periods of severe anxiety. Next write down an alternative way of thinking that is more realistic and less catastrophic. After making note of your competing ways of thinking, use the double-­column table to list reasons for believing or doubting the alternative.

Anxious Thinking Write down a threatening thought, prediction, or interpretation that is associated with your anxiety problem. This anxious thought is a more extreme, even catastrophic, worst-case prediction that makes you feel highly anxious when you think about it.

Alternative Thinking Briefly describe an alternative prediction related to the outcome stated above. It will be a way of thinking about possible outcomes that is less extreme, more realistic, and more manageable if it occurred. The alternative will still be undesirable, but it’ll cause less anxiety. Evidence/reasons for believing the alternative

Evidence/reasons for doubting the alternative

1.

1.

2.

2.

3.

3.

4.

4.

5.

5.

6.

6.

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

137

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considering the alternative an acceptable way to understand your anxious concern. Next, identify any reasons or evidence that cause you to doubt the believability of the alternative. After you’ve generated an alternative explanation for your anxious concern, try applying the more realistic explanation whenever you begin to feel anxious. Continue to gather evidence from your daily experiences that strengthens your belief in the alternative. Â Troubleshooting Tips: Additional Suggestions for Generating Alternatives

In our experience most people have great difficulty generating a different, less threatening perspective on their anxious concern. Often there needs to be considerable input from the therapist. So if you are finding this intervention difficult, don’t despair. This happens more often than not in the early sessions of CBT. But with practice we’ve found that people can learn to think in a less threatening way. We’ve listed some additional tactics you can use to sharpen your ability to discover an alternative, plausible perspective on your anxiety. „ Try to adopt an objective, scientific perspective on your anxious concern. Don’t try to

come up with a perspective you already believe or accept. Instead, adopt the attitude of a detached observer, like a therapist, who interprets the situation in a more likely, less emotional, and more realistic manner. „ Imagine that the anxious concern or situation belonged to a friend or colleague. How

would you advise that friend to think about their anxious concern? „ You could also ask close friends, a family member, or your partner how they see the

situations that make you anxious. Adopt their nonanxious way of thinking as your alternative and work on gathering evidence/reasons for it. „ If you are in therapy, learning to accept an alternative perspective will be a major

focus of your cognitive behavior therapist.

Discovering an alternative, less threatening way to think of your anxious concern is difficult because once we start thinking about threat and danger, it’s hard to see it any other way. If this is happening to you, consider Jody’s example of alternative thinking. She had developed a type of agoraphobic anxiety in which she avoided public places for fear of physical harm or injury from others. Her anxious mind assumed that public places should be avoided because people are dangerous and not to be trusted. If she ventured into these places, she believed she was putting herself at great risk. Alternatively, her anxiety was not caused by dangerous people in public places, like a crowded mall, but by her erroneously thinking something that was relatively safe was dangerous. You can see from Jody’s list that the evidence was more supportive of the alternative view than the anxious outlook.



transform your anxious mind 139

Jody’s Alternative Perspective Form Anxious Thinking Write down a threatening thought, prediction, or interpretation that is associated with your anxiety problem. This anxious thought is a more extreme, even catastrophic, or worst-case prediction that makes you feel severely anxious when you think about it.   People can’t be trusted; they are threatening and capable of

causing harm so better to leave before I lose control. Alternative Thinking Briefly describe an alternative prediction related to the outcome stated above. It will be a way of thinking about possible outcomes that is less extreme, more realistic, and more manageable if it occurred. The alternative will still be undesirable, but it’ll cause less anxiety. To get along in this world we have little choice but

to assume people are nonviolent unless proven otherwise. My anxiety in crowds is due to my relentless search for threat and my inability to recognize the existence of safety cues. I can just let the anxiety decrease on its own. Evidence/reasons for believing the alternative 1.  I’ve never been a victim of random acts of

violence in public places. Therefore, my anxiety must be due to thinking it’s dangerous rather than the presence of actual danger. 2.  It’s only been the last few years that I’ve been anxious around other people. In the past I must have trusted people and assumed they weren’t a threat. When I didn’t think of people as threatening, I wasn’t anxious around them. 3.  My friends, family, and coworkers aren’t anxious in crowded public places, because they assume public places are more safe than dangerous. Because I assume the opposite, I’m always anxious around others. 4.  I have more self-­control than I give myself credit for. Even when highly anxious, I’ve never lost control or drawn attention to myself. 5.  I’ve noticed that when I’m highly anxious in

public places it depends on what I think about the place rather than any objective signs of danger. 6.  When I stay in a public place and let the anxiety decline naturally, everything works out fine. I’m not putting myself at greater risk by feeling anxious in a public place.

Evidence/reasons for doubting the alternative 1.  Whenever I’m in public places I feel anxious, so

there must be something wrong. This is my body telling me to leave, that it’s not safe here.

2.  Once I leave a public place, the anxiety

immediately decreases. This tells me I’m doing the right thing.

3.  Bad things happen to people when they least

expect it. We hear all the time about random acts of violence.

4.  When I’m highly anxious, I feel so out of control.

I’m concerned that people will notice there’s something wrong with me and then feel threatened by me.

5.

6.

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Learning to counter your anxious thinking with a more realistic, less anxious alternative takes practice. It has nothing to do with intelligence or creativity. Everyone finds it hard to “override” their anxious mind and think about their concerns from a different perspective. So give yourself time and repeated practice generating alternatives. Every time you experience your anxiety problem, ask yourself: „ How

am I thinking about this situation that’s making me more anxious?

„ How

could I think about this situation that would make me feel less anxious?

And keep generating these alternatives even if they feel like an intellectual exercise. They’ll be hard to believe at first, but your acceptance of them will grow stronger the more you work on gathering evidence/reasons that support the alternative.

The Next Chapter The anxious mind makes an important contribution to the creation of anxiety problems. It magnifies anxiety symptoms by causing us to misinterpret threat, believe we’re helpless and unable to cope, commit cognitive errors, and underestimate the presence of safety and security. This anxious way of thinking can be depicted in a “mind map” that guides your treatment approach. In this chapter you also learned about CBT’s most effective cognitive interventions for anxiety reduction—­evidence gathering, cost–­benefit analysis, identifying cognitive errors, and generating alternatives. With practice, you’ll gain proficiency in these cognitive skills and begin to see changes in how you experience your problematic anxiety. But cognitive change is not enough to experience the degree of anxiety reduction you most likely desire. Behavioral change is also a key treatment component in CBT for anxiety, and so behavioral change is the subject of our next chapter.

7 curb anxious behavior

W

hen anxiety dominates your life, it may seem like courage is in short supply. But nothing could be further from the truth. Courage is the determination to stand up to danger, fear, and difficulties. No doubt you can think of family, friends, or neighbors who showed courage when facing major difficulties such as a life-­threatening illness, loss of employment, death of a loved one, unexpected financial loss, or a broken relationship. It takes courage to survive in this challenging and uncertain world. But courage is not something evident only when you’re facing external problems. It takes courage to face problems from within and make personal changes that boost life satisfaction. You, too, can act with strength and courage. The only difference between you and the people you consider courageous is that anxiety makes it difficult to recognize your courage or to remember how well you’ve faced problems and challenges in the past. The courage you once had seems inexplicably gone. But the truth is you still have courage. This chapter will help you rediscover your courage and use it in your work against anxiety problems. Even those whose acts of courage seem much more heroic than yours can have an apparent “loss of courage” and then reclaim it, as illustrated in the following story. Gerard, a 32-year-old, six-foot, two-inch, 220-pound combat soldier in top physical condition, had just returned from a second tour of southern Afghanistan, where he was frequently assigned foot patrols in dangerous villages, participated in convoys that came under enemy fire, and engaged in several firefights with the Taliban. Repeatedly he had placed himself in harm’s way and on one occasion pulled an injured soldier to safety under intense fire. When he got home, however, Gerard’s toughness and resilience seemed to desert him. Within a couple of months he became so irritable, short-­tempered, and anxious that his life started to crumble. He spent most days with a queasy feeling in his stomach and an overwhelming sense that something bad was about to happen. His anxiety seemed particularly severe around other people, so he 141

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started to avoid socializing. Crowds were particularly difficult, so he chose to stay at home. When he did venture into public places, he feared a loss of control over his feelings and actions. He became very dependent on his partner, not wanting to make decisions or take initiative around the house. Over time he became more depressed, cynical, and hopeless about life and his future. From a courageous, resilient soldier to a lonely, scared father cowering in his basement to avoid others—the fall could not have been more dramatic! It took a few months of persuasion by his family for Gerard to agree that anxiety and depression had overtaken him and he needed help. At first he didn’t realize that seeking help was an act of courage, and it wasn’t until he used a systematic program of behavioral change like the one in this chapter that he found he could once again face fear and anxiety. Like Gerard, perhaps you’ve forgotten that you were once courageous, able to face the difficulties and uncertainties of life. But the good news is that you can regain courage to face what’s causing your emotional distress. Anxiety cannot eliminate courage; it can camouflage it or override it, but it cannot eliminate it. You were introduced to the basic CBT model of anxiety in Chapter 4 (see Worksheet 4.6). It has three components: triggers, anxious thinking, and behavioral symptoms. Chapter 6 focused on the second component, anxious thinking, and introduced treatment strategies that can transform your anxious mind. In this chapter we consider the third component of the model, the behavioral symptoms. You’ll learn about several ways of acting that increase anxiety, and interventions that change how you deal with your anxiety problem. It’s important to remember that Chapters 6 and 7 complement each other. You need both cognitive (thinking) and behavioral change to achieve a genuine reduction in fear, anxiety, and worry. As you do the work in this chapter, from time to time review what you did in Chapter 6. The strategies in the two chapters are meant to be used together for all types of anxiety problems. Let’s begin with courage because that is what you’ll need to make the changes described in this chapter.

Acts of Courage Maybe you’ve been struggling with intolerable anxiety for so long that you haven’t thought of courage for years. Just because you can’t see yourself as having courage doesn’t mean it’s vanished from your life. On the contrary, anxiety can feel like a thick fog. You may not be able to see the ground because of fog, but it’s still under your feet. Being anxious about mundane things doesn’t mean you have no courage. When was the last time you persevered at something or took a course of action that required strength, determination, and acceptance of some risk? Maybe you confronted some-



curb anxious behavior 143

one about an issue you knew would be difficult, made a decision of conscience that you knew would bring some hardship and uncertainty, or faced a difficult situation that seemed insurmountable. Life has a way of presenting us with challenges we didn’t anticipate, whether it’s moving to an unfamiliar city, starting a new job or school program, dealing with a serious illness, losing your job, having an intimate relationship end, parenting a difficult or rebellious child, or living with a partner who abuses drugs or alcohol. E VA L U AT ION EXER C I S E 

Remembering Courage

Rediscovering courage starts with remembering times in the past when you displayed some degree of strength and courage. Start by noting some recent experiences that involved a difficult and uncertain situation or circumstance in your life. Some of these may be major life events, such as loss of a loved one, or they could be minor, such as speaking up at a meeting when you were feeling especially anxious. Next consider how you showed strength and determination to deal with these difficulties. Fill in Worksheet 7.1 by considering what you did to cope with the circumstance. How were you able to “keep your head above water” during these difficult times? On these occasions you were acting courageously. Â Troubleshooting Tips: Recognizing Courage

If you feel uncomfortable writing down instances of your own courage, keep in mind that no one needs to see this list besides you. If you really can’t think of yourself as ever having been courageous, try asking a close friend, partner, parent, or family member if they can think of any experiences where you displayed strength of character and resourcefulness.

The responses you listed in Worksheet 7.1 represent an expression of the adaptive mode, which we introduced in Chapter 1. This refers to ways we think, act, and feel that enrich our lives and boost self-­esteem. In CT-R we call these moments of being at our best, and acting with courage is a prime example of adaptive mode functioning. If you take the example in Worksheet 7.1, accepting a cancer diagnosis, obtaining knowledge about breast cancer treatment and prognosis, and shifting to a more present focus were coping strategies based on courage. Reviewing your entries in Worksheet 7.1, are there courage-based strategies you used that could be helpful in dealing with situations that trigger your anxiety problem? As you work through this chapter, keep Worksheet 7.1 handy as a reminder that courage is part of your adaptive mode. Our goal is to help you tap into your adaptive mode and face your anxiety problems courageously.

W ORK SHEE T 7.1

My Acts of Courage Instructions: List several past or current situations in which you displayed some degree of strength and courage. In the second column, indicate what you did or how you coped with that situation in a way that indicates you displayed some perseverance, strength, and determination. An example is provided in the first row.

Distressing, difficult, or uncertain situations Ruth’s example:

10 years ago I was diagnosed with stage 1 breast cancer and had treatment

How you showed strength and courage (How did you cope with this situation that indicates you had strength, determination, and courage to overcome fear or anxiety?)

I cried a lot at first but then started reading material on treatment options and prognosis. I came to accept my cancer rather than wish it away. I worked on developing a positive but realistic attitude and accept that my future was more uncertain. I needed to make the most of every day rather than take them for granted.

1.

1.

2.

2.

3.

3.

4.

4.

5.

5.

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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curb anxious behavior 145

Self-­Protection: The Anxious Way to Cope The self-­protective mode evolved as an early warning system for danger.27 Detecting danger or threat mobilizes responses to eliminate the threat. These responses are the basis of anxiety, fear, and worry, and they become problematic when they exaggerate threat and helplessness and rely on unhelpful (maladaptive) coping strategies. Figure 7.1 illustrates how the self-­protective mode can lead to an escalation in anxiety. In Chapter 6 we explained how the anxious mind operates (the left side of Figure 7.1). In this chapter we delve into aspects of anxious behavior that contribute to a problem with anxiety (the right side of Figure 7.1). Consider how the self-­protective mode explains Gerard’s problem with anxiety. One of his triggers is being in public places like a shopping mall or the movies. When he’s exposed to a public place, first his anxious mind kicks into gear. He overestimates threat, thinking that people around him pose a threat to his physical well-being. He views himself as weak and unable to deal with his feelings when in public. His thought process is riddled with cognitive errors like jumping to conclusions, emotional reasoning, and catastrophizing. He is unable to evaluate the public setting more realistically because he’s not attending to the many safety cues around him. With his anxious mind fully activated, Gerard quickly decides to leave the public setting. He’s convinced the anxiety is too much to bear. He might try certain coping strategies like controlled breathing, analyzing his feelings, or distraction, but nothing works, so he leaves. This type of anxious behavior will reinforce his anxious mind (for example, Anxiety triggers

Anxious mind

Anxious behavior

• Overestimated threat • Helplessness thinking • Cognitive errors • Underestimated safety

• Intolerance of anxiety • Search for safety • Avoidance • Ineffective coping

F I G U RE 7.1.  

Self-­protective mode activation that characterizes problematic anxiety.

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“it’s a good thing I left; I was losing control; I can’t cope with being in crowds”) and make him even more sensitive to its triggers.

E VA L U AT ION EXER C I S E 

How You Self-­Protect

No doubt self-­protection plays a role in your anxiety problems. The exercise in Worksheet 7.2 focuses on how you respond when your anxiety problem is triggered. Leaving a situation or avoiding it altogether might be your most obvious self-­protective response, but try to think more broadly about all the ways you try to deal with the threat that’s making you feel anxious. Begin with writing down situations that trigger your problematic anxiety by reviewing your entries on previous worksheets. Next describe how you typically respond in these anxiety-­provoking situations. Use your ratings on the Ineffective Coping Checklist (Worksheet 4.3) as a guide to your typical coping strategy when feeling severe anxiety. Gerard’s anxiety responses are presented as an example in the first row of the worksheet.

What did you notice about your self-­protective responses? Are you, like Gerard, trying to tolerate the anxiety at first but then giving up and escaping to a safer place? Do the same self-­protective responses show up repeatedly in a variety of situations you encounter? Keep Worksheet 7.2 handy as we consider the four features of the self-­ protective mode. You may want to make changes to your entries as you learn more about the self-­protective way of responding to severe anxiety.

Intolerance: “I Can’t Stand This Feeling” If you’ve had repeated experiences with anxiety over many months, it’s understandable that you’re feeling frustrated and upset with being anxious. We’ve often heard people with anxiety exclaim, “I just hate this feeling. I would do anything to get rid of it. If only I could feel normal again.” Over time individuals develop certain ideas or beliefs about the experience of anxiety. They tend to catastrophize about being anxious, developing an intolerance of anxiety itself. The very experience of anxiety becomes a threat or danger that the person tries to avoid at all costs. This is more likely to happen if you have high anxiety sensitivity, discussed in Chapter 5. The following are some typical beliefs people hold when intolerant of anxiety: „ I

can’t stand feeling anxious.

„ If

I don’t control the anxiety, it will lead to something far worse (cause a heart attack, loss of sanity, loss of complete control, and so forth).

„ Anxiety

will continue until I stop it.

W ORK SHEE T 7. 2

My Self-­Protective Response Instructions: List several situations that trigger your problematic anxiety in the first column. In the second column, write down how you respond in each situation to manage the perceived threat and reduce your anxious feelings. Anxiety triggers Gerard’s example:

Grocery shopping with Susan and the store is crowded; immediately feel anxious

Anxiety reductions responses

I grip the shopping cart and try not to look at people; I tell myself to stay calm and take slow, deep breaths; I try to focus on the grocery list and think about what we’re putting in the cart; finally the anxiety is too much to bear, so I leave and wait for Susan in the truck.

1.

1.

2.

2.

3.

3.

4.

4.

5.

5.

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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„ Anxiety

is worse than physical pain, disappointment, or loss.

„ Persistent „ Anxiety „ It’s

anxiety can harm your health.

is a sign that you are losing control.

important to remain calm and not get so physically keyed up and agitated.

Intolerance of uncertainty is another important set of beliefs about anxiety. This is the tendency to react negatively to unpredictable or uncontrollable situations and events.28 This intolerance is especially toxic for anxiety because uncertainty is at the heart of what makes us anxious. We worry and get anxious about bad things that could happen in the future, being unsure whether they will happen or not. Anxiety over your health is a good example that shows how intolerance of uncertainty accelerates anxiety. You can’t be certain you won’t get ill, so if you have difficulty tolerating uncertainty, you could become highly anxious about your health. You want to know that you won’t get cancer, have a heart attack, or the like. Jade, for example, had a persistent and excessive fear of cancer. Despite having had numerous medical tests and being told her health was excellent, she continued to check medical sites on the internet whenever she experienced an unexplained physical symptom. Jade wanted to know for certain whether she would get cancer. Her anxiety was driven by her intolerance of uncertainty and her belief that it was important to reduce uncertainty to an absolute minimum. A third set of beliefs is discomfort with novelty, the unfamiliar. People with anxiety problems often hate new, unexpected, or unfamiliar situations. Novelty is viewed as threatening. They may believe their anxiety is worse in unfamiliar situations, that they can’t cope with novelty. They may seek to stay with the familiar because they believe it is more predictable and controllable. Being in situations that are unpredictable and uncontrollable is especially difficult for the person with anxiety. If you’re relatively intolerant of anxiety, uncertainty, and the unfamiliar, then you’ll be motivated to protect yourself. You’re more likely to try to escape or avoid anxious experiences. In fact, you may find yourself on a quest to be anxiety-free. But what if the intolerance for anxiety is part of the reason anxiety has become a problem in your life? It shifts your perspective into the self-­protective mode, in which escape and avoidance become the preferred modus operandi. If you’re wondering whether intolerance of anxiety is a problem for you, complete the Beliefs about Anxiety Scale. E VA L U AT ION EXER C I S E 

Beliefs about Anxiety

Use this exercise to assess your beliefs about anxiety. Worksheet 7.3 presents 17 belief statements about anxiety, uncertainty, their controllability, and their consequence. Rate how much you agree with each belief statement based on your experiences with severe

W ORK SHEE T 7.3

Beliefs about Anxiety Scale Instructions: Use the 5-point scale at the top of the table to check off your level of agreement with each statement. Base your answers on what you’ve come to believe about your anxiety, not on what you think you should believe. Belief statements

Completely Disagree disagree somewhat

Agree somewhat

Strongly agree

Completely agree

  1. I find it very hard to tolerate the feeling of anxiety.

  2. It is important to control anxiety as much as possible.

  3. I try to keep my anxiety episodes as brief as possible.

  4. I frequently avoid situations to prevent anxiety.   5. I am concerned about the longterm health effects of persistent anxiety.   6.  My anxiety episodes are more distressing than anything else I’ve experienced.   7. It is important that I develop better control over anxious thoughts and feelings.   8. It is important that I not appear anxious or nervous in front of others.   9.  The physical symptoms of anxiety scare me. (continued) From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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Belief statements

Completely Disagree disagree somewhat

Agree somewhat

Strongly agree

Completely agree

10. I’m concerned the physical symptoms of anxiety could be related to a serious medical problem. 11. If I don’t get better control over my anxiety and worry, I could have a complete mental breakdown. 12. I am more vulnerable when I am feeling uncertain.

13. I can’t function very well when I am having doubts and uncertainty. 14.  For me the feeling of doubt and uncertainty is upsetting and anxiety provoking. 15. I try to deal with my uncertainties as quickly as possible. 16. It is important to avoid the unfamiliar and unexpected because they make me more anxious. 17. It is important to anticipate the future as much as possible and be prepared for unforeseen circumstances.

anxiety. Make a note of the belief statements that seem particularly relevant for you. If you’re in therapy, you could discuss these beliefs with your therapist. The Beliefs about Anxiety Scale was developed for this workbook, so cutoff scores are not available. However, if you scored in the “Agree” to “Completely agree” range on 10 or more statements, you may have a problem with intolerance of anxiety. Also, circle the items you checked as “Strongly agree” or “Completely agree.” You’ll want to work on these beliefs as you make changes to your response to anxiety.

W ORK SHEE T 7.3 (continued)

curb anxious behavior 151

Searching for Safety When anxiety continually intrudes into a person’s life, causing great personal distress, it’s only natural to desire the opposite emotional state—to feel calm, relaxed, and in control. In the course of treatment we often hear individuals with anxiety exclaim, “If only I could calm down, relax, or just take things as they come.” This desire for calm and comfort causes us to engage in safety-­seeking behavior. The ability to feel calm, relaxed, safe, and comfortable is vital to our physical and mental health. But in the context of problematic anxiety, there are four drawbacks to safety seeking: 1. Safety cues are more difficult to identify than threat or danger cues are. 2. Because the focus is on achieving a quick reduction in anxiety, individuals do the first thing that comes to mind, which is often a self-­defeating safety-­seeking response. 3. It prevents people from learning they are exaggerating threat and danger.

Safety-­seeking behavior is any way of thinking or acting that is done to minimize or prevent a feared outcome. It is also an attempt to reestablish a feeling of comfort or calm and a sense of being safe.29,30

4. It reinforces the unhealthy belief that risk must be eliminated at all costs. One of the most common safety-­seeking strategies is to leave a situation as soon as some anxiety is felt. Normally individuals escape to a place of comfort, like their home, where they experience quick relief and a sense of calm and safety. One of the reasons for leaving a situation in which you feel anxious is that it’s easier to detect possible threat cues but harder to identify safety cues. So you end up exaggerating the threat and missing evidence of safety.29 Let’s take the example of walking into a social gathering. You may find it quite easy to quickly pick up cues that other people don’t accept you—maybe someone frowns at you or glances at you and then immediately continues a conversation with someone else. It is much harder to recognize the cues indicating people accept you. You fail to recognize that a smile is intended for you or that someone is looking at you to include you in a conversation. Because it’s harder to process information that would make you feel comfortable and safe, you might tend to rely on strategies that will quickly reduce your anxiety. If so, you won’t learn that the situation is not nearly as threatening as you think. This biased thinking means you’ll keep trying to minimize perceived risk as quickly as possible. Inadvertently your safety-­seeking efforts contribute to a persistence of the anxiety problem.

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E VA L U AT ION EXER C I S E 

Your Safety-­Seeking Profile

Escape and avoidance are the most common safety-­seeking behaviors, but they’re not the only ones we use when feeling unsafe. This exercise will help you identify a broader array of strategies you might use to feel safer and more comfortable. Worksheet 7.4 lists several cognitive and behavioral strategies often used to reestablish a sense of calm and safety. Consider whether you never, sometimes, or often resort to these strategies when feeling severe anxiety.

Examine the items for which you circled “Often used.” These are the coping responses you’re using most often to reestablish a state of calm and safety. You know that feeling safe and comfortable is the opposite of feeling threatened and anxious. If you can feel safer, you know you’ll feel less anxious. But safety seeking is often counterproductive. Look back on the items you endorsed as “Often” or “Always” on the Ineffective Coping Checklist (Worksheet 4.3) and see if there is an overlap with the safety-­seeking responses you circled on Worksheet 7.4. Often our safety-­seeking efforts are ineffective. They also switch the focus from learning to tolerate anxiety to running from anxiety. Ultimately, the pursuit of safety is self-­defeating because you can’t live anxiety-free. Better to strengthen your anxiety tolerance than reinforce an unattainable wish to avoid it. In CBT this is accomplished by eliminating ineffective safety-­seeking behaviors and improving your ability to truly appreciate the actual safety features of situations that make you feel anxious.

Escape and Avoidance The urge to escape what you think is causing your anxiety, and then to avoid further contact with it is a natural reaction to feeling anxious. Escape and avoidance are the two strategies most commonly used to control anxiety. And we’re all very familiar with them. They are an automatic defensive response to fear and anxiety, and on the surface they seem remarkably effective in stopping anxiety dead in its tracks. Think back to the number of times you felt anxious and left the situation immediately. You’re at a party, in a crowded grocery store, at a meeting, driving an unfamiliar route, and you begin to feel anxious. What happens if you immediately leave the situation? More than likely your anxiety subsides almost immediately. Psychologists call this the fight-or-­flight response. We see it in all animals as well as humans when they are afraid. Our natural responses are to either run or stand our ground and fight. Louise had agoraphobia that involved a fear of open spaces. For years she avoided crossing most bridges in her city, which greatly restricted her ability to travel around her community. We met near one of the bridges that Louise avoided, with the goal of

W ORK SHEE T 7.4

My Safety-­Seeking Response Form Instructions: Use the 3-point rating scale to indicate how often you use any of the safety-­seeking responses when you experience problematic anxiety. Base the ratings on whether you typically use a response when feeling highly anxious. Never used

Sometimes used

Often used

Leave (escape) when first symptoms of anxiety are noticed

0

1

2

Carry antianxiety medication

0

1

2

Carry cell phone to call for help when anxious

0

1

2

Be accompanied by friend or family member in situations in which you feel anxious

0

1

2

Have water or other liquids readily available

0

1

2

Listen to music when anxious

0

1

2

Engage in relaxation or controlled breathing when anxious

0

1

2

Lie down, rest when anxious

0

1

2

Whistle, sing to yourself when anxious

0

1

2

Tense or hold on to objects when anxious

0

1

2

Distract yourself by looking away from whatever evokes fear

0

1

2

Seek reassurance from others

0

1

2

Think about something more positive or calming

0

1

2

Try to imagine yourself in a safe or peaceful situation

0

1

2

Try to reassure yourself that everything will be all right

0

1

2

Try to convince yourself you’re not really feeling anxious

0

1

2

Try to focus on the task at hand, such as work or driving, to avoid attending to the anxiety

0

1

2

Pray; seek divine protection

0

1

2

Criticize yourself for feeling anxious

0

1

2

Safety-­seeking responses Behavioral responses

Cognitive responses

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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gradually and systematically approaching the bridge on foot. As we got within 25 feet of the bridge, I could see that Louise was becoming panicky. Her breathing became shallow, her whole body stiffened, and she stopped dead in her tracks, fear written over her face. I asked her to describe what she was feeling. She said, “I feel like I can’t breathe. My legs have gone weak, and I’m terrified. It’s taking everything in my power not to run!” Escape appears to be the safest option when we’re overtaken by anxiety. We quickly learn what objects, situations, or circumstances trigger our anxiety and then we avoid future contact with these triggers as much as possible. But the fact that escape and avoidance are natural responses doesn’t make them the best anxiety-­ reduction strategies. In fact, clinical researchers and mental health professionals have long known that escape and avoidance are significant contributors to the long-term persistence of anxiety. There are three major problems with escape and avoidance: „ They

prevent anxiety from declining naturally.

„ They

reinforce the false belief that the feared catastrophe driving the anxiety has been averted.

„ They come at a great personal cost by limiting what you can do, where you can

go, and who you can be with. When you rely on avoidance, you end up believing you are weak, dependent, or inadequate—that you “no longer have a life.” For many years psychologists focused on avoidance of external objects and situations when treating anxiety. But more recently we’ve discovered that avoidance of thoughts, feelings, and the physical sensations believed to trigger anxiety episodes also contributes to the persistence of anxiety. Some people try to avoid certain thoughts or images that they find anxiety-­provoking, such as thoughts of death or dying, of saying something rude or embarrassing to others, of imagining some terrible injury happening to a loved one, or of terrible career loss or failure. Others may avoid strong emotional states like excitement, anger, or frustration, believing they are signs of losing control, which they fear could lead to an anxiety episode. Still others might try to avoid anything that causes an increased heart rate, lightheadedness, dizziness, a queasy stomach, shortness of breath, or sweating, because these sensations are also connected with anxiety. Avoidance is one of the main reasons problematic anxiety can cause so much interference in daily living. You probably have a good idea of many things you avoid because they make you anxious. However, avoidance often spreads in subtle ways, so you may not realize how much you’re avoiding because of anxiety. This next exercise will help you discover the extent of your avoidance profile.



curb anxious behavior 155 E VA L U AT ION EXER C I S E 

What Are You Avoiding?

Worksheet 7.5 categorizes avoidance into external triggers, thoughts/images/memories, and physical symptoms/sensations. The first column lists situations, objects, persons, or other external cues that you may regularly avoid because of anxiety. You are probably quite familiar with your external triggers. The second column may be the most difficult to complete because we’re often not aware that certain thoughts or images can trigger anxiety. You’ll need to read through this list carefully and recall some of your recent experiences of severe anxiety. Was there an initial thought that popped into your mind that sparked a fresh round of anxiousness? Do these initial thoughts fall within one of the cognitive themes listed in the second column? The third column lists physical sensations that are common when feeling stressed or anxious. People are often more aware of their physical arousal when anxious. Do you tend to avoid any of these sensations because they make your anxiety worse? Â Tips for Success: Detecting Subtle Avoidance

Avoidance is often easy to spot. People with agoraphobia, for example, are well aware they avoid crowded stores or shopping malls because they fear they’ll have severe anxiety or a panic attack. At other times the avoidance can be subtle, such as avoiding physical exercise because you dislike the feeling of being out of breath. To help you identify subtle avoidance of thoughts, images, or physical sensations, consider all activities and experiences that you try to avoid. Ask yourself, “Why do I hate doing this activity?” or “Why am I so intent on pushing this thought out of my mind or shutting down this physical sensation?” Question your motives. You might want to believe you’re avoiding it because you just don’t like doing it or it’s best not to do it. But if you’re being honest, you’ll recognize that you’re not doing it because it makes you anxious. You may discover several examples of such “subtle avoidance.” These should be included in your avoidance list. If you’re being treated for anxiety, your therapist should be able to help you identify subtle avoidance.

What did you learn about your escape and avoidance pattern? Although there are broad similarities in what people with the same anxiety problem avoid, the specific triggers will differ among individuals. For some people it is mainly social or interpersonal situations, for others it may be anything they think might trigger a panic attack, whereas for others it might be upsetting thoughts or images that spontaneously pop into their mind. Whatever it is that you avoid because of anxiety, it is important to discover your unique avoidance profile because it is an important contributor to anxiety problems. Repeated escape and avoidance confirm our belief that anxious

W ORK SHEE T 7.5

Discovering My Avoidance Profile Instructions: Place a checkmark beside the external triggers you often avoid. The list is selective, so there are additional spaces marked “other” where you can list external triggers that are unique to your anxiety problem. In the second column, check the unwanted thoughts, images, and memories you try not to think because they are anxiety-­provoking. Do the same in the final column, which lists specific body sensations, experiences, or symptoms that may be frightening to you.

External triggers avoided

† Driving unfamiliar routes

Thoughts, images, or memories avoided

Physical symptoms, sensations avoided

† Heart palpitations

† Being home alone

† Thoughts or images of embarrassing yourself in front of others

† Enclosed places (elevators, tunnels)

† Thoughts of causing harm, injury, or death

† Feeling lightheaded or dizzy

† Doctor, dentist visits

† Thoughts of bad or catastrophic events happening to friends or loved ones

† Crowds † Giving a speech † Initiating a conversation with unfamiliar people

† Disgusting images such as mutilated bodies

† Shortness of breath

† Sweating † Queasy stomach or nausea † Blurred vision † Feeling flushed † Being red in the face

† Answering the phone

† Thoughts or images of a past personal trauma

† Participating in a meeting

† Disgusting sexual thoughts

† Vomiting

† Walking in front of a group of people

† Thoughts about disease and contamination

† Other:          

† Stores, malls

† Thoughts of God’s punishment or the end of the world

† Other:          

† Air travel † Open spaces

† Gender/sexual orientation thoughts

† Restaurants

† Thoughts about dying

† Bridges

† Wondering if you’re liked by others

† Other:           † Other:           † Other:          

† Feeling sick

† Other:          

† Other:           † Other:           † Other:          

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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thoughts represent real threats and that we’re too weak and vulnerable to stand up to our fears. So reducing your reliance on escape and avoidance is an important goal in CBT for anxiety.

Ineffective Coping Chapter 4 explained how ineffective coping contributes to anxiety problems. You completed the Ineffective Coping Checklist (Worksheet 4.3) that listed 26 responses people often make when feeling highly anxious. All of these “ways of coping” are ineffective because they provide only temporary relief from anxiety. When these strategies are used frequently, they can contribute to the persistence of anxiety problems. You’ll notice some overlap between the Safety-­Seeking Response Form (Worksheet 7.4) and the Ineffective Coping Checklist. The safety-­seeking worksheet focuses on a smaller set of responses whose purpose is to bring about calm and a feeling of safety. The ineffective coping worksheet covers a broader range of responses that focus on reducing the feeling of fear and anxiety. Some coping strategies have this dual function of reducing anxious feelings and instilling a sense of calm and safety. CBT therapists focus on both types of coping response, as well as escape/avoidance, to help individuals achieve genuine anxiety reduction. Shortly we’ll introduce you to several behavioral interventions you can use to switch from ineffective coping to more effective ways to manage your anxiety. In the meantime use the next worksheet to summarize your responses to severe anxiety that contribute to your anxiety problem. E VA L U AT ION EXER C I S E 

Behaviors to Change

Worksheet 7.6 is for summarizing problematic escape/avoidance, safety-­seeking, and ineffective coping responses. It will be your roadmap for achieving meaningful behavioral change. You’ll need to review previous work you’ve done on identifying escape/avoidance, safety seeking, and ineffective coping.

Worksheet 7.6 is one of the most important worksheets to complete in this chapter. It’s your personal guide to the behaviors you’ll need to change to achieve significant progress on your anxiety problem. If you’re not sure how to categorize some of your behavioral responses, consider Gerard’s Behavior Change List. Don’t be too concerned about getting your behaviors in the right category. It’s more important that the key behaviors that contribute to your anxiety problem appear somewhere on the worksheet so you’ll know what behaviors you need to change. You’ll learn about four treatment strategies that are effective in reducing anxiety when combined with the cognitive interventions from the last chapter.

W ORK SHEE T 7.6

Behavior Change List Instructions: In the first section, list the most common situations, thoughts, or physical symptoms that you avoid because of anxiety, as noted on Worksheet 7.5. Next, write down safety-­seeking responses rated as 2 (often used) on Worksheet 7.4. Finally, list several ineffective coping strategies that you circled as 2 (“Often”) or 3 (“Always”) on Worksheet 4.3. A. Escape/avoidance pattern to change 1. 2. 3. 4. 5. B. Safety-­seeking behavior to change 1. 2. 3. 4. 5. (continued) From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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W ORK SHEE T 7.6 (continued)

C. Ineffective coping behavior to change 1. 2. 3. 4. 5.

Exposure: Confronting Threat Decades of research has revealed that repeated, systematic exposure to feared outcomes is one of the most powerful treatments for fear and anxiety.4,31 It can lead to the quickest and most enduring reduction in your anxiety problem. It’s adaptable and easy to understand. But it has one major drawback; people often refuse exposure treatment because they believe it’s too threatening, risky, and upsetting. For this reason they may choose a weaker, less effective treatment that is only mildly distressing. This was the case with Gerard. He was faithful in taking his medication, attending appointments, regulating his exercise and diet, and participating in various stress management interventions like meditation and yoga. But when it came to confronting his anxiety directly through exposure, he had grave reservations and misgivings. There can be no doubt that exposure challenges our resolve and determination, even for the most courageous. But if you make a commitment to do exposure treatment, the payoffs can be huge. Systematic exposure doesn’t have to be “bitter medicine.” We’ll show you how to plan effective exposures that are tolerable and can be combined with the cognitive strategies you learned in the last chapter. You can achieve significant improvements in your anxiety problems if you follow our exposure guidelines. So let’s begin with a working definition of exposure. Exposure is not about throwing yourself into the deep end of the pool to see if you sink or swim. 159

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Gerard’s Behavior Change List A. Escape/avoidance pattern to change 1.   Noisy places with lots of unfamiliar people 2.   The news or other information that covers world conflict or problems 3.   Driving in city traffic 4.   Social events that require me to engage in sustained conversation B. Safety-­seeking behavior to change 1.   I always make sure either my wife or my close friend is with me in situations where I feel anxious in

case I have severe anxiety and need to go to the hospital. 2.   I leave when my stomach starts to feel queasy because I know the anxiety is starting and I need to

get to my safe place. 3.   I focus on my breathing to keep myself calm and not let things get out of hand. 4.   I go to a safe place in my mind; I imagine sitting on a warm, sunny beach. 5.   When I start to feel uneasy, I’ll try to convince myself that I’m not anxious, I’m calm and in control. C. Ineffective coping behavior to change 1.   I often take an antianxiety medication when I know I’m facing a difficult situation. 2.   I can worry for days about being anxious, trying to figure out how I’ll deal with it when it happens. 3.   I get frustrated, impatient, and angry with people when I start to feel anxious.

Some examples of exposure are repeatedly facing an unfamiliar situation that makes you anxious, acting more assertively or speaking up at a meeting, or traveling to new places. You can think of exposure as mustering your courage and climbing out of your comfort zone. Time after time, with literally hundreds of individuals with anxi-

Exposure is the systematic, repeated, and prolonged presentation of external objects, situations, or stimuli, or internally generated thoughts, images, or memories, that are avoided because they provoke anxiety.



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ety, we have found that systematic, repeated, and prolonged exposure to their anxious triggers led to a rapid and sustained reduction in anxiety. Exposure is a form of “desensitization” in which repeated exposure to fear triggers and the accompanying anxiety is a powerful tool that reinforces a more realistic perspective on anxious situations and better tolerance of anxiety. For Gerard, exposure meant gradually and systematically increasing his contact with other people, especially in public places like grocery stores, movie theaters, and shopping malls. Take a moment to review the escape/avoidance patterns you noted on the Behavior Change List (Worksheet 7.6). Exposure is designed to help you confront the escape/ avoidance you listed on the worksheet. Select one escape/avoidance item and use the following five-step program to develop an exposure treatment plan for that item.

Step 1.  Assess Your Readiness Timing is critical when it comes to personal change. Are you ready to commit to doing some exposure? It’s important to assess your commitment level whether you’re doing exposure on your own or with therapist assistance. If you have reservations about systematic exposure, it may be due to certain beliefs you have about this form of anxiety treatment. This could be based on your past experience with CBT for anxiety or information you’ve read about exposure-based interventions. IN T ER V EN T ION EXER C I S E 

Negative Exposure Beliefs

This exercise provides an opportunity to assess your readiness to add exposure interventions to your treatment of anxiety. Worksheet 7.7 lists 12 of the most common negative beliefs that are associated with rejection of exposure. You can use your level of agreement/ disagreement with these belief statements to gauge your readiness to engage in exposure.

After completing the checklist, focus on the statements you endorsed. For each item, consider why you hold this belief about exposure. Gerard believed that the anxiety would be too intense and he’d not be able to stand it (statement 1) and that he needed to reduce his anxiety to a manageable level before doing exposure (statement 5). The first belief was based on a bad therapy experience in which he had a panic attack when the therapist asked him to visit the mall and “sit with his anxiety.” The second belief was based on what he considered common sense. “It only makes sense that exposure will be more effective if I wait until I can manage my anxiety.” Next, put your negative beliefs to the test by using the cognitive intervention skills you developed in Chapter 6. What’s the evidence for and against the reason (use Worksheet 6.5)? Are there any cognitive errors in your thinking (see Table 6.2)? Are

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you “catastrophizing” exposure, thinking it will be much worse than is likely? Are there personal costs to holding these exposure beliefs (use Worksheet 6.6)? What’s an alternative, more balanced way to think about exposure (use Worksheet 6.7)? When Gerard used his cognitive skills on his belief that he wouldn’t be able to stand the anxiety associated with exposure, he realized that many times he did face a situation in which he felt anxious and was able to tolerate the discomfort. He identified several cognitive errors in the belief, including catastrophizing and all-or-­nothing

W ORK SHEE T 7.7

Negative Beliefs about Exposure Instructions: Below are 12 common reasons people are hesitant to engage in an exposure program. Indicate whether each statement applies to you by checking “Yes” or “No.” Reasons

Yes

No

  1.  The anxiety will be too intense, and I won’t be able to stand it.   2.  The anxiety will keep escalating and remain elevated for hours or even days on end.   3. I’ve been feeling less anxious lately; exposure will only upset this relative calm.   4. I have already exposed myself to fear situations, and it doesn’t work; I still feel anxious.   5. I need to reduce my anxiety to a manageable level before I start doing exposure.   6. I need to learn better anxiety management strategies before I begin exposure.   7. I’ve been anxious for so long that I don’t see how exposure will help me.   8. I just don’t see how making myself more anxious will eventually cause me to feel less anxious.   9.  My anxiety is triggered by internal things like certain thoughts, images, memories, or worries. I don’t see how exposure can help me. 10. Exposure may be effective for others, but my anxiety is unique; I can’t see how it could possibly help me. 11. I am just too anxious now to engage in exposure. I’ll wait until the medication “kicks in” before doing exposure. 12. I don’t have the courage, the “willpower” to do exposure. From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.



curb anxious behavior 163

thinking. He was aware that the belief was costly, preventing him from engaging in a powerful anxiety-­reduction treatment. So he came up with an alternative belief statement: “I will feel anxious when I do exposure, but I can adjust the level of the exposures so they don’t exceed what I can tolerate.” By correcting your negative beliefs about exposure you are creating a more positive attitude about the treatment. This will boost your readiness to proceed with the next steps in the exposure intervention so you can see for yourself that exposure may initially cause high anxiety but that it will be bearable and that anxiety will decline naturally if you don’t leave or avoid the situation.

Step 2.  Build an Exposure Hierarchy Chloe had intense social anxiety. One of her exposure assignments involved calling a friend and inviting her to go to the movies. She put off doing the assignment until the day before her next therapy appointment. By this time the anticipatory anxiety had become so intense she was almost panicky. She eventually made the call but immediately felt a wave of relief when her friend didn’t answer. This roller-­coaster experience of intense anticipatory anxiety followed by a refreshing sense of relief convinced Chloe that she would never again do another exposure exercise. Unfortunately, Chloe was never able to work through this impasse with her therapist, and so she eventually discontinued treatment without achieving any progress with her social anxiety. Chloe made one of the most common mistakes that deters people from using exposure effectively: She dabbled in exposure and then felt much worse rather than better. These demoralizing experiences can be very damaging when treating anxiety. To avoid these negative experiences, it’s important to spend time carefully constructing a written systematic exposure plan. It will also make your exposure a more effective intervention. IN T ER V EN T ION EXER C I S E 

How to Construct an Exposure Hierarchy

There are several steps to constructing an exposure hierarchy. Begin with a blank piece of paper and write down 10–15 situations, people, places, thoughts, or physical sensations that you avoid or that cause you great anxiety if you don’t leave them. To generate your list, consult the escape/avoidance patterns from your Behavior Change List (Worksheet 7.6) as well as other anxiety triggers you identified on earlier worksheets. Select experiences that fall along the full range from those that trigger only slight anxiety and avoidance to experiences that elicit moderate and then severe anxiety and avoidance. Using My Exposure Hierarchy, Worksheet 7.8, rank-order these experiences from least to most anxious or avoidant. Remember, the goal of exposure to anxiety triggers is to feel anxious. If you do an exercise without feeling anxious, the exposure will not be therapeutic.

W ORK SHEE T 7.8

My Exposure Hierarchy Instructions: Start by listing a variety of situations or other triggers of severe anxiety in the second column. Make sure you include enough detail about what you must do in each situation to generate anxiety. Begin with situations or experiences that are least difficult and progress to the most difficult situations. In the first column, rate how difficult it would be to engage in that experience and not escape or avoid it on an 11-point scale. In the third column, write down the core anxious thought associated with each situation if this is known to you. Expected level of difficulty* (0–10)

Anxiety trigger (Briefly describe the anxiety-­ provoking/avoided situation, object, sensation, or intrusive thought/image)

Anxious thinking (What’s so threatening, upsetting about this situation that makes you anxious or want to avoid it?)

Least

Most *Difficulty scale; 0 = no difficulty; 5 = moderate difficulty, considerable anxiety and would probably escape/avoid; 10 = extreme difficulty, severe anxiety and would definitely avoid. Based on Cognitive Therapy of Anxiety Disorders (p. 229) by David A. Clark and Aaron T. Beck. Copyright © 2010 The Guilford Press. Adapted in The Anxiety and Worry Workbook, Second Edition (Guilford Press, 2023). Purchasers of this book can photocopy and/or download additional copies of this material worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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 Tips for Success: More on Exposure Hierarchies

Creating an effective exposure hierarchy is easier said than done. Effective exposure depends on a thoughtful, well-­planned hierarchy of experiences that guides you through a series of exposure assignments. The following are some additional suggestions for constructing an exposure hierarchy. „ Make sure your hierarchy has many avoided experiences (7–10) in the moderate

range of difficulty (scored in the range of 3–7). If most of your hierarchy items are too easy, the exposure won’t help reduce anxiety. If most of the items are in the highly difficult range, the exposures will cause too much anxiety and you’ll give up. „ Most of the hierarchy items should be experiences that are relevant to the escape/

avoidance patterns listed on your Behavior Change List (Worksheet 7.6). „ Avoid large difficulty gaps between exposure items. There should be no more than

two points between the difficulty of one item and the next item in the hierarchy. „ If you have doubts about your exposure plan, review it with a friend, family member,

or therapist/counselor who is familiar with your anxiety problem.

You will have difficulty creating an exposure hierarchy if you didn’t do the earlier exercises on anxiety triggers and avoidance. The exposure hierarchy is so important to exposure intervention that you should go back and do these worksheets to get a better understanding of the escape/avoidance component of your anxiety problem. If an example would help, review Gerard’s exposure plan later in the chapter.

Step 3.  Create Coping Cognitions Mental preparation is key to successful exposure. That’s why we started with exposure readiness. But there are two other considerations to take into account before starting exposure. „ Identify „ Create

the anxious thoughts that could undermine your exposure efforts.

alternative ways of thinking that will help you cope with exposure.

You noted the core thought associated with each anxiety-­provoking/avoided situation on the Exposure Hierarchy (Worksheet 7.8). It’s important to be fully aware of the thoughts about threat, danger, and helplessness you may have during exposure and to critically confront this thinking before, during, and after your exposure experience. You will recall from previous chapters that it’s the thoughts that cause you to feel anxious. Deal with the exaggerated thoughts of threat and helplessness, and you’ll

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reduce your anxiety during exposure. You can use all the cognitive skills you learned in Chapter 6 to evaluate and correct self-­defeating anxious thinking. IN T ER V EN T ION EXER C I S E 

Develop a Coping Perspective

You will feel significant anxiety when you engage in an exposure task. Thinking about threat, risk, helplessness, uncertainty, and intolerance will make the anxiety worse and convince you that escape/avoidance offers the best options. The opposite way of thinking, the coping mindset, will help you tolerate the anxiety and complete the exposure task. You can nurture this coping perspective on exposure by composing a coping cognition narrative. It should include the following elements: „ A prediction or expectation that you’ll feel significant anxiety „ A more realistic, balanced estimate of threat and safety in the exposure situation „ Specific instructions on what you’ll do during the exposure task „ Ways that you’re in control of the exposure experience and are not helpless „ A reminder that anxiety will decline, becoming more tolerable the longer you stay

with the exposure Use the space below to compose a coping cognition narrative. You may want to write several alternative narratives, recognizing that you may need different coping cognitions for different exposure tasks. When completed, load the narrative into your smartphone so you can reflect on it while doing the exposure task. My coping cognition narrative:

When anxiety becomes a problem, it can be hard to think differently about an avoided situation that you’re now trying to confront through exposure. If you’re feeling unsure about the coping perspective you composed, consider the following examples. Cynthia had severe social anxiety for many years. She developed a 20-step exposure plan that involved a range of social situations that elicited mild to severe anxiety. Here are her coping cognition narratives for a low-, a moderate-, and a high-­difficulty escape/avoidance situation:



Situation 1:

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Answering the telephone (2/10 difficulty rating)

When the phone rings, I’ll feel slightly anxious because I don’t know what to expect. It’s okay to feel a little uneasy. I can say hello even when apprehensive, and I’ll quickly find out who is calling. If it’s a friend, my anxiety will disappear rapidly; if it’s a spam call, I can simply say “No thank you” and hang up immediately. If it’s an important call like the doctor’s office about an appointment, it’s better to take it than to miss it. The caller doesn’t care whether I sound anxious or not.

Coping cognition narrative:

Situation 2:

Attending a staff meeting at work (6/10 difficulty rating)

Coping cognition narrative: I’m going to feel quite anxious at this staff meeting. I’ll be thinking

that everyone is staring at me and noticing that I’m uncomfortable. But is this really true? Look around at people. Are they really that interested in me? Do they have more important things to think about than me? I notice that some others in the room also look uncomfortable. Some look bored, and one or two people are falling asleep. It’s probably more embarrassing to fall asleep. It’s more likely that people are paying attention to more interesting things than me, like the person talking or the one falling asleep. There’s no evidence I’m the center of attention. At most a few people might notice I’m quiet and look uncomfortable. I’m perfectly capable of replying to anyone who speaks to me. I have coworkers who have too much to say, and they’re the ones people tend to gossip about later. Situation 3:

Reporting a coworker who’s treating me unfairly (9/10 difficulty rating)

Coping cognition narrative: This is going to cause a lot of anxiety. It’s not easy even for the most

confident and assertive individual to report workplace harassment. However, I can’t stand this situation any longer. Although I’ll feel severe anxiety during the meeting with my supervisor, in the end I’ll experience less stress at work if we can deal with this problem. I’m going to write down the main points I want to make with my supervisor. I’m going to admit to her that I feel very uncomfortable complaining about a coworker, and then I’ll tell her exactly what has happened and how it has affected me. Even though I’m feeling anxious, I can refer to my notes and I’ll be able to tell whether or not my supervisor understands my complaint by how she responds. Most people would feel apprehensive in this situation, but they just get on with it and do it. I can do the same. If it stops the harassment, my life will be so much better.

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Step 4.  Establish an Exposure Plan Your exposure plan will need more than cognitive coping statements to deal with the anxiety. Listed below are other strategies you can use to help you get through an exposure task. But remember, the goal of exposure is to feel anxious and then let the anxiety decline naturally. Like the coping narratives you just created, anxiety mitigation strategies are intended to make anxiety more tolerable so you complete the exposure. „ Practice

symptom segregation: Focus all your concentration on specific physical symptoms of anxiety, such as feelings of muscle tension, heart palpitations, nausea, or breathlessness. Rather than deny these symptoms, accept them. Instead of labeling them as signs of anxiety, refer to them as specific sensations like my shoulders feel tense, my heart is beating more quickly than normal, my stomach feels off.

„ Look for safety evidence: Consciously and deliberately look around your expo-

sure environment and pick out evidence that the environment is safer than you think. How are other people reacting in this situation? What characteristics of the situation indicate that it is safe, not dangerous? Are you overestimating threat? „ Control

your breathing: Some people find it helpful to focus on their breathing when anxious. Maintain a breathing rate of 8–12 breaths per minute. Make sure you don’t overbreathe (hyperventilate) or take shallow breaths.

„ Initiate

relaxation: Some people find physical relaxation or meditation calming when anxious. Others, however, find that trying to physically relax when anxious is frustrating and ineffective. You can try out this coping strategy, but never use it to avoid feeling anxious.

„ Visualize

mastery: You can visualize yourself slowly and successfully mastering the exposure task either before you enter the situation or just after you begin. Imagining yourself successfully doing the exposure can boost your positive expectations and confidence that you can be triumphant with an exposure exercise.

„ Increase

physical activity: Some people find it helpful to be physically active during exposure. Rather than stand or sit, you could walk around in the exposure situation to help channel some of the physical arousal you feel.

Exposure provides opportunities for you to tap into your adaptive mode to bring improvement to your problematic anxiety. You may recall from Chapter 3 that the adaptive mode involves ways of thinking and acting that increase our self-­esteem and



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the attainment of valued goals and aspirations. Thus the goal of your exposure plan is not only anxiety reduction, but the building of personal resilience so you’ll achieve life goals that have been stifled by anxiety. This is consistent with the CT-R approach to emotional problems, where the pursuit of goals is a key aspect of recovery. IN T ER V EN T ION EXER C I S E 

A Recovery-­Oriented Exposure Plan

This exercise is a vital part of exposure intervention because it provides instructions you can follow when doing exposure tasks. Worksheet 7.9 is organized from a CT-R perspective on anxiety. It starts with asking you to again list your treatment goals. Being able to see the connection between doing exposure exercises and reaching your personal goals will improve motivation to engage in the intervention. In the second part of the worksheet you’re asked to list effective coping strategies you can use during exposure to tolerate elevated levels of anxiety. In the last section, list safety-­seeking and coping responses that are unhealthy and only contribute to a persistence of the anxiety problem. You’ll want to detect and eliminate these unhealthy responses during exposure.

Having a recovery-­oriented exposure plan is critical to the success of this intervention. If you try to do an exposure task without a plan, it will be hard to see it through. You’re more likely to give up, thinking you can’t stand the anxiety. Having a recovery-­oriented exposure plan gives you specific instructions on how to cope with anxiety during exposure. If you’re unsure about your exposure plan, have a look at Gerard’s.

Step 5.  Doing Exposure Tasks You now have all the pieces in place to begin your exposure treatment. You’ll start with exposure tasks toward the bottom of your exposure hierarchy, working your way up the hierarchy until you get to the top. Use your Coping Cognition Narrative and Recovery-­Oriented Exposure Plan to guide you through each exposure practice session. There are two rules to keep in mind when doing exposure. R U L E 1.   PA C E   Y O U R S E L F

In the past exposure treatment was done in a graduated manner. Individuals would start exposure toward the bottom third of their hierarchy, where anxiety was moderate, and then work their way up the hierarchy in a systematic fashion. In recent years that approach has been challenged, suggesting that it might be more beneficial if individuals jumped around the hierarchy.32 Whatever the case, it’s important to pace your

W ORK SHEE T 7.9

My Recovery-­Oriented Exposure Plan Instructions: In section A, list several goals you’d like to achieve by reducing your anxiety and worry. List some coping strategies for tolerating anxiety in section B that might help with anxiety management during exposure. In section C, list the main safety-­seeking and ineffective coping responses that should be curbed during exposure sessions. A. Anxiety recovery goals Based on Worksheet 1.3, list what you want to do but can’t do because of anxiety. 1. 2. 3. 4. 5. B. Healthy responses to tolerated anxiety Based on Worksheet 3.5, list helpful ways of thinking and acting that improve tolerance of anxiety. 1. 2. 3. 4. 5. C. Safety-­seeking behavior and ineffective coping to discourage Based on Worksheets 4.3, 7.4, and 7.6, list responses to avoid because of their negative effects on anxiety. 1. 2. 3. 4. 5. From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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Gerard’s Example of a Recovery-­Oriented Exposure Plan A. Anxiety recovery goals Based on Worksheet 1.3, list what you want to do but can’t do because of anxiety. 1.   Accompany my wife and children to restaurants without leaving due to anxiety 2.   Do city driving with patience and not succumb to road rage 3.   Take the family on a winter vacation in the Caribbean 4.   Facebook my ex-­military friends without getting triggered or upset 5.   Do grocery shopping and other errands with my wife so I’m more engaged in our daily living B. Healthy responses to tolerated anxiety Based on Worksheet 3.5, list helpful ways of thinking and acting that improve tolerance of anxiety. 1.   I remind myself I’ve faced much more intense fear and anxiety while overseas so I can certainly handle

the anxiety I feel now. 2.   I focus on the task at hand and take a step-by-step approach no matter what I feel.

3.   I focus on my breathing and imagine that anxious feelings are waves that flow through my body.

I imagine the anxiety surge as I inhale and recede as I exhale, over and over with the rhythm of my breath. 4.   I recall specific times when the anxiety would build and then eventually decline. C. Safety-­seeking behavior and ineffective coping to discourage Based on Worksheets 4.3, 7.4, and 7.6, list responses to avoid because of their negative effects on anxiety. 1.   Make sure I do most of the exposures alone; I need to reduce dependency on my wife. 2.   Expect that my stomach will feel queasy when I do these exposures. I must stay in the situation even if

I don’t feel well.

3.   Stop going to my safe place in my mind at the first sign of feeling anxious. I need to ground myself in

the present and accept what I’m feeling.

4.   Slow down, don’t rush when I’m in social situations. Look people in the eye and don’t get impatient

with them.

5.   I’m not going to take antianxiety medication before starting the exposure. I can take it with me and use

if needed, but the goal is to do the exposure without taking medication. At the start of a new exposure task, I might take medication quite soon into the exposure, but I’ll work on lengthening the time so eventually I’m doing the exposure task without it.

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exposures so you experience anxiety that is only slightly greater than what you can normally tolerate. Exposure is intended to strengthen your anxiety tolerance and give you opportunities to learn that the situation is not as threatening as you think, nor are you as helpless and vulnerable as you think. Consider three examples of paced exposure. Cynthia started her exposure with “attending in-­person staff meetings” because this caused her moderate anxiety. She decided to go to as many office staff meetings as possible and gradually moved herself closer to a prominent seat in the room. José had intense fear of making mistakes. His exposure started with writing fairly insignificant emails quickly without rereading them and then moved to more significant emails in which he allowed himself to reread only once. Sanya had panic attacks and so avoided crowds or public places. Her exposure began with entering a moderately sized clothing store where only a few people would be present and then gradually increasing the size and crowd density in the store. Each of these individuals paced their exposures so they did not become overwhelmed by the task at hand. Exposure is like running a marathon: Pacing is everything! If you start with a task that provokes moderate anxiety and still find the exposure beyond tolerance, drop back to a less intense task and work on it. If the exposure is too easy, proceed up the hierarchy until you do a task that challenges your tolerability. R U L E 2 .   P R A C T I C E   D A I LY

Successful exposure is like physical exercise: Practice is critical! The more exposure you do, the better the outcome. You should aim to do some exposure every day, especially at the beginning. Also make sure you do at least 30 minutes of exposure each time. The number-one reason that exposure treatment for anxiety fails is that people do too little exposure. The problem with brief and occasional exposure is it can have a reverse effect; it can actually intensify your anxiety. You are more likely to feel overwhelmed with brief exposure (5–15 minutes). It will reinforce anxious beliefs that the situation is highly threatening and that you’re helpless when facing severe anxiety. You’ll end up discounting what you’ve written in your coping cognition narrative and conclude that the best strategy is to escape and avoid. The success of exposure depends on its “dosage.” Do the same exposure task over and over for at least 30 minutes until you can do the task with only slight feelings of apprehension. Once this happens, you’re ready to move on to the next task on your hierarchy. The next example highlights the importance of frequency and duration when doing exposure. Caleb was afraid of crossing bridges. He had done a number of exposures to bridges and now was confronting an exposure task that involved severe anxiety. One of us (DAC) accompanied Caleb to a bridge, and we planned to step on the bridge sidewalk. Caleb’s anxiety escalated rapidly as we walked toward the bridge. However, every few feet we stopped and waited for his anxiety to drop to a level that



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he felt was tolerable. We then proceeded a few more feet, stopped, and let the anxiety settle. At the same time Caleb challenged his anxious thinking about the danger in what he was doing and that he couldn’t stand the anxiety. Finally we reached the bridge, the whole exercise taking 45–60 minutes. We waited there for quite a while until Caleb felt the anxiety decline significantly. This exposure proved pivotal in Caleb’s therapy because it provided objective evidence that he could face bridges. From this point forward, Caleb began driving across bridges and within two weeks was reporting minimal anxiety. IN T ER V EN T ION EXER C I S E 

Practice Exposure

Begin practicing exposure on a daily basis by starting with a moderately anxious situation from your exposure hierarchy. Use My Exposure Practice Form (Worksheet 7.10) to record the outcome of each exposure practice session. You should complete the worksheet while you are doing the exposure exercise for better accuracy. If you’ve done a particular exposure task three or four times and you’re now able to tolerate the anxiety reasonably well, then you’ve been successful and are ready to move on to the next task in your exposure hierarchy (Worksheet 7.8). If you’re still struggling to tolerate the anxiety after three or four attempts, drop down to an easier exposure task. Practice that task again until you’re ready to return to the more difficult exposure task.

If you’re working with a therapist, review your Exposure Practice Form at the beginning of each therapy session. Otherwise, show a trusted friend or family member your practice form so there is someone who can hold you accountable for sticking with your exposure plan. If you still have questions about how to implement exposure, consider Gerard’s exposure scheme and how he put it into practice. Gerard started his exposure by going to the grocery store with his wife. He expected to feel some anxiety and that he’d be thinking about leaving, so he gave it a 4/10 difficulty rating. His most prominent anxious thoughts were “I’ll lose control and experience severe anxiety,” “People will notice there is something wrong with me and wonder if I’m going berserk,” and “I’ll have flashbacks to the crowded marketplaces in Afghanistan.” Gerard noticed that his anxiety escalated when he started thinking like this, which caused him to bolt from the situation, convinced he needed to escape before the anxiety became unbearable. So it was important that Gerard stay focused on his coping cognition narrative (“I am still in control even though I feel anxious; no one is looking at me or is even interested in me; even if I’m thinking about Afghanistan, it doesn’t change the reality that I’m safely back home in a grocery store”). As well, he grounded himself in the present moment of being in the grocery store and allowed the anxiety to dissipate naturally through continued exposure. He

W ORK SHEE T 7.10

My Exposure Practice Form Instructions: Record the date and time of your exposure session in the first column. Briefly describe the exposure task undertaken in the second column and how long you engaged in exposure. On an 11-point scale, rate your ability to tolerate feeling anxious when you first start exposure and again when you end the exposure session. Refer to the scale key at the bottom of the form. Date and time

Exposure task

Duration (minutes)

Initial Endpoint tolerability* tolerability* (0–10) (0–10)

*Tolerability scale: 0 = no tolerance, must leave now; 5 = moderate tolerance, feel severe anxiety but can stand it; 10 = easily tolerated, feel minimal anxiety. This is a positively weighted scale where high scores indicate more successful exposure. From Cognitive Therapy of Anxiety Disorders (p. 269) by David A. Clark and Aaron T. Beck. Copyright © 2010 The Guilford Press. Adapted in The Anxiety and Worry Workbook, Second Edition (Guilford Press, 2023). Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/ clark6-forms for personal use or use with clients; see copyright page for details.

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Gerard’s Exposures to Fear and Avoidance of Public Places Expected level of difficulty* (0–10) Least

Anxious thinking (What’s so threatening, upsetting about this situation that makes you anxious or want to avoid it?)

2

Answering the telephone

I don’t know who’s calling or what they want. I could get flustered.

3

Going to the corner store for a quart of milk

I get shaky when interacting with cashiers. She’ll see this and think there’s something wrong with me.

3

Waiting in line at the bank

People will notice that I look awkward. This makes me self-­conscious and nervous.

4

6

I’ll lose control and experience severe anxiety. People Going grocery shopping with my will notice there is something wrong with me and wife wonder if I’m going berserk, and I’ll have flashbacks to the crowded marketplaces in Afghanistan. Same thoughts as previous entry plus thought- I’ll Going grocery shopping alone have a panic attack and cause a scene. It’ll be so embarrassing. What if I start to panic. I’ll want to leave and can’t because she’s somewhere else in the mall.

6

Walking around a crowded mall alone while my wife shops

7

Eating at a table against the wall I’ll feel trapped because I can’t just leave whenever I at a waitered restaurant start to feel uncomfortable.

7.5

Eating at a table in the middle of I’m trapped and people will be able to see that I’m the room in a waitered restaurant anxious and losing control of my emotions.

9

Most

Anxiety trigger (Briefly describe the anxiety-­ provoking/avoided situation, object, sensation, or intrusive thought/image)

10

I’m terrible at small talk. I never know what to say. I get so nervous that I can’t track what people are talking about. This makes me look stupid. I’m such an embarrassment for my wife. is the ultimate situation for feeling trapped. I’ll Attending a sold-out movie and This have panic attack and need to leave. I’ll have to having to sit in the middle of the crawlapast a row of people who will get angry at me row for interrupting the movie.

Going to a house party and not able to leave for two hours

Based on Cognitive Therapy of Anxiety Disorders (Guilford Press, 2010, p. 229) by David A. Clark and Aaron T. Beck.

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kept going back to the grocery store with his wife as much as possible and noticed that it became much easier after a couple of weeks. He decided it was time to work on the next task in his hierarchy, going to the grocery store alone. Much of CBT’s effectiveness for reducing anxiety depends on exposure. It’s a powerful intervention, so don’t delay. Start working on your exposure plan today. Most people with anxiety find the anticipation more anxiety-­provoking than the actual exposure. It will probably be less difficult than you expect. In fact, you can boost the effectiveness of exposure by following two strategies discussed in the next section.

“Supercharge” Your Exposure Exercises There are two ways to enhance the effectiveness of your exposure experiences. You can modify your plan so it becomes either a behavioral experiment or an expectancy exposure exercise.

Behavioral Experiment

Behavioral experiment—a structured, planned exposure task that focuses on collecting evidence for and against an anxious belief about threat and helplessness. Expectancy exposure—testing a prediction made about the outcome you expect from doing an exposure task.

In our version of CBT we use exposurebased behavioral experiments to help people evaluate and correct their unhealthy beliefs about threat and relearn that anxious situations are actually safer than they think.31 Exposure tasks are structured so they more directly target anxious thinking and beliefs. What this means is that you use the work you did in Chapter 6 on your anxious mind to develop exposure tasks that function as a behavioral experiment. We can take Gerard’s anxiety about crowded grocery stores as an example. His anxious belief was “I’ll become overwhelmed with anxiety and lose control.” After generating evidence for and against this belief, Gerard’s therapist noted that the best way to evaluate this belief would be to go into a crowded grocery store, stay there for at least 30 minutes, and record what happened to his anxiety. You’ll see how Gerard conducted his “supermarket experiment” and what he learned from the behavioral experiment example presented below. IN T ER V EN T ION EXER C I S E 

Exposure-Based Behavioral Experiment

This exercise shows you how to turn your exposure into a behavioral experiment with the potential of changing your anxious thinking. The Behavioral Experiment Form (Work-



curb anxious behavior 177

sheet 7.11) is useful for planning and then recording what you experienced while doing the exposure task. Start by writing down the anxious thought or belief you plan to test with the behavioral experiment. You can see from Gerard’s example he tested his belief that he couldn’t stand the anxiety and so he’d have to leave the supermarket. Describe how you’ll conduct the exposure task and record evidence for and against the anxious thought/belief based on your exposure experience. No doubt some of your experience will confirm your anxious belief, but then some things will be inconsistent with the belief. After listing evidence for and against, write an alternative interpretation based on what you learned from the exposure. You’ll notice that Gerard concluded that he could stand the anxiety better than he predicted and he didn’t lose complete control. Â Tips for Success: Refining Your Behavioral Experiment

Turning an exposure exercise into a behavioral experiment is one of the most difficult interventions in CBT. Even experienced cognitive behavior therapists can struggle with creating a behavioral experiment that precisely tests the validity of a negative thought or belief. It’s a more challenging intervention than the conventional exposure protocol described previously. Here are some additional tips for improving the effectiveness of your behavioral experiments. „ Make sure the exposure task is a direct test of the anxious thought or belief you

want to evaluate with your experiment. When you do the exposure task, it should cause you to have the anxious thought/belief that you wrote down on My Behavioral Experiment. „ Write out a thorough description of the exposure task so you know exactly what to

do, when, with whom, and where. „ Make sure the exposure task is moderately difficult so you give yourself an opportu-

nity to learn from the experience. „ Write down your observations about evidence for and against the anxious thought/

belief immediately after the exposure task. You could include observations of anyone who accompanied you during the exposure. It’s important to be honest with yourself about what actually happened. „ If you’re having difficulty coming up with an alternative view of your experience,

consult with your therapist, partner, or close friend. They may see something in your exposure experience that you can’t see.

What did you learn from your behavioral experiment? We do exposure-based behavioral experiments to obtain hands-on experience that tests whether our thoughts

W ORK SHEE T 7.11

My Behavioral Experiment Instructions: Start by writing out an anxious thought or belief you intend to test with your exposure task. Next, describe how you’ll conduct the exposure exercise. Use the double-­column table to record what happened when you did the exposure. In the left column, list any experience during exposure that confirmed or validated the anxious thought/belief. In the right column, record any experiences during exposure that contradicted or refuted the anxious thought/belief. Based on your exposure experience, write an alternative way of thinking that is more balanced, realistic, and helpful than the anxious thought/belief.

1. Anxious thought/belief related to exposure task:



2. Description of exposure task:



Evidence for anxious thought/belief (What happened during the exposure that confirmed your anxious thought/belief?)

Evidence against anxious thought/belief (What happened during the exposure that disconfirmed your anxious thought/belief?)

1.

1.

2.

2.

3.

3.

4.

4.

5.

5.

6.

6.

7.

7.

3. What’s an alternative way of thinking that is more consistent with your exposure experience?



From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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curb anxious behavior 179

Gerard’s Example of a Behavioral Experiment 1. Anxious thought/belief related to exposure task:   If I go into a crowded grocery store, my anxiety will be

so severe I won’t be able to stand it. I’ll get frustrated, angry, and lose control. I’ll frighten people in the store. 2. Description of exposure task:   I’ll walk into a large supermarket at 4:00 p.m. on a Friday afternoon. I’ll go

with my wife, and I’ll plan to stay for 30 minutes until we finish doing the grocery shopping. I’ll push the shopping cart, and she’ll put groceries in it. We’ll end up going through the cashier line together. Evidence for anxious thought/belief (What happened during the exposure that confirmed your anxious thought/belief?)

Evidence against anxious thought/belief (What happened during the exposure that disconfirmed your anxious thought/belief?)

1.  As expected, my anxiety was really bad when I

1.  I didn’t have a panic attack, which surprised me.

2.  I felt really frustrated and angry that people

2.  I didn’t ram anyone’s shopping cart, and I asked

entered the store and it remained high until I left.

were so pushy with their carts.

my wife later and she said I wasn’t rude to anyone. 3.  The cashier line was quite long, and I was getting 3.  I made it through the entire shopping spree, so I impatient. I was fairly sharp with the cashier withstood the anxiety better than I expected. when we got to her. 4.  My wife noticed I was very uncomfortable and 4.  As bad as I felt, no one took notice of me. she kept saying “Are you okay?” Everyone seemed far too preoccupied with their shopping or looking at their cell phone. 5.  I felt so anxious and “skittish”; it was almost as 5.  In all honestly, I felt a lot more frightened in bad as when I did foot patrols in Afghanistan. Afghanistan than in the grocery store. The difference is my anxiety in the supermarket makes no sense. 6.  6.  The cognitive coping narrative, focused breathing, and staying grounded in the present helped me stand the anxiety. 7.  7.  The anxiety did decline a little by the end of the grocery shopping but it never went away completely. 3. What’s an alternative way of thinking that is more consistent with your exposure experience? Clearly, I

can stand the anxiety better than I think and I’m more controlled than I feel. Inside I feel out of control, but it’s clear that I’m not losing control of my actions and no one seems to notice what’s going on inside of me.

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and beliefs about threat, helplessness, and safety are misguided and to discover an alternative way of thinking about our anxious concern that is more realistic and helpful. Behavioral experiments are effective in changing the anxious mind and weakening the association between our triggers and heightened emotional distress. This is what makes the intervention so effective. Your exposure exercises will be more powerful agents of change if you can turn them into behavioral experiments.

Expectancy Exposure A process known as aversive associative learning is critical in the development of fear and anxiety.33 This term may sound like a mouthful, but all it means is that anxiety problems develop when we learn through repeated experiences that certain stimuli (situations, the unfamiliar, unexpected bodily sensations, or thoughts) elicit certain feelings (like physical arousal) and behavior (such as avoidance). Aversive associative learning is evident in the following example. Brigitte’s anxiety problem was a crippling fear of getting sick. She repeatedly checked mirrors to see if she looked flushed or she’d ask coworkers whether they thought she looked unwell. Brigitte’s parents were also concerned about illness, so as a child a great fuss was made whenever she felt unwell. Repeated experiences of stomachaches, slight fever, and the like resulted in emotional upheaval in the family. Through repetition Brigitte learned that any unexpected ache or pain was threatening, and so she developed a severe fear response to a slight feeling of being unwell. But Brigitte learned something else through this process. She started making predictions like “If my stomach feels off, it means I’m getting the flu and will spend the next week in bed.” We call this expectancy. Brigitte developed an expectation that even minor physical sensations might result in a frightening illness. But her expectation was clearly exaggerated, and it caused a great deal of anxiety in her life. In recent years a newer version of learning theory has emerged called inhibitory learning.32 One aspect of this new theory is especially relevant here. It’s called expectancy violation. It goes like this. Brigitte developed an expectancy that feeling unwell could be a symptom of more serious illness. This elevated her anxiety level. If Brigitte thought more deeply about her anxiety experiences, she’d discover that more often than not her mild physical symptoms did not predict a serious illness. They simply went away once she got busy with her day, had something to eat, or rested. These experiences would be contrary to her expectation that “mild symptoms mean I’m getting seriously ill.” That is, the experiences “violate” Brigitte’s catastrophic expectation of illness. The next exercise shows how to include expectancy violation in your exposure plan.



curb anxious behavior 181 IN T ER V EN T ION EXER C I S E 

Expectancy Violation Exposure

This exercise builds on what you’ve learned about exposure in the previous exercises. This time, however, you’ll be modifying your exposure protocol so it tests a specific expectancy or prediction associated with an anxiety experience. Use Worksheet 7.12, My Expectancy Exposure Form, to make expectancy violation a part of your exposure plan. Begin by describing the exposure task you plan to do. Next, write out what you expect will happen when you do the exposure. No doubt you are expecting that the exposure will not go well and that’s why you’ve avoided doing it until now. Your negative expectation will include how you expect to feel and behave during the exposure. The third item asks that you record exactly what happened during the exposure task. The final question focuses on what you learned from doing the exposure and whether it confirmed or refuted your negative expectancy. What new insight or understanding can you take away from doing the exposure?

We could easily turn Gerard’s behavioral experiment into an expectancy exposure task. The exposure task would remain the same (see item 2 in Gerard’s behavioral experiment example). Gerard’s negative expectancy was “I’ll become overwhelmed with anxiety and have to leave the supermarket after 5–10 minutes before I lose control.” He would then describe what actually happened during his 30-minute supermarket exposure. For the third question on the Expectancy Exposure Form he might write, “I’m surprised I stayed for the entire 30 minutes. The anxiety was severe at first, but it got a little better by the end. I didn’t lose control, I didn’t have a panic attack, and no one paid attention to me.” In answer to the final question, Gerard might conclude, “The anxiety was bad, but I tolerated it better than I expected. Maybe the problem is that I feel inside like I’m losing control even though on the outside I look like I’m holding it together. I bet with practice I could get to the point where I could go grocery shopping alone and feel uncomfortable but not panicky.”

More Healthy Coping Cognitive skills that transform your anxious thinking (Chapter 6) and exposure-based interventions (this chapter) are the core treatments in CBT for anxiety. But there are other strategies that can be helpful when working on your anxiety problem. Unfortunately, space limitations don’t allow us to go into details about these interventions, but we list a few of them for your information. You should use these strategies only to help you tolerate severe anxiety aroused during exposure. They can undermine the effectiveness of exposure if used to avoid feeling anxious. Also, all of these coping

W ORK SHEE T 7.12

My Expectancy Exposure Form Instructions: Begin by describing a specific exposure task taken from your exposure hierarchy. Next, write out a prediction of what you expect will happen when you start to engage in the exposure task. The third question asks you to record what actually happened during exposure. Use the last question to write down what you learned from the exposure experience.

1. Description of exposure task:







2. What are you worried will happen if you do the exposure task? What’s the bad outcome or worst experience you expect could happen while doing the exposure?





3. Briefly describe what happened during your exposure task. How did you feel, what did you do, and how did others treat you?









4. What did you learn from doing the exposure? Was it as bad as you expected (see item 2)? Was the experience less difficult than you expected? If so, how? Were you able to tolerate the anxiety better than you expected?









From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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curb anxious behavior 183

strategies are learned skills that require considerable practice before they can be used during a period of acute anxiety. .

1.  Relaxation: As noted earlier, physical arousal is one of the main components of severe anxiety. Often CBT therapists teach relaxation skills so individuals who are highly anxious can learn to dampen the physical symptoms of anxiety. One approach, called progressive muscle relaxation, involves intentionally tensing and then releasing specific muscle groups.4 After repeated practice, the number of muscle groups is reduced so that eventually an individual can tense and relax their whole body in a few seconds. A second technique involves noticing tension in specific parts of the body and then relaxing the tension away.34 2.  Controlled breathing: There’s an automatic tendency to take shallow, rapid breaths when experiencing severe anxiety. Sometimes this can be so extreme that the person hyperventilates, which often happens during a panic attack. Diaphragmatic breathing is a technique used to counter the negative effects of taking rapid, shallow breaths. It involves breathing normally through your nose at a four-­second rate of inhale (count 1-2-3-4) and exhale (count 1-2-3-4).35 3.  Meditation: There is evidence that meditation can be effective in the treatment of anxiety problems.36 Attentional retraining is thought to be an important process in how meditation can reduce anxiety. For this reason there is considerable overlap between meditation and mindfulness so that mindfulness meditation is the most common type of meditation used in the treatment of anxiety problems. Another variation is lovingkindness meditation, which involves focused attention on your chosen image of a compassionate person expressing warmth, caring, love, and acceptance toward you while you’re meditating. 4.  Mindfulness: This involves taking a passive, nonjudgmental approach in which you become an observer who watches your thoughts and feelings in the moment without any attempt to change your inner experience.37 Mindfulness is a skill in which individuals learn to distance themselves from their anxious thoughts regardless of the severity of their symptoms. It’s akin to watching thoughts of threat and vulnerability pass through your mind like a bystander watching a parade. 5.  Physical activity: In Chapter 5 you learned that a program of regular physical exercise is effective in reducing anxiety and improving tolerance of anxiety symptoms. This means that maintaining physical fitness might be a helpful coping strategy for anxiety. As well, many people become hyper, impatient, and easily frustrated when feeling severe anxiety. Learning to slow down, pace yourself, and focus on the task at hand is an effective way to counter the spiraling effects of severe anxiety.

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The Next Chapter How we act has a major impact on our problems with anxiety. If we are intolerant of anxiety, opt for escape/avoidance, seek safety, and rely on unhealthy coping strategies, then our anxiety problem will get worse. But this doesn’t have to happen. At the beginning of this chapter you were reminded of times when you exercised courage. You haven’t lost that courage. Maybe it’s been dormant for a while, but it’s time to resurrect it once again. With courage you can use exposure-based interventions to improve your tolerance of anxiety. And with renewed tolerance, you’ll experience a significant improvement in your problematic anxiety. The way we think (Chapter 6) and how we cope (Chapter 7) are not the only contributors to anxiety problems. Worry, the topic of our next chapter, is a third factor that amplifies anxiety problems. In Chapter 8 you’ll learn about the toxic effects of excessive worry and how it contributes to all types of problematic anxiety. Worry is a hard habit to break, but, just like escape/avoidance, there are specific CBT skills that can improve self-­control over a worried mind.

8 take control of your worried mind

M

akayla is a “worry wart,” or at least that’s the reputation she has with her friends, family, and coworkers. Ever since high school she has worried about the possibility of impending doom. Now she worries about anything and everything—her own health and her husband’s, the volatility in her financial investments and the looming prospect of retirement, her work performance, her daughter-in-law’s pregnancy, her younger son’s search for a new job, their plans to remodel a bathroom. Even mundane tasks like housework can trigger a fresh round of worry. She has tried a number of interventions over the years, from antidepressants and tranquilizers to repeated sessions with various mental health professionals, but nothing has solved the worry problem. As the years have advanced so has her worry, and now Makayla feels trapped, with worry robbing her of what had promised to be “the best years of my life.” Worry is the central characteristic of generalized anxiety disorder (GAD), but it is also seen in most other anxiety problems. If you have severe anxiety in social situations, you likely worry about what other people think of you. If you have panic attacks, you probably worry about having another attack. And if you have health anxiety, you worry that you might have a life-­threatening illness that hasn’t been detected. Worry is such an important part of many types of anxiety that we call it a transdiagnostic process. That’s why we’ve given worry its own chapter. Regardless of your anxiety problem, you’ll want to spend time in this chapter if you worry. We’ve all worried about an important decision, how to deal with a problem, or some calamity that could unfold in the future. It’s quite normal to worry. Life is full of bad or threatening possibilities, so it makes sense to be prepared for the worst. The proverb “Plan for the worst but hope for the best” captures the essence of worry. Worry is all about thinking of serious, threatening possibilities in the future and then working out a plan for dealing with them. 185

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The Anxie t y and Worry Workbook

Unfortunately, sometimes worry gets out of hand. When it lasts for hours, occurs more Worry is a persistent, repetitive, days than not, and spreads to almost every and difficult-to-­control chain of aspect of your life, it becomes problematic. thinking that focuses on negative or Sometimes your best efforts don’t control it threatening possibilities. It involves and the worry sticks in your mind. You can the rehearsal of various problem-­ feel yourself spiral downward into severe solving solutions in an attempt anxiety and despair. Soon you find that worry to reduce a heightened sense of becomes a mental habit, a way of thinking uncertainty about possible threat. that makes it impossible to live a healthy, satisfying life. This is excessive worry, and it’s the topic of this chapter. When worry becomes excessive, we experience other symptoms of problematic anxiety, like: „ Poor

concentration

„ Increased „ Fatigue

irritability

during the day

„ Heightened „ Frequent

muscle tension

problems with sleep

„ Agitation,

restlessness, and feelings of being on edge

In the last three decades mental health researchers have learned a great deal about worry. Based on their insights, we offer a special type of CBT that targets the cognitive and behavioral processes responsible for runaway worry.

Helpful versus Harmful Worry We’ll start by examining what makes worry helpful or harmful so you can discover what we call “the sweet spot” of worry. You’ll learn how to assess your worry and use five tailored CBT interventions that give you better control over your worried mind.

Helpful Worry When worry is helpful, you might be thinking a lot about a significant problem and all the things that could go wrong, but you’re able to accept that you can’t be certain of the future. Your thinking about the problem leads to the belief that you’ll be able to cope if it does occur. In CT-R helpful worry is considered adaptive: an expression



take control of your worried mind 187

of your more positive way of thinking. It boosts self-­esteem by focusing your attention on what can be controlled in your pursuit of cherished goals while accepting the uncertainties of the future. Makayla’s husband, Richard, was approaching 60 and had high blood pressure, was overweight, and had a family history of heart disease. If Makayla worried about Richard’s health in a helpful way, she might think about all the ways she could encourage and support his efforts to develop a healthier lifestyle. At the same time, she would come to grips with the uncertainty of life, realizing that healthier living reduces the risk of premature death but it cannot guarantee longevity for anyone. She couldn’t imagine life without Richard, but she also knows that, like most women, someday she would probably need to cope with widowhood. Worrying about Richard’s health in this way allowed Makayla to shift her attention from the what-ifs of the future to what’s happening today.

Harmful Worry Harmful, or problematic, worry involves processes that lead to a different outcome than helpful worry. Here the individual repeatedly thinks about the worst possible outcome to a perceived problem, rehearsing responses that might lower the probability or impact of this worst-case scenario. All of these responses are rejected as inadequate, and the person is left with an uncomfortable feeling of uncertainty about the future. This type of worry can feel as natural as breathing to the person with an anxiety problem. It’s a product of the worried mind and an expression of the self-­protective mode. This means harmful worry is entirely focused on minimizing the possibility of threat and danger, without accepting the uncertainties of the future. It does not boost self-­esteem by giving the person a sense of what can be controlled toward reaching important goals. It makes a substantial contribution to severe anxiety by: „ Ensuring

selective attention to thoughts of threat and danger

„ Reinforcing „ Increasing

a sense of personal helplessness

a sense of uncertainty due to its preoccupation with the future

„ Functioning as a strategy for avoiding the core fear that underlies anxiety prob-

lems Instead of using her worry to plan how she could promote Richard’s health, many times throughout the day Makayla would be reminded of his unhealthy lifestyle and his risk of a heart attack and get fixated on the thought of him having a heart attack and not being able to get to a hospital in time to save him. She would think about getting the news of his death, his funeral, and then life without Richard. She thought

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of all the ways she’d tried to get him to change his habits, lose weight, and exercise, but he wasn’t listening. Makayla felt like she was living with a time bomb that was set to explode at any moment. The constant barrage of what-if thinking was becoming more than Makayla could bear. Does Makayla’s harmful worry sound familiar? If so, know that it doesn’t have to be this way—you can shift from harmful to more helpful forms of worry.

Worry Content The thoughts, ideas, and memories that comprise our mental experience of worry are unique to each person. We call this worry content, and what you worry about very much depends on your personality and life circumstances. No two people have exactly the same worry content, but there are some common themes that cut across all worry. These themes can range from the most inconsequential daily task (like getting to a hair appointment on time) to very significant personal tragedies (having a terminal illness) to major world affairs (failing to deal with climate change). Whether you’re a helpful or harmful worrier, take a moment to consider which of the following worry themes or concerns are most relevant for you. E VA L U AT ION EXER C I S E 

Worry Concerns

Worksheet 8.1 presents a list of common worry concerns. As you read through this list, consider whether each concern has personal relevance or significance. For those concerns that are personally relevant, determine whether you repeatedly think about them in a helpful way that leads to some constructive decision or action. The remaining relevant concerns may cause you more anxiety because you have difficulty thinking about them in a constructive manner. These are the worry concerns that will be the focus of your work in this chapter.

Did you have a mix of helpful and harmful worry concerns? This was the case with Makayla. Several of the categories were associated with harmful worry such as health and safety of family and friends, finances, work performance, and minor responsibilities. However, Makayla also discovered there were issues she worried about in a more helpful way, such as her physical appearance, getting older, and travel. Although she thought about these things often, she usually did so in a way that led to some constructive decisions or action as well as an acceptance of what could or could not be changed. Were you surprised to find that you didn’t worry excessively about everything? Did some concerns cause you excessive worry but other issues you



take control of your worried mind 189

W ORK SHEE T 8.1

Assessing Common Worry Concerns Instructions: Beside each concern write helpful if that’s a concern that you think about in a helpful or productive way. You often think about this concern, but it doesn’t cause you much anxiety. Write harmful beside those concerns that you think about in an unhelpful way. This type of worry is uncontrollable and is associated with considerable anxiety. If you rarely think about a particular concern, leave it blank.        Intimate (love) relationship         Physical appearance         Family relationships (children, parents, siblings)         Aging (getting older)         Work/school (performance, job security, finding a job, career issues)

       Your physical health (illness, disease, injury, fitness, weight)         Pet’s health        Your mental health (unwanted emotions, behavior)         Spiritual/religious (matters of faith, morality, and conscience)        Health and safety of family, friends

       Your future        Finances         Travel (driving, flying, trains, vacations)

        Minor responsibilities (being punctual, house repairs/cleaning, making appointments)

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

left blank because they didn’t cause you any worry at all? Did you worry in a helpful way about several personal concerns?

Is Your Worry Harmful or Helpful? A better understanding of your worry starts with knowing whether you tend to worry in a helpful or harmful manner. Table 8.1 presents the defining features of harmful and helpful worry. All worry is about the future and what might happen. Worry can be thought of as what-if thinking in which there’s an attempt to find a response that provides a sense of certainty or comfort about imagined possibilities. But that’s where the similarities between harmful and helpful worry end. As noted earlier, harmful worry is excessively focused on self-­protection where helpful worry is focused on self-­expansion, or adaptation and planning to meet goals. You can see these differences in the characteristics listed in Table 8.1. Harmful worry focuses on exaggerated possibilities of threat

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The Anxie t y and Worry Workbook TA B L E 8 .1.  

Characteristics of Harmful and Helpful Worry

Harmful worry

Helpful worry

Focus on distant, imagined what-if scenarios

Focus on more immediate, realistic problems

Focus on imagined problems that you have little control or ability to influence

Focus on impending problems over which you have some control or influence

Tendency to focus on how upset you would feel if the worry concern actually happened

Greater focus on problem-­solving the worry concern

Failure to accept any solution for the worry concern because it cannot guarantee success

Able to try out and evaluate less-than-­perfect solutions to the worry concern

Relentless pursuit of a sense of safety and certainty about the imagined outcome

Willingness to tolerate reasonable risk and uncertainty

A very narrow and exaggerated focus on the imagined threat or worst-case scenario (that is, catastrophizing)

A broader, more balanced focus on all aspects of the worry concern; the ability to recognize the positive, negative, and benign aspects of the situation

A feeling of helplessness to cope with the worry situation

A greater degree of self-­confidence in your ability to cope with the worry situation

High levels of anxiety or distress

Low anxiety or distress

Based on Cognitive Therapy of Anxiety Disorders (Guilford Press, 2010, p. 427) by David A. Clark and Aaron T. Beck.

and strives for an unattainable level of safety and certainty about the future. Helpful worry tends to consider problems rooted in the present, with less focus on worst-case outcomes and the need to know for certain whether the catastrophe will happen or not. Let’s look at Makayla’s way of thinking about a bathroom renovation as an example of the two types of worry. Makayla’s experience of harmful worry involved long periods of getting fixated on highly negative possibilities: “What if the contractors we hired are incompetent and do a poor job?” “What if they don’t listen to what we want and we end up with renovations we hate?” “What if they get started and then leave for weeks on end to do other jobs?” “What if we go way over our budget?” She tried to counter her catastrophic thinking by mentally rehearsing various strategies to deal with the contractors that guaranteed they’d keep to their schedule, do the job to her satisfaction, and not run over budget. But nothing seemed to help, and she ended up with a sick feeling in her stomach that the whole project would be a disaster. She tried to stop worrying by reminding herself that it was just a bathroom renovation and everything would be fine, but she couldn’t convince herself. She started worrying that her uncontrolled worry about such mundane matters was taking a toll on her



take control of your worried mind 191

health and that she’d end up having a “nervous breakdown” or worse, a heart attack from all the stress. If Makayla could remind herself that renovations hardly ever go as planned and to “expect the unexpected,” she’d be on her way to helpful worry. If she had doubts about the contractor, she might go through a checklist to remind herself what she had done to hire the most competent person (checked references, obtained a detailed work estimate, signed a contract, and the like). She could talk with friends who had done similar renovations and work on accepting the risk and uncertainty of hiring contractors. She could remind herself that there were lots of things in her house she would like to change but had been able to live with. If she ended up not 100% satisfied with the bathroom renovation, she could live with that as well. She could focus on the fact that any improvements would be better than the existing bathroom, which she had lived with for years. If the contractors reneged on the contract, she had legal avenues for dealing with that problem. Finally, she could reframe the problem and remind herself that a new bathroom would have little impact on her life satisfaction and personal meaning. Even if she felt a little apprehensive about launching into a bathroom renovation at this time, she could normalize these feelings and accept them, realizing that most people feel uneasy when they spend a significant amount of money. When it comes to worrying about a specific issue, it can be difficult to know if you are worrying in a helpful or harmful way. Often it’s easier to see this difference in other people than in yourself. The following quiz gives you an opportunity to practice distinguishing helpful and harmful worry.

Quiz: Worrying about Unemployment Worksheet 8.2 presents two people who had different ways of worrying about unemployment. Both faced the possibility of losing their job through downsizing. You’ll find a brief description indicating how each person worried about being unemployed. Using the characteristics listed in Table 8.1, decide which person exhibited harmful or helpful worry. What are the reasons for your decision? Did you think that Jin’s worry about unemployment was harmful and Katya’s worry was more helpful? Notice that when Jin worried about his job he did a lot of what-if thinking about worst possible outcomes. He kept thinking about being unemployed for months, how awful he’d feel during this period of no work, and how his job searches would be futile because of an economic reality that was beyond his control. You can see his anxiety and worry build in this scenario because of his difficulty tolerating the uncertainty of his employment situation. Katya’s worry took a more practical, problem-­solving approach to possible unemployment. Notice she was much more focused on the present than on the future. She figured out what she could do now to prepare for possible job loss in the near future.

W ORK SHEE T 8. 2

Harmful/Helpful Worry Quiz Instructions: Read each worry scenario and decide whether the person’s worry is helpful or harmful. Explain why you think the worry is harmful or helpful in the space provided.

Jin’s Worry Jin has been working for several years at a retail outlet in the mall. He heard a rumor that the head office might be closing his store. This was a month ago, and since then he can’t stop thinking about it. He keeps thinking about losing his job and being unemployed for months. He imagines long hours of futile attempts to find work, but given a soft economy, retail jobs are scarce. He thinks about how awful it feels to be unemployed. He keeps asking people at work whether there’s any news from the head office, but there is none. He’s more conscious of the drop in customers and can feel his anxiety build on slow days. Jin can think of little else than his impending unemployment and how bad his life is about to get. Is Jin’s worry helpful or harmful? Why?

Katya’s Worry Katya just started work at a retail outlet in the mall. One day a coworker told her a rumor that the head office might be closing the store. At first Katya felt anxious about the possibility of having to look for work again. She’d been unemployed before and it was certainly a difficult time in her life. The current economy was not good and retail jobs were scarce. But then she started to think about the strategies she had used in the past to find work. She was able to remember that she’d always found a job, although sometimes it took much longer than she liked. She decided that instead of waiting for the store to close, she’d start job searching now. Who knew? Maybe she’d find an even better job, or she’d find something that would hold her over until something better came along. Or maybe it was time to go back to school. Katya spent a lot of time thinking about her future and whether this was a good time to make a significant career move. Is Katya’s worry helpful or harmful? Why?

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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take control of your worried mind 193

She didn’t focus on her emotions, that is, how bad she’d feel without employment. Instead of thinking the worst (sitting at home bored, miserable, and discouraged), she thought about the various options open to her if she soon lost her job. Katya was better at embracing the unknown, the uncertainty of the future. As a result her worry resulted in problem solving and preparation rather than an overwhelming feeling of threat and defeat. As you think about your times of worry, are you a Jin or a Katya? Worry focuses on the situations, problems, and issues that are important to us. Because of this our worries concentrate on a few areas or domains of life such as health, family, relationships, work/school, safety, community, and spiritual/moral matters. Do you have worries in one or more of these life domains? E VA L U AT ION EXER C I S E 

What I Worry About

The exercise in Worksheet 8.3 asks you to think about 10 aspects of living called life domains and consider whether you have a specific worry in each domain. If you do, indicate whether the worry is helpful or harmful.

What did you learn about your worry? Is it focused on one or two areas of your life, like health or your intimate relationship? Or do you worry about most things in life? When you evaluated your worry against the criteria in Table 8.1, is all your worry helpful, harmful, or a mix of the two? This chapter is about harmful worry. So if several of your worries on Worksheet 8.3 are problematic and they make you feel anxious, don’t despair! The rest of this chapter is written for you. It shows you how to shift out of your harmful worry and adopt more effective ways to deal with an uncertain future.

What Makes Worry Harmful Like Makayla, many people worry a lot about many different things. If you’re among them, you might be wondering why your worry has become uncontrollable and makes you feel so anxious. People are more likely to experience worry and generalized anxiety when there’s more stress in their daily life or when they are experiencing significant life difficulties.4 But even more than our life circumstances, how we process our worrisome thoughts can have an impact on whether it’s the harmful type or not. Table 8.2 presents several critical thought processes that transform worry from a helpful, problem-­solving approach to an extreme, uncontrollable, and harmful way of thinking that can foster an intolerable state of uncertainty.

W ORK SHEE T 8.3

My Worry across Life Domains Instructions: Write down what you currently worry about in each domain. If you have more than one worry in a domain, list them all. If you don’t have any worries in a particular domain, leave it blank. After each worry, write in parentheses whether the worry is “helpful” or “harmful.” Base this distinction on the criteria in Table 8.1. Make multiple copies of the worksheet if you need more space. Worry

Label helpful or harmful

 1. Health (self):

  2. Health (family, friends):

  3.  Safety concerns (self, children, family):

  4.  Work or school:

 5. Finances:

 6. Intimate relationships:

  7. Other relationships (family, friendships, work colleagues, etc.):

  8.  Minor matters (making appointments, completing daily chores, etc.):

  9.  Community, world affairs (global warming, terrorist attacks, etc.):

10.  Spiritual matters:

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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take control of your worried mind 195 TA B L E 8 . 2 .  

Key Cognitive Features of Harmful Worry

Cognitive process

Explanation

Example

Catastrophizing

Exclusive focus on the possibility of a highly disturbing or threatening future outcome (worst-case scenario)

“What if my 5-year-old has a head injury while playing at school?”

Heightened anxiety

Experiencing physical symptoms of anxiety while worrying (tension, restlessness, feeling on edge, nausea)

When Makayla thought of her daughterin-law’s pregnancy, she could feel a rising tension in her body and a knot in her stomach.

Intolerance of uncertainty

Difficulty accepting the uncertainty of future events and so striving to gain reassurance that a dreaded possibility won’t happen

“I can’t stand waiting to know whether this skin rash is malignant melanoma.”

Safety seeking

Striving to attain a sense of safety, comfort, or relief from possible threat or danger to self or loved ones

Repeatedly asking for reassurance from your supervisor that you’re performing well at your new job.

Failed problem solving

Repeated attempts to prepare an effective response to a possible catastrophe but being dissatisfied with each potential solution

You worry about your teenage son, who is defiant and getting into trouble, but everything you think of doing about the problem seems likely to fail.

Striving for perfection

Attempts to find a perfect solution for the possible threat that will bring relief and a sense of personal safety or security

“What if my spouse is having an affair? I need to approach this perfectly so it brings out the truth but doesn’t destroy our marriage.”

Heightened control effort

Repeated efforts to stop worrying that paradoxically increases the tendency to worry

Keep telling myself not to be so stupid and try harder to stop worrying.

Unhealthy worry beliefs

Having positive beliefs that worry is helpful but also negative beliefs that it’s harmful to your health and well-being

“Worrying about my child’s safety is a sign that I’m a caring mother” (positive belief). “If I don’t stop worrying, I’m going to have a heart attack” (negative belief).

E VA L U AT ION EXER C I S E 

Discover Your Unhealthy Worry Processes

Can you see how the ways of thinking in Table 8.2 could turn the worries you listed in My Worry across Life Domains (Worksheet 8.3) into a harmful, anxious way of thinking? Worksheet 8.4 gives you an opportunity to identify the role these cognitive processes play in creating harmful worry.

W ORK SHEE T 8.4

My Cognitive Characteristics of Harmful Worry Instructions: Record three harmful worry examples from the previous worksheet. Then, in the table that follows, write a brief statement in the second column describing how the cognitive process in the first column expresses itself in one or more of these harmful worry examples. If a process is not relevant, leave it blank.

1. Harmful worry example:

2. Harmful worry example:

3. Harmful worry example: Note: Makayla’s harmful worries were her husband’s health, her son’s job search, and not getting housework done in a timely fashion.

Cognitive process Catastrophizing

Your experience of the cognitive process 1.          2.          3.          Makayla’s example: When I worry about Richard’s health, I think of him having a massive heart attack, dying, and my life as a widow.

Heightened anxiety

1.          2.          3.          Makayla’s example: When thinking about my son looking for work, I can feel the tension rise in my body, my stomach churns, and I feel edgy. He’s had such a difficult time finding work. (continued)

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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W ORK SHEE T 8.4 (continued)

Cognitive process Intolerance of uncertainty

Your experience of the cognitive process 1.          2.          3.          Makayla’s example: I keep trying to reassure myself Richard will be okay. I hate the uncertainty of life; not knowing when his health might give out; that he’s really living on “borrowed time.”

Safety seeking

1.          2.          3.          Makayla’s example: I keep telling myself it’s okay to have a messy house; it’s no big deal. So I leave it and watch a movie, go shopping, get out of the house, visit with friends, but I can’t stop thinking about the mess at home.

Failed problem solving

1.          2.          3.          Makayla’s example: I keep thinking about what advice to give my son about job

searching, but nothing I can think of is satisfactory, and so I keep worrying he’ll never find a good job. (continued) 197

W ORK SHEE T 8.4 (continued)

Cognitive process Striving for perfection

Your experience of the cognitive process 1.          2.          3.          Makayla’s example: I can’t stop worrying about the house unless it’s perfectly clean and there is absolutely no mess. But this lasts only a moment because I have a messy husband and son living in the same house. Before I know it, the house is a mess and I’m worrying about getting it back to good order.

Heightened control effort

1.          2.          3.          Makayla’s example: I keep telling myself to stop worrying. I try to push the worry

from my mind by distracting myself or telling myself it’ll be alright. But the more I do this, the more I worry. Unhealthy worry beliefs

1.          2.          3.          Makayla’s example: If I worry about Richard’s health, I’ll be motivated to keep at him to stick to his diet and exercise. But the worry is making me so anxious, it can’t be good for me. If I don’t stop worrying, I could end up having a “nervous breakdown.”

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take control of your worried mind 199

Were you able to discover how your way of thinking about issues in your life has made your anxiety and worry worse? The thought processes you identified are responsible for turning worry from a helpful process into a harmful one. We’ll be returning to these thought processes later in the chapter when we introduce you to CBT strategies that reduce worry. These strategies target many of the thought processes in Table 8.2. Before we discuss worry assessment and treatment, let’s take a moment to consider what more you need to know about the worried mind.

The Worried Mind So far we’ve made a distinction between helpful and harmful worry. It’s the harmful worry that drives up anxiety and causes us to feel apprehensive about the future. We also identified eight thought processes that intensify harmful worry. Let’s pull all this information together and take a look at how the worried mind operates. We call this the CBT model of worry, and it’s illustrated in Figure 8.1. As you can see, there are four main elements to the worried mind: (1) exposure to triggers or a stimulus that’s relevant to your worry concerns, (2) activation of worry-­related positive and negative beliefs, (3) the experience of harmful worry, and (4) elevation of associated anxiety. The worried mind operates as a feedback loop in which worry causes an elevation in anxiety, which itself will increase the frequency, intensity, and uncontrollability of worry. I’m anxious because I worry, but I’m also worried because I’m anxious.

1.  Triggers and Intrusions Worry is always triggered; it rarely occurs for no reason. It may be a situation, a person, something you’re told, or exposure to some information. There’s usually something that kick-­starts the worry process. It often starts when a thought, image, or memory pops into your mind—what we call unwanted intrusive thoughts. We have hundreds, probably even thousands, of intrusive thoughts daily, but only some of these thoughts trigger worry. The ones that cause worry are intrusive what-if thoughts involving the possibility of some future threat, danger, or negative outcome. Some examples of worry-­related intrusions are: „ Thinking

of going into next week’s meeting without your report ready

„ Remembering

a friend telling you she saw your husband with another woman

at a restaurant „ Being

reminded of the bank foreclosing on your mortgage

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Trigger/stimulus (intrusive thought/image/memory; situation, circumstance, information)

Activated worry beliefs (positive and negative beliefs about worry, threat, uncertainty, and vulnerability)

Safety seeking

Mental control effort

Catastrophizing

Harmful worry

Failed problem solving

Intolerance of uncertainty

Strive for perfection

Elevated anxiety F I G U RE 8 .1.  

„ Imagining

CBT model of worry.

that your child is injured at day care

„ Remembering

the doctor telling you of a positive test for breast cancer

The human mind is highly creative, and our external environment is constantly changing, so there is an endless number of mental intrusions that could trigger worry. We ignore or are hardly aware of most of them. So for an intrusive thought to grab our attention and cause worry it must be: „ Personally

relevant: Intrusive thoughts related to our personal goals, values, and concerns have a higher potential for worry. For example, only highly religious people would pay attention to an intrusive thought about whether they’ve been earnest and sincere in their daily prayers.

„ An

exaggeration of threat: Intrusive thoughts about a catastrophic, worst-case



take control of your worried mind 201

outcome are more likely to trigger worry. In fact, it is the thought of some impending catastrophe to self or loved ones that really grabs our attention. „ Externally cued: Often worry-­related intrusions are triggered by circumstances

or information encountered during our daily activities. A television commercial, a remark at the office, something noticed on the way home from work . . . we process millions of cues that could trigger an intrusive thought. Makayla would hear a baby cry, have an intrusive thought about her daughter-in-law’s pregnancy, and then start worrying about the health of the unborn child.

2. Belief Activation What we believe about worry and its consequences has a significant impact on the worry process. Negative beliefs about the need to control worry and minimize its impact on emotional health can lead us down the path to uncontrollable, harmful worry. Likewise positive beliefs that worry is useful can contribute to uncontrolled worry. What do you believe about worry? E VA L U AT ION EXER C I S E 

Your Worry Beliefs

Use this exercise to discover whether you have unhealthy beliefs about worry. The worksheet consists of 20 belief statements based on the six characteristics of harmful worry depicted in Figure 8.1. The Worry Beliefs Checklist (Worksheet 8.5) is intended to give you a rough idea of the role that positive and negative worry beliefs play in your experience of harmful worry.

Makayla had a number of problematic worry beliefs. When she worried about retirement, she was convinced they wouldn’t have enough money to make ends meet even though she and Richard had adequate retirement savings. She could only think about having to sell the house and move into a tiny apartment. At her age, she could not figure out any solution other than working well into her 70s. She repeatedly sought financial advice and talked to her husband endlessly about how they could afford retirement, but in the absence of a “crystal ball” that showed her happy and secure, nothing eased her worry about the future. Makayla believed that her worry about retirement meant that she was taking it seriously and that it prevented her from making a mistake and retiring from work too early. On the other hand, the worry was an “unstoppable force” that was robbing her of momentary joy. Any advantages of worry were outweighed by a mountain of misery and anxiety. You can see that Makayla would agree with many of the worry statements in Worksheet 8.5.

W ORK SHEE T 8.5

Worry Beliefs Checklist Instructions: Place a checkmark under “Agree” or “Don’t agree” to indicate whether you tend to agree with each belief statement or not. If you can’t decide, force yourself to make a choice by considering whether you mostly agree or mostly disagree with the statement.

Belief statements

Agree

Don’t agree

  1.  My problem is that I have poor mental control.   2.  You should keep trying until you find the very best solution.   3.  I have bad luck. If something bad happens to me in the future, it will probably be the worst possibility.   4.  I cannot tolerate making mistakes.   5.  It’s important to minimize uncertainty as much as possible.   6.  I’ll feel less anxious if I can be more certain of the future.   7.  It’s important to get relief when feeling threatened or anxious.   8.  Perfection’s not possible, but we should strive for it anyway.   9.  You should keep trying until it feels right. 10.  Bad things are more likely to happen to me than good things. 11.  If you can’t come close to the perfect solution, you shouldn’t do it. 12.  Anything less than your very best is unacceptable. 13.  If you try hard enough, you can stop worrying. 14.  One should strive to feel safe as much as possible. 15.  I can’t stand not knowing how important things in my life will turn out. 16.  Always be prepared for the worst. 17.  If you have a bad feeling about a decision or course of action, don’t do it. 18.  You shouldn’t do anything that makes you feel uncomfortable. 19.  If you can’t control your worry, it’s a sign that you’re losing control. 20.  It’s important to think through all possibilities, especially the most extreme or catastrophic ones. From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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3.  The Worry Process Figure 8.1 includes six core thought processes (defined in Table 8.2) that cause worry to become anxiety-­provoking and uncontrollable. C ATA S T R O P H I Z IN G

Our worry becomes harmful when we get focused on the worst possible outcome of a situation and have difficulty considering less extreme possibilities. We spend so much time on the catastrophe that we become convinced it is the most likely outcome. Negative outcomes that may be more likely but less severe fade from attention. We dismiss them outright, convinced we’re just “brainwashing” ourselves into thinking it might not be so bad after all. Imagine you’re the parent of a 17-year-old daughter who is out with friends and it’s now two hours past her curfew. She’s not answering her cell phone, and she blocked her location. It would be natural to think the worst—that she’s been assaulted, is strung out on drugs, is at some wild party, or was involved in a fatal car crash. It would be hard to think of less dire possibilities like her cell phone had died or she was having a good time and lost track of time. You might even forget that she’s done this before and not been in danger. You would be “sick with worry” because you’d be constantly thinking of the worst—that she was in trouble and beyond help. E VA L U AT ION EXER C I S E 

Your Worry Catastrophe

Look back at the harmful worry you recorded on My Worry across Life Domains (Worksheet 8.3). Select a couple of your worry concerns and write them in the space provided. Next, write down a worst-case scenario or catastrophe that you think about when you are worrying about that concern. 1. Harmful worry concern: Catastrophic thinking: 2. Harmful worry concern: Catastrophic thinking: Makayla’s harmful worry concern:  

My investments are not doing so well.

Makayla’s catastrophic thinking:   I’ll never be able to retire. I’ll be working in this miserable job

until my health gives out. I’ll be stuck alone in an apartment, unable to go anywhere until I’m forced into a nursing home.

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IN T O L E R A N C E O F U N C E R TA IN T Y

We feel most uncertain when confronting situations that are unpredictable, novel, or ambiguous.38 If you have a low tolerance for uncertainty, you’ll find it especially difficult to deal with novel, unpredictable situations. The natural reaction is to worry. In fact, low tolerance of uncertainty is a critical factor in generating harmful worry. It triggers the what-if questions that are a core feature of harmful worry.39 The entire worry process can be viewed as an attempt to regain a sense of certainty about what the future holds. But it’s a futile attempt because we cannot know the future. We can make predictions, imagine possibilities, but in the end we can’t know for certain what will happen. We have no choice but to live in uncertainty until the future happens. In our previous example, being uncertain about your daughter’s whereabouts may feel intolerable as the minutes tick past her curfew. You might try to convince yourself of this possibility or that, but nothing satisfies the nagging sense of uncertainty. When worry becomes a problem, it’s not just the occasional incident that triggers intolerable uncertainty. Individuals who experience frequent harmful worry are seeking a higher level of certainty about the future.39 This intolerance of uncertainty becomes a catalyst for the worry process. Later you’ll learn about CBT interventions that can raise your tolerance of uncertainty and stem the relentless flow of what-if questions. STRIVING FOR PERFECTION

Some people can’t stop worrying because they are looking for a perfect solution to a problem. One possibility after another is rejected because an unrealistic standard of acceptability is demanded. Flaws, mistakes, or shortcomings cannot be tolerated. Perfectionism is not a contributor to all harmful worry, but when it’s present it can be a significant factor in its persistence. Latoya is a young woman who worries she won’t find love and will spend the rest of her life alone and miserable. She’s had numerous dates, but each man has fallen short of her unrealistic standards. Her close friends keep telling her “You’ll never find Mr. Perfect,” but Latoya can’t tolerate the slightest shortcoming when it comes to her attention. You can see how Latoya’s perfectionism about relationships would contribute to her worry about her relationship status. If you’re wondering whether perfectionism might play a role in your worry, consider two workbooks on the subject, When Perfection Isn’t Good Enough40 and Overcoming Perfectionism.41 FA I L E D P R O B L E M   S O LV I N G

Harmful worry involves an incessant search for solutions—some way to deal with the predicted catastrophe and stop the worry process. In his book Anxiety Free, Robert



take control of your worried mind 205

Leahy noted that needing an answer right now is an important contributor to worry.42 People who experience harmful worry are able to problem-solve, but there are several weaknesses in their approach. They: „ Lack „ Are

confidence in their problem-­solving ability

overly focused on future threat

„ Have

a negative expectation about the problem-­solving outcome

„ Search

for the perfect solution

„ Tend

to focus on irrelevant information or compulsively check to reduce uncertainty42

The end result is that individuals caught in a cycle of harmful worry spend a lot of time “spinning their wheels.” They think through numerous possible responses to a feared outcome but end up rejecting each solution as unacceptable. This leaves them with a feeling of helplessness, unable to deal with a world of encroaching threat, danger, and uncertainty. Derrick, a college student, worried about being embarrassed in social situations because of ridicule and rejection. If invited to a party, he’d spend several days before the event mentally rehearsing how he could deal with various awkward social encounters. He searched for online resources that provided coaching on how to be friendly and avoid embarrassing social gaffes. But everything he read or mentally rehearsed didn’t quite work for him. He couldn’t imagine himself being socially confident and competent. He was convinced he’d come across as awkward and insincere, which would elicit even more disapproval and the possibility of embarrassment. So he was left fretting, worrying about how he could overcome his anxiety and fear of embarrassment. M E N TA L C O N T R O L E F F O R T

How many times have you heard people say “Oh, don’t worry about it” or “Stop worrying”? You want to retort “Of course I know I should stop worrying, but I can’t!” When caught in a cycle of harmful worry, it may feel like you’ve lost control of your mind. But at the very moment when you think “Am I losing my mind?” you end up trying even harder to stop the worry. This is based on the belief that “I can’t stop worrying because I’m not trying hard enough.” But there is a problem with this reasoning. Mental control is a paradoxical process in which the harder you try not to worry, the more you will worry. Harvard psychologist Daniel Wegner discovered a phenomenon known as the

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ironic effects of mental control.43 In his research he had individuals try not to think about something like a white bear for several minutes. After they stopped trying to suppress thoughts of a white bear, he discovered they had more white bear thoughts intrude into their mind than the group of individuals who had not tried to suppress their thoughts. In other words, trying not to think about white bears caused people to think about white bears even more than if they had just left the thought alone. If you’re doubtful, try the white bear experiment. E VA L U AT ION EXER C I S E 

White Bear Experiment

The experiment is done in two stages. Have a pen and sheet of paper available. Start the stopwatch on your mobile phone, close your eyes, and think about a white bear. Try as hard as you can to keep the white bear in your mind. If your mind drifts to other thoughts, note the mental interruption by making a mark on the paper (you might have to peek for a second), and then refocus on the white bear. After two minutes, stop the experiment and count the number of interruptions you experienced while thinking about the white bear. Record the number of mental interruptions and rate your experience using the 3-point scale below. Thinking of the White Bear Number of mental interruptions: 1. Success in staying focused on the white bear thought: 0 = not at all successful; 1 = slightly successful; 2 = very successful 2. Mental effort needed to stay focused on the white bear thought: 0 = no effort; 1 = slight effort; 2 = great deal of effort For the second stage, again close your eyes, and for the next two minutes, try not to think about a white bear. You should try as hard as you can to keep your mind focused on anything but the white bear. If the white bear thought intrudes into your mind, make a tally mark indicating the intrusion occurred (you might have to peek again), and then gently turn your attention back to other thoughts. Use the following scales to record your experience of not thinking about the white bear. Not Thinking about the White Bear 1. Number of white bear intrusions: 2. Success in suppressing the white bear thought:



take control of your worried mind 207

0 = not at all successful; 1 = slightly successful; 2 = very successful 3. Mental effort needed to not think about the white bear: 0 = no effort; 1 = slight effort; 2 = great deal of effort What did you notice about this experiment? Were you better at keeping the white bear thought in your mind or stopping yourself from thinking about the white bear? Did it take more mental effort to suppress the white bear than to intentionally think about it? If you’re like most people, no doubt you found thought suppression—not thinking about the white bear—much harder than thinking about the bear. Â Tips for Success: Mental Control of Worry

You can increase the relevance of the white bear experiment by repeating it with one of the harmful worry concerns you noted on My Worry across Life Domains (Worksheet 8.3). Follow the same instructions, but instead of thinking or not thinking about white bears, replace this with thinking about your worry concern. Record the number of interruptions at each stage and complete the rating scales. Now compare your results with the first time you did the experiment with the white bear. What did you find? You probably found it even harder to not think about your worry than you did to not think about the white bear. That’s because the worry is much more important to you, so it’s even harder to divert your attention from it.

Again the take-home message from the white bear experiment is this: The more you try not to worry, the more you worry. As you’ll discover in the second half of this chapter, many of the CBT interventions for worry focus on relinquishing our efforts to directly control worry. You’ll find that when you stop trying to control worry it’ll become less dominant and anxiety-­provoking. SAFET Y SEEKING

When worry becomes harmful, we’ll do almost anything to obtain some relief, a sense of safety and comfort. It’s common to seek relief through reassurance seeking. If you’re worried about some terrible possibility, it’s natural to seek reassurance from friends and loved ones—“Do you think everything will be okay?”—or to try convincing yourself that “everything will be all right.” You might invent clever arguments to convince yourself that you’re prepared for the worst. But worry is always about the future, and so you’re left with this nagging sense of uncertainty. You seek safety and security, but it remains elusive. In fact, the search itself paradoxically intensifies the worry experience.

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There are two factors that increase the safety-­seeking urge. The first is called emotional reasoning. Worry causes us to feel anxious. We take feeling anxious as a sign that the worry threat must be real and more likely to happen. So feeling anxious proves we should be worried. Ironically, we then assume the inverse is true: “If I don’t feel anxious, I don’t have anything to worry about.” Even though we might reduce anxiousness by taking a tranquilizer, this can’t change the future or ensure that what we’re worried about will not occur. Just as feeling calm doesn’t mean there’s no need to worry, feeling anxious doesn’t mean we should worry. What we feel doesn’t change the possibility of a future threat. Worry about worry is another strong motivator to seek safety and relief from worry. British psychologist Adrian Wells noted that people with persistent and anxiety-­ provoking worry become worried about worrying.44 This involves a set of negative beliefs about worry such as “I’ll go crazy unless I stop worrying,” “I’ve lost all control over worry,” or “I can’t do anything productive as long as I am worrying.” Once we become worried about the negative effects of worry, we become even more desperate to find relief or some type of resolution of our worry concerns. As well, this “fear of worry” motivates us to try even harder to stop worrying, which sets in motion the paradoxical effects of mental control. Avoidance and the search for safety, then, take on a renewed sense of urgency because we’re convinced we must do whatever it takes to stop worry and reduce our anxiety. After years of worry, Makayla was convinced that her life had been ruined by her pathological worry. She came to fear the worry episodes and tried to discover her worry triggers so she could avoid these situations or experiences. Of course, this turned out to be futile and only left her feeling trapped and defeated.

Worry Assessment What you’ve learned about worry allows you to construct a worry profile that will guide your CBT worry interventions. We begin with another assessment tool to help you determine whether worry is a problem for you.

E VA L U AT ION EXER C I S E 

The Problem of Worry

Most of us can get stuck in harmful worry when something unusual happens in our life. So you may be wondering if you experience enough harmful worry to consider it a problem in your life. The Worry Wart Checklist (Worksheet 8.6) can help you make this assessment. It consists of 10 statements about worry experiences. If you circled “Yes” for most of the items, then harmful worry is likely a problem for you.

W ORK SHEE T 8.6

Worry Wart Checklist Instructions: Below are 10 statements about worry. Check Yes if the statement characterizes how you tend to worry or No if the statement does not apply. Statement

Yes

No

  1.  When I worry, I get stuck on the most negative possibility (what-ifs) of the situation.   2.  When I worry, I tend to think about how upset I will feel if this situation actually happened.   3.  When I worry, I keep trying to figure out what I can do to prevent the worstcase scenario.   4.  When I worry, I keep trying to convince myself the worst-case scenario won’t happen, but I can never feel assured or convinced that everything will be all right.   5.  When I worry, I come up with various responses or solutions to the problem, but I end up rejecting them all because they don’t seem adequate enough to deal with the situation.   6.  When I worry, it is “not knowing” about the future that bothers me most.

  7. During worry episodes I feel so helpless and ill-­prepared to deal with life’s difficulties.   8. Despite my best efforts, I end up feeling frustrated and discouraged with my inability to stop worrying.   9.  When I worry, I keep trying to work out what is the most likely outcome of this situation, but I am always left feeling uncertain. 10. I often think about how miserable my life will be if I don’t get a handle on this worry.

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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The Anxie t y and Worry Workbook

Track Your Worry Up to this point you’ve been relying on your memory to complete the various exercises and worksheets on worry. To truly understand your worry, it’s important to collect some data in real time. The next exercise presents another important assessment tool, the Worry Diary. E VA L U AT ION EXER C I S E 

Worry Self-­Monitoring

You can use this form to record your daily experiences of worry. This will give you valuable information on how to use CBT interventions to reduce worry. The Worry Diary (Worksheet 8.7) plays a central role in CBT for worry. You’ll want to keep the diary handy and complete it as close to the worry episode as possible. Record in the diary each time you experience a significant bout of worry.

There’s a lot you can learn about your worry from keeping a diary. Are there common triggers of your worry episodes? Do you find yourself having the same what-if questions over and over? Are you focused on certain catastrophes? Are you trying to work out solutions in your mind? You’ll want to continue using the Worry Diary to record your worry experiences while using the worry interventions in this chapter.

Your Worry Profile Having a plan to guide your treatment will make your worry interventions more effective. You can create a plan, or worry profile, from all the assessment and evaluation exercises you’ve done up to this point. The Worry Profile highlights specific thought content, catastrophic thinking, worry beliefs, and control responses that you’ll target with our worry interventions. E VA L U AT ION EXER C I S E 

Create a Worry Profile

There are five sections to the Worry Profile (Worksheet 8.8): your three most frequent and distressing harmful worries; the most common triggers for each, including both external triggers (situations, people, information) and internal triggers (intrusive thoughts, memories, feelings); the worst-case scenario (the what-if questions) for each worry; positive and negative beliefs you hold about worry; and ways that you try to cope with worry. Â Troubleshooting Tips: Help with the Worry Profile

Review the work you’ve done on various worksheets in this chapter. This will help you complete the profile. If you skipped over these worksheets, you may need to go back and complete them before doing the profile. Here are some other specific suggestions:

W ORK SHEE T 8.7

Worry Diary Instructions: Record the date when each worry episode happened in the first column. Use the second column to record what triggered the episode. It could be a situation, a circumstance, a reminder, something said to you, an intrusive thought, or some combination of triggers. In the third column, briefly describe what you were thinking about while worrying. Finally, rate how anxious you felt while worrying on a 0–10 scale, where 0 = no anxiety, 5 = moderately anxious, and 10 = extremely anxious. The first row provides an example of a young woman, Cara, who suffered frequent bouts of anxiety and worry about her job performance.

Date

Trigger (What started you worrying?)

Worry thoughts (What are you thinking? What negative possibilities or threats are you focused on? List your what-if questions.)

Anxiety (0–10)

Cara’s example:

March 24

I spent the next two hours thinking what Feel very anxious 8/10 At work, I submitted a large could be wrong with my report. What if he thinks it needs to be rewritten? I don’t have project in the morning. That time to redo it. What if he thinks it’s badly afternoon I got a call from my manager that he wanted researched or disagrees with my conclusions? What if it’s so bad he assigns it to someone to see me in two hours. He else and I get a negative comment in my work sounded annoyed. I had an evaluation? I know he doesn’t like me, so this intrusive thought that my could be an excuse to get rid of me. I can’t report must be awful. afford to lose this job.

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

211

W ORK SHEE T 8.8

Worry Profile Instructions: Refer to earlier worksheets to remind yourself of responses that will help you complete this worksheet. (A) Fill in the blanks with your most frequent and distressing harmful worries. (B) List the most common external and internal triggers for each worry. (C) State the worst-case scenarios you think about for each worry. (D) Provide three to four beliefs, both positive and negative, you have about worry. (E) List three to four ways you try to cope with worry by controlling it. A. Worry thoughts 1. Harmful worry: 2. Harmful worry: 3. Harmful worry: B. Worry triggers 1. Triggers for first worry: 2. Triggers for second worry: 3. Triggers for third worry: C. Catastrophic possibilities (worst-case outcome) 1. Catastrophic thinking associated with first worry: 2. Catastrophic thinking associated with second worry: 3. Catastrophic thinking associated with third worry: D. Worry beliefs (both positive and negative)



E. Worry control



From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

212



take control of your worried mind 213 „ If you have only a couple of entries in the Worry Diary (Worksheet 8.7), you may need

to spend more time self-­monitoring your worry episodes. The Worry Diary provides valuable information necessary to complete most sections of the profile. „ If you don’t have episodes of persistent, uncontrolled, and anxiety-­provoking worry,

then the profile is not relevant for you. Consult My Worry across Life Domains (Worksheet 8.3) and My Cognitive Characteristics of Harmful Worry (Worksheet 8.4) when completing section A of the profile. „ For catastrophic possibilities, make a list of all the bad outcomes you think about

when worrying about a problem or issue. Focus on all the what-if questions you ask yourself. Then select the one possibility that’s the worst outcome you think of when worrying. You’ll find your answers to My Cognitive Characteristics of Harmful Worry (Worksheet 8.4) helpful when completing this section. „ Review the belief statements you endorsed on the Worry Beliefs Checklist (Work-

sheet 8.5). Select two or three statements that feature into your worry experiences and write them down in section D of the profile. „ There are many ways you may try to stop worrying. This includes criticizing yourself

for worrying, seeking reassurance from others, self-­reassurance, telling yourself to stop worrying, repeated checking, distraction, searching for solutions, and the like. „ You could complete the Worry Profile collaboratively with your therapist or someone

who knows about your struggle with worry, like a partner, family member, or friend.

The Worry Profile is one of the most important worksheets you’ll use in this chapter. You need to know what you are treating before you can start using worry interventions. If you’re unsure of your worry profile, have a look at Makayla’s example on page 214.

The Problem-­Solving Approach to Worry Earlier in this chapter we discussed differences between helpful and harmful worry. The distinction was based on how you experienced worry, whether it helped you solve problems in your life or you got stuck in persistent, uncontrollable, and anxiety-­ provoking worry. But there’s another way to think about worry that’s based on what we worry about. Sometimes we worry about issues or problems that arise in our everyday life, and at other times we worry about problems that could possibly arise in the future but are not part of our current life. The first we call reality-based worry, and the second we can call imaginative worry. Any of the worry concerns listed in Worksheet 8.1 could involve either type of worry.

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The Anxie t y and Worry Workbook

Makayla’s Worry Profile A. Worry thoughts 1. Harmful worry:   Fretting about Richard’s poor health and terrible health habits 2. Harmful worry:   Fearful that I’m not performing well at work and am considered incompetent 3. Harmful worry:   That we’ll spend too much on the bathroom reno and still not like it B. Worry triggers 1. Triggers for first worry:   Health information, seeing Richard’s poor diet, thought of aging 2. Triggers for second worry:   Writing reports, making presentations, any feedback or criticism 3. Triggers for third worry:   Sudden intrusive thought of the reno, call from contractor C. Catastrophic possibilities (worst-case outcome) 1. Catastrophic thinking associated with first worry:   That Richard will have a massive heart attack; he’ll

be in such poor health that he’ll die young, leaving me alone and miserable 2. Catastrophic thinking associated with second worry:   That managers will be deeply dissatisfied with

my work; they’ll view me as incompetent and I’ll be asked to leave 3. Catastrophic thinking associated with third worry:   There will be huge cost overruns, the work will be

shoddy, I’ll be so upset with the reno that we sell the house at a loss D. Worry beliefs (both positive and negative)   I need to work harder at not worrying. If I don’t, worry will wreck my physical and mental health.

Sometimes worry helps me find solutions. I need to be prepared for the worst. E. Worry control   Try to think of solutions to the problem; yell at myself to “stop worrying”; try to reassure myself it’ll

be okay



take control of your worried mind 215

Two Types of Worry Life can be hard, with an endless list of potential, unexpected problems, difficulties, and uncertainties creating significant personal distress. You may struggle with separating from a partner, parenting a troubled or ill child, being unemployed, having financial loss, being diagnosed with a serious illness, having injures from an accident, or having no idea about your future. Worrying about how to deal with them is called reality-based worry. On the other hand, the human mind is highly imaginative. We can imagine any possibility from the most fantastical, like flying elephants, to the most mundane, like preparing a meal. This means our creative brain can imagine truly frightening possibilities that may never happen or might happen decades in the future. Examples would be imagining that your partner is cheating on you, that your teenage son will grow into a lazy and aimless adult, that you’ll be fired, or that you’ll die from cancer. We can worry about these possibilities even when there’s no evidence at present that these events will happen anytime soon. We call this imaginative worry, not because you’re worrying about things that couldn’t possibly happen, but because you’re worrying about terrible possibilities that have no basis in current reality. This distinction between reality-based and imaginative worry is important because we use different interventions for each worry type. E VA L U AT ION EXER C I S E 

Reality versus Imaginative Worry

Use this exercise to discover whether your harmful worry is more reality-based or imaginative in nature. Worksheet 8.9 lists five core characteristics of both types of worry. If most of your checkmarks are in either the left or right column, your worry is mainly either reality-based or imaginative.

Are the worries you find most distressing and uncontrollable mainly reality-based or imaginative? Most of Makayla’s worries were of the imaginative type. It’s true that Richard had several health indicators that increased his risk of a heart attack. But in her worry Makayla kept imagining he would die and make her a young widow. This extreme possibility could happen, but it was much less likely than an alternative like surviving a mild heart attack and then changing his lifestyle. Likewise, her daughterin-law could have a difficult, even tragic, pregnancy, but the far more likely outcome is a normal pregnancy and uncomplicated delivery. So imaginative worry is not thinking about catastrophes that are impossible but thinking of catastrophes that are highly unlikely or that could occur far in the future. If you’re facing a difficult life circumstance and that is the focus of your worry,

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The Anxie t y and Worry Workbook

W ORK SHEE T 8.9

Type of Worry Checklist Instructions: Start by listing three harmful worries. Next, place a checkmark next to the statements that best characterize your experience of these harmful worries.

1. Harmful worry:

2. Harmful worry:

3. Harmful worry:

Reality-based worry

† Mainly focused on present-day difficulty. † Primary concern is about coping with the present-day problem, difficulty. † Worry involves search for solutions. † The worrier has some influence and control over the problem’s outcome. † The worry concern is more plausible and realistic because it’s centered on a real-life problem.

Imaginative worry

† Mainly focused on what could possibly happen in the distant future. † Primary concern is reducing anxiety or distress caused by worrying about the future. † Worry less about finding solutions because worry is focused on a possibility. † The worrier has little influence over an outcome because the worry is focused on a future possibility. † The worry concern may be implausible, even bizarre, because it originates in the imagination of the worrier.

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

then the best CBT intervention is the problem-­solving approach. If your worry is more like Makayla’s and it’s focused on imaginative possibilities, then the decatastrophizing intervention is best for you. The other interventions in this chapter are useful for both types of worry.

Behavioral Intervention: Problem Solving for Reality-Based Worry For decades psychologists have been using a systematic problem-­solving approach to help people overcome life problems in health, work, family, living conditions, social relationships, leisure, recreation, finances, and the like.45 This makes it an ideal intervention for reality-based worry. Our version of problem solving consists of six steps.



take control of your worried mind 217

S T E P 1.   P E R S O N A L C O N T R O L   E VA L U AT I O N

The first step in problem solving is to figure out how much control you have over the outcome of your worry concern. You’ll have almost 100% control over some problems, such as being low on gas or consistently being late for work. Other problems you may have only partial control over, such as being promoted at work, dealing with marital conflict, reducing your risk of a heart attack, or improving your return on investments. You may have little or no control over other problems such as the results of a cancer test, your partner’s chronic medical illness, or the recent death of a loved one. You can’t use problem solving effectively if you misjudge your level of control. If you overestimate how much control you have over a difficulty, your problem-­solving efforts will be futile. If you underestimate your level of control, you’ll give up before you even start. The next exercise offers a systematic approach that will help you arrive at a clearer understanding of your level of control over worry concerns. IN T ER V EN T ION EXER C I S E 

What Can I Control?

This exercise begins by selecting a reality-based harmful worry from the Type of Worry Checklist (Worksheet 8.9). Next, think about all the factors that could influence the outcome of the worry problem, such as other people’s actions, your past actions, the environment, the situation, and even things that happened by chance. On Worksheet 8.10, list each factor and provide an estimate of the percentage of influence or control it may have over the outcome of your worry problem. These estimates are highly subjective and simply reflect whether you think a factor has more or less influence over the outcome. You’ll need to keep changing the percentages as you develop your list because they must add up to 100%. Make sure you don’t fill in the percentage control for “my current control” until you’ve provided an estimate for all the other factors. Use the pie chart to draw the percentage of control of each factor (see Joanne’s example). This will help you visual your level of control over the worry problem. Â Troubleshooting Tip: Are You Stuck on Control?

Are you struggling with this exercise? Are you having difficulty listing all the factors that have an influence over your worry problem? Is it possible you’ve not appreciated the full complexity of the problem because you’ve been so focused on what you can do to control an outcome? We provided 10 spaces in the factor list, but you don’t need to fill all those spaces. Maybe there are only two or three factors relevant to the problem you’re worried about, or you might consider getting some help from a therapist or family member who can view the problem from a different perspective. As well, don’t get too concerned about the accuracy of your estimates. These percentages are simply meant to help you appreciate the relative contribution each factor makes toward an outcome.

W ORK SHEE T 8.10

Control Pie Chart Instructions: For section A, select one of your reality-based harmful worries and write it in the space provided. Next, list in section B all the factors that could influence the outcome of the worry problem and provide an estimate of the percentage of influence it may have over the outcome of your worry problem. After recording a “percentage of influence” for all other factors, write down the remaining percentage for “What I can control now.” The percentages must add up to 100. Use the pie chart to draw the percentage control of each factor.

A. My reality-based worry problem (concern):

B. List all the factors that have some influence/control over how this problem ends. Estimate their percentage of contribution to the outcome of the problem. Factor of contribution

Percentage

Factor of contribution

Percentage

1. 

%  6.

%

2. 

%  7.

%

3. 

%  8.

%

4. 

%  9.

%

5. 

% 10.  What I can control now:

% Total = 100%

C. Pie chart

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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take control of your worried mind 219

Joanne’s Control Pie Chart A. Joanne’s reality-based worry problem (concern):   That I won’t get the promotion I applied for at work B. List all the factors that have some influence/control over how this problem ends. Estimate their percent contribution to the outcome of the problem. Factor of contribution

Percentage

1.  My manager’s recommendation 2.  Director’s support letter 3.  Competition from coworkers who

applied

4.  What’s in my employee file 5. 

Factor of contribution

Percentage

10%

 6.

%

5%

 7.

%

10%

 8.

%

30%

 9.

%

% 10.  What I can control now:

45% Total = 100%

C. Pie chart

Manager’s recommendation [10%]

What I can control now [45%]

Competition from coworkers [10%] Director’s letter [5%]

What’s in my employee file [30%]

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Some factors have a big influence over outcome (percentages in the 40–60 range), some have a moderate influence (15–39%), and some have little influence (5–14%).

Were you surprised by the number of factors that have an influence over the outcome of your worry problem? Before this exercise, were you assuming you had more control over the worry outcome because you weren’t thinking of all the factors that influence the outcome? If you’re unclear about your work with the Control Pie Chart, consider Joanne’s example. You’ll notice that she estimated her current influence quite high, at 45%, over whether she’d get a job promotion. She believed that the quality of her application letter and her performance at the interview would have considerable influence on whether she’d be offered the new position. The Control Pie Chart exercise indicated that the problem-­solving approach could be helpful in dealing with her worry about promotion. It also made Joanne realize that the current focus of her worry was misguided. Instead she needed to refocus on the specific problems she faced, writing a good application letter and polishing up her interview skills. Repeatedly using the Control Pie Chart whenever you worry can help you learn the important difference between what can and cannot be controlled—a line that is often blurred with anxiety-­provoking worry. You may decide that you have so little influence over an outcome that the problem-­solving approach is not useful for your worry. Or the Control Pie Chart exercise may help you narrow the focus of your problem-­solving efforts to a specific problem, as happened with Joanne’s worry about the promotion. This brings us to the next step in the problem-­solving approach. STEP 2.  PROBLEM DEFINITION

Finding an answer starts with asking the right question. In problem solving this means identifying a specific part of the worry concern that is under your control. Your goals or desired outcomes must be realistic and attainable. Although Joanne worried about getting the promotion, she couldn’t focus her problem solving on the promotion because it was not entirely under her control. Instead she needed to define the problem as “conduct myself in the promotion interview so that I demonstrate my knowledge and confidence to do the job.” The following are two other examples of problem definition. Example 1. Reality-based worry about a romantic relationship breakup: Inappropriate problem definition:   Ensure we remain together and avert a breakup. Appropriate problem definition:   Have honest and open communication about our

commitment to the relationship.



take control of your worried mind 221

Example 2. Reality-based worry about a house foreclosure: Inappropriate problem definition:   Make sure we keep the house. Appropriate problem definition:   Examine our financial situation and develop a plan that

considers our housing needs. IN T ER V EN T ION EXER C I S E 

What’s the Problem?

In the space provided, write out a specific problem related to your worry concern. Think about the outcome you desire and what you can do to make it happen. Be specific in your statement of the problem, focusing on actions that are under your control. This will be the focus of your problem-­solving efforts. My problem definition:

STEP 3. BR AINSTORMING

It is hard to think outside the box! There’s a natural tendency to reject ideas that don’t fit with our preconceived beliefs of right or wrong. This makes it difficult to engage in effective brainstorming, which requires us to list as many possible responses or options for a problem as possible, without judging what will work or not work. But brainstorming is at the heart of problem solving. Your problem-­solving approach to worry cannot be effective if you prejudge responses as they pop into your mind. Brainstorming requires “wild creativity,” in which you include even the most ridiculous ideas in your brainstorming list. Consider Joanne’s brainstorming for how to prepare for her promotion interview. „ Write

out a short, clear explanation of my past experiences, skills, and what I would do in the new position if promoted.

„ Talk

to a couple of colleagues who were recently promoted through an interview process.

„ Write

down a list of possible interview questions and prepare potential responses.

„ Do

“mock interviews” with a coworker.

„ Discuss

the promotion interview with my supervisor.

„ Confide

in my husband about my anxiety over the selection interview.

„ Seek

tranquilizers from my family physician.

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The Anxie t y and Worry Workbook

IN T ER V EN T ION EXER C I S E 

Brainstorming List

Use the space below to list all possible responses (options) to deal with the problem you stated in Step 2. Like Joanne, list everything you can think of, including some options that are ridiculous or might even make the problem worse. 1. 

 6. 

2. 

 7. 

3. 

 8. 

4. 

 9. 

5. 

10. 

S T E P 4 . E VA L UAT I O N

After generating your list of options, it’s time to evaluate each response. There are two questions to consider in your evaluation. „ Is

this response likely to solve the problem? How much will it contribute to the desired outcome?

„ Am

I able to implement this response? Is it under my control, and do I have the skills to put this response into action?

When Joanne evaluated her brainstorming responses, she decided that the first four options were the most constructive solutions and would do most for preparing her for the interview. She had the knowledge and skills to execute each option, and she decided that each would be helpful in preparing her for a successful promotion interview. The last three options would contribute little to her interview readiness, and she could see they might cause serious complications. IN T ER V EN T ION EXER C I S E 

Evaluate Your Options

Review your brainstorming list and consider the pros and cons of each option. You can write these on a blank sheet of paper. Evaluate each response in terms of its potential contribution to solving the problem and your ability to carry out the option. Cross out the brainstorming responses that are untenable and then list the best two or three options below. 1. Good possible option: 2. Good possible option: 3. Good possible option:



take control of your worried mind 223

S T E P 5.  TA K E A C T I O N

The effectiveness of the problem-­solving intervention depends on putting your prior work into action. This involves selecting one or more of your good options and developing an action plan consisting of a step-by-step description you’ll follow to deal with the worry concern. The plan should specify where, when, and how you’ll conduct each step of the action plan. Joanne developed the following action plan: “I’ll take 30 minutes each evening (Monday–­Friday) over the next two weeks and work on preparing for the promotion interview. I will begin by writing out a five-page explanation of my past experiences, skills, and vision for the new position. I’ll read this over several times to familiarize myself with my explanation. I’ll create a list of possible interview questions, including some possible questions that might focus on ‘gaps’ in my résumé. I’ll ask Larry and Meredith about the interview process since they were recently promoted. I’ll approach Ariana, my closest friend at work, to do two mock interviews at least three days before the actual interview. I’ll get her feedback on my performance and make adjustments where needed.” IN T ER V EN T ION EXER C I S E 

Action Plan

Use the space provided to write out your action plan. Make sure your plan is specific, detailing each step you’ll take to put the plan into action. My action plan: S T E P 6 .  E VA L UAT E A N D R E V I S E

At first Joanne thought the best way to evaluate the success of her action plan was by whether she got the promotion. But then she realized this was not the appropriate outcome because only 45% of the outcome was under her influence or control. Whether she got the promotion depended on the qualifications of the other candidates and the decision making of the selection committee. So she decided to evaluate the success of the action plan on whether it reduced her feelings of anxiety and worry over the interview. She tracked her anxiety level and worry using the Worry Diary (Worksheet

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8.7). Joanne recorded fewer worry episodes about the promotion and her anxiety was less intense after implementing the action plan. When evaluating the success of your action plan, consider the following: „ Whether „ If

you followed every step of the plan

some parts of the plan were more difficult than others

„ Your

consistency or avoidance in following the plan

„ Whether „ What

you experienced a decrease in worry and anxiety

needs to be changed to make the plan more effective for worry

IN T ER V EN T ION EXER C I S E 

Your Revised Action Plan

After completing your evaluation, write out a revised action plan in the space provided. Highlight the changes you’ve made to the plan so it’s more effective in reaching a desired outcome that will reduce your worry. If you experienced procrastination and avoidance when first implementing the action plan, include changes that will improve your dedication to the plan. My revised action plan: Â Troubleshooting Tips: Making the Most of Problem Solving

If you tried the problem-­solving approach and it didn’t help with your anxiety and realitybased worry, make sure one or more of the following did not undermine your efforts. „ Seeking perfect solutions: rejecting every response to a problem because it didn’t

provide a perfect solution „ Overestimating your control: thinking you can ensure a desired outcome when you

have only partial control or influence over the outcome „ Unrealistic expectations: problem solving will only reduce worry and anxiety; it

won’t eliminate it entirely „ Vague action plan: you must be very specific about your action plan: what to do, how

to do it, and when to do it „ Inadequate brainstorming: it’s important to generate a list of several options for a

problem before you start eliminating them as inappropriate „ Highly “imagined” threat: problem solving cannot deal with vague, remote, and



take control of your worried mind 225

highly imagined or hypothetical threats that have only limited connection with reality (“What if I die young?” or “What if no one likes me?” or “What if I never succeed in life?”)

Cognitive Intervention: Decatastrophizing All types of worry, whether reality-based or imaginative, involve some degree of catastrophizing. This is especially true with imaginative worry, where the worst possible outcome has very little connection to your current circumstances, involving outcomes that often never occur or might possibly occur in the far distant future. The basis of catastrophizing is the activation of exaggerated beliefs about threat and helplessness. Worry feeds on catastrophic thinking! If you stop catastrophizing, you will cut off the life supply for worry. This is easier said than done since catastrophizing is second nature for harmful worry. But we’ve found that teaching chronic worriers “how to kick the catastrophizing habit” can bring relief from anxious and uncontrollable worry. It’s easy to get “taken in” by catastrophic thinking. When Makayla worried about Richard’s health, it was much easier for her to imagine him having a life-­threatening heart attack than something less dire like needing single-­artery coronary bypass surgery. Decatastrophizing is the process of stripping the worst-case scenario of its strong believability so you can think more broadly about a range of less dire and more likely outcomes. Decatastrophizing will not convince you the catastrophe can’t happen. That would be impossible because the future is uncertain and truly terrible things do happen to people. Instead the goal of decatastrophizing is to restore balance to how you think about the future by taking a more detached, evidence-based approach to what could happen. There are four parts to the decatastrophizing treatment of worry. IN T ER V EN T ION EXER C I S E 

List of Dreaded Possibilities

Start with a review of the harmful worries and catastrophic possibilities you listed in the Worry Profile (Worksheet 8.8). List these catastrophic possibilities in the space provided, along with any other, less serious negative outcomes you tend to think about when worrying. Put an asterisk beside the one possibility that is the most catastrophic and that causes you the most uncontrolled worry when you think about it. We’ll focus the remainder of the decatastrophizing intervention on this possibility. 1. Possible negative outcome: 2. Possible negative outcome:

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The Anxie t y and Worry Workbook

3. Possible negative outcome: 4. Possible negative outcome: 5. Possible negative outcome:

The second part of decatastrophizing involves writing a more detailed account of the catastrophic scenario that is driving your worry. Don’t sugarcoat your description by making it balanced or reasonable. The account needs to describe the catastrophic thinking in all its extreme and exaggerated nature. It needs to be a description of how you think when you’re at the height of uncontrolled worry. Include in your account what you imagine makes this worst-case scenario more likely to happen, how it will affect you, its consequences for your life and your loved ones, and your struggle to cope with it. IN T ER V EN T ION EXER C I S E 

Your Account of a Catastrophic Possibility

In the space provided, write out your description of the catastrophic possibility you indicated was the most intense worst-case scenario. Makayla’s description of her catastrophic thinking about Richard’s health condition is provided as an example. Description of my worst-case scenario: Makayla’s worst-case scenario:   I’ve been trying to get Richard to lose weight, exercise more,

and eat healthier food, but he’s not listening to me. He just gets angry and says I’m nagging. One evening we’re sitting together, watching a movie, when suddenly Richard grabs his chest and screams out in sharp pain. Instantly he slumps to the floor. I jump to my feet and call 911. It seems like an eternity, but probably within 15 minutes the paramedics arrive. They look for vital signs and start working quickly. They grab for their defibrillator and induce cardioversion, but it’s too late. I see that he’s flatlined. I’m beside myself with shock, grief, and disbelief. Richard is gone, and I’m all alone. I should have done more to prevent this terrible day from happening. The third part of decatastrophizing involves the cognitive interventions you practiced in Chapter 6. What’s the evidence that you’re overestimating the likely occurrence of the worst-case scenario? Are you also exaggerating the severity of the outcome and its effects on you? Researchers have found that 85% of our worries don’t



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turn out as bad as we think and that most people are better than they think at coping with a worrisome outcome that did occur.46 Are you thinking you’ll be better prepared to face the worry concern if you focus on the worst-case scenario?

IN T ER V EN T ION EXER C I S E 

Evaluate the Catastrophic Scenario

Use blank worksheets from Chapter 6 to evaluate your catastrophic thinking. The Evidence Gathering Form (Worksheet 6.5) can be used to determine whether you’re exaggerating the likelihood that the worst possible outcome will occur. Consider the costs and benefits associated with your catastrophic thinking (see Worksheet 6.6). What thinking errors are present in your catastrophizing (see Table 6.2)? You’ll need these worksheets to help you develop an alternative possibility that is more likely and less extreme than the worst-case scenario.

The last part of decatastrophizing involves creating an alternative narrative that is more likely and less severe than the worst-case scenario that you automatically think about when experiencing harmful worry. Catastrophic thinking is a prediction about what might happen, but it means spending time on a prediction that may never happen and only makes you feel more anxious and worried. To decatastrophize your worry, you’ll need to imagine an alternative possibility that is a more likely, realistic outcome. The outcome will still be negative, and it may be a far cry from your most desired outcome. You’ll want to think of an alternative that lies somewhere between your most desired outcome and the catastrophic outcome.

IN T ER V EN T ION EXER C I S E 

Alternative to the Catastrophe

Use the space below to write an alternative possibility that is more realistic and probable than your worst-case scenario. Include in your description the sequence of events that would lead to the alternative outcome, its impact on you and your loved ones, how you coped with it, and how you accepted its sudden and unexpected occurrence. You may find the Alternative Perspective Form (Worksheet 6.7) helpful in composing your alternative narrative. My alternative scenario:

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 Troubleshooting Tips: Help with Decatastrophizing

If decatastrophizing doesn’t reduce your worry, you may be using it incorrectly to reassure yourself that the worst won’t happen. Make sure you’re using this intervention to correct your tendency to focus on the worst possible outcome. Remember, you can’t predict the future, and bad things could happen (Richard could have a fatal heart attack). You won’t automatically stop worrying by reminding yourself of the evidence against the catastrophe. Instead you’ll need to practice replacing the catastrophic scenario with the more realistic alternative narrative and to think about the reasons the alternative is a more likely outcome. If you do this repeatedly, you’ll find it easier to shift your attention away from the catastrophe. When this happens, you’ll experience a gradual reduction in anxiety and worry. Consider Makayla’s alternative way of thinking about Richard’s heightened risk of a cardiovascular incident. Makayla’s alternative scenario:   Richard has a chronic medical condition that places him at

increased risk of a fatal heart attack. Millions of Americans live long and productive lives with this condition. Although Richard has an elevated risk of heart attack, his chances of survival at any given moment greatly outweigh his chances of death. There are many medical interventions, medications, and lifestyle changes that can effectively lower (but not eliminate) Richard’s risk of a heart attack. Even if Richard changes his lifestyle, there is no guarantee that his heart will remain healthy until his 90s. I have no choice but to live with the uncertainty of life and death. Who knows? One of us could just as easily die from some other unknown tragedy like a car accident. So my alternative is to accept that I’m living with a husband with elevated risk of coronary artery disease who could experience any number of problems with his heart that will require some form of medical intervention.

Behavioral Intervention: Directed Worry Exposure There are two sides to catastrophic thinking. We’re drawn to imagine exaggerated possibilities of threat and danger when we worry, and yet there’s a desire to avoid facing our worst fears. Thomas Borkovec, a pioneer in worry research, has argued that we worry to avoid some dreaded future threat or danger.47 For example, a father might worry about why his teenage son is late coming home on a weekend night rather than imagine he has been in a tragic car accident. A person might worry about the results of a diagnostic medical test rather than think about living with cancer. Or an individual might worry about whether she has offended a close friend rather than think about losing that friendship. In other words, worry is often an attempt to avoid thinking about what we fear most, like death, not being loved, meaninglessness,



take control of your worried mind 229

worthlessness, abandonment, and the like. The problem is that worry is not an effective avoidance strategy and is one of the reasons for the persistence of harmful worry. Doing the opposite of avoidance, facing your worst fear, has become an important ingredient in CBT for worry. To do the next exercise, you’ll need access to the worst-case scenario you completed in the decatastrophizing intervention. Review your scenario and write down in the space provided what you fear most about this catastrophic outcome. Usually these fears focus on a basic aspect of life, such as death, meaning, value or respect, being loved, abandonment, lack of freedom or control, and the like. What I fear most:  Makayla’s fear:   abandonment—that Richard would die, leaving me alone and miserable for the

rest of my life IN T ER V EN T ION EXER C I S E 

Intentional Worry Exposure

This exercise involves taking control of worry by scheduling systematic, planned worry sessions. Start by having your description of a catastrophic or worst-case scenario available. Schedule a daily 30-minute imaginal worry session in a quiet location where you won’t be interrupted. During this time, bring to mind the catastrophic scenario, thinking deeply on every aspect of the scenario but especially what you fear most about this possibility. Use the following guidelines to structure your exposure session. 1. Start with five minutes of controlled, relaxed breathing. 2. Bring to mind the catastrophic scenario, focusing on every detail, such as what caused the catastrophe, what role you played, and its consequences for you and your loved ones. 3. As you imagine the catastrophic outcome, focus as fully as possible on what you fear most about this catastrophic scenario, whether it’s death, loss of love, or a lack of purpose or value. 4. Be especially aware of any feelings of anxiety or distress during the worry exposure. Notice how you’re becoming more anxious as you continue to imagine the catastrophic scenario. 5. Replace the catastrophic scenario with your alternative to the catastrophe scenario. Think deeply about this alternative scenario, including its effect on you, how you can cope with it, and why it’s more likely than the catastrophic scenario. 6. Spend five minutes thinking about the catastrophe and then five minutes thinking about the alternative. Do this several times for the remainder of the worry session.

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7. You may be surprised to learn that your mind will wander during the session. When this happens, gently bring your attention back to the catastrophic scenario or its alternative. 8. After 30 minutes, stop the worry session. End with another five minutes of controlled breathing. Record your experience on the Worry Exposure Form (Worksheet 8.11). After that, engage in a normal daily activity that requires some concentration and physical action. Â Troubleshooting Tips: When Worry Exposure Causes More Distress

If you’re feeling more anxious after several sessions of worry exposure or your catastrophic thinking has become more believable, then immediately stop this intervention. There are several reasons worry exposure may not be working for you. „ You may be using a negative possibility that is not your worst fear. You need to be

imagining your “worst possible outcome” to achieve significant reductions in worry. „ The catastrophic outcome you imagine must be extreme. The intervention won’t be

helpful if you tone down the imagined outcome, making it less fearsome or anxiety provoking. „ It’s critical to write down your worries, the worst-case scenario, and its alternative.

You can’t just rely on your memory. Also you need to read both scenarios out loud over and over during the exposure sessions. „ Worry exposure must be done again and again in a systematic manner. Repetition is

critical! Many people try this once or twice and then conclude it doesn’t work. Worry exposure won’t be effective if you do it a couple of times; you must do it so often that you begin to feel bored and disinterested. „ If any of these points are relevant, modify your exposure sessions and restart the

intervention. On the other hand, stop practicing imaginal worry exposure if you’re believing the catastrophic scenario more than the alternative. This will make you feel worse. There are other interventions in this chapter you can use to treat your harmful worry.

Did you practice intentional worry exposure daily for at least two weeks? What did you notice about your anxiety level during these sessions? There is research evidence that repeated sessions of worry exposure alone can reduce anxiety.48 It’s expected that the frequency and intensity of your worry will decline and the associated anxiety will decrease with repeated worry exposure. You might even start to feel bored with the worry session. This is because you are taking control of your worry and replacing the possibility that you fear most with a more realistic, less distressing alternative.



take control of your worried mind 231

W ORK SHEE T 8.11

Worry Exposure Form Instructions: After each intentional worry session, briefly describe what you worried about and how anxious you felt during the exposure session. Under anxiety level, rate from 0, for none, to 10, for extreme.

Date

Imaginal content during exposure session (Note: Did you think about the catastrophic possibility? Did you imagine your worst fear? List other possibilities you thought about.)

Anxiety level (0–10)

Sunday Monday Tuesday Wednesday Thursday Friday Saturday From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

Behavioral Intervention: Worry Postponement This intervention is used along with worry exposure. When you start your worry exposure sessions, your worry will still be triggered throughout the day. You’ll continue to experience harmful worry. So rather than get drawn into worry, you acknowledge the presence of worry thoughts in your mind but then tell yourself you’ll postpone the worry for now and save it for your scheduled worry exposure session. If some new idea or perspective on your worry pops into your mind, write it down and incorporate this new thought into the catastrophic account you’ve created for worry exposure. Imagine you are a 55-year-old middle manager and you hear rumors that the company is downsizing. Given your age and position, you’re at high risk of losing your job. As days turn into weeks the uncertainty mounts. Thoughts of unemploy-

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ment flood your mind, and you frequently lapse into harmful worry. Your work productivity slumps, and you’re irritable and on edge at home. You decide to make “being unemployed at 55 years old and losing all respect of your family and friends” the catastrophic narrative of your worry exposure. But you keep having intrusive worrying thoughts of job loss throughout the workday. You decide to use the worry postponement strategy at work. When the thought of job loss pops into your mind, you acknowledge the mental intrusion. You tell yourself that it’s okay to have such thoughts given the circumstances. You remind yourself that tonight you’ll spend time thinking more deeply about losing your job. If a new angle or idea about unemployment intrudes into your mind, you write it down in a notebook or enter it in the notes app of your smartphone. This way you’ll remember to add it to your catastrophic narrative so you can think deeply about it during the scheduled worry exposure session. Once noted, you go back to a work task. If the worry thought returns again and again, you restate your intention to think about it later.

Cognitive Intervention: Building Tolerance of Uncertainty Previously we noted that intolerance of uncertainty is a core process in harmful worry. It is a negative feeling, or fear, about situations that are novel, ambiguous, or unpredictable.49 The uncertainty is felt as stressful and threatening to individuals who worry, so they seek to feel sure about an outcome by obtaining reassurance from self or others. Since we cannot know what the future holds, it’s the focus of our uncertainty. We expect tomorrow to unfold in a predictable way, but we can’t be certain. The person with low tolerance of uncertainty would rather know that something bad will happen than be left guessing about the future. Luis, for example, was worried about his final exam in organic chemistry. He kept thinking about the likelihood of failure in an effort to convince himself that it wouldn’t happen. Katrina was worried about selling her house and kept thinking over and over whether she would ever find a buyer. Samantha worried that her husband might be having an affair and spent many hours trying to convince herself he was faithful and would not leave her. In each of these cases, the worry process was driven by a desire to “know the future,” to reduce uncertainty. The problem with the “need to know” is the future can never be known with absolute certainty. What you’re seeking is a feeling of knowing, a feeling of being sure about something, rather than a “knowing of knowing.”50 Worry is an attempt to reassure ourselves of the future—an attempt to reduce life’s uncertainties, to eliminate the what-ifs in our life. But this search for a feeling of knowing, a relief from uncertainty, has the opposite effect; it makes us more anxious and worried about the future. Learning to accept risk and uncertainty will reduce worry and generalized anxiety.49



take control of your worried mind 233

In this section we introduce two interventions that can help you build tolerance of uncertainty. IN T ER V EN T ION EXER C I S E 

Uncertainty Tolerance in Everyday Life

Daily living requires tolerance of considerable risk and uncertainty. When it comes to situations that cause no anxiety, your tolerance for uncertainty is greater than you realize. This exercise is aimed at raising your awareness of how much uncertainty you already tolerate in your daily life. Use the Daily Uncertainty Record (Worksheet 8.12) to write down experiences where you take some action or decide without knowing the outcome for certain. The worksheet starts with two examples of uncertainty taken from Makayla’s daily experience.

Were you able to record several uncertainty experiences? What you recorded would be a fraction of the many decisions or actions you take every day that involve some level of uncertainty. When it comes to situations that don’t involve your anxiety-­ related concerns, you accept uncertainty. In fact, you are tolerating uncertainty frequently throughout the day. One of the most daunting uncertainties is reproduction. If you think about all the problems that can occur in utero, at childbirth, in the first few months of a newborn, and then throughout childhood and adolescence, why would anyone have children? The uncertainties we tolerate with having children is truly remarkable. Probably nothing could be more uncertain than bringing a child into this world. And yet we do it. If you can tolerate this uncertainty, you already have the “muscle” to accept your worry uncertainty. Are you curious that you’re able to tolerate uncertainty in these situations but not when it comes to your worry concern? Take a look at what you wrote in the second column. This will give you a clue about how you tolerated uncertainty. If you’re like Makayla, there are two main themes to uncertainty tolerance: „ You

believe you’re able to manage the situation even if something goes wrong.

„ You’re

convinced the outcome won’t be terrible; it won’t be a catastrophe.

In the first example Makayla tolerated the uncertainty of her new hairstylist by thinking that she could fix the problem if it occurred. In the second example she believed that an unlocked door would not be a catastrophe. Did you use the same way of thinking for your uncertainty tolerance? What did you learn from the actual outcome in the final column? No doubt you discovered that most times there was no cost or disadvantage of accepting uncertainty. Our decisions or actions are not always the best, but the outcome we fear that drives our worry and intolerance of uncertainty usually never materializes. This

W ORK SHEE T 8.12

My Daily Uncertainty Record Instructions: Be aware of times when you were uncertain about the outcome of actions or decisions you took throughout the day. Record these in the first column. In the second column, explain how you managed to tolerate not knowing how the experience would turn out. Use the third column to record what eventually happened. Uncertainty experience

How I managed to tolerate the feeling of not knowing

Makayla’s example:

Told myself I can fix the hair myself if I Decided to try a new upscale don’t like it, or I could go to another hair salon and have them fix it. If the hair’s too short, hairstylist. it’ll always grow out. I’m tried of the old look, so need to take a chance on a new style. Makayla’s example: Told myself that I’ve never not locked the door when leaving home, so it’s likely locked. Got halfway to work and had doubts about locking the I can’t be late for work this morning because front door. I’d gone too far to we have an important client meeting. If someone wants to break in, they can go turn back and check. through the backyard window.

What happened

The new style wasn’t so bad. The cut was good, and I simply styled it myself next time I washed my hair. Got home that evening and the front door was locked.

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3.

4.

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From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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exercise reveals your baseline tolerance of uncertainty. The same tolerance strategies you use in nonworry situations can be applied to your worry concerns. That is, focus on how you can deal with the worry situation and how the outcome may not be ideal but won’t be the worst either. We now turn to a second intervention that is used to strengthen uncertainty tolerance. IN T ER V EN T ION EXER C I S E 

Building Uncertainty Tolerance

You can think of this activity as a training exercise in uncertainty tolerance. The idea is to catch yourself trying to reduce the uncertainty of a worry concern and then practice doing the complete opposite, that is, act in a way that accepts the feeling of uncertainty associated with the worry. Start by recording a worry experience in which you have a distinct feeling of uncertainty. Use the Tolerance Fitness Form (Worksheet 8.13) to record this experience. Next think about the best outcome you’d like to see happen and how you try to convince yourself that it will happen. No doubt you try to seek reassurance or try to reason with yourself that what you’re worried about will turn out okay. After identifying your efforts to reduce uncertainty, consider a response that would be the complete opposite; a response that accepts or lives with the uncertainty that a more negative outcome might happen. Next, practice this opposite coping response whenever you start to worry about the concern you recorded on your worksheet. After several experiences of practicing uncertainty tolerance, record what happened with the worry problem. If you’re unsure about this exercise, you’ll find a couple of examples in the first two rows of the worksheet. Â Tips for Success: More on Improving Uncertainty Tolerance

Increasing tolerance for uncertainty can be difficult because it may seem like a very abstract concept. The following are some additional suggestions for improving your work on this skill. „ When we worry, there’s not only a dreaded catastrophe but also a desired outcome.

For example, if you’re worried about the results of a medical exam, your desired outcome is a negative result. When completing the second column of My Tolerance Fitness Form, start by listing several “better” outcomes associated with the worry. Then select the one outcome you prefer most. „ Next, think about all the ways you try to convince yourself the “best outcome” is

more likely to happen than the worst outcome. Write these strategies in column 2. These are also the tactics used to reduce a feeling of uncertainty. „ The third column takes some creative thinking. What would be the opposite way to

act or think given what you wrote in the second column? These opposite responses would involve letting the feeling of uncertainty sit in your mind. You’re not trying to

W ORK SHEE T 8.13

My Tolerance Fitness Form Instructions: List several worry problems in which you are concerned about the potential outcome. Next, think about the potential outcome in the first column. In the second column, think about the outcome that you desire for that worry concern and how you try to convince yourself that the desired outcome is most likely. In the third column, propose an opposite response to what you wrote in the second column. This would involve some concrete steps you could take that involve accepting or living with uncertainty. In the final column, record the actual outcome of the worry concern. Worry-­related uncertainty Luis’s example:

Keep questioning how I’ll do on the chemistry final; there’s a good chance I’ll fail.

Katrina’s example:

Keep questioning whether our house will sell; what if we have to keep lowering the price.

Desired safety-­seeking response Opposite response to reduce uncertainty that accepts uncertainty

I want to seek reassurance from my parents that I’ll do fine; also want to test my knowledge against my classmates to see if I can answer questions they can’t answer. I want to keep calling the realtor and asking whether there’s been any interest in the house; what people liked or didn’t like about it.

I’ll stick with my study plan and not seek reassurance. Also I’ll refrain from quizzing other students. I’ll keep reminding myself I can only do my best. Exams are always uncertain. Don’t call the realtor or check the real estate listings. Live each day as if I have no intention of selling the house.

Outcome of worry concern

The organic chemistry final was brutal. I ended up with a B– and I was hoping for a B+. I didn’t fail, and my grade in the course is respectable. It took much longer to sell than expected, but eventually it sold. We had to settle for 5% less than we wanted.

1.

2.

3.

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5.

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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take control of your worried mind 237

reduce the uncertainty or avoid it. You’re acknowledging it and then getting on with your daily activity. „ It’s important to practice what you wrote down in column 3. Every time you worry,

you should practice the opposite responses in column 3. This is the only way you’ll strengthen your “tolerance of uncertainty muscle.”

This is an exercise you’ll want to do repeatedly to strengthen your acceptance of uncertainty. It requires that you refrain from engaging in the safety-­seeking responses you use to convince yourself of a desired outcome. Safety-­seeking responses, like looking for reassurance or trying to convince yourself the feared outcome won’t happen, are intended to reduce a feeling of uncertainty. It’s the opposite response, as you described in the third column, that builds up your ability to tolerate uncertainty. But it’s important not to just write about it. You’ll need to practice column 3 over and over each time you worry. Eventually you’ll feel better able to tolerate the uncertainty associated with your worry concerns. When this happens, you won’t need to worry. Instead you’ll accept the uncertainty of these “worry” concerns just like you accept uncertainty in many other aspects of daily living (see your entries in Worksheet 8.12, My Daily Uncertainty Record).

Cognitive Intervention: Detached Worry In Chapter 7 we introduced mindfulness as a healthy coping strategy for anxiety. This approach is especially helpful when dealing with worry. Detached worry is based on mindfulness. It involves adopting a distant, observer perspective on your worry thoughts. You notice the worry thought in your mind, but you treat it as a thought that requires no evaluation, no response, and no effort to control. You passively and nonjudgmentally observe the worry thought, letting it fade from your mind naturally and without effort. In detached worry you are the observer of your thoughts and nothing more. It’s relatively easy to be detached from thoughts that are not emotional. It’s much harder to detach yourself from highly emotional thoughts that you consider personally significant. If you have the thought “My house is on fire,” that’s not the time for detached awareness. But worry is about imagining the worst, like “What if my house caught on fire?” and so mindful detachment is very appropriate in that instance. Visualization is a strategy we use to help people take an impersonal, distant approach to emotional thoughts like worry. The idea is to imagine that your worry thoughts are like objects moving through your field of vision. You, the observer, stand still and see these “thought objects” move past in your mind’s eye. You don’t chase

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after the worry thought, nor do you try to catch it and hold it close to you. Instead you watch the worry thought pass by you. There are several image scenes that can be used34: „ You

can imagine your worry thoughts are floats in a parade. You stand on the sidelines, watching your thoughts float through your field of vision. You can look down the street at new thoughts that will soon parade past you, and you can look up the street at old thoughts that already went through your field of vision. Some of the floats have your worry thoughts, but other floats have nonworry content.

„ You

can imagine your worry thoughts as clouds in the sky that pass overhead. Each cloud is a different thought, with some clouds carrying your worry thoughts.

„ You

can imagine your thoughts as leaves floating on a drifting swallow stream. Put your thought on a leaf and watch it float by as it heads downstream and out of sight. Then put another thought on a leaf and watch it float by.51

Hofmann, in The Anxiety Skills Workbook, 34 offered an interesting imagery script for detached worry. Imagine that you are standing on the platform of a train station and your thoughts are trains passing through the station without stopping. Some of your thoughts are positive and helpful, so you may want to jump on these trains. Other thoughts, like worry, are negative and upsetting, so you stay on the platform and watch these trains pass by.

„ Stefan

IN T ER V EN T ION EXER C I S E 

Practice Detached Worry

Write your version of a detached worry script in the space provided. You can use one of the visualization scenes described in this chapter or create your own version. It should include a statement of your worry thoughts and instructions on how you’ll visualize these thoughts passing through your mind in a detached manner. My detached worry script:

Detached worry is most effective when it becomes a strategy you use whenever you start to worry. But it’s not a natural response to worry. You’ll need to practice detached worry first. We suggest you schedule practice sessions in which you intentionally worry and then react with your detached worry script. This is like directed



take control of your worried mind 239

worry exposure, except you are working on becoming more proficient with a mindfulness approach to worry.

The Next Chapter Worry amplifies anxiety. This means that interventions for excessive worry must be included in any CBT plan for anxiety. But worry is a normal process we use to deal with life problems. So one of the first tasks is distinguishing between your experience of normal worry and your experience of excessive worry. This chapter provided guidance and assessment tools for determining when worry becomes harmful or problematic. A CBT formulation was offered that can guide your worry treatment plan. Six CBT interventions were presented that directly treat excessive worry. You’ll want to build these interventions into your cognitive behavior treatment plan regardless of your anxiety problem. Worry is the cognitive face of anxiety. Physical symptoms play a minor role when excessive worry is prominent. But many people experience anxiety in a completely different way. For them the physical symptoms of anxiety are most disturbing. Panic attacks, the most extreme expression of physical anxiety, are the topic of our next chapter. And like worry, panic attacks can occur in any type of problematic anxiety.

9 defeat the fear of panic

L

ucia had her first panic attack six months after her father recovered from a serious heart attack. The heart attack took the whole family by surprise—her father had no cardiac risk factors, was in excellent health, and exercised religiously. Lucia took time off from work and from taking care of her three children to help her father get back on his feet. She was at work on what she later described as “the worst day of my life.” It had been a particularly stressful day filled with pressing deadlines and numerous interruptions that kept putting her further and further behind. Suddenly, out of the blue, Lucia felt a crushing pain in her chest, her heart started beating rapidly, she felt hot and flushed, and she couldn’t seem to get enough air. She loosened the top of her blouse and noticed that her hand was trembling. She tried to get up from her seat but felt a weakness throughout her body. Her knees began to buckle, and she had to hold on to her desk to keep from falling. She felt dizzy and somewhat disoriented. All she could think about was her father’s heart attack. Was she now experiencing the same thing? She thought, “Is this what it feels like to have a heart attack?” Although it took only a few minutes for the symptoms to start subsiding, time seemed to drag. Lucia eventually made it to the washroom, where she bathed her face in cold water. Still, there was a lingering heaviness in her chest, and she seemed to struggle to get enough air. She returned to her desk, but she was much too worried and keyed up to work. She told her supervisor she was not well and left the office early. Instead of driving straight home, Lucia stopped at the emergency room of her local hospital, where a battery of tests turned up nothing that could account for her symptoms. The ER physician concluded that Lucia had experienced a panic attack. He gave her antianxiety medication and told her to see her family physician. That was three years ago. Since then Lucia’s world has been turned upside down. She now experiences almost constant anxiety. She worries about having another panic attack. The once energetic, competent mother and resourceful employee has cut back so much that she now practically confines herself to work and home. She refuses to

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travel outside her city, avoids public places, can’t cross bridges, and is afraid to be left alone at night. She is preoccupied with her physical state and is now afraid that she’s developing a serious mental illness. She has tried various medications, but the only thing that seems to work is a tranquilizer, and even that calms her down for only a few hours. It’s been ages since she got a good night’s sleep. Lucia realized she needed help, so she sought out a CBT therapist. For three years she’d felt as if the fear of panic attacks was holding her hostage. She was ready to be liberated. You may feel the same way, especially if you’ve done the exercises in the previous chapters but still avoid participating fully in your life for fear of having another panic attack. In this chapter we’ll show you how to customize the interventions you learned earlier in the book to address panic and the fear of panic. Just as you created a worry profile in the last chapter, you’ll create a panic profile here. You’ll learn about five CBT interventions for panic: reappraisal, rescripting, induction, exposure, and response removal.

What Is a Panic Attack? No doubt there are times when you’ve exclaimed “I’m in a panic.” On these occasions you feel like you’re running out of time and can’t meet all the demands of the moment. You’re stressed and overwhelmed, and you want to run. But this is not what we mean by panic. The term panic attack has a more technical meaning. If you’ve ever experienced a true panic attack, you know it’s memorable; it’s like no other experience of stress or anxiety. Sometimes people experience a warning of an emerging attack, like feeling a little on edge or less calm, and then suddenly they’re hit with a wave of intense anxiety. At other times the panic can emerge completely out of the blue when you least expect it. We call these spontaneous panic attacks, and they feel like a sudden, terrifying loss of control in which anxiety overwhelms every fiber of your body. Possibly your surges of anxiety are less intense, what we call anxiety attacks or limited-­symptom panic attacks. A full-blown panic attack has a specific definition (see sidebar). A full-blown panic attack is an intense physical manifestation of anxiA panic attack is a distinct period or ety. Its main feature is a sudden hyperepisode of intense fear or discomfort arousal of multiple physical sensations that builds suddenly, peaks briefly, and is like increased heart rate, rapid breathcharacterized by at least four unwanted ing, sweating, abdominal discomfort, and inexplicable physical sensations and trembling, weakness, lightheadedness or frightening cognitions. Typically panic ­dizziness, hot flashes, and/or tingling senattacks last between 5 and 20 minutes. sations. Frightening cognitions also may

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be present, like a fear of uncontrollability or of dying or a feeling of being detached from reality. This sudden surge of physiological hyperarousal is associated with a core fear that the individual is having a heart attack, suffocating, experiencing a seizure or brain tumor, or going crazy. After repeated panic attacks the core fear may crystallize as a fear of having another panic attack. The fear or worry of having a panic attack persists over weeks or months and often leads to behavioral changes involving avoidance of places or activities thought to increase the risk of panic attacks. Examples include public places like large stores or shopping malls, crowds, large gatherings or social settings, unfamiliar places, travel, workplaces. Certain activities like exercise may be avoided due to their increase in physiological arousal, and individuals with panic often make sure they are close to exits for fear of being trapped. Being alone or too far from hospitals can raise anxiety for people with panic because they believe medical help may be needed in case they have an incident. Fear of panic can cause a dramatic reduction in quality of life, which has been termed agoraphobic avoidance. In extreme cases individuals can become housebound, afraid to venture beyond the limits of their own property due to the risk of having a panic attack. E VA L U AT ION EXER C I S E 

Your Worst Panic Attack

Think back to your most severe anxiety attack. This would be a sudden surge in anxiety that peaked within 5–10 minutes, although it may take several hours for anxiety to subside completely. In the space below, state where the anxiety attack occurred, the physical symptoms that intensified, and what you feared most from this attack (such as a heart attack, dying, that it wouldn’t stop, having another panic attack). (For a list of typical symptoms of anxiety, see Worksheet 5.1.) Situation: Physical symptoms: Core fear: Lucia’s worst panic attack: Situation:   I was getting groceries. The supermarket was exceptionally crowded. I had just started

my shopping when suddenly I felt like I was trapped and couldn’t breathe.



defeat the fear of panic 243

Physical symptoms:   shortness of breath, choking sensation, heart palpitations, shaking, felt

faint and dizzy, started sweating from hot flashes, knees felt weak like they could buckle Core fear:   I’m losing control and going to faint. This will be so embarrassing because paramedics

will be called and I’ll be making a big scene. Everyone will wonder what’s wrong with me. They’ll take me to the ER and my husband will be called to come and get me. It’ll be another example of my weak, pathetic state.

Anatomy of the Fear of Panic Panic attacks are more common than you may think. Between 13 and 33% of the general population report having experienced at least one panic attack in the last year.52,53 If panic attacks are that common, why do some people develop a problem with panic and others don’t? The answer lies in the fear of panic. When we develop a fear of having panic attacks, this primes us to experience more frequent panic because the panic experience and its triggers become the threat we seek to avoid. As discussed previously, once our anxious mind locks on to a particular threat, like concern about having a panic attack, we become hypersensitive to any cues associated with the threat. Because our anxious mind is on the lookout for any signs of possible panic, it paradoxically increases the likelihood that panic will be experienced. Likewise we carry this fear of panic with us whenever we leave our “safety zone.” This means our escape and avoidance responses are linked more to the fear of panic than to panic itself. Most people with a history of panic attacks will leave a situation at the earliest sign of rising anxiety because they fear an impending attack. Because fear of panic plays such a central role in problematic panic, this is the process we target in CBT for panic. There are four phenomena that drive fear of panic.

Panic Triggers Most often a problem with panic begins with one or two unexpected attacks that occur completely out of the blue in situations in which you wouldn’t expect to have a panic attack. Subsequent to these first attacks, most people learn what triggers their panic and will avoid these situations for fear of having another attack. Lucia soon learned that unfamiliar situations heightened her anxiety and the risk of a panic attack, so she restricted herself more and more to home and work.

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E VA L U AT ION EXER C I S E 

What Triggers Your Panic?

What are the situations that you fear will trigger a panic attack? How often do you avoid these situations for fear of panic? In the blank space below, list the situations that you fear will most likely trigger a panic attack. Next to each, note whether you always avoid this situation or avoid it only sometimes. 1. 2. 3. 4. 5. Â Tips for Success: Discovering Your Panic Triggers

You’ve already done a lot of work on identifying anxiety triggers in earlier chapters. Many of these situations, thoughts, and feelings might also be relevant to panic. Review the work you’ve done in these worksheets. Do any of these triggers also cause panic?

Symptom Hypersensitivity A fear of panic can make you overly sensitive to what’s happening with your body. You may engage in body scanning, looking for any unexplained physical sensation. Because of her fear of heart attacks, Lucia became preoccupied with pains, tightness, and pressure in her chest. She even started to take her pulse periodically to ensure she wasn’t having heart palpitations. It was as if she had lost all confidence in her cardiovascular system, fearful it would go awry and her heart would beat erratically. E VA L U AT ION EXER C I S E 

Know Your Panic Symptoms

What physical symptoms scare you most? Are there certain bodily sensations that you tend to monitor for fear they signal an impending panic attack? Write down the two or three bodily sensations that you tend to look for because they signal the possibility of a panic attack. Consider the physical symptoms you listed in the first exercise in this chapter. 1. 2. 3.



defeat the fear of panic 245

Catastrophic Thinking about Panic Over the years we’ve treated many people with problematic panic. Time and again people tell us how much panic has come to dominate their life. They spend a lot of time thinking about panic and worrying that another attack is just around the corner. Often their life has become so limited through avoidance that they find even the most basic aspects of daily life daunting. When panic overtakes life in this way, it has truly become a catastrophe. The catastrophic thinking most common in panic is: „ Fear

of dying from a heart attack, suffocation, brain tumor, or the like

„ Fear

of losing control, “going crazy,” or causing extreme embarrassment

„ Fear

of having more frequent, intense, and uncontrolled panic attacks

It’s not that you necessarily believe you’re having a heart attack or going insane. The catastrophic thinking occurs automatically, as a question, like “What if this feeling of not getting enough air gets worse and I can’t breathe?” Also, the catastrophic thinking is normally linked to specific bodily sensations such as chest tightness and heart attacks, nausea and uncontrollable vomiting, or dizziness/lightheadedness and losing control or going crazy. How individuals interpret their bodily sensations determines whether they develop a fear of panic or not. At the very heart of the cognitive behavior treatment of panic is the assertion that it’s the catastrophic misinterpretation of bodily sensations that is the core problem in repeated panic attacks.4,54,55 Lucia connected chest tightness and heart palpitations with her panic attacks. Whenever she felt some unexplained pressure in her chest, she automatically thought, “What’s wrong with my chest? It doesn’t feel right to me. Am I getting anxious or stressed out? Is this putting too much strain on my heart? How would I know if I’m having a heart attack? What if this leads to a full-blown panic attack right here in front of all these people?” E VA L U AT ION EXER C I S E 

Your Catastrophic Misinterpretation

Whenever you experience unwanted bodily sensations related to panic, what is the worst possible outcome (catastrophe) you fear? Write down the most frequent catastrophic misinterpretation (the worst possible outcome) that lingers in the back of your mind when you feel panicky. Consider whether your misinterpretation involves several fears, such as “I’ll have the most intense panic attack ever, I’ll embarrass myself in public, and I’ll weaken my heart because of the extra strain I’m putting on it.”

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My catastrophic misinterpretation: Lucia’s catastrophic misinterpretation:   When my chest tightens and I notice an increase in my

heart rate, I wonder if this is caused by stress and anxiety. What if I’m putting extra strain on my heart and this increases the chance that one of these times I’ll have a heart attack? I know these are the first symptoms of a panic attack, so I’m mostly terrified I’m having another attack, and yet the fear of a heart attack lingers in the back of my mind. What are the physical symptoms that you misinterpret? Is your catastrophe another panic attack or something worse, like a heart attack, suffocation, or even death? Whatever the exact nature of your catastrophic misinterpretation, CBT for panic focuses on decatastrophizing your perception of these physical sensations and de-­escalating your fear and experience with panic.

Unhealthy Panic Prevention Strategies Panic attacks are so dreaded that people come to rely on a narrow range of coping strategies to calm their panic fear and reduce the risk of further attacks. They strive to feel safe and comfortable because they believe this is the best defense against panic. The main coping responses are escape, avoidance, and safety seeking. Unfortunately these strategies have an unintended consequence. They may provide some short-term relief from the fear of panic, but they also ensure a persistence of the panic problem. Lucia avoids places that make her feel more anxious. If she undertakes a “highrisk” activity, she always has medication close by in case it’s needed, and she goes certain places only if her husband is with her. Several worksheets in Chapter 7 assessed typical cognitive and behavioral safety-­seeking measures. Many of these strategies will be relevant to dealing with panic and fear of panic. If you need to remind yourself of how you usually try to avoid triggers of panic, review some of the work you did earlier (such as Worksheets 7.2 and 7.4). E VA L U AT ION EXER C I S E 

Seeking Safety from Panic

When you’re afraid you might have a panic attack, what do you do to maintain a sense of safety and comfort? Look at how you filled in Worksheets 7.5 and 7.6 on unhealthy coping



defeat the fear of panic 247

and safety-­seeking responses to anxiety. Some of these strategies may be relevant to how you deal with fear of panic. Write the top three responses you use most often in the space below. 1. 2. 3.

The Panic-­Stricken Mind Lucia knew she wasn’t having a heart attack when she felt pressure and tightness in her chest. She realized it was probably just anxiety or stress. But she couldn’t seem to stop herself from thinking the what-ifs: “What if this time the chest tightness is due to problems with my heart?” “What if the symptoms persist and develop into a full-blown panic attack?” “What if I lose complete control and the symptoms don’t go away?” Even though Lucia had now experienced the physical symptoms of anxiety dozens of times and the worst thing that had happened was heightened anxiety, she couldn’t help thinking about these worst-case scenarios. Because of repeated anxiety and panic episodes, Lucia developed a heightened concern about the functioning of her heart, which meant that threatening explanations for unexpected cardiac sensations automatically came to her mind. These what-ifs were the first thoughts that popped into her mind, which she tried to counter with reminders that it was just anxiety or stress. But these first apprehensive thoughts were powerful, and they always focused on some mental, emotional, or medical catastrophe. Lucia had developed a panic-­stricken mind, and it was this way of thinking that was responsible for her continued problem with panic attacks. The catastrophic misinterpretation of anxiety symptoms is pivotal to the development and persistence of panic attacks. CBT focuses on modifying the panic-­stricken mind to eliminate fear of anxious feelings (anxiety sensitivity) and thereby reduce the frequency and intensity of panic episodes. The diagram in Figure 9.1 illustrates the CBT model of panic attacks. There are four components to this model that guide treatment.

Hypervigilance As shown in the diagram, when you have frequent panic attacks, you can become preoccupied with your physical state, frequently monitoring your bodily functions for unwanted and unexplained physical sensations. That is, you develop a state of

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Anxiety triggers

Escape, avoid anxiety triggers

Heightened attention to unwanted bodily/mental sensation(s)

Misinterpretation of bodily sensations

Inability to correct misinterpretation causes increased anxiety

Safety seeking and avoidance fail

F I G U RE 9.1.  

Panic attack

CBT model of panic.

symptom-­focused hypervigilance. If a physical symptom, like chest tightness, difficulty breathing, dizziness, or nausea, can be explained or is expected (“I just walked up a flight of stairs, so of course I’m out of breath,” for example), you feel somewhat better, although the remote possibility of the worst-case scenario may still linger in the back of your mind. If the physical sensation is unexpected and inexplicable (such as “I’m just sitting at my desk; I shouldn’t be feeling like I can’t get enough air”), apprehension sets in immediately and you begin to think about catastrophic possibilities. You think: “This is not normal,” “Why am I feeling this way?” or “Something’s not right with me.” Also, you’ll become overly focused on the troubling physical sensation, which in turn drives up the anxiety experience. This tendency to excessively monitor your physical state and become overly attentive to the physical symptoms that



defeat the fear of panic 249

do occur is targeted in CBT for panic because these processes intensify panic-­related anxiety. Lucia, for example, became hypersensitive about the functioning of her heart and lungs. She became preoccupied with any sensation in her chest, her heart rate, and whether she was breathing properly. She even got to the point of frequently taking her pulse throughout the day to see if her heart rate was elevated. Whenever she was aware of an unwanted physical sensation, she immediately became apprehensive, asking “What’s wrong with me?” People who have frequent panic attacks often develop a hypersensitivity to the first physical signs of anxiety, which causes them to feel perpetually anxious about their physical state. CBT for panic focuses on “turning down” this excessive body self-­monitoring.

Catastrophic Misinterpretations Earlier we said that catastrophic misinterpretation of unexplained physical sensations is at the core of panic attacks, which is why this element is highlighted in the center of the diagram: It’s the pivotal process in creating panic. Hypervigilance can produce an immediate, automatic thought of the worst-case scenario: “What if I’m having a heart attack? What if I lose control and this develops into full-blown panic? What if I’m going crazy?” In panic the catastrophic thinking involves exaggerating the likelihood and severity of this worst possible outcome, such as overestimating the probability that heart palpitations reflect an underlying cardiac problem. When asked about chest tightness, Lucia completely overestimated the number of times it’s linked to cardiac dysfunction. Certain physical sensations are associated with particular misinterpretations. Examples of catastrophic misinterpretations of bodily sensations are presented in Table 9.1. Do you experience any of these ways of thinking about your physical sensations when you’re feeling anxious? Often the catastrophic misinterpretation softens with repeated panic attacks. You may realize the physical symptoms don’t signify something as severe as a heart attack, suffocation, or a brain tumor. However, you still misinterpret the symptoms as a threat. Now the fear is the physical symptoms could develop into another panic attack, or even just severe anxiety. This “lighter” form of misinterpretation is sufficient to trigger avoidance and persistence of the panic problem. CBT teaches you how to counter this misinterpretation of physical sensations so that anxious feelings do not escalate into panic.

Failure to Correct We’ve all experienced unexpected, spontaneous physical sensations, and possibly even entertained a catastrophic interpretation on occasion (“Could this be something

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Examples of Catastrophic Misinterpretations of Bodily Sensations

Internal sensation

Catastrophic misinterpretation

Chest tightness, pain, heart palpitations

• Something’s wrong with my heart. • Could I be having a heart attack? • Am I putting too much stress on my heart?

Breathlessness, smothering sensation, irregular breathing

• I’m not getting enough air. • What if I start to suffocate? • I can’t breathe deeply enough.

Dizziness, lightheadedness, faintness

• I’m losing control. • Am I going crazy? • Could this be a symptom of a brain tumor?

Nausea, abdominal cramps

• What if I become really sick and start vomiting?

Numbness, tingling in extremities

• Am I having a stroke? • Am I losing control and going crazy?

Restlessness, tension, agitation

• Is this the beginning of a full-blown panic attack? • Am I losing complete control of my emotions? • I’m overly stressed.

Feeling shaky, trembling

• [same interpretation as previous symptoms]

Forgetfulness, inattention, loss of concentration

• I’m losing control over my mental functioning. • Something is terribly wrong with me. • What if I have a serious loss of intellectual ability?

Feelings of unreality, depersonalization

• Could this develop into a seizure? • Is this a sign that I am going insane, that I am having a nervous breakdown?

Based on Understanding and Treating Panic Disorder (Wiley, 2000) by Stephen Taylor. Used by permission.

s­erious?”). But where most people tend to correct that initial anxious thought—to reevaluate the bodily sensation as a random, benign, and inconsequential occurrence—the ability to do so becomes very hard if you have frequent panic attacks. It’s as if your first automatic anxious thought (“Something could be terribly wrong with me”) takes off on its own, like a runaway freight train, unchecked by more rational thinking. One of the main reasons the automatic anxious thought is so believable is that we all tend to engage in emotional reasoning when anxious. It goes something like this: “I’m feeling anxious; therefore something awful must be about to happen.” So Lucia would feel pressure or tightness in her chest, become anxious, and in the very process of being anxious the thought that something bad was about to happen



defeat the fear of panic 251

became much more plausible. She tried to tell herself “Oh, it’s nothing; it’s probably just indigestion,” or “It’s just a random physical sensation,” but she struggled to fully believe these alternatives. We all experience daily fluctuations in breathing, heart rate, gastrointestinal and neurological sensations, muscle aches, and pains that result from the changing demands on our body. It would be unrealistic to expect our bodies to function perfectly given the stresses and strains of living. Are you inclined to be too hasty, jumping to conclusions (a cognitive error) about what might be causing a particular physical sensation? Listed below are some alternative, more benign causes of physical sensations that are common and expected in healthy people. Compare these causes to the catastrophic misinterpretations in Table 9.1 and ask yourself which you find more believable for the bodily sensations you repeatedly experience. „ Having

engaged in physical activity, exercise

„ Having

had a poor night’s sleep, resulting in fatigue or loss of energy

„ Having

consumed or reduced your intake of a stimulant like caffeine

„ Having consumed or reduced your intake of alcohol or prescription medication „ Feeling

stressed by time pressures, excessive workload, unrealistic demands, and the like

„ Having

a sudden loss of balance

„ Having

experienced a change in lighting, temperature, humidity, or other aspect of your immediate environment

„ Being

preoccupied by or excessively monitoring your physical state

„ Observing

or hearing about physical symptoms in others

„ Having

indigestion, acid reflux, or other digestive reactions to food

„ Having

bowel irregularity, motility, or gut contractions

„ Experiencing

an allergic reaction

„ Feeling

frustrated, irritable, or angry

„ Having

premenstrual symptoms

„ Adhering „ Having

to a strict diet, feeling hungry

random fluctuations in bodily function

„ Becoming

overly focused on a specific physical sensation

The CBT interventions in this chapter will strengthen your reappraisal capabilities so you can correct your tendency to catastrophize.

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Safety Seeking A natural consequence of “thinking the worst” is feeling like you’re losing control. As the physical symptoms intensify and you become more and more anxious, it may seem like you’re losing complete control of your mind and body. You become convinced that the situation is intolerable—­something must be done. So naturally you seek to regain control, escape the situation, calm yourself, and seek a place of safety. As discussed in Chapter 7, escape, avoidance, and the search for safety become the modus operandi of the anxious mind. In panic this includes any strategy that helps you relax by reducing the feared physical sensation—for example, consuming alcohol, taking medication, meditating. Situations thought to trigger anxiety are avoided, and often you learn to flee at the first signs of anxiety. This is why agoraphobia is often a complication when panic attacks become frequent and severe. Lucia came to realize that public places like grocery stores, malls, and movie theaters heightened her anxiety level and increased the risk of panic attacks, so she started avoiding these places. In a few months she found herself practically housebound. The search for safety, escape, and avoidance are major contributors to the persistence of anxiety and panic, which is why the elimination of avoidance and safety seeking is such an important component of CBT for panic. You have already done a lot of work on avoidance and safety-­seeking responses to anxiety in previous chapters. The next exercise gives you an opportunity to collect all this information and apply it your avoidance and safety-­seeking responses to panic.

E VA L U AT ION EXER C I S E 

Avoidance and Safety-­Seeking in Panic

This exercise focuses specifically on escape, avoidance, and coping responses used to reduce the fear of panic. Start by reviewing your completed Discovering My Avoidance Profile (Worksheet 7.5) and Behavior Change List (Worksheet 7.6). Select the triggers that you primarily avoid because you’re afraid they’ll cause you to have a panic attack, and list them on Worksheet 9.1. In the same way, select coping responses and safety-­seeking strategies you employ to control or minimize feared physical sensations.

Maybe the avoidance and safety-­seeking information you collected for anxiety does not fully cover your responses to fear of panic. Shortly you’ll be using the Weekly Panic Log to monitor your panic attacks. You can add more avoidance and safety-­ seeking information to Worksheet 9.1 from the new information collected in your Weekly Panic Log. CBT teaches you how to relinquish futile efforts at control and safety seeking by adopting a more positive approach to the physical manifestations of anxiety and panic.

W ORK SHEE T 9.1

My Panic Avoidance and Safety-­Seeking Record Instructions: In the left column, list anything you avoid because it might trigger a panic attack. In the right column, record coping strategies you use to reduce a fear of panic or associated anxiety and to reestablish a feeling of ease or calm. Avoided situations (triggers) (List situations, thoughts, physical sensations that you avoid because you fear a panic attack.)

Safety-­seeking strategies (List strategies used to minimize your fear of panic, to keep yourself calm and comfortable.)

 1.

 1.

 2.

 2.

 3.

 3.

 4.

 4.

 5.

 5.

 6.

 6.

 7.

 7.

 8.

 8.

 9.

 9.

10.

10.

11.

11.

12.

12.

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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Panic Assessment Most people with problematic anxiety have experienced panic attacks. If you have social anxiety, you’ve had panic attacks in social situations. If your problem is generalized anxiety, you could have such an intense period of uncontrolled worry that it elicited panic. If the problem is health anxiety, you could panic over the appearance of an unexplained physical anomaly. With panic and fear of it so common across different types of anxiety problems, you may be wondering if your panic has become a problem in its own right and requires panic-­specific interventions. If you’ve been given a diagnosis of panic disorder, you’ll want to spend a lot of time in this chapter as well as Chapter 5 on symptom tolerance. However, you may still want to do the work in these chapters if fear of panic attacks plays a dominant role in whatever anxiety problem you have. At the very least, we suggest you complete the assessment exercises in this section to determine the relevance of CBT interventions for panic. E VA L U AT ION EXER C I S E 

Problematic Panic

Let’s start the assessment with a checklist of statements that indicate whether panic attacks have become a problem for you that might benefit from panic-­specific interventions. This is not a checklist for diagnosing panic disorder, but it may help you gauge the severity of your panic and decide whether it’s time to take further action. Read each statement in Worksheet 9.2 and decide whether it applies to you. If you answered “Yes” to most of these statements, it’s likely that panic attacks are a serious clinical problem for you.

Panic attacks come in different forms as well as varying levels of severity. Many people with problematic panic wake up in the middle of the night with a panic attack (called nocturnal panic attacks). Also most people with panic experience frequent limited-­symptom panic (mini-­attacks) that involve only one to three physical symptoms but with significant apprehension and avoidance. The specialized interventions in this chapter can be helpful for all these forms of panic. Their goal is to normalize the panic experience—reduce its frequency, severity, and duration so that panic attacks play no greater role in your life than they do for the millions of people who have only occasional “nonclinical” panic.

The Panic Log The weekly panic log is an important tool in CBT for panic attacks. We’ve found that individuals with frequent panic can achieve significant reductions in their frequency

W ORK SHEE T 9. 2

Panic Self-­Diagnostic Checklist Instructions: The following 15 statements represent ways in which panic attacks can be problematic. Indicate whether or not each statement describes your experience of panic. Statements

Yes

No

  1. I have full-blown panic attacks several times a week.   2.  My panic attacks typically involve several internal sensations listed on page 250.   3. I have become frightened of having panic attacks.   4. I tend to avoid a number of common, everyday situations for fear of panic.   5.  Whenever I feel a little anxious, I worry it will escalate into a panic attack.   6. I find myself preoccupied with monitoring my body for unexpected physical sensations and symptoms.   7. I am increasingly relying on other people to accompany me so I’ll feel less anxious.   8.  Whenever I have an unexplained body sensation or physical symptom, my initial reaction is to assume the worst possible outcome.   9. I find it very difficult to think more rationally when I’m feeling panicky. 10. I try hard to keep myself calm so I don’t become too stressed out and anxious. 11. I have become much less tolerant with feeling anxious. 12. I seem less capable of correcting my initial catastrophic misinterpretation of unexplained physical sensations. 13. I feel like I’ve become too emotional and concerned about losing control. 14.  Fear of panic is significantly interfering in my work, school, leisure, and quality of life. 15.  My family and friends are losing patience with my struggle with panic and my avoidance of everyday situations. From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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simply by keeping a panic log. There are several reasons that monitoring your panic attacks can be therapeutic. „ You

learn to slow down and catch the automatic misinterpretations of physical symptoms that cause panic attacks.

„ Your

anxiety becomes less surprising and unexpected as you learn more about

it. „ You’ll

feel a greater sense of personal control over your anxiety the more you understand the processes that drive panic and fear of panic.

„ It

provides opportunities for you to document evidence that is contrary to your automatic catastrophic misinterpretations.

E VA L U AT ION EXER C I S E 

Using the Weekly Panic Log

Worksheet 9.3 presents a copy of the Weekly Panic Log. You should include full-blown panic attacks, limited-­symptom or partial attacks, and times when you were afraid of having a panic attack but it didn’t happen. Complete the panic log as accurately as possible and as soon after an episode as feasible. Do this until you have recorded a few panic episodes that will provide enough information to fill out your panic profile. The more information you gather on your panic attacks and record in your panic log, the greater its therapeutic effect. We advise people to maintain their panic log throughout the duration of their treatment. Â Troubleshooting Tips: Self-­Monitoring Panic Symptoms

Sometimes people have difficulty capturing their catastrophic misinterpretation of physical sensations when they start using panic logs. If this happens, it might be helpful to review your work on the anxious mind in Chapter 6. Table 6.1 on catastrophic anxious thinking and your Anxious Mind Map (Worksheet 6.4) will give you some insights into the misinterpretations relevant to panic. Some people are reluctant to complete panic logs because they think it will draw attention to their panic and make it worse. In our experience the opposite happens—­completing panic logs helps people understand their panic process and thus reduces panic symptoms. Remember that “knowledge is power” when it comes to beating panic, so don’t give up on completing your panic log.

Your Panic Profile After you’ve recorded several panic episodes in your Weekly Panic Log, you’re ready to map out your panic profile. You’ll also find the exercises you completed earlier in this chapter as well as the Panic Avoidance and Safety-­Seeking Record (Worksheet 9.1) helpful when completing your profile.

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My Weekly Panic Log

Rate fear of panic (0–10) Physical/mental symptoms

Catastrophic misinterpretation (Anxious, fearful interpretation of physical symptoms)

Safety-­seeking responses (Avoidance, other strategies to feel calm, less fearful)

From Cognitive Therapy of Anxiety Disorders (p. 329) by David A. Clark and Aaron T. Beck. Copyright © 2010 The Guilford Press. Adapted in The Anxiety and Worry Workbook, Second Edition (Guilford Press, 2023). Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

Date

Panic triggers (Situations, thoughts, sensations)

Instructions: Use this form to record all full-blown and limited-­symptom panic attacks that occurred over the past week. These are defined as a sudden onset of acute anxiety involving at least one disturbing physical or mental symptom. In the third column, “Rate fear of panic,” 0 = none and 10 = extreme. Make multiple copies of the log so you can maintain a continuous record of panic attacks over several weeks.

W ORK SHEE T 9.3

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E VA L U AT ION EXER C I S E 

The Panic Profile

Complete each of the sections in this flowchart (Worksheet 9.4). Write down all the situations that make you anxious, the unwanted physical sensations that make you uncomfortable, the worst outcome you dread, your safety-­seeking responses, and any other strategies used to avoid or minimize the risk of panic. This profile is also relevant to the persistence of your fear of panic.

Did you have enough information to complete your panic profile? The panic profile is a critical part of CBT for panic. It guides the treatment strategies used against panic by highlighting the core processes responsible for your fear of panic. With the panic profile you’ll be able to tailor your CBT to address unique features of your panic experience. We’ve provided an example of a panic profile based on Lucia’s experience with anxiety.

Cognitive Intervention: Panic Reappraisal Looking back on your panic log and panic profile, you might be thinking “Why do I so easily jump to the catastrophic misinterpretation of these physical symptoms?” This was Lucia’s response after spending a couple of weeks monitoring her anxiety and panic attacks. After she calmed down, she could easily see that her chest tightness was a benign sensation, a sign of stress or a random physical event. But in the moment of panic, she could not shake that initial catastrophic thought, “What if I’m having a heart attack?” Learning to correct her initial misinterpretation was an important part of Lucia’s treatment approach to panic. One of the best ways to correct this tendency to jump to catastrophic conclusions is to develop a more realistic, alternative explanation for unwanted bodily sensations and reactions. We call this panic reappraisal because it involves reevaluating your physical symptoms of anxiety in a more balanced, realistic manner. In the CBT model it’s the catastrophic misinterpretation that turns anxiety into panic. So reinterpreting your physical symptoms in a less catastrophic manner is a powerful intervention for preventing your anxiety from spiraling into panic.

IN T ER V EN T ION EXER C I S E 

Antipanic Interpretations

For the next couple of weeks, use the Antipanic Symptom Interpretation Record (Worksheet 9.5) to generate alternative explanations for your panic-­related unwanted and uncomfortable physical, mental, or emotional sensations. Review the list of alternative interpretations

W ORK SHEE T 9.4

Panic Profile Instructions: Complete each of the sections below by referring to your panic log (Worksheet 9.3). Main Anxiety Triggers Related to Panic (situations, thoughts, sensations, expectations) 1. 2. 3. 4.

 Physical Sensations

 Misinterpretation of Physical Sensations First anxious thoughts: Catastrophic outcome, what you dread:

 Avoidance and Safety Seeking How you try to reduce fear of panic or risk of panic attacks:

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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Lucia’s Panic Profile Main Anxiety Triggers Related to Panic (situations, thoughts, sensations, expectations) 1.   Supermarkets 2.   Not being close to a hospital; more than 15 minutes away 3.   Large bridges with multiple lanes and high elevation 4.   Being at home alone in the evening

 Physical Sensations

Chest tightness, increase in heart rate, sweaty palms, feeling lightheaded, legs feel weak like I could collapse, breathing becomes more rapid and shallow (it feels like I’m not getting enough

 Misinterpretation of Physical Sensations First anxious thoughts:   My anxiety is getting out of control; I’m going to have a panic attack;

can’t stand the feeling, it’s unbearable. Catastrophic outcome, what you dread: [two catastrophic themes] (a) I’m putting strain on

my heart, eventually I’m going to have a heart attack; maybe I’m having one now. (b) I’m going to have the worst panic attack of my life; I’ll have to be taken to the hospital.

 Avoidance and Safety Seeking How you try to reduce fear of panic or risk of panic attacks:   I avoid anxiety situations as

much as possible; I also carry medication in case I need it; I often take my husband because I feel safer with him; I imagine going to my safe place.

W ORK SHEE T 9.5

Antipanic Symptom Interpretation Record Instructions: Use this form to generate alternative, more benign explanations for why you’re experiencing the physical or mental sensations that make you feel panicky. Rate how much you believe each explanation is a credible, truthful reason you experienced the unexpected, distressing physical or mental sensation: 0 = absolutely no belief in the explanation, 10 = absolutely certain that this is the cause of the physical sensations. Unexpected physical symptom

List possible alternative explanations for the unexpected physical symptom

Lucia’s example:

My symptoms are due to feeling rushed, impatient because the store is crowded and I just want to get Chest feels tight, out of here. I’m probably moving quickly, almost increased heart rate, feel flushed, lightheaded running to get done. I didn’t get much sleep last night, so I feel tired and cranky; everyone annoys me. When I feel this way I tend to have more symptoms of stress and anxiety. I definitely feel stressed and anxious, so this could be causing the physical symptoms; most often I remain anxious without having a full-blown panic attack

Rate belief in alternative explanation (0–10)

7/10 belief that symptoms are due to excessive activity 3/10 that symptoms are due to lack of sleep 9/10 that symptoms are due to stress and anxiety

From Cognitive Therapy of Anxiety Disorders (p. 330) by David A. Clark and Aaron T. Beck. Copyright © 2010 The Guilford Press. Adapted in The Anxiety and Worry Workbook, Second Edition (Guilford Press, 2023). Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/ clark6-forms for personal use or use with clients; see copyright page for details.

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to physical sensations on page 251 and select two or three possibilities if you need help in coming up with alternatives. Also on a blank sheet of paper, write down specific experiences—that is, evidence—that support the alternative explanations. Attach your evidence sheet to Worksheet 9.5 so you can be reminded of the experiences you’ve had that support the alternative explanations for physical sensations. The first row in the worksheet provides an example of reinterpretation based on Lucia’s experience with panic.

Generating realistic, believable alternative interpretations of your panic-­related physical symptoms is a critical skill in CBT for panic. In fact all the remaining interventions in this chapter depend on having a credible and believable alternative explanation for your physical symptoms. If you believe the catastrophic misinterpretation, the other therapy strategies will be difficult to implement. It’s important that you spend time on this intervention and that you collect evidence from your daily experience that strengthens your belief in the symptom reappraisal. Once you’ve accepted the symptom reappraisal as a credible explanation for your physical symptoms, you can create an antipanic flashcard. IN T ER V EN T ION EXER C I S E 

The Antipanic Flashcard

Review your Weekly Panic Log (Worksheet 9.3) and the Antipanic Symptom Interpretation Record (Worksheet 9.5). Select the main physical, mental, or emotional symptom that is most closely related to your panic attacks. Next select the most believable alternative explanation for each physical symptom you listed on Worksheet 9.5. Elaborate on why you think this alternative interpretation is a better explanation than the catastrophic interpretation. Now write the alternative interpretation on a 3×5 index card or in the notes app on your smartphone. This will become your Antipanic Flashcard. Follow the steps below to make the most effective use of the flashcard. 1. Before entering an anxiety-­provoking situation, spend two to three minutes reflecting on what you wrote on the flashcard. Remind yourself that you’re likely to experience some physical symptoms. Think about what is causing the physical sensations and why your alternative explanation is the most accurate. 2. Also, think about how you’ll cope with these physical symptoms in the situation you’re about to enter. 3. After leaving the anxiety-­provoking situation, make a note of your experience. What happened that confirmed the alternative explanation is correct? Did anything happen that indicates the alternative explanation needs to be changed? Make any necessary revisions to your flashcard.



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The Antipanic Flashcard is a way for you to apply panic reappraisal to your anxiety and panic in real time. It won’t be effective if you simply read it quickly before a difficult situation. Rather you’ll need to think deeply on why the alternative interpretation is a better explanation for your physical symptoms than the catastrophic misinterpretation that feeds panic attacks. You may obtain additional ideas on writing an effective flashcard from Lucia’s example. Lucia’s antipanic flashcard:   I’m going to experience chest tightness, heart palpitations, and

weakness when I confront situations that raise my fear of panic. I know these symptoms are a sign that I’m anxious and stressed. Also they are more intense for me than most people because I’m so focused on them. I can feel uncomfortable with my heart just by being attentive to my heart rate. I have these physical symptoms a lot, and most times I manage okay. I can do the same now knowing they are caused by stress and my tendency to be hyperaware of my body.

Cognitive Intervention: Panic Rescripting In Chapter 8 we introduced a CBT intervention called detached worry. With a few modifications the same type of therapeutic strategy can be used for panic attacks. The basic idea is to deliberately confront your fear of panic in your imagination. The objective is to reduce this fear before confronting it in real life. People with repeated panic attacks can become so frightened of the experience that even thinking about panic attacks makes them anxious. There are three components to rescripting panic in your imagination. „ Create

a detailed account of the catastrophic scenario involving a panic attack.

„ Follow

this with a rescripting or rewriting of the scenario incorporating your alternative explanation for your physical symptoms.

„ Engage

in daily, scheduled imaginal exposure to your panic attack scenario.

IN T ER V EN T ION EXER C I S E 

Panic Rescripting

Step 1: Start by writing about one of your most severe panic attacks. Describe where it happened, who was present, what you felt, your physical symptoms/sensations, the sights and sounds (even smells) related to the attack, and how you responded to the experience. Your description should include what you were thinking, including the catastrophic misinterpretation (“Am I having a heart attack [going crazy, dying, and so forth]?”). Your

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narrative should be written in the first person and in the present tense (“I’m starting to  shake  .  .  .”). Feelings of helplessness and loss of control should be included in the script. Step 2: Next rewrite your panic scenario so you’re experiencing all the physical sensations and anxiousness described in Step 1. But now you make the alternative interpretation of your physical symptoms/sensations. You don’t try to shut down the panic, escape, or calm down. You let the physical symptoms ebb and flow as you remain in the panic situation. You imagine yourself coping with the feelings, focused on the tasks associated with the situation (such as shopping if you’re in a crowded supermarket). You remain fixed on that image of coping, dealing with the panic, and letting it run its natural course. Step 3: Schedule 20- to 30-minute sessions each day in which you repeatedly imagine the panic attack (Step 1) and then rescript it (Step 2). You’ll do 10–12 repetitions of imagery rescripting in each session. Stop the sessions when you become bored and the practice of imagining your severe panic episode no longer elicits anxiety. Write your panic rescripting narrative in the space provided below. Use additional paper if you need extra space. An example of Lucia’s rescripting of her first unexpected panic attack at work follows. Panic rescripting narrative: Lucia’s rescripting narrative:   Step 1. 

Catastrophic scenario: I remember that day so well, the worst day of my life. I’m sitting at my desk, working on a senior manager’s presentation I had to make later that day. I’m not ready. I’m falling behind, and I keep getting phone calls and interruptions that make it impossible to work on the presentation. It’s now noon, and I’m feeling panicky. I have about 3 hours of work left but only 1 hour until the presentation. I’m thinking I’ll make such a fool of myself. I start to feel very hot and sweaty. Then suddenly the room feels like it’s spinning. Instantly I can feel my heart pounding in my ears, and I start shaking uncontrollably. I have no idea what is happening to me. It feels like some uncontrollable physical reaction. Instantly I think about my father. Is this what he experienced? Am I having a heart attack? Am I dying? I loosen my blouse, drink some water, throw more water on my face in the washroom, but it’s not



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going away. I can’t stand it any longer. I tell my manager that I’m not well, that they’ll have to postpone the meeting for a later date, and I leave for home. Step 2.  Rescripted scenario: [the second part of the scenario is rescripted starting with “Am I having a heart attack?”] I tell myself that I’m not having a heart attack. I’m experiencing a severe reaction to being under stress about the presentation. This is what happens when I get overwhelmed and start thinking that I’m going to look stupid or incompetent. I’ll take 15 minutes to let the symptoms cool down. I’ll get out of the office and take a walk. After this I’ll get something at the local sandwich bar and think about the big gaps missing in the presentation. Then I’ll go back to my desk and ignore emails, ringing phones, and those sorts of distractions. If anyone drops by to chat, I’ll tell them I must work on the presentation. I do all of this, and I can feel the symptoms subside. They don’t completely go away, but they become tolerable. I make the presentation. It goes okay, but I’m relieved to see the end of a very difficult day.

Behavioral Intervention: Panic Induction In Chapter 5 you were introduced to a CBT intervention called symptom provocation. It involves deliberately provoking anxiety symptoms in a controlled manner and then letting the symptoms fade naturally. You don’t try to minimize or control the anxiety but instead observe what you’re feeling from a passive, somewhat detached perspective. It’s a type of repeated exposure to anxiety symptoms so you no longer fear them. It’s an intervention aimed at raising your tolerance for anxiety. You can use the same intervention, with modifications, to effectively treat panic and fear of panic. Start by considering the physical symptoms you listed in your Panic Profile (Worksheet 9.4). These are the symptoms you’ll target with this intervention. Follow the steps outlined in the intervention exercise called deliberate symptom exposure (see Chapter 5, pages 106–108). Replace the term anxiety symptoms with panic symptoms. In Step 2 you’ll identify the main physical panic symptom that bothers you most when you fear the occurrence of a panic attack. This could be, for example, chest pain, heart palpitations, shortness of breath, nausea, or dizziness. This is the physical symptom that you’ll deliberately provoke using one of the symptom provocation techniques listed in Table 5.1. Schedule daily panic induction sessions by following Steps 5–10 so you experience controlled exposure to the physical symptom of panic you fear most. Write down the results of your panic induction sessions using My Symptom Provocation Record (Worksheet 5.8). Many of the physical symptoms of panic can be produced by hyperventilation.

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For this reason, overbreathing is the symptom provocation technique most often used in CBT for panic. The next exercise outlines how to conduct a hyperventilation panic induction, although you can use the same steps for any of the other provocations listed in Table 5.1. As with all symptom provocations, you’ll want to do your first hyperventilation session with your therapist. If you’re not in therapy, do the first session with your partner, close friend, or trusted family member. Afterward you can do the induction sessions alone. IN T ER V EN T ION EXER C I S E 

Hyperventilation Induction

1. Know the rationale: You are intentionally producing the physical symptoms of panic by hyperventilating for two minutes. Although it’s not exactly like a panic attack, the physical sensations will be similar enough to produce an exposure effect. Hyperventilation is not harmful, but you can expect to feel uncomfortable. 2. Ensure medical clearance: Ask your family physician if there’s any reason you should not overbreathe for two minutes. If you have a respiratory condition, cardiovascular disease, obesity, epilepsy, pregnancy, or some other medical condition, you should not engage in hyperventilation. You might be able to use another provocation technique listed in Table 5.1. 3. Practice controlled breathing: Take five minutes and practice controlled breathing. This involves deeper, slower diaphragmatic breathing of approximately 8–12 breaths per minute. During this time, focus deeply on what it feels like to take slow, deep but normal breaths. 4. Record preinduction physical sensations: Write on a blank sheet any physical sensations that you currently feel. Give them a rating from 1 = barely noticeable to 10 = intense, I can hardly tolerate the symptom/sensation. 5. Two-­minute overbreathing: Use the stopwatch function on your phone and overbreathe for two minutes or as long as you can stand it. Do not go beyond two minutes. Overbreathing or hyperventilation involves sitting in a chair and breathing as deeply and rapidly as possible. This is normally done through open-mouth breathing. Notice the physical symptoms that develop as you hyperventilate. 6. Record post-­induction symptoms: Stop hyperventilating and write down the three or four most prominent physical symptoms you’re experiencing. Rate the intensity of the symptoms using the 10-point scale. Note whether you’re experiencing the same physical symptoms that you get during a panic attack. 7. Practice controlled breathing: After recording your symptoms, do two minutes of controlled breathing. Afterward, rate your physical symptoms. Record the outcome of your hyperventilation exercise on Worksheet 5.8.



defeat the fear of panic 267

There are several benefits to symptom provocation exercises, like hyperventilation, that make them an effective treatment for panic attacks. „ You’ll

discover that repeated exposure to panic-­ related physical symptoms reduces your fear of panic attacks.

„ You’re

challenging the catastrophic misinterpretation of the physical symptoms by intentionally producing the symptoms.

„ You’re

introduced to the possibility that overbreathing or hyperventilation might play a contributing role in your panic attacks.

„ You’ll

notice that the physical symptoms of panic are weakened by engaging in controlled breathing.

Behavioral Intervention: Panic Exposure Most people who have panic attacks discover that certain situations trigger the physical symptoms that lead to panic. For example, you might avoid flying or sitting in the middle row of a movie theater because you feel trapped. This may lead to certain physical sensations like feeling hot or flushed, lightheaded, or feeling dissociated from your body and surroundings. These symptoms scare you because they signal the possible onset of a panic attack. So you avoid airplanes or movie theaters; in fact, you avoid anything that might trigger an escalation into panic. The problem is that the list of avoided situations expands over time, so many people with panic develop full-blown agoraphobia. This is why systematic exposure to avoided situations is an important component of CBT for panic. Chapter 7 discussed how to develop an exposure plan. You’ll want to focus panic exposure on the triggers that you listed in the first section of your Panic Profile (Worksheet 9.4). Also, the avoided situations listed on your Panic Avoidance and Safety-­ Seeking Record (Worksheet 9.1) will help you structure an exposure program. Next, complete My Recovery-­Oriented Exposure Plan for panic (Worksheet 7.9) in which you replace the term anxiety with panic. For instance, in section A, list what you’d like to do if you didn’t have a fear of panic (your panic recovery goals). Consider healthy responses that would help you tolerate fear of panic in section B and safety-­seeking behavior you use to reduce risk of panic in section C. The only other modification is to ensure that your exposure focuses on situations that generate a fear of panic. Once again the critical elements are (a) gradually increasing the difficulty level of the exposure exercises, (b) ensuring that each exposure session lasts until your anxiety declines by at least half, and (c) practicing the correction of automatic thoughts of threat and danger that occur during exposure.

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IN T ER V EN T ION EXER C I S E 

Situational Exposure for Panic

Construct a hierarchy of panic-­related triggers that starts with moderately distressing situations that you usually avoid and proceeds up to panic-­inducing situations you always avoid. Use the Exposure Hierarchy (Worksheet 7.8) to guide your panic exposure treatment. Begin with the moderately distressing situations and engage in repeated situational exposure several times a week. Continue exposing yourself to a situation until you can do it with half as much anxiety as when you began. Then move on to the next situation in your hierarchy. Exposure is complete when you no longer avoid the situations in your hierarchy. Â Troubleshooting Tips: Help with Panic Exposure

If you’re having difficulty following an exposure plan, review the work you completed in Chapter 7. This will help you remember strategies you can use to overcome barriers to exposure. If agoraphobic avoidance is prominent in your problem with panic, situational exposure will play a much bigger role in your treatment strategy. Reduction in avoidance through exposure is vital to reducing the frequency and severity of full-blown and limited-­symptom panic attacks.

Situational exposure is a core intervention that’s included in any cognitive behavior treatment plan for panic. It’s especially effective when used with panic reappraisal, panic induction, and panic response removal (see below). In fact all the other interventions will not be effective if you continue to avoid panic triggers. This makes it imperative that you engage in systematic exposure to panic triggers when treating your fear of panic.

Behavioral Intervention: Panic Response Removal Safety seeking and other responses aimed at controlling fear of panic and reducing the risk of panic attacks are prominent when the attacks are frequent and debilitating. It’s important to be aware of your safety-­seeking profile and to work on eliminating these responses when you engage in panic induction and exposure. You already collected information on safety seeking with My Weekly Panic Log (Worksheet 9.3) and incorporated this into your Panic Profile (Worksheet 9.4). You might also examine the responses you endorsed in My Safety-­Seeking Response Form (Worksheet 7.4). Many of these strategies are relevant to fear of panic.



defeat the fear of panic 269 IN T ER V EN T ION EXER C I S E 

Safety-­Seeking Removal

Make a list of the most common safety-­seeking strategies you use when fearful of a panic attack. Some strategies, like carrying antianxiety medication or being accompanied by a friend, can be stopped before you even begin exposure. Others, like visualizing yourself in a safe place, self-­reassurance, or trying to relax, must be interrupted and eliminated during exposure. When engaged in exposure, practice training your attention on the safety aspects of situations (for example, “What is the evidence that I’m actually safe standing here in the mall even though I’m feeling incredibly anxious?”) and learning to tolerate, even accept, the state of feeling anxious. This will help you challenge the catastrophic misinterpretation and strengthen your belief in the alternative interpretation of the physical symptoms of panic.

Escape and avoidance were Lucia’s preferred responses to fear of having a panic attack. There were many external situations that triggered her fear of panic, so she created a hierarchy to guide her situational exposure. She decided to start with grocery shopping because it was in the middle of her hierarchy. Having to rely on others to get groceries also greatly limited her freedom, independence, and ability to meet the basic requirements of daily living. She started by going to smaller grocery stores at off hours when there were few customers. One of her safety responses was to insist that her husband go with her. She agreed that he’d wait in the car the first few times and then she’d drive to the store alone. This was an example of gradually removing a safety-­seeking response while doing situational exposure to fear of panic. She decided to stop thinking about a safe place when she detected the onset of anxiety symptoms. Instead she’d let the symptoms ebb and flow on their own and focus her attention on grocery shopping. She also kept reminding herself to go slow and not rush around the aisles. Once she was able to shop at this smaller grocery store without panic and reliance on safety-­seeking responses, she progressed to a larger store that was more crowded.

The Next Chapter Panic attacks and worry are transdiagnostic features of anxiety. Both can be present in any anxiety problem, or they can be the main symptom that requires treatment. Presence of spontaneous and debilitating panic attacks is the primary symptom in those diagnosed with panic disorder. But whether panic and the fear of it are the sole symptoms or part of a larger anxiety problem, the catastrophic misinterpretation of specific physical symptoms is responsible for amplifying anxiety into panic. The CBT treatment of panic focuses on correcting the catastrophic misinterpretation through

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symptom reappraisal. It also uses symptom induction, situational exposure, and inhibition of safety-­seeking responses to overcome fear of panic. Let’s take a moment to consider what you’ve done in this chapter. Panic is a very difficult form of anxiety because the attacks can be so intense. A full-blown panic attack can feel like you’re dying. So if you have panic attacks and you completed the intervention exercises, we commend you for your courage and determination. Panic induction and exposure demand a lot from individuals. If you’ve done the work and achieved some success, you’ve accomplished a great deal. No doubt you’ll find the other cognitive and behavioral interventions for anxiety much easier. But for now we leave the world of panic attacks and consider another problem that’s common across a variety of anxiety problems—the pain of social anxiety.

10 conquer social anxiety

T

he human experience is steeped in social interaction. Practically everything we do involves interaction with other people. We live and work in communities, our family and kinship network informs our identity, and our most enjoyable leisure and recreational activities are spent with friends and family. Important life roles as intimate partner, parent, and mentor are deeply relational. We depend on relationships to learn and adapt in this ever-­changing world. And it is through our relationships that we achieve the deepest sense of meaning, spiritual nourishment, and life satisfaction. Given the centrality of social interaction in the human experience, it is little wonder that social situations are also the source of some of our greatest fears and anxieties. There are two ways to think about anxiety in social settings. The first is social-­ evaluative anxiety, in which individuals are mainly concerned with the negative evaluation of others. The second is performance-­evaluative anxiety, where the focus is on making a mistake or failing in front of others. Most individuals with problematic social anxiety have both types of anxiety. And yet there are others who function reasonably well in social settings but then experience severe anxiety in evaluative situations like writing tests, interviews, or performing in front of an audience. In the following example, Antonio struggled with both social-­evaluative and performance-­ evaluative anxiety.

Antonio’s Fear Antonio was painfully shy, or at least that’s how he’d always thought of himself. Even as a child he had always felt nervous, especially around other kids. He recalls a solitary childhood, with only one close friend and a constant fear of being singled out in the classroom. Now, 33, single, and working for a software developer, he continues to feel alone and isolated. A few years ago he had to move several hours away from his family for a new job, and the adjustment was difficult. In the last six months his 271

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mood became sullen, he lost interest in things he once enjoyed, he felt tired most of the day, and he had insomnia. His doctor said he was depressed and started him on antidepressants, which made him feel a little better, but a deep sense of loneliness, boredom, and dissatisfaction lingered. Antonio kept to himself at work and chose to work from home when it became an option. At first coworkers tried to include him in conversation and invited him for drinks after work. But Antonio always turned them down. He felt tense, awkward, and self-­conscious around others and didn’t seem to know how to carry on a casual conversation. When he got anxious, his face flushed, he started to tremble, his heart raced, he felt hot and sweaty, and he felt like he couldn’t breathe properly. He was convinced other people noticed his anxiety and were thinking “What’s wrong with him?” or “What’s he so nervous about?” or “Is he mentally ill?” In this state of intense anxiety, Antonio was convinced other people were staring at him and conjuring up all sorts of negative conclusions about the way he acted. The minute they paid attention to him his self-­consciousness soared. On occasion when he tried to say something, the words didn’t come out right, and he was left feeling deeply ashamed and embarrassed. Sometimes he would mentally rehearse what to say to people, but it seemed to make matters worse because when spoken his words came across as canned and insincere. If he was told about a scheduled work meeting, Antonio’s anxiety escalated the closer he got to the event until the anticipatory anxiety was unbearable. He might spend a couple of sleepless nights worrying about how he could cope with any upcoming social event. Although he felt some relief afterward, it was always short-lived because he would start mentally rehashing the event and what people might have thought of him. This tendency to replay past social interactions over and over—what we call postevent processing—resulted in a belief that he’d embarrassed himself once again, which only cemented his conviction that he was hopeless around other people. Antonio’s main strategy for coping with his intense social anxiety was avoidance. He avoided a variety of interpersonal situations, such as making appointments, attending social gatherings, having a friend over for dinner, starting conversations and expressing opinions, going on dates, and answering the phone, as well as numerous performance situations, like speaking at meetings, eating/drinking in public, shopping in a busy store, walking in front of a group of people, and performing before an audience. If he couldn’t avoid a social situation, Antonio would say as little as possible and leave as soon as he could. His anxiety was a little better if he had a few drinks or kept a tranquilizer handy. Antonio has a problem with social anxiety, one of the most common types of anxiety, which affects an estimated 14.8 million American adults (7.1%) each year.56 Social anxiety problems often begin in childhood or early adolescence and can take a chronic course that lasts for decades. They can cause a lifetime of disappoint-



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ment, loneliness, and distress and are often associated with other condiSocial anxiety is an enduring nervous or tions, like major depression, generanxious feeling in most social or performance 4 alized anxiety, and alcohol abuse. situations because individuals fear being Milder forms of social anxiety are evaluated negatively by others or acting in even more common in the general a foolish, embarrassing manner. They are population, and heightened anxiety especially sensitive to the scrutiny of others in social situations is a frequent comand fearful that others will notice they’re plaint in a variety of anxiety condianxious. Social interactions are avoided or tions. endured with intense anxiousness, especially Despite making progress on your if they involve unfamiliar people. anxiety in earlier chapters, you may be feeling that social anxiety, even though a minor part of your anxiety problem, has not been addressed adequately. In this chapter we focus on social anxiety generally and discuss interventions you can use that are specifically designed to reduce heightened social and evaluative anxiety. CBT for social anxiety is based on the cognitive and behavioral interventions presented in Chapters 6 and 7, but they’ve been modified to address unique aspects of anxiety in social settings.

What Will People Think? At the heart of social anxiety is a heightened concern about what others think. Of course everyone wants people to think well of them. It’s perfectly natural to want to be liked by others, to receive their approval, acceptance, and maybe even their admiration. Compliments, praise, and positive feedback from significant people in our lives make us feel great, whereas criticism, rejection, disapproval, and negative feedback can be upsetting. Being embarrassed is one of the most uncomfortable emotions we all feel, so of course we try our best to avoid making a negative impression. Let’s face it, we all like to fit in, feel like we’re accepted. It’s uncomfortable to stand out from the crowd and be conspicuous. This means it’s perfectly normal to feel somewhat nervous or tense when we find ourselves in an unfamiliar social situation or must introduce ourselves, carry on conversations, give our opinion—all while appearing relaxed, confident, and engaging or witty. Everyone thinks at times “How am I doing?” “I wonder what they think of me,” “I hope I didn’t say something stupid,” “I really feel like a fish out of water,” or “I can’t wait to get out of here.” We look for indications from others that we’re doing okay, that we fit in; and we may feel uneasy, even embarrassed, if we get a sense that others are bored, uninterested, or, worse, annoyed with us. After leaving these

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awkward social interactions, we rehash the night’s events in our minds—how we “performed,” other people’s reactions to us—trying to come to some answer to the question “Did I make a fool of myself?” If you have social anxiety, everything we just described probably feels magnified a thousand times. Maybe you feel paralyzed by fear in social situations, living in dread of making a negative impression. The possibility of embarrassing yourself may seem like a catastrophe that you can’t risk. You’re so convinced that you look awkward and inept that you start monitoring your every verbal utterance and gesture in an effort to make a good impression. But over time you seem to be losing the battle: The harder you try to fit in, the worse the perceived outcome. You become convinced you’ve embarrassed yourself, so you look back at social interactions with shame, remembering them as the worst experiences in your life. Eventually you decide you can’t put yourself through such torture anymore; better to avoid others as much as possible than endure the humiliation. And so you start isolating yourself, withdrawing behind walls of self-­protection, barricading yourself from the rest of humanity. But this comes at a great cost; you often feel alone, with a profound sense of dissatisfaction and reduced quality of life. The other great cost is that you become less practiced in the “art of social discourse” and so feel more and more awkward in social situations. You’re caught in a vicious cycle that seems impossible to escape! Are you burdened by social or performance anxiety? Are you too concerned about what people think about you? In the space below, list the personal costs of social anxiety. What’s missing in your life because of your anxiousness around others?

















Considering the negative impact of social anxiety, is it now time to tackle this problem? If you’ve done the work in the previous chapters, you already have a strong foundation in CBT for anxiety. We’ll show you how to focus your CBT skills on the specific features of social anxiety so you’re no longer hindered in your relations with others.

The ABCs of Social Anxiety I (DAC) recently spoke to an elderly widow who was feeling bored, isolated, and alone. I was making suggestions of where she could go, who she could contact, and various seniors’ events and gatherings she could attend. Suddenly she interrupted me.



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“Oh my,” she exclaimed, “I couldn’t go anywhere alone. I’d feel too uncomfortable. I’d never enjoy it. At my age, why make myself do something I wouldn’t enjoy?” The woman’s social anxiety wasn’t severe but was still significantly diminishing her life. To understand how people choose a lesser life, it’s important to consider the three processes that make social anxiety such a powerful influence: 1. Fear of negative evaluation: the fear of being judged negatively by others and incurring their scorn and disdain—fear that others will think you’re stupid, weak, inept, maybe even crazy. 2. Heightened self-­focused attention: being intensely focused on your social performance, imagining how you’re coming across to others to the point where you can barely hear what people are saying. Paradoxically, the more you try to control and evaluate every utterance, facial expression, and gesture, the more awkward you become in your social interactions. What drives this intense selffocus is a fear that others will notice you’re anxious or that you’re making a bad impression that will be embarrassing, humiliating, and possibly lead to rejection. 3. Escape and avoidance: avoiding people as much as possible and escaping at the earliest opportunity when forced into social situations. By limiting social contact to a shrinking circle of safe and familiar people, the person who is socially anxious becomes less skilled at navigating novel and unfamiliar social situations. Antonio was gripped with fear that others would notice his anxiety in social situations. He was convinced they would see his flushed face, trembling hands, halting speech, and then wonder what was wrong with him. He told himself they were probably thinking “Poor guy—he looks so anxious,” “What a weak, pathetic person who can’t even relate to other people,” or “He probably has some severe mental illness.” This highly negative view made him more self-­conscious, which then increased his anxiety—but it also made his concern about his lack of conversational skills actually come true because he found it difficult to listen and concentrate on what people were saying to him. In the end the anxiety was so great that Antonio would leave these social functions as soon as possible. Escape brought him instant, unbelievable relief. Every time, he would vow never to put himself through such torment again. It’s hard not to admire those gregarious people who are full of charm, wit, comfort, and confidence around others. Their bold and vibrant personalities dominate our favorite movies, setting cultural standards of social performance that are unrealistic for most people. In real life we know highly sociable individuals who can fill a room with their presence and appear to draw the approval of others. It is easy for this to

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become the standard of social performance for the individual who is socially anxious. But it’s an unrealistic standard, born of perfectionism, which can only amplify our anxiety around others. This sets up a dual process in the individual who is socially anxious—a fear of negative evaluation and unrealistic standards of social performance. E VA L U AT ION EXER C I S E 

Social Expectations of Self and Others

Our best and worst expectations of self and others will have a profound impact on our anxiety level in social situations. Use the space below to describe what standard of social performance you wish for yourself. You can think of this as the most positive impression you’d like to make on others. Would you like to come across as friendly, confident, relaxed, witty, intelligent, or some other characteristic? My most positive impression: Next use the space below to record the most negative impression you fear you could make on others. What is your most feared negative evaluation? For example, do you fear they’ll think you’re stupid, weak, insecure, pathetic, unstable, or some other attribute? My most negative impression:

You can think of fear of negative evaluation and perfectionistic social standards as dual processes that pull you into social anxiety. Antonio’s most negative impression was that he’d come across as anxious and pathetic when interacting with unfamiliar people. At the same time he dreamed of impressing others with his calm, confident, and witty manner. But in reality Antonio knew he was much closer to making a negative impression on others. These two diametrically opposed expectations ensured that Antonio avoided uncomfortable social situations as much as possible.

The Socially Anxious Mind Social anxiety becomes a pervasive life problem through a circular feedback loop. You start by anticipating social encounters with some degree of trepidation, then you find yourself in the social situation experiencing unhelpful thoughts and actions



conquer social anxiety 277

that drive up your anxiety, and then afterward you rehash and brood over the social encounter, which only exaggerates the dread you feel for the next social interaction. The CBT model, with these three phases, is depicted in Figure 10.1.

Phase I. Anticipation Although social interactions can occur unexpectedly (such as when you run into a work colleague while shopping), most often we know about meetings, interviews, and parties well in advance. This means that during this anticipatory phase we have lots of time to think about them. Anxiety can build dramatically during a period of anticipation, depending on the circumstances. For example, if your supervisor asked you to give a brief presentation at this Friday’s department meeting, anticipatory anxiety will be much greater than if you were simply required to attend. Many of our clients have said their anxiety is often more intense during anticipation than when they’re actually exposed to the event. Two things will influence the degree of anticipatory anxiety you experience: „ The

immediacy of the event: The closer you get to a dreaded social event, the more intense your anxiety, since anxiety builds over the anticipatory phase. This is what psychologist John Riskind called looming, and it’s known to play an important role in anxiety.57

„ Exaggerated

thinking about threat: Catastrophizing about the social event, thinking that you’ll probably embarrass or humiliate yourself, or maybe have a panic attack, and predicting that you’ll perform badly based on memories of past social events, will also drive up your anxiety level.

The problem with anticipatory anxiety is that it sets the stage for feeling intense anxiety even before you encounter the social situation. It makes you feel defeated before you even get started! Antonio had intense anticipatory anxiety whenever he had to interact with unfamiliar people. One morning last week a work colleague popped into Antonio’s office and invited him to lunch with a few people, including one of the new hires in the department. Antonio felt he couldn’t refuse but then worried all morning about the lunch: “What will I talk about? I’m so bad at chitchat!” “What if I get really nervous and self-­conscious?” “Will others notice my anxiety and wonder what’s wrong with me?” “Last time I went out with people at work, I felt like such a dork, just sitting there with nothing to say while everyone else was talking and laughing.” For several days after that incident Antonio hadn’t been able to face anyone at work without feeling embarrassed. Now his anxious thinking was so bad that he could hardly work. By lunchtime he was feeling severe anxiety.

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Reminded of upcoming social event

Anticipatory phase Feeling more anxious and worried when anticipating the social event

Actual social encounter

Increased persistence of social anxiety

Anxious thinking

Anxious behavior

1. Thinking about negative evaluation by others 2. Feeling highly selfconsciousness 3. Focused on signs, evidence of negative evaluation, embarrassment 4. Overly self-critical of social performance

1. Make futile efforts to stay calm and conceal anxiety 2. Overcompensate in effort to make a positive impression 3. Become very quiet and inhibited 4. Try to escape or at least hide from others

Postevent processing (highly negative recall and reevaluation of past social events)

F I G U RE 10 .1.  

CBT model of social anxiety.

Based on Cognitive Therapy of Anxiety Disorders (Guilford Press, 2010, p. 349) by David A. Clark and Aaron T. Beck.



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We can literally whip ourselves into a heightened state of anxiety even before a social event occurs. CBT reduces anticipatory anxiety by providing you the tools to correct your anxiety-­inducing expectations.

Phase II.  Social Encounter The time arrives and you find yourself at the dreaded social event. This is your moment of exposure to other people, and it’s the defining experience for the socially anxious. As you can see from the middle, circled portion of Figure 10.1, several cognitive and behavioral processes act as an accelerant for social anxiety. 1.   N E G AT I V E S O C I A L   B E L I E F S

One of the first things that’s likely to happen when you enter an interpersonal situation is that underlying negative beliefs about yourself and other people are activated. A selection of beliefs common in social anxiety is listed in Table 10.1. If any of these beliefs are personally relevant for you, list them in the space provided below. They’ll become an important focus of your CBT treatment plan. My negative social beliefs:

Antonio had several beliefs that increased his anxiety around others. He was convinced he was dull and boring but felt like he should strive to be engaging, entertaining, and appear relaxed and confident. As a result he felt it was critical to conceal his anxiety as much as possible—not only would others judge him harshly if they noticed he was nervous, but feeling embarrassed seemed like just about the worst thing that could happen to him. “Better to avoid people as much as possible than to risk embarrassment or humiliation,” Antonio believed. 2 .  N E G AT I V E E VA L UAT I V E T H O U G H T S

If you’re socially anxious, you automatically think that other people are noticing your anxiety, making negative judgments about your behavior, and wondering what’s wrong with you. You might imagine them thinking: “What’s wrong with her?” “Why is she so anxious?” “She must be emotionally disturbed.” “That was a stupid thing to say.” “She is so incompetent; I wish she would just keep quiet or disappear.”

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Common Social Anxiety Beliefs

Type of belief

Examples of specific beliefs

Beliefs about yourself

• I’m boring, unfriendly, and uninteresting to others. • People don’t tend to like me. • I’m socially awkward; I don’t fit in.

Beliefs about others

• People tend to be highly critical. • In social situations people are always making judgments, scrutinizing other people, looking for their flaws and weaknesses. • I can’t stand confrontation.

Beliefs about disapproval

• It’s awful when people disapprove of me. • It would be horrible if others thought I was weak or incompetent. • It is a personal catastrophe to embarrass myself in front of others. • People don’t want to include me; they would like to exclude me from their social events.

Beliefs about performance

• It’s important not to show any signs of weakness or loss of control around others. • I must appear confident and interpersonally competent in all my social interactions. • I must always sound intelligent, come across as interesting, or be entertaining around other people.

Beliefs about anxiety

• Anxiety is a sign of weakness and loss of control. • It is important not to show any signs of anxiety around others. • If people see that I’m blushing, perspiring, shaking, and so forth, they will wonder what’s wrong with me. • If I’m anxious, I won’t be able to function in this social situation. • I can’t stand feeling anxious around people.

From Cognitive Therapy of Anxiety Disorders (p.  350) by David A. Clark and Aaron T. Beck. Copyright © 2010 The Guilford Press. Reprinted by permission.

Like other anxious thoughts, these negative evaluative cognitions are automatic and are quite convincing during states of heightened anxiety. In fact they might occur as unwanted intrusive thoughts. That is, the negative thoughts seem to spontaneously pop into your mind, and once you’re aware of them they become “sticky thoughts.” You find it hard to concentrate on anything other than the bad impression you’re convinced you are making. It’s as if social anxiety leaves you with a one-track mind: People are thinking poorly of me. You’ll have an opportunity later to keep a record of your negative evaluative thoughts, but for now write down a couple of more forceful negative thoughts you’ve had during past experiences of social anxiety.



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My negative social evaluative thoughts: Antonio’s negative social evaluative thoughts:   People are looking at me. They can see that I’m

nervous. I’m shaky, and my voice sounds weak and quavery. They’re probably thinking “What’s wrong with him? Why is he so anxious around us? He’s pathetic.” 3 .  B I A S E D AT T E N T I O N T O T H R E AT

When we’re anxious in a social situation, our attention also becomes distorted. First we become entirely self-­focused. Experimental research has shown that individuals with social anxiety engage in excessive self-­monitoring and negatively misinterpret their physical and emotional sensations in a manner that actually increases their anxiety.4 You might become preoccupied with whether your face looks flushed, whether your hands are trembling, whether your conversation makes sense, whether your speech flows or is halting and awkward. Of course this heightened self-­consciousness has a negative effect: „ It

magnifies anxiety symptoms and a sense of losing control.

„ It

causes you to be so entirely self-­focused you can’t properly pay attention to how other people are responding to you.

„ It

impairs your ability to perform socially.

Second, when we’re socially anxious, our attention becomes narrowly focused on internal and external signs of threat, embarrassment, and negative evaluation. Say you’re nervously trying to make a comment. Your attention becomes fixed on the person checking her smartphone or glancing in the other direction. Immediately you interpret these cues as a sign of boredom and disinterest. You’re already feeling anxious, so your attention becomes highly selective and you tend to lock on to any facial expression, behavior, or gesture that could suggest a negative evaluation. You fail to notice indicators that people are supportive or interested in you. You do the same with your internal experience, paying attention to flushed sensations that you interpret as indicating overt anxiety but ignoring that your speech is coherent and flows reasonably well. In CBT we teach people how to correct their biased attention so they can lower their social anxiety rather than fuel it. Take a moment to consider what you focus on internally when socially anxious and what you pay attention to in others (your audience) when your anxiety flares up in social situations.

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What I attend to in myself when anxious: What I attend to in others when anxious: 4 .  S E L F - ­C R I T I C A L   T H O U G H T S

When you’re intensely focused on your own performance, you’ll quickly jump to the conclusion that you’re making a poor impression or actually experiencing public humiliation. You probably engage in a running commentary on your social performance, concluding that you’re failing miserably. Antonio was especially self-­conscious about whether he was blushing while talking to others. He became acutely aware of feeling hot or flushed, and the first signs that he was blushing would distract him from the conversation at hand. He assumed the blushing was more noticeable and distracting to others than it was and that it was making his ability to converse less coherent and more awkward. He quickly assumed that he was making a horrible impression and embarrassing himself with others. CBT will help you stop this internal, self-­ critical commentary about your performance and how unsatisfactory it is and the conclusion that surely you’re an embarrassment. In the space below, write down your most critical self-talk in social situations. The most critical statements I tell myself when socially anxious: 5. CONCE ALMENT EFFORTS

You may have tried several strategies to conceal your anxiety or at least minimize the most obvious symptoms. Maybe you avoid eye contact, tense your arms or legs to control shaking, wear excessive clothing to conceal sweating, wear heavy makeup to hide blushing, or memorize what to say at social gatherings.58 Unfortunately, some of these safety behaviors actually draw more attention rather than less. One woman believed that exaggerated controlled breathing calmed her down, but her breathing was so loud and labored that it could be heard several feet away, possibly drawing the attention of others, who might have wondered whether she was



conquer social anxiety 283

having an asthma attack or some other medical emergency. Recall some of your past experiences with social anxiety. How do you try to conceal your anxiety or at least reduce the more obvious symptoms that others might notice? My concealment strategies: 6. OVERDOING IT

To deal with perceived social skills deficits and make a positive impression, have you ever caught yourself overcompensating? You might have occasionally tried so hard to be funny, intelligent, or friendly that you inadvertently made an unfavorable impression. When Antonio realized he tended to look down when talking to others, he tried to correct the habit by looking straight at them but ended up staring so hard that other people became uncomfortable. Has a friend or family member ever mentioned anything you overdo in social situations (for example, laugh too loud or inappropriately, talk too much or too quickly, stare at people, stand too close to them, interrupt a lot)? List some of your overcompensation behaviors here.











7.   S O C I A L I N H I B I T I O N A N D   E S C A P E

Anticipating embarrassment naturally makes you inhibited around others. Have you concluded you’re too stiff or rigid in social interactions? Perhaps you stammer or struggle to find the right word to express your thoughts. If you’ve had this experience, you know it’s as if the very thing you fear most is happening to you. When it does happen, it’s no wonder you have the urge to escape. Because everything he tried to say seemed to come out wrong, Antonio was determined to stay by himself or at least say as little as possible when he couldn’t avoid a social encounter. Trying hard to stay calm, attempting to conceal anxiety, trying to compensate for social awkwardness, and being generally inhibited can all lead to the actual thing that you fear most—­negative evaluation and embarrassment. The CT-R approach to social anxiety emphasizes change in your coping strategies so your interpersonal behavior contributes to better social relations rather than relationships tainted by fear and anxiety. What are your social inhibitions when you feel the wave of anxiety sweep over

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you in social situations? Do you become speechless, break eye contact, go blank, physically withdraw from other people, look at your phone? Think back to some recent social experiences and list some of your typical social inhibition responses in the space provided. My most common social inhibition responses:

















Phase III.  Postevent Processing In many respects social anxiety is “the gift that keeps on giving.” Although you may experience relief after leaving an anxiety-­arousing social situation, the reprieve is usually short-lived. Soon you find yourself rehashing and overanalyzing a social ­encounter—“How did I perform?” and “Did I say something stupid, rude, or embarrassing?”—and trying to recall what people said to determine whether you made a good or bad impression. But this postmortem tends to be very selective: You keep asking yourself whether the social encounter was humiliating, and the more you ruminate on that question, the more evidence you tend to unearth to answer it in the affirmative. This postevent processing could last hours or even several days, depending on the importance of the event. Most of the rehashing goes on in your mind, but sometimes you might ask repeatedly for feedback from close friends or family. Typically with social anxiety, no matter what others say to the contrary, you end up convinced that “Yes, it was a terrible experience, I completely embarrassed myself, and everyone probably thinks I’m a total loser.” The end result? Your social anxiety is reinforced and intensifies. Postevent processing was a significant problem in Antonio’s social anxiety. He could spend days reanalyzing what he said in a conversation and how the other person responded. The more he thought about it, the more convinced he became that his anxiety was on full display and that his conversation was so incoherent that it had left the other person perplexed. In some cases he would avoid this person at work, feeling embarrassed every time he ran into the coworker. On occasion Antonio even thought that maybe the work colleague was telling others about the strange conversation the colleague had had with him. It’s common in social anxiety to relive what you perceive as past embarrassing social encounters in a selective and highly biased way that leads to an exaggerated perception of shame and embarrassment. Since this postevent processing is a key contributor to social anxiety, it becomes an important target for change in CBT.



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Does postevent processing play a role in your social anxiety? In the space provided below, describe a recent experience of postevent processing. Briefly describe what you thought about as you mentally rehearsed a recent experience of social anxiety. Were you analyzing the social event to determine whether you made a bad impression on others? Were you most concerned that you might have said something inappropriate or stupid? Were you trying to analyze the meaning behind a puzzling comment made during the event? Recent experience of postevent processing:

Social Anxiety Assessment We’ve all had times when we were socially anxious. Maybe it was attending a large gathering where you didn’t know anyone, having a business dinner with an important customer, being interviewed for a job, or having to perform before an audience. Some of us are anxious in most social settings, and others are anxious in only a few settings. Some experience severe anxiety, others mild discomfort. And many people are by nature shy and introverted. In one survey 40% of people considered themselves chronically shy,59 and in another general population study 7.5% of adults had significant symptoms of social anxiety.60 If you happen to find yourself at one of those uncomfortable cocktail parties where you hardly know anyone, look around you. If there are 50 people at this party, there is a good chance that at least 20 of them are feeling some discomfort, and maybe 5 people are experiencing high levels of anxiety. Given all these considerations, there’s a good chance that there will be times when you have anticipatory anxiety or engage in postevent processing even if social anxiety is not a significant, ongoing problem for you. The work you’ve done up to this point will be helpful for the full range of social anxiety. This section provides tools you can use to assess the degree to which you’re experiencing problematic social anxiety and how you might benefit from the interventions that follow. E VA L U AT ION EXER C I S E 

The Social Anxiety Checklist

Worksheet 10.1 asks questions about different aspects of social anxiety based on the characteristics of the socially anxious mind.

W ORK SHEE T 10.1

Social Anxiety Checklist Instructions: Read each question and determine whether the item is mostly relevant to your current functioning in social situations. If you answered “Yes” to more than five or six questions, then social anxiety is probably a significant problem for you. Questions

Yes

No

  1. Do you almost always feel quite anxious in a variety of social situations that you encounter on a daily basis?   2. Do you often feel apprehensive or worried about upcoming social events?   3. Do you avoid or make excuses to get out of social obligations?   4.  When you can’t avoid a social encounter, do you try to leave as soon as possible?   5. Do you tend to assume you are making a poor impression on people or that they are judging you in a negative manner (thinking you are stupid, incompetent, disturbed, and so forth)?   6.  Are you intensely afraid of saying something embarrassing or humiliating when talking to others?   7. Do you try hard not to appear anxious in social situations?   8.  When you are around other people, do you try to say as little as possible to avoid drawing attention to yourself?   9. In social situations, are you quite preoccupied with your performance, tending to “overanalyze” how you are coming across to other people? 10. Do you rely on various coping strategies to reduce your anxiety around others, such as avoiding eye contact, rehearsing what you say before speaking, and taking deep breaths? 11. Has social anxiety held you back in your occupation, family relations, leisure activities, or friendships? 12.  After a social interaction, do you often go over and over in your mind what you said or how you came across to other people? 13. Do you seem to have a particularly good memory for difficult or embarrassing past social encounters? 14. Do you often feel like you don’t know what to say to other people? 15. Do you believe you are particularly incompetent or inept around other people? 16. Is embarrassing yourself in front of others just about the worst thing you can imagine? 17. Do you have problems being assertive or stating your opinion? 18.  Would people who know you best say you are a shy or anxious person? 19. Do you often feel like everyone is looking at you in social situations? 20. Do you think you are more anxious in social situations than most people? 21. Have you been socially anxious or inhibited most of your life? 22. Have you tried to overcome social anxiety but had only limited success in beating it? From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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If you endorsed many of the items on the Social Anxiety Checklist, don’t feel discouraged. The CBT strategies discussed in this chapter will be particularly relevant for you because they are designed for people with moderate to severe social anxiety.

Social Values, Goals, and Aspirations Let’s assume you concluded that your social anxiety is a problem that you’d like to work on. The next step is to determine what you’d like to change in your ability to relate to others. In CT-R we don’t focus just on reducing social anxiety, even though this will be your primary objective. We also emphasize the pursuit of positive aspirations and values. How would you like to function in social situations? How would you need to think, feel, and act so you turn your social interactions into a positive experience, a source of increased self-­esteem? If you’ve been struggling with social anxiety, you’ve probably never considered that difficult social interactions could boost your self-worth and enrich your life. But in treating social anxiety it’s important to look beyond anxiety reduction to what you’d like to become. This means discovering your social values and aspirations and then creating relevant goals and objectives. E VA L U AT ION EXER C I S E 

Social Values and Aspirations

Following is a list of common relational values and aspirations. Check off the ones that apply to you. These are the values that you aspire to in your relationships with others. You can also think of these values/aspirations as the positive impression that you’d like to make in your social interactions. How would you like to come across to people? There are three blanks at the end of the list for you to write in any unique social values/aspirations you might hold that are not included in the list. † Competent, knowledgeable

† Energetic, lively

† Confident

† Spontaneous

† Authentic, honest

† Friendly

† Controlled

† Supportive

† Interesting, unique

† Assertive

† Other:

† Understanding

† Calm

† Other:

† Compassionate, empathic

† Pleasant

† Other:

† Witty, humorous

Once you’ve identified your social values and aspirations, the next step is to formulate some specific goals that are consistent with how you’d like to function in social relationships.

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E VA L U AT ION EXER C I S E 

Goals for Social Change

Start Worksheet 10.2 by thinking about three or four social situations that cause you moderate to severe anxiety and yet are critical to your quality of life. Then consider how you’d like to function in each situation that would be consistent with your aspirations and would reduce your anxiety. Try to be as specific as possible about how you’d like to think, feel, and act in each situation. These will become the goals you can work on when you practice the intervention strategies later in the chapter.

Were you able to formulate some social performance goals for three or four situations that trigger moderate to severe social anxiety? Exposure to situations that provoke social anxiety is a major component of CBT for social anxiety. You can use the goals you wrote about in Worksheet 10.2 as a guide for conducting your exposures to these particular social situations. Think of the goals as a description of “how you’d like to be” when encountering the social situation listed in the first column.

Social Anxiety Self-­Monitoring An accurate assessment of anxiety depends on collecting real-life experiences. Throughout this workbook we’ve emphasized the importance of keeping a weekly log of your anxiety episodes. This is also true for social anxiety. A systematic description of your social anxiety episodes recorded as close as possible to their actual occurrence provides the best insight into your social anxiety problem. How you think about yourself, other people, and your anxiety will determine whether you experience mild or severe anxiety. It’s important to discover how you think during actual social encounters.

E VA L U AT ION EXER C I S E 

Maintain a Weekly Social Anxiety Log

Keep a record of your social interactions while you are working on the CBT interventions in this chapter. My Social Anxiety Log (Worksheet 10.3) focuses specifically on how you think during the three phases of social anxiety: anticipation, encounter, and postevent remembering. How you cope with your anxiety is also important, but the log focuses on your cognitions because they are the hardest to identify. The first column asks you to briefly describe the anticipated social situation that triggers your anxiety. The next three columns should be completed as soon as possible after you progress through each phase of the social encounter. By keeping a self-­monitoring sheet you’ll be training yourself to identify ways of thinking that make your anxiety worse and prevent you from attaining your social relatedness goals.

W ORK SHEE T 10. 2

My Social Change Goals Instructions: In the left-hand column, list a few social situations that are important to you but cause moderate to severe social anxiety. Use the right-hand column to explain how you’d like to feel, act, and think in each situation that would be consistent with the aspirations you endorsed in the previous exercise. The first row presents an illustrative example taken from Antonio’s story. Social situation Antonio’s example:

Meeting with my manager to review my work

Social performance goal

In this situation I want to be competent, knowledgeable, confident, and calm. These are the social values most important in this situation. This means I need to focus on the work I’ve produced and not on how I feel. I’ll need to actively listen to my manager’s questions and comments. If I don’t have an answer, I’ll write down the question and get back to him later with an answer. I need to remember that I know more about this document than anyone.

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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Anxious thoughts during anticipation phase

Anxious thoughts during encounter phase

Anxious thoughts during postevent processing

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

Social anxiety trigger (situation, thoughts, memories)

Instructions: Use the following form to record your daily experience of situations that cause you some level of social anxiety. Record the social encounter in the left column. Use the next three columns to write about what you were thinking before the social encounter, your thoughts while engaged in the social interaction, and then how you evaluated yourself and the social experience after the event.

W ORK SHEE T 10.3



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 Troubleshooting Tips: Completing the Social Anxiety Log

If you have difficulty maintaining a social anxiety log, consider the following: „ Make sure you are recording situations that evoke a moderate to severe level of

anxiety. If you’re only mildly anxious, you won’t have the unhealthy anxious thinking that is the signature feature of problematic social anxiety. „ Write down what you think is the worst that could happen or did happen in the social

situation. No doubt your anxious thinking in each phase is concerned about your impression on others, what they think of you, and how you behaved. „ Your anxious thinking might focus on fear of embarrassment. How are you thinking

you might embarrass yourself? When you reflect on the social encounter, are you ruminating on whether you said something embarrassing?

Antonio felt like he could fill up several social anxiety logs in a typical week. There were many examples of social encounters at work but also outside of work in everyday living that made him anxious. One of his social anxiety log entries involved having to return a defective item purchased at a hardware store. In the first column he wrote “I need to return a defective 18-volt cordless drill that I bought two weeks ago. It’s a $125 purchase, so it’s important that I get my money back. I’ve discovered that this brand of drill has a terrible performance rating.” In the anticipatory column he wrote “Customer service will give me a hard time. They’ll claim I abused the drill. I’ll have to stand my ground, but I hate confrontation. I’ll get so anxious. I won’t be able to stand it.” Immediately after leaving the hardware store, Antonio wrote in the encounter column “It was awful. I got so anxious. My face got flushed, I was shaking, my voice quavered, and I could tell the clerk was wondering why I was getting so upset. I probably scared her and she wondered if I’d lose control. I did get my money back, but I’m so embarrassed at how I acted.” For the next several days Antonio couldn’t get the incident off his mind. In the postevent column he wrote “I keep thinking about how I scared that young woman. I acted badly and it wasn’t her fault. She was being quite nice and only doing her job. I’m sure other customers walking by must have noticed me at the counter and wondered ‘What’s wrong with that guy?’ Maybe I scared a lot of people. I obviously can’t be trusted to deal with confrontation.”

Social Anxiety Profile Based on what you’ve learned so far, it’s time to bring your knowledge and insights together and create your unique social anxiety profile. As in other chapters, the social

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anxiety profile is a guide that will focus CBT interventions on important aspects of your anxiety in social settings. The structure of the profile is based on the CBT model of social anxiety in Figure 10.1. The next five steps will show you how to build your social anxiety profile.

Step 1.  Know Your Social Triggers Review the first column of My Social Anxiety Log (Worksheet 10.3) to generate a list of situations that trigger moderate to severe social anxiety. Write down approximately 20 social situations that make you anxious. You probably won’t have that many entries in your Social Anxiety Log, so you’ll need to think about a full range of social activities that could make you anxious. You should include a mix of situations that cause you varying levels of anxiety, from moderate to severe discomfort. Make sure you include thoughts or memories about social experiences that can trigger anxiety. Also choose some triggers that occur daily, many that occur weekly, and only a couple that occur less frequently. For example, giving a speech might be the most anxiety-­provoking situation you can imagine, but unless your job requires public speaking, you may rarely have an opportunity to give a speech and so should exclude this from your list. After you’ve developed your list of situations, arrange them hierarchically from least to most anxiety provoking. You can use My Exposure Hierarchy (Worksheet 7.8) to create your social anxiety exposure hierarchy. We’ll be returning to these situations later in the chapter.

Step 2.  Discover Your Anticipatory Anxiety We’ve discussed why the anticipation of social encounters is so important in the social anxiety process. Despite its significance, this is often the least understood by the person who is socially anxious. Even though you collected information on your anticipatory thinking in the Social Anxiety Log, you may need to do extra work to complete this section of the profile. E VA L U AT ION EXER C I S E 

Anticipatory Anxiety Analysis

The Anticipatory Social Anxiety Form (Worksheet 10.4) is designed to provide a more complete assessment of your socially anxious thinking during the anticipatory phase. Use the worksheet to record your level of anxiety in the hours, days, or maybe even weeks prior to a social event. Also state whether the anxiety got worse as the event got closer and what you were thinking about the approaching event. Were you worried about what might happen, how others might respond to you or how you might feel and act, your performance in the situation, whether you were thinking about past similar events, or whether you were thinking of possible embarrassment?



conquer social anxiety 293

W ORK SHEE T 10.4

Anticipatory Social Anxiety Form Instructions: Record anxiety-­arousing social situations that you anticipate will happen in the coming days or weeks. Rate how anxious you feel just thinking about the future event on a 11-point scale, where 0 = no anxiety, and 10 = intense, panic-level anxiety. Use the third column to describe how you are thinking about this impending event. Write down anything you remember from past events that might contribute to your current anticipatory anxiety. Social situation anticipated

Anxiety level (0–10)

Anticipated threat

Recalled past memories

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

Antonio comes from a large extended family that holds a big annual summer party including many aunts, uncles, and distant cousins. He is expected to attend, but the event fills him with dread. This is one of the social events he recorded on Worksheet 10.4. Just thinking about the event filled him with considerable anxiety, he scored it a 6 out of 10. As the dreaded event got closer, his anxiety soared to a 9 out of 10. The anticipated threat was “I’ll be meeting people I barely know. They’ll ask why I’m still single. Some of the younger cousins will think I’m such a nerd. I’ll be expected to chitchat, which I’m terrible at. I’ll feel extremely uncomfortable, and I can’t leave because of my parents. I’ll have to suffer through to the bitter end.” In the last column of Worksheet 10.4 Antonio wrote about a memory of last year’s family gathering when he was the only single young adult. He was expected to join in conversation with other married men his age who only talked about their

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house renovations and sports. Neither topic was of any interest to Antonio. He ended up playing games on his phone. He heard later that some relatives commented that he was cold and distant.

Step 3.  Identify Anxious Social Thinking By now you’ve done a lot of work on identifying the negative thoughts at the heart of your social anxiety. Earlier you wrote about the most negative impression you might make and some of your more pronounced negative social evaluative thoughts. You’ve also been recording your anxious thoughts during social encounters on the Social Anxiety Log (Worksheet 10.3). It’s now time to compile all this information so you have a clear and precise understanding of your socially anxious thinking. E VA L U AT I V E EXER C I S E :

Negative Social Evaluative Thinking

In the space below, list the most frequent negative thoughts that run through your mind when you’re in social situations. These could include negative evaluative thoughts like the feared opinions or judgments of others, any social threat cues that come to your attention (facial expressions that seem negative, whether they look bored, and the like), what you fixate on within yourself (“Am I blushing?” “Am I talking too fast?”), any self-­critical thinking (such as “Did I just say something stupid?”), or worries that others will notice you’re anxious. Most frequent socially anxious thoughts:



































Step 4.  Note Unhealthy Coping and Avoidance When we feel very anxious in a social situation, we rarely do nothing. Our priority is to do something about feeling so emotionally upset and distraught. In Chapter 7 we discussed at length the role of safety seeking, escape/avoidance, and unhealthy coping in the persistence of problematic anxiety. That discussion is highly relevant to the



conquer social anxiety 295

ways people respond when feeling socially anxious. Review your completed Safety-­ Seeking Response Form (Worksheet 7.4), Discovering My Avoidance Profile (Worksheet 7.5), and Behavior Change List (Worksheet 7.6). Determine which answers or entries also describe how you cope with social anxiety and include them under the appropriate category in the following exercise. E VA L U AT I V E EXER C I S E :

Safety and Avoidance Protocol

Below are four categories of safety seeking, avoidance, and unhealthy coping in social anxiety. Based on your work in Chapter 7, list the strategies you tend to use when you feel anxious in social situations. Consult your Social Anxiety Log (Worksheet 10.3) to help you recall additional responses you make in social situations that elicit anxiety. A. Safety-­seeking behaviors (how I try to conceal my anxiety, appear in control, or reduce anxious feelings) 1. 

 4. 

2. 

 5. 

3. 

 6. 

B. Efforts to impress (how I try to make a favorable impression) 1. 

 4. 

2. 

 5. 

3. 

 6. 

C. Inhibited behavior (how I act inhibited or awkward; how I might embarrass myself) 1. 

 4. 

2. 

 5. 

3. 

 6. 

D. Escape or avoid 1. 

3. 

2. 

4. 

 Tips for Success: Digging Deeper into Social Coping Responses

Some of our responses when socially anxious can be hard to identify because they are so automatic. This is especially true of impression management and inhibited behaviors.

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If you’re unsure whether you’ve accurately documented your safety-­seeking and coping responses, monitor your actions in social situations over the next two weeks. You could make up a form like the Social Anxiety Log that divides your responses into safety seeking, efforts to impress, inhibited behavior, and escape/avoidance. Each time you have a social experience, write down how you acted in each of the four categories. You could also ask a trusted friend, family member, or partner to observe you in social settings and record what they notice. Sometimes people will make a comment that indicates you are coping in a certain way, like “I’m sorry, could you speak up?” or “I notice you were standing alone by the door.” The first comment would indicate inhibited behavior (speaking softly) and the second would be escape/avoidance (near an exit for a quick escape).

Step 5.  Do a Postevent Analysis The final component of your social anxiety profile focuses on the time after a social experience. It’s important to determine the nature and extent of your rumination over past social experiences. We have already explained the importance of postevent processing as one of the three key components of social anxiety. You may want to review what you wrote earlier about a recent postevent processing experience. Here we delve into the topic more deeply so you have a better understanding of what needs to change in your postevent thinking to eliminate its influence on your social anxiety. E VA L U AT ION EXER C I S E 

Negative Postevent Thinking

Review your entries in the final column of the Social Anxiety Log (Worksheet 10.3). Read through the anxious thoughts you recorded during the postevent processing phase of your social anxiety episodes. Next complete the Postevent Analysis Form (Worksheet 10.5) based on what you recorded in your Social Anxiety Log.

Did you endorse several items on the Postevent Analysis Form? It’ll be these features of postevent thinking you’ll want to change when you later work on eliminating negative postevent processing. Antonio noticed that he checked several items about embarrassment, confirming that this is one of his greatest fears. He spent a lot of time rehashing a social encounter, trying to figure out whether he had embarrassed himself.

Step 6.  Compose the Profile It’s now time to pull all this information together into a single diagram that represents your pathway to problematic social anxiety. This profile will act as your guide through our intervention strategies and indicate what aspects of your social anxiety

W ORK SHEE T 10.5

Postevent Analysis Form Instructions: Below are listed 11 statements that pertain to various aspects of postevent thinking. Check Yes if the statement describes how you tend to think about a past social experience during the postevent period and No if the statement is not applicable. Postevent processing statements

Yes

No

A.  Reevaluating the social encounter   1. I become more convinced that people negatively judged me.   2. I think about how I behaved or what I said that made a negative impression on others.   3. I become convinced I embarrassed or humiliated myself.   4.  The more I dwell on the social event, the more I’m convinced it was a terrible experience; that the outcome was truly awful.   5. I keep thinking about how I failed in this social interaction.   6.  The more I think about the experience, the more convinced I become that the anxiety was intolerable; that I couldn’t face a similar experience again. B.  Past memories of difficult social events   7. I think about embarrassing past social experiences.   8. I think about how people responded to my anxiety in past social experiences.   9. I think about how these embarrassing experiences continue to affect me. 10. I have a vivid image of these difficult social events when I recall them. C.  Ruminative themes 11.  When I think back to a difficult social encounter, I analyze over and over: a.  how anxious I felt b.  whether I was inappropriate, rude, or insulting c.  whether others noticed I was anxious d.  whether I appeared incompetent, boring, or socially awkward e.  that I was ignored by others and felt their disapproval f.  any critical remarks made by others From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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need to be targeted for change in the three stages of social anxiety: anticipation, social encounter, and postevent processing. E VA L U AT ION EXER C I S E 

Your Social Anxiety Profile

Much of the information for your Social Anxiety Profile can be obtained from the Social Anxiety Log (Worksheet 10.3). A full set of instructions for completing the profile can be found in Worksheet 10.6.

If you had difficulty completing your Social Anxiety Profile, read Antonio’s example. His way of thinking and responding to social anxiety at all three phases is quite typical of individuals with problematic social anxiety. If you skipped some of the exercises and worksheets earlier in the chapter, you may need to go back and complete them before you can compose an accurate social anxiety profile. We strongly recommend that you not proceed to the CBT interventions in the remainder of the chapter until you’ve completed your Social Anxiety Profile. It’s your roadmap for using CBT strategies to overcome your experience with social anxiety. We’ve organized our CBT interventions around the four components of social anxiety headlined in the profile.

CBT for Anticipatory Social Anxiety How we think about an approaching social event determines whether we feel severe or mild anticipatory anxiety. Catastrophizing about a future social situation will only make matters worse, causing severe anxiety and making you feel defeated even before you begin. We present three CBT interventions you can use to reduce anticipatory social anxiety and boost self-­confidence in social situations. They build on the cognitive skills you learned in Chapter 6, especially evidence gathering and generating alternative interpretations. At the anticipatory phase we become anxious because of the way we’re thinking about an approaching social event. Because of this, it makes sense that interventions at this stage focus on changing our thought patterns.

Cognitive Intervention: Modify Your Social Expectations Anticipatory anxiety increases when we imagine all the possible ways an impending social interaction could go wrong and cause us embarrassment, even shame. The antidote to making catastrophic predictions about the social event is imagining a more realistic prediction of what is most likely to happen.

W ORK SHEE T 10.6

My Social Anxiety Profile Instructions: Complete the following sections based on the entries you made in previous worksheets, especially the Social Anxiety Log. Select 10 social situations that elicit moderate to severe anxiety for section A. You may have recorded some of these situations in the Exposure Hierarchy (Worksheet 7.8). Choose situations that are more frequent and that play an important role in your daily living. Also arrange the situations from least to most anxiety-­provoking. The Anticipatory Social Anxiety Form (Worksheet 10.4) will provide information on your most typical anxious thinking during the anticipatory phase (section B). For the behavioral side, consider what you tend to do to feel less anxious when anticipating an upcoming social event that you know will cause significant anxiety. Section C asks that you list the most typical anxious thoughts and beliefs activated during a social encounter. What are you thinking about when engaged in a social experience that elevates your anxiety considerably? You’ll find lots of information from the Safety and Avoidance Protocol exercise (pages 295–296) that will help you list your safety-­seeking, avoidance, and coping responses. For section D the most typical negative thoughts and memories that occur during postevent processing can be obtained from the Post­ event Analysis Form (Worksheet 10.5). A. Social situations associated with moderate to severe anxiety  1. 

 6. 

 2. 

 7. 

 3. 

 8. 

 4. 

 9. 

 5. 

10. 

B. Anticipatory anxiety phase

Anxious thoughts

Safety-­seeking/avoidance/coping responses

 1. 

 1. 

 

   

 2. 

 2. 

 

   

 3. 

 3. 

 

   

 4. 

 4. 

 

   

 5. 

 5. 

 

    (continued)

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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W ORK SHEE T 10.6 (continued)

C. Social encounter phase Negative evaluative thoughts/beliefs

Safety-­seeking/avoidance/coping responses

 1. 

 1. 

 

   

 2. 

 2. 

 

   

 3. 

 3. 

 

   

 4. 

 4. 

 

   

 5. 

 5. 

 

   

D. Postevent processing phase  Negative recall of social events  1. 

 6. 

 

   

 

   

 2. 

 7. 

 

   

 

   

 3. 

 8. 

 

   

 

   

 4. 

 9. 

 

   

 

   

 5. 

10. 

 

   

 

   

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conquer social anxiety 301

Antonio’s Social Anxiety Profile A. Social situations associated with moderate to severe anxiety 1.    Chitchatting with coworkers

  6.    Eating alone in a restaurant

2.    Participating in department meetings

  7.    Stating my opinion or point of view

3.    Answering the telephone

  8.    Speaking to an attractive woman

4.    Speaking to unfamiliar people (strangers)

  9.    Dealing with anger or confrontation

5.    Making a formal presentation at work



10.    Speaking to people in authority

B. Anticipatory anxiety phase Anxious thoughts

Safety-­seeking/avoidance/coping responses

1.    I’ll become intensely anxious; I can’t stand it.

1.    I try to convince myself it won’t be that bad;



maybe I won’t feel anxious. 2.    I try not to think about the social event.



2.    I’ll

appear awkward, and people will think there’s something wrong with me. 3.    I need to hide my anxiety; keep it under control. 4.    I wonder if I can avoid this social event.





3.    I distract myself; I try to keep busy.



4.    I

take a tranquilizer when I feel anxious and can’t stop thinking about the event.



C. Social encounter phase Negative evaluative thoughts/beliefs 1.    I’m

Safety-­seeking/avoidance/coping responses

feeling hot, sweaty, and I’m blushing; everyone can see that I’m anxious. 2.    They’re wondering what’s wrong with me, thinking that I’m weak and pathetic. 3.    My mind went blank, and I said nothing; they must think I’m so stupid. 4.    I’m losing control; I can’t stand the anxiety.

1.    I



I try to look interested but maybe I look stupid. 5.  The anxiety becomes too much; I make an excuse and leave; I take the rest of the day off work. 



5.    Everyone

with me?

else looks so calm; what’s wrong

try to take relaxing breaths, but it’s not working. 2.    I go to the washroom and splash water on my face, but I’m not cooling down. 3.    I sit at the back of the room and say nothing.



4.  I can’t focus so wonder if I’m staring too much;

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D. Postevent processing phase Negative recall of social events 1.    I

keep going over in my mind whether my anxiety was noticeable to others.





was asked a couple of questions and keep thinking about my answers; whether they sounded stupid or not. 3.    I try to recall how people reacted, whether there was evidence they thought badly of me.

4.    I

keep thinking about how I could have been calmer and appeared more competent.





5.    I wonder if people realized I took the rest of the

will replay conversations in my mind to figure out if I might have offended anyone.



2.    I



 6.   I

 7.   When

I think I’ve been criticized, I imagine different ways that I could have responded and defended myself rather than say nothing.  8.   If a person says something ambiguous or unexpected to me, I’ll analyze it over and over in an effort to discover its true meaning.  9.             







10.              

day off because of my anxiety.











IN T ER V EN T ION EXER C I S E 

Keep It Realistic

Use the Social Expectations Form (Worksheet 10.7) to identify and evaluate varying expectations associated with an approaching social encounter. Start with a meaningful social event you’ve been thinking about over the last few days and then follow the instructions to fill out the rest of the worksheet. Â Tips for Success: Keeping Your Anticipation Realistic

When you write down the worst outcome you’ve been thinking about when anticipating the event, be sure to include some negative evaluation by others that would embarrass you. To come up with the best possible outcome, really allow yourself to dream. You could also look back at your Social Change Goals (Worksheet 10.2) for inspiration. Your answer to section D in Worksheet 10.7 will require some creativity. Here you want to come up with an outcome that is most likely to happen based on your social experiences. It won’t be the best or the worst. Finally, when you reflect on reasons the worst is unlikely to happen and the realistic expectation is more likely, you can include evidence from your past social experiences.

W ORK SHEE T 10.7

Social Expectations Form Instructions: In response to section A, briefly describe a social event you’re expected to attend in the next two to four weeks. Next, write about a catastrophic outcome you imagine in section B and the best possible outcome you imagine in section C. For section D, record the most realistic outcome associated with this event. Finally, list reasons the catastrophic outcome is not likely to happen and the realistic outcome is more likely. A. Social event: What’s the approaching social event you’ve been worried about? B. Worst expectation: What’s the worst that could happen to you? What do you consider a catastrophe, the most embarrassing thing that could happen? Please describe:

C. Best expectation: What’s the most desirable, ideal outcome you can imagine? This might be the best impression you could make on others. Please describe:

D. Realistic expectation: What’s most likely to happen at this social event? Will it be somewhere between worst and best? Please describe: Reasons or evidence why the worst outcome is unlikely to happen

Reasons or evidence that the realistic outcome is likely to happen

1.

1.

2.

2.

3.

3.

4.

4.

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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Antonio worried for several days before the monthly team meeting. His worst expectation was being questioned by his manager, getting flustered, and then having a panic attack. His best expectation was going to the meeting feeling positive and relaxed. He’d be questioned but would reply with crisp, insightful answers, impressing others with his knowledge and brilliance. But realistically Antonio knew from experience that he’d most likely feel quite anxious. He’d say very little, sit at the back of the room, and provide short, incomplete answers to questions.

Behavioral Intervention: Acting Realistic Once you’ve discovered a more realistic prediction, it’s important to put it to work whenever you start feeling anxious about the approaching social event. You can do this by continuing to add to the list of reasons/evidence that the realistic expectation is more likely to happen. Also, practice repeatedly imagining the realistic outcome happening during the social encounter. Doing so will reduce your anticipatory anxiety compared to imagining the catastrophic outcome happening. The next step in building on your more realistic expectation is to create a plan for putting it into action when you encounter the social setting. This starts with accepting that you’ll be anxious and then thinking of some minor ways you could improve your social functioning that are consistent with your realistic prediction of the anticipated social situation.

IN T ER V EN T ION EXER C I S E 

Active Acceptance

In the space provided below, list three ways you might improve your social functioning in the situation, but make sure these are changes that are doable given your level of anxiety. They’re ways to cope with your anxiety that are consistent with your more realistic expectation. My realistic expectation for this situation: Three changes that put my realistic expectation into practice: 1. 2. 3.



conquer social anxiety 305

Antonio’s example of realistic change:

I’ll feel quite anxious—say very little, sit at the back of the room, and provide short, incomplete answers to questions. Antonio’s realistic expectation:

Three changes that put Antonio's realistic expectation into practice: 1.    I

can sit farther into the room so more people see me. This is one way I can accept my anxiety and not try to hide. 2.    When I’m asked a question, I’m going to ask the person to repeat it rather than pretend I heard it correctly the first time when I didn’t because of my anxiety. 3.    I’m going to pay attention to other people when they are asked questions. Do any of them look uncomfortable? Can you see how these minor changes in Antonio’s behavior would help him be more accepting of his anxiety and act in a way that is consistent with his realistic expectation? By making a plan to change some aspects of your social behavior in the anticipated situation, you’re shifting your focus from “how awful it’ll be” to “What can I do differently in this situation knowing I’m going to feel anxious?”

Behavioral Intervention: Self-­Instructional Training You’ve evaluated the catastrophic and realistic expectations in the previous exercises and have come to accept the latter expectation. You started to put this new perspective into practice by making some minor changes in your coping behavior. The final step is to shift your perspective more fully from an emotion-­focused view to a problem-­focused outlook. You’ll have high anticipatory anxiety if you keep thinking about the catastrophic possibility and how anxious you’ll feel. If you shift your focus to developing a more detailed plan for how you’ll act in the social situation, you’ll be more problem-­focused in your approach. This will reduce anticipatory anxiety because you’re thinking about “what I can do” rather than “what I may feel.”

IN T ER V EN T ION EXER C I S E 

The Social Anxiety Flashcard

Like the Antipanic Flashcard in Chapter 8, create a Social Anxiety Flashcard for each social situation you encounter. These flashcards are developed during the anticipatory phase to establish a problem-­focused approach to your anticipatory anxiety. The flashcard should provide explicit instruction on how to act and communicate in the social situation. It should be portable so you can refer to it just before you enter the social situation. You can use the

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space below to compose a Social Anxiety Flashcard and then copy it onto a 3×5 index card or type it into the notes app on your smartphone. My social anxiety flashcard:

We’ve provided an example of a social anxiety flashcard based on Antonio’s assignment to make a brief instructional presentation at work. Antonio’s social anxiety flashcard:  I must give a 10-minute presentation on the new mobile

device synchronization program we are introducing to company employees. I’ll feel moderately anxious, which will be obvious to others. The presentation won’t be great, but I’ll get the main points across to my coworkers. Everyone already knows I get anxious, but it hasn’t changed how they relate to me. In the past I’ve never done anything embarrassing or inappropriate other than feel highly anxious. I can write out what I am going to say, practice making the speech, and learn to deliver it even when feeling nervous. So the bottom line is that I will feel anxious when making the presentation, but it’ll have no lasting impact. Â Troubleshooting Tips: Discovering the Realistic Expectation

Even after correcting their exaggerated anxious thinking about a future social event, some people have difficulty coming up with a more helpful way of thinking during the anticipation phase. Asking a close friend or family member what they think about when nervous about a future event like a job interview or a dinner party with unknown guests might give you some ideas. Also, the alternative normalized way of thinking must include the fact that you will feel anxious in the event. Trying to convince yourself when you are anticipating a social event that you won’t feel anxious won’t help because it’s not a realistic expectation.

To summarize, the CBT approach to reducing anticipatory anxiety involves three objectives: 1. Abandon the catastrophic prediction of the anticipated social experience. 2. Accept a more realistic prediction that acknowledges you will be socially anxious. 3. Take a problem-­focused approach to improving some aspects of social functioning during the encounter phase.



conquer social anxiety 307

CBT for Social Exposure Exposure is the most important component in CBT for social anxiety. You cannot achieve significant change in your social anxiety unless you engage in frequent, sustained exposure to difficult and avoided social situations. As you’ve learned in this chapter, social anxiety persists because of negative social-­ evaluative thinking and unhealthy beliefs about social threat and vulnerability. Exposure-based exercises provide crucial real-life evidence that challenge this unhealthy way of thinking and give you the building blocks to construct a less anxious way of relating to others. So we encourage you to spend lots of time on the interventions in this section. You’ll need to go slow, be patient with yourself, and approach these exercises with courage and determination.

Behavioral Intervention: Construct and Implement an Exposure Plan Taking concrete steps to overcome your social anxiety involves courageously exposing yourself to the source of your anxiety—the fear you experience when around people. We can’t emphasize enough that applying the behavioral strategies in Chapter 7 to your feared social situations is a necessary component of CBT for social anxiety. IN T ER V EN T ION EXER C I S E 

Graded Social Exposure

Earlier in the chapter you developed an exposure hierarchy of social situations (see section A of your Social Anxiety Profile, Worksheet 10.6). Select a social situation that is three or four items from the bottom of the hierarchy—one that causes you moderate anxiety and occurs at least two or three times a week. Next, construct an exposure plan for that situation using Worksheet 10.8 as your format. You’ll want to make extra copies of the worksheet because each social situation in your hierarchy will require its own exposure plan (see www.guilford.com/clark6-forms to download and print). Â Tips for Success: More on Social Exposure

The hardest part of exposure is getting started. Sometimes people start with social situations that are too easy, and so they end up making little progress because they are doing things they would probably do anyway. At the other extreme are people who start with tasks too challenging and so become quickly overwhelmed with anxiety and discouragement. Soon they give up on the exercise. To ensure that you are starting off exposure with the best chance of success, you could consult with your therapist or your partner, a close friend, or a family member who knows about your social anxiety to get their opinion on a realistic first exposure assignment. It is important that the task

W ORK SHEE T 10.8

My Social Exposure Plan Instructions: Select a social situation that causes moderate anxiety and that you avoid if possible. In section A, briefly describe how you can behave so you function at an acceptable level in the situation even though still feeling anxious. Identify key social-­evaluative cognitions that drive up your anxiety in section B and alternative, healthier ways of thinking that can reduce anxiety in section C. In section D, list unhealthy responses that inadvertently increase anxiety, and in section E, list coping strategies that potentially lower your anxiety in the selected social situation. State the anxiety-­provoking social situation:

A. Action plan (my role, function in the situation):









B. Negative social-­evaluative thoughts/beliefs to correct:







C. Healthy, realistic thoughts to adopt:







D. Unhelpful safety and control behaviors to eliminate:







E. Healthy coping strategies to implement:







From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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conquer social anxiety 309

be challenging but not overwhelming. You don’t want to defeat yourself before you get started. We’ve provided an example of a social exposure plan based on Antonio’s social anxiety at work.

After creating an exposure plan it’s important to carry it out without delay. You’ll want to do the exposures over and over until you feel significantly less anxious. Once that has been achieved, you can progress to the next social situation in your hierarchy. Create a social exposure plan for that situation and then carry it out repeatedly until you feel less anxious. You continue in this manner until you’ve overcome all the social situations in your hierarchy.

Antonio’s Social Exposure Plan State the anxiety-­provoking social situation:   Join coworkers for coffee break A. Action plan (my role, function in the situation):   At least three times a week I’ll join my coworkers for the

10:30 a.m. coffee break. I’ll sit quietly, drink my coffee, and listen to the back-and-forth banter. I’ll plan to make at least one comment on one of the topics brought up in conversation. If someone asks me a question or for my opinion, I’ll give a short answer. Everyone will see that I’m very uncomfortable with casual conversation, but I won’t try to hide it. B. Negative social-­evaluative thoughts/beliefs to correct:   People will be wondering why I started drinking

coffee with them. They’ll think I’m a very unfriendly person. They’ll notice that I blush when spoken to. They’ll think I’m a very strange person. C. Healthy, realistic thoughts to adopt:   It’s okay to be quiet; I don’t have to say anything if I don’t feel like it.

They need time to get used to me. In some ways I’m like a new employee and everyone needs time to get used to each other. They’ll see that I’m anxious, but they’ll also see that I’m trying to improve myself and be more friendly. D. Unhelpful safety and control behaviors to eliminate:   I need to stay the full 15 minutes and not bolt when

I start to feel anxious. I’ll resist the urge to check my phone because I’ll only get drawn into the screen, which is a way of escaping the situation. E. Healthy coping strategies to implement:   I need to practice my active-­listening skills and pay attention to

what people are saying. I also need to work on making eye contact and not look down when I speak to others. If I don’t find something funny, I can make an amusing smile rather than ignore the comment unless it violates my moral code in some way.

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After writing out his detailed exposure plan, Antonio began attending at least three coffee breaks over the next week. He used the Exposure Practice Form (Worksheet 7.10) to keep a summary of his exposure experiences. From this he noticed a significant decrease in anxiety over time. By the end of three weeks, Antonio felt minimal anxiety during coffee breaks and couldn’t believe this had been such a difficult social situation for him just a few weeks earlier.

Cognitive Intervention: Correct Unrealistic Expectations Unrealistic expectations or standards of performance are especially toxic to overcoming anxiety in social situations. Read over the following list and check any of the expectations that you may hold about doing exposure. You can add to the list other expectations that may be unique to you but could undermine the success of your exposure tasks. † After completing all the workbook exercises, I should be so well prepared that I won’t feel anxious when exposing myself to social situations. † I should be able to suppress my anxiety and feel in control around others. † I must be fully engaged with others throughout the exposure task. † For an exposure assignment to be successful, I need to be positive and feel good about myself. † I need to feel I’ve been effective with other people or that the exercise was highly successful to benefit from a social exposure assignment. † I need to experience some signs of approval or acceptance from other people to benefit from a social exposure task. † I must feel that I’m wanted and accepted by others present in the social situation.

If you endorsed several statements, you may be holding yourself to an unrealistic standard. This will weaken your resolve and cause you to abandon the intervention before it’s had a chance to be effective. You might be wondering what’s the most helpful attitude toward exposure. It’s important to realize that you’ll feel anxious during exposure to the social situation, you probably won’t come across to others as well as you’d like, and some people probably will detect that you’re nervous. Also, you may feel awkward, different from others, and not particularly well accepted in the social situation. No doubt you’ll feel self-­conscious and come away from the social interaction aware of weaknesses in your social performance. But the important thing to



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remember about exposure is that you’re facing your social fears and you’ll conquer them with practice, practice, practice. Before each exposure task, do a mental check of your expectations. You might be surprised at how easily these unrealistic expectations and wishes creep back into your mind. If you find yourself hoping that the exposure will unfold in an unrealistic fashion, correct it by doing a reality check, reminding yourself of the alternative perspective (that you will be anxious, and so forth), which is more practical and is firmly anchored in reality.

Cognitive Intervention: Helpful Mental Strategies You’ve seen from the CBT model of social anxiety (Figure 10.1) that the way we think in social settings has a major impact on our level of anxiety. Thinking that you’re being an embarrassment and that others are evaluating you in the most negative way possible, as well as focusing inwardly on your anxious feelings, will make your social exposures more anxiety provoking. There are several cognitive strategies you can use to reverse this pattern of toxic thinking and improve your social exposure experiences. 1.   M A I N TA I N A N E X T E R N A L   F O C U S

To break the habit of being overly attentive to your internal emotional state and sensations, deliberately and consciously take note of other people. Pay attention to what people are saying. You might have to repeat what they are saying to yourself to make sure you’re tracking the conversation. 2.  LOOK FOR POSITIVE SOCIAL CUES

To counter your sensitivity to signs of threat or disapproval, intentionally seek out positive cues from others. Focus on the person who looks interested, who has a positive facial expression, and who is paying attention to your conversation. Both of us were university professors and have given hundreds of lectures to students, professionals, and the public. As a speaker you learn quickly to focus on the one or two students who look interested in your lecture and to pay as little attention as possible to the students who are sleeping, texting, or look utterly bored with your talk. This is the number-one survival tip of the professional public speaker! 3.  MINIMIZE THINKING ERRORS

Many of the thinking errors discussed in Chapter 6 dominate when we expose ourselves to social fear situations. Mind reading (assuming we know what other people

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are thinking), jumping to conclusions, tunnel vision, and all-or-­nothing thinking are common mistakes. Learning to identify these errors and reminding yourself that the way you see the situation is probably biased and overly negative is an important therapeutic strategy to practice. The most important fact to keep in mind is that no one can be sure what people think of them or control how they evaluate use. We have no choice but to accept that much is unknown and beyond our control in social situations. Trying to guess what people are thinking is fertile soil for preconceived biases and thinking errors. 4 .  C O R R E C T E X A G G E R AT E D T H R E AT A P P R A I S A L S

In social situations the person with anxiety will tend to think that the probability and severity of other people’s rejection, disapproval, or negative judgment is much greater than it really is. Recognizing your tendency to exaggerate the negative and learning to recalibrate your evaluations so they are closer to reality is necessary for reducing your anxiety level. IN T ER V EN T ION EXER C I S E 

Practice Prosocial Cognitive Skills

Changing your cognitive style in social situations that provoke anxiety is difficult because the anxious way of thinking is so automatic. You’ll need to train your mind to think differently when doing social exposures. One way is to keep a record of your experience in using prosocial cognitive skills during your exposure experiences. Worksheet 10.9, the Prosocial Cognitive Skills Form, lists five prosocial cognitive skills. After an exposure experience, briefly describe how you engaged in each of the skills. The second column provides an example based on Antonio’s anxiety in extended family gatherings. Make multiple copies of Worksheet 10.9 because you’ll want to continue to use the form after multiple social exposures (see www.guilford.com/clark6-forms to download and print). Â Tips for Success: Prosocial Cognitive Training Strategy

Implementing cognitive strategies to correct biased thinking can be difficult when feeling severe anxiety. One way to overcome this problem is to practice these skills in nonanxious or mildly uncomfortable situations. You can practice directing your attention to other people, processing the positive cues in your social environment, catching cognitive errors, and correcting biased threat-­related evaluations in these less intimidating situations. With dozens of practice trials these cognitive skills will become more automatic so you can begin using them in high-­anxiety situations. Another approach is to work on one cognitive skill at a time. For example, identify one specific anxious thought (for example, “I am drawing attention to myself”) and work

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Prosocial Cognitive Skills Form

I was able to listen to conversations and not think only of how I felt.

I noticed that relatives asked me questions and did respond when I said something.

1.  Maintained an external focus

2. Observed signs of interest, acceptance in others

Social exposure 1

Social exposure 2

Social exposure 3

(continued)

Social exposure 4

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

Antonio’s example (a family gathering)

Prosocial cognitive skills

Instructions: The first column lists five cognitive skills that can improve social performance. The second columns shows examples based on Antonio’s experience. Use columns 3–6 to indicate how you worked on each cognitive skill in several anxiety-­provoking social situations that were the target of your exposure exercises.

W ORK SHEE T 10.9

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Antonio’s example (a family gathering)

5. Acknowledged my anxiety

It’s okay to be nervous with relatives I don’t know well. I notice some of them look nervous talking to me. Just be myself.

total loser” with “they know me and what I accomplished; probably they consider me shy.”

4. Corrected I countered the thought catastrophizing “they think I’m a

conclusions when I really don’t know what people think of me.

3. Countered I caught myself mind thinking errors reading and jumping to

Prosocial cognitive skills

W ORK SHEE T 10.9 (continued)

Social exposure 1

Social exposure 2

Social exposure 3

Social exposure 4



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on correcting only it, rather than every anxious thought you are having in the situation. Next, decide on which cognitive strategy you will use to counter this anxious thought and then practice using the strategy against the anxious thought. Once you’ve made progress on that thought, move on to another anxious thought and try using another cognitive strategy.

Keeping a record of your practice using prosocial cognitive skills is a good way to retrain how you think when feeling anxious in a social situation. With repetition you gradually shift from the negative social-­evaluative way of thinking to healthier strategies that help quell an anxious mind. In addition, self-­monitoring your prosocial cognitive skills offers a more positive approach by emphasizing what you’re doing right to overcome your social anxiety.

Behavioral Intervention: Take Action with Helpful Strategies You’ve learned about some cognitive strategies that can help you cope better with anxiety feelings during exposure. Now we’d like to suggest some behavioral techniques you can add to your toolkit. You’ll notice our behavioral strategies focus on building up a response repertoire that enables you to perform better in anxiety-­provoking situations. Some of the strategies explain how to train yourself in positive social skills, whereas others focus on ways to overcome accelerants of social anxiety. As you read about these behavioral strategies, select two or three that you think will be especially helpful when confronting difficult social situations. 1 .  R O L E -­P L A Y I N G

Cognitive behavior therapists do a lot of role-­playing when treating social anxiety. Therapist and client act out various social situations that the individual experiences in everyday life. New ways of interacting can be practiced, and the therapist can run through various worst-case scenarios a person might imagine, such as dealing with an angry or critical response from a person or handling potential embarrassment. Also role-plays are a great way to elicit automatic anxious thoughts that can be corrected on the spot. If you are not in therapy, you can do role-plays with your partner, a family member, or a close friend. In fact having two or three people as role-play partners will introduce some variation and novelty into the practice sessions. Video conferencing by computer, iPad, or smartphone provides even more opportunity to practice social skills. You could start out using your phone camera to record yourself rehearsing a social interaction. Next you could rehearse the same skill with a friend using Facetime

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or video conferencing. Sometimes people find it less anxiety provoking to practice their social skills virtually before trying them out in face-to-face interaction. Antonio, for example, wanted to ask a female acquaintance out for a date but was petrified even thinking about it. He worked with his therapist on how to initiate a conversation with her. They spent a considerable amount of time repeatedly role-­ playing how to strike up a casual conversation, working on Antonio’s communication skills, and practicing strategies for interacting with others even when feeling moderately anxious. 2 .  B E H AV I O R A L R E H E A R S A L

This is very similar to role-­playing. Select two or three specific social behaviors that you’d like to improve. Some examples are maintaining eye contact, improving your posture, speaking more loudly, expressing your opinion, responding to questions, or learning to interrupt others in a polite manner so you are not left out of conversations. Work on these behaviors and give yourself opportunities to practice them in actual social situations before moving on to another behavior you want to improve. Also try out these new behaviors in repeated role-plays and in nonanxious social situations so they become more automatic even when you feel severe anxiety. Behavioral rehearsal is another term for “learning a new skill through experience.” If you want to learn to play a musical instrument, for example, you repeatedly practice some core elementary skills involved in playing that instrument. Eventually you integrate these skills into a coordinated, holistic action that we call playing the instrument. It’s the same with behavioral rehearsal of specific social skills. You practice and refine these skills so they are combined and integrated with other social skills so you end up with greatly improved social performance. In this way you’re able to progress toward realizing the social change goals you listed in Worksheet 10.2. 3 .  E L I M I N AT E S A F E T Y B E H AV I O R

When feeling socially anxious, inhibition is our natural response. Looking down, mumbling, holding a rigid body posture, having a drink, taking deep breaths, continually looking down at your notes, clearing your throat repeatedly, and wearing dark sunglasses are some examples of inhibitory behavior. Inhibitory (or safety-­seeking) behavior gives us the false sense that we’re managing anxiety, but more often these behaviors make our social interactions more inhibited and awkward, which then draws unwanted attention from others. Weaning yourself off these unhealthy coping strategies is an important part of overcoming social anxiety. Antonio, for example, would take “relaxing” breaths when he became severely anxious, but these came across as deep sighs that were annoying to other people. If it’s



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hard for you to identify your safety behaviors, have a friend observe you in social situations and note anything you might be doing quite automatically that interrupts the flow of your social interaction. Of course if you’re in therapy, your cognitive behavior therapist will be working with you on reducing your safety-­seeking behavior. IN T ER V EN T ION EXER C I S E 

Strengthening Prosocial Behavior

There are specific prosocial behaviors you’ll want to practice in your role-plays and behavioral rehearsal. Use the Behavioral Retraining Guide (Worksheet 10.10) to describe the skills you want to practice. The worksheet then becomes the guide you follow when doing your role-play practice sessions. Â Tips for Success: How to Maximize Role-Plays and Social Skills Practice

Start by selecting a moderately anxiety-­provoking social situation from your exposure hierarchy (Worksheet 7.8). Ask a friend or your partner to engage in role-plays of this situation with you. Make sure you do the role-play several times a week. Ask your roleplay partner for feedback on any safety behaviors that may be evident during your role-play. Correct any negative thoughts you have about your role-play performance and practice one or two specific social skills. Develop a flashcard for dealing with this social situation. After several role-play practices, engage in the actual social activity, and record the outcome on your Social Anxiety Log (Worksheet 10.3). Remember, role-­playing is another name for acting. Many of us are not natural actors, so you might find it difficult to pretend to be someone else. Sometimes when people role-play, they comment on the role rather than getting into the role (they talk about what they should say rather than actually saying “their lines” in the role-play). If this is happening to you, try writing out a script first—a set of lines to say just like an actor’s script. Now try acting out the lines by saying them as if you were in the feared social situation. Eventually you should work up to being more spontaneous and not reading lines when you practice role-­playing social situations.

Improving your verbal communication, being more assertive, and dealing better with anger, conflict, or criticism from others can all ease social anxiety. Once again role-plays and behavioral rehearsal are indispensable for identifying weaknesses in your social performance and practicing new social skills. Don’t try to change too many behaviors at once. Above all, be kind to yourself. Don’t expect too much too quickly. Behavioral change takes a lot of time and practice. You are trying to break habits that may have been present for a lifetime. Don’t expect to break a lifelong habit in a couple of weeks. Be realistic with yourself and give yourself credit when you’ve made changes and faced your daunting social fears.

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W ORK SHEE T 10.10

My Behavioral Retraining Guide Instructions: Record feedback you receive from your role-play partners in the first column. Use the second column to write out a concise, step-by-step description of how you want to act in specific social situations. List inhibitory and safety-­seeking behaviors to eliminate in the third column. Role-play feedback

Prosocial skills to practice

Inhibitory, safety-­seeking behaviors to eliminate

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

The most effective way to overcome social anxiety is to engage in role-play practice prior to a social interaction and then repeatedly expose yourself to the actual social situation. In the end it is your exposure experiences to real-life anxiety-­provoking social situations that will radically alter your anxiety and boost your self-­confidence around other people.

CBT for Postevent Processing Ruminating on past social experiences can have a major impact on your current level of social anxiety, so it’s important to correct how you remember these experiences. After you’ve encountered a social situation, do you tend to think about it for days on end? In the assessment section you already did some work on evaluating your post­event thinking. Take a moment to review the statements you endorsed on the



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Postevent Analysis Form (Worksheet 10.5). Which of the three aspects of postevent processing is most relevant: reevaluating the social encounter, remembering past difficulties, or ruminating on the past? Use the postevent analysis statements you endorsed as a guide for the treatment you’ll use in this section. The objective of CBT strategies for postevent processing is to shift from rumination about past social experiences to a more proactive focus on the present. Individuals with social anxiety rarely learn from postevent processing because the focus tends to be self-­critical and catastrophic in nature. It’s also an attempt at self-­reassurance that the social encounter was not so bad after all but the arguments are not convincing. So treatment of postevent processing involves using the cognitive strategies you learned in Chapter 6 and applying them to postevent thinking. The following is a single intervention with several steps that can counter the negative effects of postevent processing.

Step 1. Identification In the space below, write about one or two past traumatic social experiences that come to mind whenever you think about your social anxiety. These experiences should involve your worst experience of social anxiety. They may be recent, or they could be events that go back several years, even to your childhood or adolescence. These social events are “the worst thing that has ever happened to you” and usually involve some experience of heightened embarrassment, humiliation, or feelings of shame. My most embarrassing social experiences: 1. 2.

Now write down two or three more recent social experiences that you listed under the “negative recall of social events” section of your Social Anxiety Profile (Worksheet 10.6). These may not be your worst experiences, but they are events you’re still thinking about days or weeks later. Recent social events: 1. 2. 3.

For his most “traumatic” social experience, Antonio wrote about giving a speech to his ninth-grade class. He said it was the worst day in his life. He was so terrified

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that he shook uncontrollably and started stuttering. He noticed that some of the students were snickering and the teacher stopped him in the middle of the speech and told him to go back to his seat. When he thinks about his problem with social anxiety, he practically relives that terrible experience. For his most recent social events, Antonio wrote down several experiences at work, such as having lunch with his coworkers and then worrying whether he said something stupid, or having to give a brief to his supervisor and wondering whether he came across as incompetent or poorly prepared. Once you’ve identified the social events you find yourself mulling over long after the events ended, it’s important to deal with these memories in a more constructive manner. Let’s start with your most recent social experiences. The objective is to discover whether you’re exaggerating the negative aspects of the experience and to decatastrophize how you remember the experience so your thinking is more realistic and balanced. Once again we use the evidence gathering, consequences, and alternative thinking strategies in Chapter 6 to correct memories of recent social events. Ask yourself three questions: 1. Did other people really evaluate me as badly as I remember? 2. Were my anxiety and social performance as awful as I remember? 3. Am I exaggerating the significance and long-term impact of the experience (that is, am I exaggerating the negative consequence or outcome)?

Step 2.  Evaluate Your Recall At the heart of social anxiety is the fear that others evaluated you negatively in a social interaction. When you think back on these experiences during the postevent period, is your memory negatively biased? Maybe you’re selectively remembering negative cues and failing to remember more positive information that would be inconsistent with your assumption that “I made a fool of myself.” Or you may be misinterpreting some of the social cues you got from others. It’s easy to misinterpret a facial expression or an isolated comment, especially when you go into a social situation expecting to make a bad impression on others. There are three things to keep in mind when trying to figure out the opinions of others. 1.   P R A I S E I S   E P H E M E R A L

What we think about a person changes from moment to moment. So there is no way to earn a “permanent” or guaranteed positive evaluation from other people. Their evaluation will change from moment to moment depending on their mood state, their circumstances, and other factors.



conquer social anxiety 321

2.  PEOPLE ARE FICKLE

Do you really think it’s possible for everyone in a social situation to judge you positively? If you say, “No, of course not,” then how many people need to hold a positive impression for you to feel good about yourself? Is it really a simple majority, like 51%? Most people with social anxiety have unrealistic beliefs about people’s evaluation. Even if 90% of the people at a social event form a reasonably positive impression of you, those one or two people who have a negative impression will outweigh all the positive evaluations. Are you overly focused on one or two people who hold a negative opinion? Are there many more people in the social situation who may have had a slightly positive or at least a neutral (benign) impression of you?

3 .  T R U E E VA L UAT I O N S A R E H I D D E N

Rarely do we tell people what we really think about them. We might smile, nod, and give someone lots of eye contact so they think we’re interested in them. But to ourselves we might be thinking “What a bore! I wish she would stop talking,” or “How could he be so stupid?” The point is we can never really know what people truly think about us. We don’t go around revealing our true feelings about people. If we did, life would be chaotic and extremely stressful. So we keep our thoughts about other people to ourselves. What this means is that in the end you’ll never really know what a person thinks of you. There is always a big blank about what others truly think of us, and we are all left guessing, filling in the blanks with our preconceived assumptions. The problem in social anxiety is that we always assume that other people think negatively about us.

IN T ER V EN T ION EXER C I S E 

Memory Evaluation

The aim of this exercise is to reevaluate your past social activities to restructure how you remember these experiences. It’s important to focus on specific social experiences that cause you to engage in negative postevent processing. Use the Postevent Negative Evaluation Form (Worksheet 10.11) to work on several social experiences. You’ll need to make multiple copies of the worksheet (see www.guilford.com/clark6-forms to download and print). Â Tips for Success: Avoiding Reassurance Seeking

In deciding what people most likely thought of you in the social situation, you can ask friends who were present for their observations, but you need to be careful that this doesn’t become a form of habitual reassurance seeking.

W ORK SHEE T 10.11

Postevent Negative Evaluation Form Instructions: Begin by recording a recent negative social event in section A. In the first column, list all the evidence that makes you think some people formed a harsh negative opinion of you. In the second column, list the evidence that some people had no clear opinion of you or seemed indifferent. And in the third column, write down evidence of positive comments, interest, or even praise directed toward you. After completing this analysis, write down what you think is the most likely judgment or opinion that other people had of you in the social situation.

A. Recalled negative social experience:

Memory evaluation Evidence of negative judgment of others

Evidence of indifference/ neutrality of others

Evidence of positive view/ comments by others

What I conclude about the opinion of others:



B. Recalled negative social experience:

Memory evaluation Evidence of negative judgment of others

Evidence of indifference/ neutrality of others

Evidence of positive view/ comments by others

What I conclude about the opinion of others:

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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Antonio often rehearsed what he said at department meetings. The last meeting was a week ago, and since then he’s been going over in his mind whether he sounded incompetent when he answered a couple of questions. To stop his postevent rumination, Antonio could do a memory evaluation. Antonio’s example shows what he might have discovered. After looking over the evidence from his postevent evaluation Antonio would conclude that most people probably thought he was competent but quite shy and not a very good public speaker. This was a more realistic, balanced way to think about his past social performance. He would be able to shift from thinking “how I embarrassed myself” to “how I can improve my performance at department meetings in the future.” When our thinking becomes more problem focused, it reduces the tendency to ruminate on the past.

Antonio’s Postevent Negative Evaluation Last week at the department meeting I had to answer a few questions about our new synchronization program. I was so anxious that I can hardly remember what I said. I’m sure everyone at the meeting wondered what was wrong with me.

A. Recalled negative social experience:  

Memory evaluation Evidence of negative judgment of others

Evidence of indifference/ neutrality of others

1.  Susan looked puzzled by my 1.  A couple of people were paying no attention at the answer. meeting. They were texting 2.  Jaron asked a question and the whole time. then followed up with another 2.  I only had a couple of question. Clearly I didn’t questions from two people. answer his first question. The rest just accepted what 3.  Our manager, who chaired I said. I couldn’t tell if they the meeting, cut me off once cared what I said. when I was answering a question.

Evidence of positive view/ comments by others

1.  I noticed that Sharon took some notes when I did a review of my work progress. 2.  After the meeting, Theresa said she was interested in what I was doing and wondered if I could help her with a software problem. 3.  After the meeting, our manager assigned me an even more difficult software project.

What I conclude about the opinion of others:   No doubt everyone knew I was anxious, but it was clear a few

people at the meeting were paying no attention to me. A few were paying attention to my answers. They asked questions and took notes. My manager obviously thought I was competent, because she gave me an even harder assignment. Out of the 12 people at the meeting, maybe two were quite critical of my answers. These are the same people who consistently treat me poorly, so they probably don’t like me or respect me.

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Step 3.  Decatastrophize the Consequence A predominant theme in postevent processing is thinking over and over about the consequences of your actions. You’ve already done some work on your memory of what happened, but you can take this one step further by using the decatastrophizing strategy explained in Chapter 8. In this case you focus on decatastrophizing what you think are the immediate and long-term consequences of your perceived “poor performance” in a past social interaction. Start by writing out the catastrophe you’ve been thinking about during the post­ event period. No doubt the catastrophic possibility that bothers you most involves some level of shame or embarrassment felt in the social situation. This will be the postevent catastrophic scenario you’ve been thinking about for days after the social experience.

IN T ER V EN T ION EXER C I S E 

The True Cost of Embarrassment

Once you’ve identified what you think was “catastrophic embarrassment,” it’s time to determine whether you’re exaggerating its significance. Is it possible you’re overthinking the immediate and long-term impact of your embarrassment on yourself and others? If you are ruminating on a past social interaction, you may be convinced you’ve done irreparable damage to your impression on others because of your embarrassing behavior. But is that true? Take time to think deeply and more practically about the effects of the embarrassing experience. The Cost of Embarrassment Form (Worksheet 10.12) can be used to record your evaluation of the realistic consequences of your embarrassing performance. Â Tips for Success: Questioning Your Embarrassment

In the moment embarrassment can be painfully uncomfortable. But the intensity of that momentary distress can be misleading. It causes a bias in our thinking so we assume the embarrassment must have a devastating consequence. But the effects of embarrassment most often fade quickly. Ask yourself the following questions as you reevaluate a past embarrassing experience. We’ll assume that many people at the social event noticed you and thought you were inappropriate, incompetent, or defective in some way. „ How has this negative opinion changed my life? „ Do my work colleagues, friends, or family now treat me differently? „ Is their negative opinion of me permanent? Am I thinking that, whatever I do for

years to come, this one embarrassing event will override everything? „ Do I think people’s negative evaluation changes from one day to the next?

W ORK SHEE T 10.12

Cost of Embarrassment Form Instructions: Briefly describe an experience of significant and memorable embarrassment in the space provided. Next use the columns to list all the short- and long-term consequences you’ve experienced because of the embarrassing experience. Use the left column to write about the immediate effects of the embarrassment and the right column to record long-term, more permanent changes caused by the embarrassing experience. After completing this analysis, use the space provided to compose a more realistic perspective on the personal, long-term significance of the embarrassing experience. State the “catastrophic embarrassment” you ruminate about during the postevent period:

Immediate costs/consequences

Long-term costs/consequences

1.

1.

2.

2.

3.

3.

4.

4.

5.

5.

6.

6.

After considering the consequences, what’s the most likely effect of your embarrassing experience on self and others? From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

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„ What’s the effect of time on embarrassment? Most people will forget about it except

the person who feels embarrassed. „ How important is the social event in terms of reaching my life goals and aspirations?

Most of our daily social interactions are quite trivial and mundane when viewed from the broader perspective of life purpose and meaning. „ Might some people have a different reaction to witnessing my embarrassment? For

example, some might feel empathy and understanding when they see someone feel embarrassed because they know what that feels like. Is it possible that a few people made a harsh judgment of you but others might see it differently?

Were you able to arrive at a more realistic appraisal of the consequences of your embarrassing experience? If you are struggling to shift from “catastrophic” remembering of the embarrassment to more “realistic” thinking of your performance, reconsider the probing questions listed in the Tips for Success section. They’re designed to help you reevaluate the significance of what you think is an embarrassing performance at a social event. Taking time to question and evaluate your interpretation of embarrassment is a good way to recalibrate the importance of a social event and see it for what it is: just one of many interpersonal interactions we have during normal daily living.

Step 4.  Generate an Alternative Now that you’ve evaluated the past social situation and decided that you have been thinking the worst about the situation, it’s time to come up with a more realistic account of the social encounter. What is the best, most realistic way to look back on your social experience? Focus on: „ Developing

a new understanding of the social experience

„ Learning

from the social interaction so you can act and think differently when you encounter similar social events in the future

When generating an alternative perspective, it’s important to focus on the facts, what happened based on the evidence rather than on how you feel. You may feel anxious or embarrassed about the situation, but stick to what actually happened when developing your new perspective. Review the work you did in Step 2 (Evaluate Your Recall) and Step 3 (Decatastrophize the Consequence) to reevaluate how others reacted to you and how you behaved in the social encounter. When thinking back on



conquer social anxiety 327

the experience, are you exaggerating its significance and influence on your life? Based on these observations, generate an alternative account of the past social experience. IN T ER V EN T ION EXER C I S E 

Create a New Postevent Perspective

Use Worksheet 10.13 to integrate the work you’ve done in this section on postevent processing. Start by briefly stating the social experience you’ve been thinking about during the postevent period. Then fill out the rest of the worksheet. Make multiple copies so you can use the worksheet with several social encounters (see www.guilford.com/clark6-forms to download and print). Â Troubleshooting Tips: Runaway Rumination

Sometimes we can be so embarrassed about a social experience that we ruminate about what happened almost constantly throughout the day. If this is happening to you, don’t try to suppress or control your anxiety. Let it ebb and flow naturally as you go about your daily tasks. Jot down the things about the social event that you are recalling and then plan to have a special 30- to 45-minute worry session at home in the evening. Take out the things you recorded through the day and work on them using the Worry Exposure Form (Worksheet 8.11) in Chapter 8. Once the emotion associated with the rumination has faded, resume your work on evaluating the consequences of your embarrassed experience and generating an alternative perspective.

To stop postevent processing from fueling your social anxiety, you must be able to decatastrophize the past and put it in perspective. Generating a new understanding about your perceived social failures and embarrassment is a critical part of this process. Once the alternative perspectives have been developed, you can practice replacing the anxious memory of past events with the alternative, more balanced explanation. This will defuse the anxiety and renew your confidence for facing future social events. It’s an effective way to diminish the postevent ruminative thinking. If you are wondering if your alternative explanation can be effective in reducing social anxiety, have a look at Antonio’s example. Congratulations! You’ve made it to the end of our CBT intervention for social anxiety. It’s time to review the work you’ve done in this chapter. Did you find one of the three components of social anxiety more relevant than the others? If so, you might want to spend a little more time on the anticipatory, social encounter, or postevent processing stage. It’s also time to revisit My Social Change Goals (Worksheet 10.2), considering the work you’ve done on reducing your social anxiety. Your recovery from social anxiety will be greater if you also see these interventions from a CT-R

W ORK SHEE T 10.13

A Realistic Reevaluation of My Past Social Performance Instructions: First briefly describe the specific social encounter that you’ve been thinking about for the past several days or weeks and then state how you think you embarrassed yourself in that situation. Use the third item to record a different, more realistic, and balanced perspective on your performance in that situation. Finally, list three or four things you’ve learned from this experience that you can apply to future experiences of distressing postevent recall. 1. Past social experience recalled during postevent thinking:



2. The “catastrophic” embarrassment/social failure:





3. Alternative, more realistic understanding of your social performance:







4. What you learned from this social experience: a. b. c.

From The Anxiety and Worry Workbook, Second Edition, by David A. Clark and Aaron T. Beck. Copyright © 2023 The Guilford Press. Purchasers of this book can photocopy and/or download additional copies of this worksheet at www.guilford.com/clark6-forms for personal use or use with clients; see copyright page for details.

328



conquer social anxiety 329

Antonio’s Realistic Reevaluation of His Past Social Performance 1. Past social experience recalled during postevent thinking:   I keep thinking about last week’s meeting with

my supervisor and worry about my performance and his opinion of me. 2. The “catastrophic” embarrassment/social failure:   I had a difficult time articulating myself; I know he

noticed I was blushing, that my hands were trembling, and that I couldn’t express myself clearly. He probably is wondering what’s wrong with me, why I was so nervous. He asked several questions, which means I wasn’t making sense. I’m so embarrassed; he’s probably wondering whether I’m competent enough to do this job. 3. Alternative, more realistic understanding of your social performance:   He probably realized I was nervous,

but he already knows I’m shy and anxious. He still gives me work to do and frequently asks for my advice. There is plenty of evidence from the nature of his questions that he understood what I was telling him. Since our meeting his behavior toward me has not changed, and he still gives me work and asks my opinion. So obviously he doesn’t think I’m incompetent. He can still think I’m competent and even gifted, and possibly even a nice person, but that I have a problem with anxiety. It’s likely that he accepts my anxiety better than I do. 4. What you learned from this social experience: a.   I can expect to be anxious in social situations; I should accept the anxiety, work with it rather than try

to conceal it from others or suppress it. b.   I need to slow down when I talk; I try to rush when I’m anxious because I want to get it over with; this only makes matters worse and harder for people to follow what I am saying. c.   Next time, I can ask my manager in advance the purpose of the meeting; then I can write down a few key points that I can refer to during the meeting.

perspective. Can you see how the work you’ve done in this chapter can also enrich your social relationships and help you achieve the social change goals you listed in Worksheet 10.2?

Conclusion Social anxiety is one of the most common anxiety problems, often starting in childhood and continuing for decades. It can have a debilitating effect on quality of life and cause considerable personal distress. In this chapter we presented the CBT model

330

The Anxie t y and Worry Workbook

of social anxiety, which emphasizes three components: anticipatory period, the social encounter, and postevent processing. Numerous interventions were described that modify the crippling fear of negative evaluation by others and help change unproductive social performance and coping responses that perpetuate a sense of vulnerability and avoidance. But you don’t have to settle for just reducing social anxiety. CBT can also bolster and enrich social relationships, one of the cornerstones to personal resilience and emotional well-being.

resources Associations Various professional mental health associations have websites that provide useful information on the latest research and treatment of anxiety for the general public. A few of these sites also provide information on how to locate a competently trained cognitive behavior therapist in your region.

United States Anxiety and Depression Association of America Website: www.adaa.org Association for Behavioral and Cognitive Therapies (ABCT) Website: www.abct.org Academy of Cognitive and Behavioral Therapies (ACBT) Website: www.academyofct.org Beck Institute Website: www.beckinstitute.org

Canada Canadian Association of Cognitive and Behavioural Therapies (CACBT) Website: www.cacbt.ca Canadian Psychological Association Website: www.cpa.ca

United Kingdom British Association for Behavioural and Cognitive Therapies Website: www.babcp.com British Psychological Society Website: www.bps.org.uk 331

332 resources

Australia Australian Association for Cognitive and Behaviour Therapy Website: www.aacbt.org

European and Global European Association for Behavioural and Cognitive Therapies (EABCT) Website: www.eabct.eu World Confederation of Cognitive and Behavioural Therapies (WCCBT) Website: www.wccbt.org

New Zealand Aotearoa New Zealand Association for Cognitive Behavioural Therapies (AnzaCBT) Website: www.cbt.org.nz

Internet Resources Anxiety Canada Website: www.anxietycanada.com Anxiety and Depression Association of America Website: www.adaa.org International OCD Foundation Website: www.iocdf.org National Alliance on Mental Illness Website: www.nami.org National Center for PTSD Website: www.ptsd.va.gov National Institute for Health and Care Excellence Website: www.nice.org.uk NIMH Anxiety Disorders Website: www.nimh.nih.gov/health/topics/anxiety-­disorders Social Anxiety Association Website: www.socialphobia.org

resources 333

Recommended Reading The following are self-help books that offer various types of cognitively oriented treatments for anxiety and its disorders. These resources vary in their emphasis on cognitive and behavioral strategies for reducing anxiety. Some include alternative strategies for reducing anxiety such as meditation, mindfulness training, and acceptance/commitment approaches. We also include resources on depression.

Anxiety Disorders (General) Bourne, E. J. (2020). The anxiety and phobia workbook (7th ed.). Oakland, CA: New Harbinger. Bourne, E. J., & Garano, L. (2016). Coping with anxiety: 10 simple ways to relieve anxiety, fear and worry (2nd ed., rev.). Oakland, CA: New Harbinger. Butler, G., & Hope, T. (2007). Managing your mind: The mental fitness guide. Oxford, UK: Oxford University Press. Clark, D. A. (2018). The anxious thoughts workbook: Skills to overcome the unwanted intrusive thoughts that drive anxiety, obsessions and depression. Oakland, CA: New Harbinger. Clark, D. A. (2020). The negative thoughts workbook: CBT skills to overcome repetitive worry, shame, and rumination that drive anxiety and depression. Oakland, CA: New Harbinger. Clark, D. A. (2022). The anxious thoughts workbook for teens: CBT skills to quiet the unwanted negative thoughts that cause anxiety and worry. Oakland, CA: New Harbinger. Forsyth, J. P., & Eifert, G. H. (2016). The mindfulness and acceptance workbook for anxiety: A guide to breaking free from anxiety, phobias and worry using acceptance and commitment therapy. Oakland, CA: New Harbinger. Greenberger, D., & Padesky, C. A. (2015). Mind over mood: Change how you feel by changing the way you think (2nd ed.). New York: Guilford Press. Hofmann, S. G. (2020). The anxiety skills workbook: Simple CBT and mindfulness strategies for overcoming anxiety, fear, and worry. Oakland, CA: New Harbinger. Knaus, W. J. (2014). The cognitive behavioral workbook for anxiety: A step-by-step program (2nd ed.). Oakland, CA: New Harbinger. Leahy, R. L. (2009). Free anxiety: Unravel your fears before they unravel you. Carlsbad, CA: Hays House. Leahy, R. L. (2020). Don’t believe everything you feel: A CBT workbook to identify your emotional schemas and find freedom from anxiety and depression. Oakland, CA: New Harbinger. McKay, M., Davis, M., & Fanning, P. (2021). Thoughts and feelings: Taking control of your mood and your life (5th ed.). Oakland, CA: New Harbinger. Norton, P. J., & Antony, M. M. (2021). The anti-­anxiety program: A workbook of proven strategies to overcome worry, panic, and phobias (2nd ed.). New York: Guilford Press. Schab, L. M. (2021). The anxiety workbook for teens: Activities to help you deal with anxiety and worry (2nd ed.). Oakland, CA: New Harbinger. Tirch, D.  D. (2012). Overcoming anxiety: Using compassion-­focused therapy to calm worry, panic, and fear. Oakland, CA: New Harbinger. Watt, M. C., & Stewart, S. H. (2009). Overcoming fear of fear: How to reduce anxiety sensitivity. Oakland, CA: New Harbinger. Winston, S. M., & Seif, M. N. (2017). Overcoming unwanted intrusive thoughts: A CBT-based

334 resources

guide to getting over frightening, obsessive, or disturbing thoughts. Oakland, CA: New Harbinger. Winston, S. M., & Seif, M. N. (2022). Overcoming anticipatory anxiety: A CBT guide for moving past chronic indecisiveness, avoidance, and catastrophic thinking. Oakland, CA: New Harbinger.

Panic Disorder Antony, M. M., & McCabe, R. E. (2004). 10 simple solutions to panic: How to overcome panic attacks, calm physical symptoms, and reclaim your life. Oakland, CA: New Harbinger. Barlow, D. H., & Craske, M. G. (2007). Mastery of your anxiety and panic (4th ed.). New York: Oxford University Press. McKay, M., & Zuercher-White, E. (1999). Overcoming panic disorder and agoraphobia—client manual. Oakland, CA: New Harbinger.

Social Anxiety Disorder Antony, M. M., & Swinson, R. P. (2017). The shyness and social anxiety workbook: Proven, step-by-step techniques for overcoming your fear (3rd ed.). Oakland, CA: New Harbinger. Bulter, G. (2021). Overcoming social anxiety and shyness: A self-help guide using cognitive behavioural techniques (2nd ed.). London: Constable & Robinson. Hope, D.  A., Heimberg, R.  G., & Turk, C.  L. (2010). Managing social anxiety workbook: A cognitive-­behavioral therapy approach (2nd ed.). Oxford, UK: Oxford University Press. Stein, M. B., & Walker, J. R. (2002) Triumph over shyness: Conquering shyness and social anxiety. New York: McGraw-Hill.

Generalized Anxiety Disorder and Worry Leahy, R. L. (2005). The worry cure: Seven steps to stop worry from stopping you. New York: Harmony Books. Meares, K., & Freeston, M. (2008). Overcoming worry: A self-help guide using cognitive behavioural techniques. London: Constable & Robinson. Orsillo, S. M., & Roemer, L. (2016). Worry less, live more: The mindful way through anxiety workbook. New York: Guilford Press. Robichaud, M., & Buhr, K. (2018). The worry workbook: CBT skills to overcome worry and anxiety by facing the fear of uncertainty. Oakland, CA: New Harbinger. Robichaud, M., & Dugas, M.  J. (2015). The generalized anxiety disorder workbook: A comprehensive CBT guide for coping with uncertainty, worry, and fear. Oakland, CA: New Harbinger. Rygh, J. L., & Sanderson, W. C. (2004). Treating generalized anxiety disorder: Evidence-based strategies, tools, and techniques. New York: Guilford Press. Seif, M. N., & Winston, S. M. (2019). Needing to know for sure: A CBT-based guide to overcoming compulsive checking and reassurance seeking. Oakland, CA: New Harbinger.

resources 335

Depression Addis, M.  E., & Martell, C.  R. (2004). Overcoming depression one step at a time: The new behavioral activation approach to getting your life back. Oakland, CA: New Harbinger. Bieling, P. J., & Antony, M. M. (2003). Ending the depression cycle. Oakland, CA: New Harbinger. Leahy, R. L. (2010). Beat the blues before they beat you: How to overcome depression. Carlsbad, CA: Hays House. Teasdale, J., Williams, M., & Segal, Z. (2014). The mindful way workbook: An 8-week program to free yourself from depression and emotional distress. New York: Guilford Press. Wright, J. H., & McCray, L. W. (2012). Breaking free from depression: Pathways to wellness. New York: Guilford Press.

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index

Note. f or t following a page number indicates a figure or table. Accountability, 104 Action planning, 223–225 Adaptive mode. See also Strengths acts of courage and, 143 establishing an exposure plan and, 168–169 My Acts of Courage (Worksheet 7.1), 144 My Adaptive Anxiety Profile (Worksheet 3.5), 57–58 overview, 11, 52–59 Adaptive responses helpful worry and, 186–187 overview, 11, 50–52 When My Anxiety Was Helpful (Worksheet 3.4), 51 Aerobic exercise. See Exercise, physical Agoraphobic avoidance, 242. See also Avoidance All-or-nothing thinking, 122t, 311–312. See also Thinking errors Alternative perspectives technique decatastrophizing intervention and, 227–228 discovering the alternative technique 135–140 My Alternative Perspective Form (Worksheet 6.7), 137, 139 My Behavioral Experiment (Worksheet 7.11), 178, 179 overview, 135–140 A Realistic Reevaluation of My Past Social Performance (Worksheet 10.13), 328, 329 social anxiety and, 326–329 worry and, 227–228 Anticipatory anxiety. See also Anticipatory phase of social anxiety; Threat prediction Anticipatory Social Anxiety Form (Worksheet 10.4), 293 coping cognitions and, 165–167 exposure techniques and, 163

interventions for social anxiety with, 298, 302–306 modifying social expectations and, 298, 302–304 My Exposure Hierarchy (Worksheet 7.8), 164, 175 My Social Anxiety Profile (Worksheet 10.6), 299–300, 301–302 overview, 10 realistic expectations intervention and, 304–305 self-instructional training intervention, 305–306 social anxiety and, 277, 278f, 279, 292–294 Social Expectations Form (Worksheet 10.7), 303 Anticipatory phase of social anxiety. See also Anticipatory anxiety My Social Anxiety Profile (Worksheet 10.6), 299–300, 301–302 overview, 277, 278f, 279 Social Expectations Form (Worksheet 10.7), 303 Antipanic Flashcard, 262–263 Anxiety. See also Anxiety sensitivity; Helpful anxiety; Normal anxiety; Panic attacks; Problematic anxiety; Social anxiety; Worry compared to fear, 36–38 effectiveness of CBT with, 10–11 levels of, 2–3, 2f mental fitness and, 19 mild anxiety, 2f, 3–5, 4f moderate anxiety, 2f, 24 My Social Anxiety Log (Worksheet 10.3), 290 overview, x, 1–3, 2f prevalence of, ix, 9

341

342 index Anxiety (continued) resources regarding, 333–334 severe anxiety, 2f, 5–9 Anxiety attacks, 241. See also Panic attacks Anxiety sensitivity. See also Anxiety; Anxiety threshold and tolerance; Symptoms of anxiety assessing, 96, 97 context and consequence in, 90–95 Discovering the Importance of Context (Worksheet 5.2), 91 My Anxiety Sensitivity Beliefs (Worksheet 5.4), 97 My Symptom Tolerance Scale (Worksheet 5.1), 89 overview, x, 87–90 pacing of work through this CBT program and, 20–21 physical exercise and, 103–104, 105 Symptom-Consequence Match-Up (Worksheet 5.3), 93, 95 Weekly Exercise Log (Worksheet 5.7), 105 Anxiety Symptom Profile mind mapping and, 125 My Anxiety Symptom Profile (Worksheet 4.6), 79–80, 82 overview, 77, 79–82 Anxiety threshold and tolerance. See also Anxiety sensitivity confronting fear of anxiety symptoms and, 100–103 context and consequence in anxiety sensitivity and, 90–95 Discovering the Importance of Context (Worksheet 5.2), 91 examples illustrating, 85–87 Focused Attention Symptom Diary (Worksheet 5.6), 102 My Symptom Provocation Record (Worksheet 5.8), 109 My Symptom Tolerance Scale (Worksheet 5.1), 89 Nonthreatening Symptom Diary (Worksheet 5.5), 99 overview, 84–85, 85f physical exercise and, 103–104, 105 strengthening, 96, 98–108 symptom provocation and, 104, 106–108, 107t Symptom-Consequence Match-Up (Worksheet 5.3), 93, 95 Weekly Exercise Log (Worksheet 5.7), 105 Arousal, physical. See Physical symptoms of anxiety Assignments. See Exercise overviews Automatic thoughts, 23, 249–251, 250t. See also Thoughts

Aversive associative learning, 180–181, 182 Avoidance. See also Escape; Ineffective coping; Self-protection Behavior Change List (Worksheet 7.6), 158–159, 160 creation of problematic anxiety and, 64 Discovering My Avoidance Profile (Worksheet 7.5), 156 intolerance of anxiety and, 146, 148–150 My Panic Avoidance and Safety-Seeking Record (Worksheet 9.1), 253 My Safety-Seeking Response Form (Worksheet 7.4), 153 overview, 10, 11–12, 152, 154–157, 184 panic and panic attacks and, 243, 246–247, 248f, 252–253 panic exposure techniques and, 267–268 Panic Profile (Worksheet 9.4), 259, 260 panic response removal intervention and, 269 problematic anxiety and, 73t social anxiety and, 275, 294–296 worry and, 208

B Beck, Aaron T., vii, 1, 10 Behavioral experiment, 176–180. See also Exposure techniques Behavioral rehearsal, 316, 317–318 Behaviors. See also Ineffective coping; Selfmonitoring acts of courage, 142–144 awareness of symptoms during low threat situations, 98–100 Behavior Change List (Worksheet 7.6), 158–159, 160 behavioral experiments and, 176–180 creation of problematic anxiety and, 70–72 Discovering My Avoidance Profile (Worksheet 7.5), 156 expectancy exposure and, 180–181, 182 exposure techniques and, 159, 160–181 healthy coping strategies, 181, 183 identifying behaviors to change, 157–159, 160 Ineffective Coping Checklist (Worksheet 4.3), 71 My Acts of Courage (Worksheet 7.1), 144 My Anxiety Symptom Profile (Worksheet 4.6), 79–80, 82 My Behavioral Experiment (Worksheet 7.11), 178, 179 My Expectancy Exposure Form (Worksheet 7.12), 182 My Recovery-Oriented Exposure Plan (Worksheet 7.9), 170, 171

index 343 My Safety-Seeking Response Form (Worksheet 7.4), 153 My Self-Protective Response (Worksheet 7.2), 147 My Symptom Self-Monitoring Form (Worksheet 4.5), 76, 78 overview, 10, 10f, 184 problematic anxiety and, 73t self-protection and, 145–159, 145f strengths and, 53, 58–59 worry and, 213 Belief activation, 200f, 201–202. See also Beliefs Beliefs. See also Challenging unhelpful beliefs or thoughts; Cognitive processes; Thoughts awareness of symptoms during low threat situations, 98–100 awareness of thinking errors and, 133–135 Beliefs about Anxiety Scale (Worksheet 7.3), 149–150 brainstorming and, 221–222 doubts regarding the effectiveness of CBT exercises and, 26–29 exposure techniques and, 161–163 intolerance of anxiety and, 146, 148–150 keeping anxiety in the normal range and, 44–45, 45f My Anxiety Sensitivity Beliefs (Worksheet 5.4), 97 My Behavioral Experiment (Worksheet 7.11), 178, 179 My Cognitive Characteristics of Harmful Worry (Worksheet 8.4), 196–199 Negative Beliefs about Exposure (Worksheet 7.7), 162 problem-solving approach to worry and, 221–222 social anxiety and, 279–284, 280t worry and, 195t, 199–208, 200f, 213 Worry Beliefs Checklist (Worksheet 8.5), 202 Worry Profile (Worksheet 8.8), 212, 214 Bodily feelings of anxiety. See Physical symptoms of anxiety Brainstorming, 221–222, 224 Breathing establishing an exposure plan and, 168 as a health coping strategy, 183 panic induction intervention and, 265–267 Butterflies in the stomach, 52. See also Mild anxiety

C Catastrophic misinterpretations. See also Catastrophic thinking Antipanic Symptom Interpretation Record (Worksheet 9.5), 261 My Weekly Panic Log (Worksheet 9.3), 257

panic and, 249–251, 250t, 269–270 Panic Profile (Worksheet 9.4), 259, 260 panic reappraisal technique and, 258, 261–263 Catastrophic thinking. See also Catastrophic misinterpretations; Thinking errors Antipanic Symptom Interpretation Record (Worksheet 9.5), 261 cost–benefit analysis and, 129, 131–133 decatastrophizing intervention and, 225–228 directed worry exposure intervention and, 228–231 examples of, 116t My Cost–Benefit Form (Worksheet 6.6), 132, 133 My Threat Estimations (Worksheet 6.2), 117 overview, 114–116, 116t, 122t panic and, 245–246, 247, 249–251, 250t panic reappraisal technique and, 258, 261–263 problematic anxiety and, 73t Prosocial Cognitive Skills Form (Worksheet 10.9), 313–314 social anxiety and, 324–326 worry and, 195t, 200f, 203, 213, 225–231 Worry Profile (Worksheet 8.8), 212, 214 Challenging unhelpful beliefs or thoughts, 26–29. See also Beliefs; Thoughts Checking behaviors, 213 Childhood experiences, 23 Cognitive behavior therapy (CBT). See also Exercise overviews; Practice doubts regarding the effectiveness of, 25–33 effectiveness of, 10–11 overview, 1, 10–11, 10f, 22–25 panic and, 247–253, 248f, 250t practice and, 25 social anxiety and, 276–285, 278f, 280t using this workbook, 12–15, 13t–14t worry and, 199–208, 200f Cognitive errors. See Thinking errors Concealment of anxiety, 282–283 Confronting fears of anxiety symptoms, 100–103 Consequences of anxious thinking, 90–95. See also Cost–benefit analysis; Physical symptoms of anxiety; Social concerns; Thoughts Context, 90–95 Control acceptance in place of, 21 Control Pie Chart (Worksheet 8.10), 218, 219 creation of problematic anxiety and, 66 evaluating how much control you have, 217–220 feeling helpless and, 118–120 My Cognitive Characteristics of Harmful Worry (Worksheet 8.4), 196–199 panic response removal intervention and, 268–269 worry and, 195t, 217–220, 224

344 index Controlled breathing establishing an exposure plan and, 168 as a health coping strategy, 183 panic induction intervention and, 265–267 Coping cognition narrative, 165–167, 173 Coping response. See also Behaviors; Ineffective coping; Self-protection building tolerance of uncertainty and, 235–236 creation of problematic anxiety and, 70–72 detached worry intervention, 237–239 establishing an exposure plan and, 168–169, 170, 171 feeling helpless and, 118–120 healthy coping strategies, 181, 183 Ineffective Coping Checklist (Worksheet 4.3), 71 keeping anxiety in the normal range and, 45f, 46–47 My Anxiety Symptom Profile (Worksheet 4.6), 79–80, 82 My Helplessness Thinking Record (Worksheet 6.3), 120 My Mild Anxiety Log (Worksheet 3.3), 48–49 My Panic Avoidance and Safety-Seeking Record (Worksheet 9.1), 253 My Recovery-Oriented Exposure Plan (Worksheet 7.9), 170, 171 My Self-Protective Response (Worksheet 7.2), 147 My Tolerance Fitness Form (Worksheet 8.13), 236 overview, 140, 184 panic and panic attacks and, 243, 246–247 problematic anxiety and, 73t regulating anxiety and, 59–60, 59f social anxiety and, 294–296 Correct unrealistic expectations intervention, 310–311 Cost–benefit analysis, 129, 131–133, 140 Courage acts of, 142–144 exposure techniques and, 160–161 My Acts of Courage (Worksheet 7.1), 144 overview, 141–142 COVID-19 pandemic, ix, 114–115

D Danger. See also Threat interpretation; Vulnerability thoughts creation of problematic anxiety and, 66–70 examining specific dangers that make you anxious, 112–125, 116t, 122t, 123f My Self-Protective Response (Worksheet 7.2), 147

self-protective mode and, 145, 145f thinking errors and, 120–121, 122t Decatastrophizing strategy decatastrophizing intervention and, 225–228 A Realistic Reevaluation of My Past Social Performance (Worksheet 10.13), 328, 329 social anxiety and, 324–326, 327 Depression, resources regarding, 335 Desensitization, 161. See also Exposure techniques Detached observation, 101–103 Detached worry technique, 237–239, 263–265. See also Worry Directed worry exposure intervention, 228–231 Discomfort with novelty, 148, 149–150 Distorted thinking. See Thinking errors; Thoughts Doubts about this program, 26–29, 32

E Embarrassment, fear of. See also Social anxiety Cost of Embarrassment Form (Worksheet 10.12), 325 decatastrophizing intervention and, 324–326 overview, x, 273–274 practice and, 31 social anxiety and, 281–282, 283–284 Emotional health, 20. See also Mental fitness/ health Emotional reasoning, 122t, 208. See also Thinking errors Emotions, 23 Escape. See also Avoidance; Ineffective coping; Self-protection Behavior Change List (Worksheet 7.6), 158–159, 160 Discovering My Avoidance Profile (Worksheet 7.5), 156 My Panic Avoidance and Safety-Seeking Record (Worksheet 9.1), 253 My Safety-Seeking Response Form (Worksheet 7.4), 153 overview, 10, 152, 154–157, 184 panic and panic attacks and, 243, 248f, 252–253 panic response removal intervention and, 269 problematic anxiety and, 64, 73t social anxiety and, 275, 283–284 Evaluation, negative, 275, 279–281, 280t Evidence gathering technique My Behavioral Experiment (Worksheet 7.11), 178, 179 My Evidence-Gathering Form (Worksheet 6.5), 128, 130 overview, 125–129, 140

index 345 Exaggeration of threat. See Threat interpretation Examining the evidence technique. See Evidence gathering technique Exercise, physical establishing an exposure plan and, 168 as a health coping strategy, 183 My Anxiety-Reduction Goals (Worksheet 1.3), 17 overview, 19–20, 103–104, 105 Weekly Exercise Log (Worksheet 5.7), 105 Exercise overviews. See also Practice; Using this workbook modifying, 33 My Beliefs about Practice Assignments (Worksheet 2.1), 27–28 overview, 21–22 Seven Characteristics of Effective Assignments (Worksheet 2.2), 32 Expectancy exposure, 180–181, 182. See also Exposure techniques Expectations correcting unrealistic expectations intervention, 310–311 expectancy violation, 180–181, 182 modifying social expectations and, 298, 302–304 realistic expectations intervention and, 304–305 regarding working through anxiety, 20 social anxiety and, 276, 298, 302–305 Social Expectations Form (Worksheet 10.7), 303 worry and, 224 Exposure hierarchy. See also Exposure techniques establishing an exposure plan and, 169, 173 My Expectancy Exposure Form (Worksheet 7.12), 182 My Exposure Hierarchy (Worksheet 7.8), 164, 175 overview, 163–165 panic and panic attacks and, 268 social anxiety and, 292, 307 Exposure techniques behavioral experiments and, 176–180 coping cognitions and, 165–167 directed worry exposure intervention and, 228–231 doing exposure tasks, 169, 172–176 enhancing the effectiveness of, 176–181 expectancy exposure and, 180–181, 182 exposure hierarchy and, 163–165 exposure plan and, 168–169, 170, 171 My Behavioral Experiment (Worksheet 7.11), 178, 179 My Expectancy Exposure Form (Worksheet 7.12), 182

My Exposure Hierarchy (Worksheet 7.8), 164, 175 My Exposure Practice Form (Worksheet 7.10), 174 My Recovery-Oriented Exposure Plan (Worksheet 7.9), 170, 171 My Symptom Provocation Record (Worksheet 5.8), 109 Negative Beliefs about Exposure (Worksheet 7.7), 162 overview, 159, 160–176, 184 panic and panic attacks and, 267–268, 269 panic induction intervention and, 265–267 panic reappraisal technique and, 263–265 panic response removal intervention and, 268–269 Prosocial Cognitive Skills Form (Worksheet 10.9), 313–314 readiness for, 161–163 social anxiety and, 307–318 symptom provocation as, 104, 106–108, 107t Worry Exposure Form (Worksheet 8.11), 231 worry postponement technique and, 231–232

F Failed problem-solving. See Problem-solving Failure to correct, 249–251, 250t Fear. See also Panic, fear of anxiety sensitivity and, 88, 92–94, 100–103 compared to anxiety, 36–38 Focused Attention Symptom Diary (Worksheet 5.6), 102 making anxiety helpful and, 50–52 My Symptom Provocation Record (Worksheet 5.8), 109 symptom provocation and, 104, 106–108, 107t Fight-or-flight response, 152. See also Avoidance; Escape Fitness. See Exercise, physical; Mental fitness/ health Focusing on symptoms, 100–103. See also Symptoms of anxiety Friendships awareness of thinking errors and, 134 My Anxiety-Reduction Goals (Worksheet 1.3), 16 physical exercise and, 104 Future, goals for. See Goals for the future

G Gathering the evidence technique. See Evidence gathering technique Generalized anxiety disorder (GAD), 185, 333–334

346 index Generating alternatives technique. See Alternative perspectives technique Goals for anxiety-reduction. See Exercise overviews My Anxiety-Reduction Goals (Worksheet 1.3), 16–17 My Social Change Goals (Worksheet 10.2), 289 overview, 15–18 social anxiety and, 287–288 Stating Your Workbook Goals exercise, 15 Goals for the future. See Exercise overviews keeping anxiety in the normal range and, 45 My Social Change Goals (Worksheet 10.2), 289 physical exercise and, 104 social anxiety and, 287–288

H Harmful worry. See also Worry building tolerance of uncertainty and, 232– 237 CBT model of worry, 199–208, 200f Control Pie Chart (Worksheet 8.10), 218, 219 detached worry intervention, 237–239 determining if your worry is harmful or helpful, 189–193, 190t, 194 Harmful/Helpful Worry Quiz (Worksheet 8.2), 192 My Cognitive Characteristics of Harmful Worry (Worksheet 8.4), 196–199 My Daily Uncertainty Record (Worksheet 8.12), 234 My Tolerance Fitness Form (Worksheet 8.13), 236 My Worry across Life Domains (Worksheet 8.3), 194 overview, 187–188, 239 Type of Worry Checklist (Worksheet 8.9), 216 what makes worry harmful, 193, 195–199, 195t Worry Beliefs Checklist (Worksheet 8.5), 202 worry postponement technique and, 231–232 Worry Profile (Worksheet 8.8), 212, 214 Health anxiety, 17, 181, 183, 254 Helpful anxiety. See also Anxiety; Helpful worry; Strengths comparing fear to anxiety, 36–38 overview, 34–36, 50–52 physical symptoms of anxiety and, 46 When My Anxiety Was Helpful (Worksheet 3.4), 51 Helpful mental strategies intervention, 311–315

Helpful worry. See also Helpful anxiety; Worry determining if your worry is harmful or helpful, 189–193, 190t, 194 Harmful/Helpful Worry Quiz (Worksheet 8.2), 192 My Worry across Life Domains (Worksheet 8.3), 194 overview, 186–187, 239 Worry Profile (Worksheet 8.8), 212, 214 Helpless. See also Threat interpretation creation of problematic anxiety and, 66 mind mapping and, 121, 123–125, 123f My Anxious Mind Map (Worksheet 6.4), 124, 126 My Helplessness Thinking Record (Worksheet 6.3), 120 My Self-Protective Response (Worksheet 7.2), 147 overview, 118–120, 140 self-protective mode and, 145–159, 145f Hierarchy, exposure. See Exposure hierarchy; Exposure techniques Homework. See Exercise overviews; Practice doubts regarding the effectiveness of, 25–33 Hypersensitivity to symptoms, 244 Hyperventilation, 265–267 Hypervigilance, 247–249, 248f

I Identifying cognitive errors technique, 133–135, 140 Imagery, 168, 237–239 Imaginal exposure, 263–265. See also Exposure techniques Imaginative worry, 213, 215–216. See also Worry Inducing panic intervention, 265–267, 269 Ineffective coping. See also Avoidance; Behaviors; Coping response; Escape; Safetyseeking behaviors; Self-protection Behavior Change List (Worksheet 7.6), 158–159, 160 creation of problematic anxiety and, 63f, 64, 70–72 Ineffective Coping Checklist (Worksheet 4.3), 71 My Panic Avoidance and Safety-Seeking Record (Worksheet 9.1), 253 My Recovery-Oriented Exposure Plan (Worksheet 7.9), 170, 171 overview, 157–159, 160 social anxiety and, 294–296 Inhibition, social, 283–284, 316–317, 318 Inhibitory learning, 180–181, 182

index 347 Intentional worry exposure intervention, 228–231 Interference with daily functioning avoidance and, 154 panic and, 254, 255 problematic anxiety and, 73t worry and, 185–186, 187–188, 193, 195–199, 195t, 239 Interpretation. See also Thoughts; Threat interpretation alternative perspectives technique and, 135–140 Antipanic Symptom Interpretation Record (Worksheet 9.5), 261 catastrophic misinterpretations in panic, 249–251, 250t Cost of Embarrassment Form (Worksheet 10.12), 325 creation of problematic anxiety and, 63f, 64 examining specific threats, dangers, and uncertainties that make you anxious, 112–125, 116t, 122t, 123f My Daily Anxiety Record (Worksheet 6.1), 113 panic and, 245–246 Panic Profile (Worksheet 9.4), 259, 260 panic reappraisal technique and, 258, 261– 263 Postevent Negative Evaluation Form (Worksheet 10.11), 322, 323 social anxiety and, 321–322, 324–326 Intolerance of uncertainty. See also Uncertainty building tolerance of uncertainty and, 232– 237 My Daily Uncertainty Record (Worksheet 8.12), 234 My Tolerance Fitness Form (Worksheet 8.13), 236 overview, x, 12, 148 worry and, 195t, 200f, 204, 232–237 Intrusive thoughts, 199–201, 200f. See also Thoughts Isolation, 274. See also Social anxiety

J Judgment from others Cost of Embarrassment Form (Worksheet 10.12), 325 Postevent Negative Evaluation Form (Worksheet 10.11), 322, 323 social anxiety and, 321–322, 324–326, 373–374 Jumping to conclusions, 122t, 311–312. See also Thinking errors

K Kindness towards self, 21

L Limited-symptom panic attacks, 241, 254. See also Panic attacks Loss of control. See Control Lovingkindness meditation, 183

M Mapping your mind, 121, 123–125, 123f, 126, 140 Medication, 10–11, 23 Meditation, 183 Mental control, x, 200f, 205–207 Mental fitness/health overview, 19–20 physical exercise and, 103–104, 105 starting points and steps towards, 20–21 Mild anxiety. See also Anxiety; Normal anxiety Anxiety Trigger Checklist (Worksheet 3.1), 39–41 keeping anxiety in the range of, 44–49, 45f making anxiety helpful, 50–52 Mild Anxiety Checklist (Worksheet 3.2), 43 My Adaptive Anxiety Profile (Worksheet 3.5), 54–56, 57–58 My Mild Anxiety Experiences (Worksheet 1.1), 4 My Mild Anxiety Log (Worksheet 3.3), 48–49 noticing, 38, 42–44 overview, 2f, 3–5, 4f, 83 triggers of, 38, 39–41 When My Anxiety Was Helpful (Worksheet 3.4), 51 Mind mapping, 121, 123–125, 123f, 126, 140 Mind reading thinking error, 311–312. See also Thinking errors Mindfulness, 183, 237–239 Mode, 11 Moderate anxiety, 2f, 24. See also Anxiety Monitoring your experiences of anxiety. See Self-monitoring Motivation doubts regarding the effectiveness of CBT exercises and, 25–33 making anxiety helpful and, 50–52 overview, 24–25 physical exercise and, 104 When My Anxiety Was Helpful (Worksheet 3.4), 51

348 index

N Narrowed thinking. See Thinking errors; Thoughts Nearsightedness, 122t. See also Thinking errors Negative evaluation, fear of, 275, 279–281, 280t Negative thoughts, 110–112, 279–281, 280t, 294. See also Thoughts Nervousness, 51, 52. See also Mild anxiety Nocturnal panic attacks, 254. See also Panic attacks Nonproblematic anxiety, 62. See also Anxiety; Mild anxiety; Normal anxiety Normal anxiety. See also Anxiety; Mild anxiety keeping anxiety in the range of, 44–49, 45f Mild Anxiety Checklist (Worksheet 3.2), 43 My Mild Anxiety Log (Worksheet 3.3), 48–49 noticing, 38, 42–44 overview, 83

O Observation, detached, 101–103. See also Confronting fears of anxiety symptoms Overcompensation, 283

P Pacing of CBT program, 20–21, 169, 172 Panic. See also Panic attacks Antipanic Symptom Interpretation Record (Worksheet 9.5), 261 assessing, 254–258, 259–260 catastrophic thinking about, 245–246 CBT model of, 247–253, 248f, 250t fear of, 240–241, 243–247 My Panic Avoidance and Safety-Seeking Record (Worksheet 9.1), 253 My Weekly Panic Log (Worksheet 9.3), 257 overview, 269–270 panic exposure techniques and, 267–268 panic induction intervention and, 265–267 Panic Profile (Worksheet 9.4), 259, 260 panic reappraisal technique and, 258, 261–263 panic rescripting intervention and, 263–265 panic response removal intervention and, 268–269 Panic Self-Diagnostic Checklist (Worksheet 9.2), 255 problematic anxiety and, 73t resources regarding, 334 unhealthy prevention strategies for, 246–247 Panic attacks. See also Anxiety; Panic, fear of Antipanic Symptom Interpretation Record (Worksheet 9.5), 261 assessing, 254–258, 259–260

CBT model of, 247–253, 248f, 250t My Panic Avoidance and Safety-Seeking Record (Worksheet 9.1), 253 My Weekly Panic Log (Worksheet 9.3), 257 overview, x, 2, 12, 239, 240–243, 269–270 panic exposure techniques and, 267–268 panic induction intervention and, 265–267 Panic Profile (Worksheet 9.4), 259, 260 panic reappraisal technique and, 258, 261– 263 panic rescripting intervention and, 263–265 panic response removal intervention and, 268–269 Panic Self-Diagnostic Checklist (Worksheet 9.2), 255 prevalence of, 243 problematic anxiety and, 73t resources regarding, 334 unhealthy prevention strategies for, 246–247 Panic induction intervention, 265–267, 269 Panic reappraisal technique, 258, 261–263 Panic rescripting intervention, 263–265 Panic response removal intervention, 268–269 Partners, 16, 134 Perception. See Thoughts Perfectionism My Cognitive Characteristics of Harmful Worry (Worksheet 8.4), 196–199 using this workbook, 22 worry and, 195t, 200f, 204, 224 Performance anxiety, 273–274, 280t. See also Social anxiety Perspectives, alternative. See Alternative perspectives technique Physical fitness. See Exercise, physical Physical symptoms of anxiety. See also Selfmonitoring; Symptoms of anxiety Antipanic Symptom Interpretation Record (Worksheet 9.5), 261 anxiety sensitivity and, 88 awareness of symptoms during low threat situations, 98–100 catastrophic misinterpretations of, 249–251, 250t context and consequence in, 90–95 creation of problematic anxiety and, 66–67 Discovering My Avoidance Profile (Worksheet 7.5), 156 Discovering the Importance of Context (Worksheet 5.2), 91 fears regarding, 92–94 keeping anxiety in the normal range and, 45f, 46 My Anxious Thinking Form (Worksheet 4.2), 68, 69 My Mild Anxiety Log (Worksheet 3.3), 48–49

index 349 My Symptom Self-Monitoring Form (Worksheet 4.5), 76, 78 My Weekly Panic Log (Worksheet 9.3), 257 overview, 59f, 92 panic and panic attacks and, 244, 248–249, 248f panic induction intervention and, 265–267 Panic Profile (Worksheet 9.4), 259, 260 panic reappraisal technique and, 258, 261–263 Symptom-Consequence Match-Up (Worksheet 5.3), 93, 95 worry and, 239 Positive thinking and beliefs, 24, 46. See also Beliefs; Thoughts Postevent processing phase of social anxiety alternative perspectives technique and, 326–329 CBT for, 318–329 Cost of Embarrassment Form (Worksheet 10.12), 325 decatastrophizing intervention and, 324–326 My Social Anxiety Profile (Worksheet 10.6), 299–300, 301–302 overview, 278f, 284–285 Postevent Analysis Form (Worksheet 10.5), 297 Postevent Negative Evaluation Form (Worksheet 10.11), 322, 323 A Realistic Reevaluation of My Past Social Performance (Worksheet 10.13), 328, 329 social anxiety and, 296–297, 318–329 Practice. See also Exercise overviews; Homework cognitive behavior therapy (CBT) and, 25 doubts regarding the effectiveness of, 25–33 exposure techniques and, 169, 172–176, 312–315 importance of, 29–31 modifying, 33 My Exposure Practice Form (Worksheet 7.10), 174 prosocial cognitive skills and, 312–315 Seven Characteristics of Effective Assignments (Worksheet 2.2), 32 social anxiety and, 310–311, 312–315 Prediction, threat. See also Anticipatory anxiety; Threat interpretation My Threat Estimations (Worksheet 6.2), 117 overview, 114–116, 116t realistic expectations intervention and, 304–305 Problematic anxiety. See also Anxiety; Anxiety Symptom Profile; Severe anxiety anxiety triggers, 64–66 Core Characteristics of My Problematic Anxiety (Worksheet 4.4), 75

creation of, 63–72, 63f ineffective coping and, 70–72 Ineffective Coping Checklist (Worksheet 4.3), 71 My Anxiety Symptom Profile (Worksheet 4.6), 79–80, 82 My Anxiety Trigger Evaluation Form (Worksheet 4.1), 65 My Anxious Thinking Form (Worksheet 4.2), 68, 69 My Symptom Self-Monitoring Form (Worksheet 4.5), 76, 78 overview, 61–63, 72–74, 73t, 83 thoughts and, 66–70 Problem-solving brainstorming and, 221–222 evaluation and revision and, 222, 223–225 My Cognitive Characteristics of Harmful Worry (Worksheet 8.4), 196–199 problem definition and, 220–221 reality-based worry and, 216–225 regulating anxiety and, 59–60, 59f setbacks and disappointments and, 21 taking action, 223 worry and, 195t, 200f, 204–205, 213, 215– 225 Processing after a social event. See Postevent processing phase of social anxiety Productive worry, 31. See also Worry Prosocial cognitive skills, 312–315 Protection, self. See Self-protection Provocation of symptoms, 104, 106–108, 107t, 109

R Readiness for exposure. See also Exposure techniques coping cognitions and, 165–167 establishing an exposure plan and, 168–169, 170, 171 overview, 161–163 Reality-based worry. See also Worry Control Pie Chart (Worksheet 8.10), 218, 219 overview, 213, 215–216 problem-solving approach to, 216–225 Type of Worry Checklist (Worksheet 8.9), 216 Reappraisal, panic, 258, 261–263, 269 Reassurance seeking building tolerance of uncertainty and, 235– 236 evidence gathering technique and, 126 My Tolerance Fitness Form (Worksheet 8.13), 236 worry and, 207, 213

350 index Recovery-oriented cognitive therapy (CT-R) establishing an exposure plan and, 169, 170, 171 keeping anxiety in the normal range and, 45, 46 overview, ix–x, 1–2, 11, 35 social anxiety and, 283 using this workbook, 12–15, 13t–14t Relationships, 16, 104. See also Friendships Relaxation, 73t, 168, 183 Rescripting panic, 263–265 Resilience, 168–169 Responses to anxiety, 147, 149–150. See also Adaptive responses; Coping response Role-playing My Behavioral Retraining Guide (Worksheet 10.10), 318 social anxiety and, 315–316 strengthening prosocial behavior and, 317–318 Rumination, 327

S Safety evidence gathering technique and, 125–129 evidence of, 168 loss of, 73t mind mapping and, 121, 123–125, 123f My Anxious Mind Map (Worksheet 6.4), 124, 126 My Evidence-Gathering Form (Worksheet 6.5), 128, 130 My Self-Protective Response (Worksheet 7.2), 147 overview, 140 self-protective mode and, 145–159, 145f Safety-seeking behaviors. See also Avoidance; Escape; Self-protection Behavior Change List (Worksheet 7.6), 158–159, 160 building tolerance of uncertainty and, 235– 236 ineffective coping and, 157–159, 160 My Behavioral Retraining Guide (Worksheet 10.10), 318 My Cognitive Characteristics of Harmful Worry (Worksheet 8.4), 196–199 My Panic Avoidance and Safety-Seeking Record (Worksheet 9.1), 253 My Recovery-Oriented Exposure Plan (Worksheet 7.9), 170, 171 My Safety-Seeking Response Form (Worksheet 7.4), 153 My Tolerance Fitness Form (Worksheet 8.13), 236 My Weekly Panic Log (Worksheet 9.3), 257 overview, 11–12, 151–152, 184

panic and panic attacks and, 246–247, 248f, 252–253 Panic Profile (Worksheet 9.4), 259, 260 panic response removal intervention and, 268–269 social anxiety and, 282–283, 294–296, 316–317 worry and, 195t, 200f, 207–208 Security, loss of, 73t Self-consciousness, 273–274, 281–282. See also Embarrassment, fear of Self-critical thoughts, 282. See also Thoughts Self-focused attention, 275, 281–282 Self-kindness, 21 Self-monitoring. See also Symptoms of anxiety My Social Anxiety Log (Worksheet 10.3), 290 My Symptom Self-Monitoring Form (Worksheet 4.5), 76, 78 My Weekly Panic Log (Worksheet 9.3), 257 overview, 74, 76–77 panic symptoms, 256, 257 social anxiety and, 281, 288, 290, 291 worry and, 210, 211, 213 Worry Diary (Worksheet 8.7), 211 Self-protection. See also Avoidance; Behaviors; Coping response; Escape; Ineffective coping; Safety-seeking behaviors Behavior Change List (Worksheet 7.6), 158–159, 160 Beliefs about Anxiety Scale (Worksheet 7.3), 149–150 Discovering My Avoidance Profile (Worksheet 7.5), 156 intolerance of anxiety and, 146, 148–150 My Safety-Seeking Response Form (Worksheet 7.4), 153 My Self-Protective Response (Worksheet 7.2), 147 overview, 145–159, 145f safety and, 151–152 Self-talk, 110–112. See also Thoughts Sensations, physical. See Physical symptoms of anxiety Sensitivity, anxiety. See Anxiety sensitivity Setbacks, 21 Severe anxiety, 2f, 5–9, 51. See also Anxiety; Problematic anxiety Situational exposure, 268, 269. See also Exposure techniques Social anxiety. See also Anxiety; Embarrassment, fear of; Social concerns anticipatory phase of, 277, 278f, 279, 292– 294, 298, 302–306 Anticipatory Social Anxiety Form (Worksheet 10.4), 293 assessing, 285–291

index 351 behavioral strategies and, 315–318 CBT model of, 276–285, 278f, 280t concerns with what others will think, 273– 274, 321–322, 324–326 correcting unrealistic expectations intervention, 310–311 Cost of Embarrassment Form (Worksheet 10.12), 325 creating your social anxiety profile, 291–298, 299–302 exposure techniques and, 307–318 helpful mental strategies intervention, 311–315 identifying anxious thinking and, 294 modifying social expectations and, 298, 302–304 My Behavioral Retraining Guide (Worksheet 10.10), 318 My Social Anxiety Profile (Worksheet 10.6), 299–300, 301–302 My Social Change Goals (Worksheet 10.2), 289 My Social Exposure Plan (Worksheet 10.8), 308, 309 overview, 12, 271–273, 274–276, 329–330 panic attacks and, 254 Postevent Analysis Form (Worksheet 10.5), 297 Postevent Negative Evaluation Form (Worksheet 10.11), 322, 323 postevent processing phase of, 278f, 284–285, 296–297, 318–329 prevalence of, 285 Prosocial Cognitive Skills Form (Worksheet 10.9), 313–314 realistic expectations intervention and, 304–305 A Realistic Reevaluation of My Past Social Performance (Worksheet 10.13), 328, 329 resources regarding, 334 self-instructional training intervention, 305–306 Social Anxiety Checklist (Worksheet 10.1), 286 social encounter phase of, 278f, 279–284, 280t Social Expectations Form (Worksheet 10.7), 303 strengthening prosocial behavior and, 317–318 triggers of, 292 unhealthy coping and avoidance and, 294–296 using this workbook, 12–15, 13t–14t values and aspirations regarding social change, 287–288, 289 Social concerns. See also Social anxiety avoidance and, 152, 154–157 awareness of symptoms during low threat situations, 98–100

overview, 92 Symptom-Consequence Match-Up (Worksheet 5.3), 93, 95 Social encounter phase of social anxiety, 278f, 279–284, 280t, 299–300, 301–302 Social expectations, 276. See also Expectations Social inhibition My Behavioral Retraining Guide (Worksheet 10.10), 318 social anxiety and, 283–284, 316–317 Spontaneous panic attacks, 241. See also Panic attacks Strengths. See also Adaptive mode; Helpful anxiety My Acts of Courage (Worksheet 7.1), 144 My Adaptive Anxiety Profile (Worksheet 3.5), 54–56, 57–58 overview, 52–59, 141–142 recovery-oriented cognitive therapy (CT-R) and, 1–2 Stress, 51, 103–104, 105 Striving for perfection. See Perfectionism Symptom hypersensitivity, 244. See also Symptoms of anxiety Symptom provocation My Symptom Provocation Record (Worksheet 5.8), 109 overview, 104, 106–108, 107t panic induction intervention and, 265–267 Symptom-focused hypervigilance, 248–249. See also Hypervigilance Symptoms of anxiety. See also Anxiety sensitivity; Anxiety Symptom Profile; Physical symptoms of anxiety; Selfmonitoring awareness of during low threat situations, 98–100 confronting fear of anxiety symptoms, 100–103 Core Characteristics of My Problematic Anxiety (Worksheet 4.4), 75 establishing an exposure plan and, 168–169, 170, 171 first symptom experienced when feeling anxious, 87 Focused Attention Symptom Diary (Worksheet 5.6), 102 My Adaptive Anxiety Profile (Worksheet 3.5), 57–58 My Anxiety Symptom Profile (Worksheet 4.6), 79–80, 82 My Symptom Provocation Record (Worksheet 5.8), 109 My Symptom Self-Monitoring Form (Worksheet 4.5), 76, 78

352 index Symptoms of anxiety (continued) My Symptom Tolerance Scale (Worksheet 5.1), 89 Nonthreatening Symptom Diary (Worksheet 5.5), 99 overview, 59–60, 59f panic and, 244, 269–270 physical exercise and, 103–104, 105 problematic anxiety and, 72–74, 73t symptom provocation and, 104, 106–108, 107t Symptom-Consequence Match-Up (Worksheet 5.3), 93, 95 tracking, 74, 76–77 Weekly Exercise Log (Worksheet 5.7), 105 worry and, 186 Systematic exposure, 159. See also Exposure techniques

T Tension, 52. See also Mild anxiety Thinking errors. See also Catastrophic thinking; Thoughts alternative perspectives technique and, 135–140 awareness of, 133–135 cost–benefit analysis and, 129, 131–133 evidence gathering technique and, 125–129 exposure techniques and, 161–162 mind mapping and, 121, 123–125, 123f My Alternative Perspective Form (Worksheet 6.7), 137, 139 My Anxious Mind Map (Worksheet 6.4), 124, 126 My Cost–Benefit Form (Worksheet 6.6), 132, 133 My Evidence-Gathering Form (Worksheet 6.5), 128, 130 Negative Beliefs about Exposure (Worksheet 7.7), 162 overview, 120–121, 122t, 140 Prosocial Cognitive Skills Form (Worksheet 10.9), 313–314 social anxiety and, 311–312 worry and, 195t Thoughts. See also Beliefs; Challenging unhelpful beliefs or thoughts; Interpretation; Self-monitoring alternative perspectives technique and, 135–140 as an anxiety trigger, 64–66 Assessing Common Worry Concerns (Worksheet 8.1), 189 awareness of, 21, 67–70, 81, 133–135 awareness of symptoms during low threat situations, 98–100

CBT model of worry, 199–208, 200f cognitive behavior therapy (CBT) and, 23 confronting fear of anxiety symptoms, 100–103 coping cognitions and, 165–167 cost–benefit analysis and, 129, 131–133 creation of problematic anxiety and, 66–70 detached worry intervention and, 237–239 Discovering My Avoidance Profile (Worksheet 7.5), 156 doubts regarding the effectiveness of CBT exercises and, 26–29 examining specific threats, dangers, and uncertainties that make you anxious, 112–125, 116t, 122t, 123f examining the evidence for, 125–129 exposure techniques and, 165–167 keeping anxiety in the normal range and, 44–45, 45f mind mapping and, 123–125, 123f My Alternative Perspective Form (Worksheet 6.7), 137, 139 My Anxiety Symptom Profile (Worksheet 4.6), 79–80, 82 My Anxious Mind Map (Worksheet 6.4), 124, 126 My Anxious Thinking Form (Worksheet 4.2), 68, 69 My Behavioral Experiment (Worksheet 7.11), 178, 179 My Cognitive Characteristics of Harmful Worry (Worksheet 8.4), 196–199 My Cost–Benefit Form (Worksheet 6.6), 132, 133 My Daily Anxiety Record (Worksheet 6.1), 113 My Evidence-Gathering Form (Worksheet 6.5), 128, 130 My Exposure Hierarchy (Worksheet 7.8), 164, 175 My Helplessness Thinking Record (Worksheet 6.3), 120 My Mild Anxiety Log (Worksheet 3.3), 48–49 My Self-Protective Response (Worksheet 7.2), 147 My Symptom Self-Monitoring Form (Worksheet 4.5), 76, 78 My Threat Estimations (Worksheet 6.2), 117 negative thoughts, 110–112 overview, 10, 10f, 140 panic and, 247–253, 248f, 250t regulating anxiety and, 59–60, 59f self-protective mode and, 145–159, 145f social anxiety and, 279–284, 280t, 294, 311–315 thinking errors, 120–121, 122t worry and, 188–189, 195t

index 353 Worry Diary (Worksheet 8.7), 211 Worry Profile (Worksheet 8.8), 212, 214 Threat interpretation. See also Helpless; Interpretation; Vulnerability thoughts Anticipatory Social Anxiety Form (Worksheet 10.4), 293 awareness of symptoms during low threat situations, 98–100 bias and, 11–12 coping cognitions and, 165–167 cost–benefit analysis and, 129, 131–133 creation of problematic anxiety and, 66–70 evidence gathering technique and, 125–129 examining specific threats that make you anxious, 112–125, 116t, 122t, 123f intolerance of anxiety and, 146, 148–150 keeping anxiety in the normal range and, 44–45, 45f mind mapping and, 121, 123–125, 123f My Anxious Mind Map (Worksheet 6.4), 124, 126 My Anxious Thinking Form (Worksheet 4.2), 68, 69 My Cost–Benefit Form (Worksheet 6.6), 132, 133 My Evidence-Gathering Form (Worksheet 6.5), 128, 130 My Exposure Hierarchy (Worksheet 7.8), 164, 175 My Self-Protective Response (Worksheet 7.2), 147 My Threat Estimations (Worksheet 6.2), 117 Nonthreatening Symptom Diary (Worksheet 5.5), 99 overview, 140 problem-solving approach to worry and, 224–225 safety-seeking behaviors and, 151–152 self-protective mode and, 145–159, 145f social anxiety and, 281–282, 292–294, 312–315 thinking errors and, 120–121, 122t worry and, 200–201 Threat prediction, 114–116, 116t, 304–305. See also Anticipatory anxiety Threshold, anxiety. See Anxiety threshold and tolerance Time involved in CBT, 20 Tolerance for anxiety. See Anxiety threshold and tolerance Tracking symptoms. See Self-monitoring Transdiagnostic processes, 12, 269–270 Triggers. See also Self-monitoring Anxiety Trigger Checklist (Worksheet 3.1), 39–41 avoidance and, 152, 154–157

awareness of symptoms during low threat situations, 98–100 creation of problematic anxiety and, 63, 63f, 64–66 Discovering My Avoidance Profile (Worksheet 7.5), 156 mild anxiety and, 3, 38, 39–41 My Anxiety Symptom Profile (Worksheet 4.6), 79–80, 82 My Anxiety Trigger Evaluation Form (Worksheet 4.1), 65 My Daily Anxiety Record (Worksheet 6.1), 113 My Exposure Hierarchy (Worksheet 7.8), 164, 175 My Mild Anxiety Log (Worksheet 3.3), 48–49 My Panic Avoidance and Safety-Seeking Record (Worksheet 9.1), 253 My Self-Protective Response (Worksheet 7.2), 147 My Symptom Self-Monitoring Form (Worksheet 4.5), 76, 78 My Weekly Panic Log (Worksheet 9.3), 257 Nonthreatening Symptom Diary (Worksheet 5.5), 99 overview, 10, 10f panic and panic attacks and, 243–244, 248f, 252–253 panic exposure techniques and, 267–268 Panic Profile (Worksheet 9.4), 259, 260 panic response removal intervention and, 269 problematic anxiety and, 63–72, 63f self-protective mode and, 145–159, 145f social anxiety and, 292 worry and, 199–201, 200f Worry Profile (Worksheet 8.8), 212, 214 Tunnel vision, 122t, 311–312. See also Thinking errors

U Uncertainty. See also Intolerance of uncertainty building tolerance of uncertainty and, 232– 237 examining specific uncertainties that make you anxious, 112–125, 116t, 122t, 123f feeling helpless and, 118–120 My Daily Uncertainty Record (Worksheet 8.12), 234 My Helplessness Thinking Record (Worksheet 6.3), 120 My Tolerance Fitness Form (Worksheet 8.13), 236 overview, x Unproductive worry, 31. See also Worry

354 index Unwanted intrusive thoughts, 64, 66. See also Intrusive thoughts; Thoughts Using this workbook. See also Exercise overviews completing the exercises and worksheets, 21–22 goals for anxiety-reduction and, 15–18 overview, 12–15, 13t–14t, 29–33 practice and, 25

V Values, 287–288 Visualization, 168, 237–239 Vulnerability thoughts. See also Helpless feelings; Thoughts; Threat interpretation feeling helpless and, 118–120 keeping anxiety in the normal range and, 44–45, 45f My Helplessness Thinking Record (Worksheet 6.3), 120

W Waking in a panic attack, 254. See also Panic attacks What-if thinking. See also Thoughts; Worry building tolerance of uncertainty and, 232– 233 CBT model of worry and, 199–201, 200f harmful worry and, 190t, 191–193 intolerance of uncertainty and, 204 My Daily Uncertainty Record (Worksheet 8.12), 234 overview, 188 panic and, 247 Worry Diary (Worksheet 8.7), 211 Worry Wart Checklist (Worksheet 8.6), 209 White Bear experiment, 206–207 Worry. See also Anxiety; Productive worry; Unproductive worry assessing, 208–213, 214 Assessing Common Worry Concerns (Worksheet 8.1), 189 belief activation, 201–202

building tolerance of uncertainty and, 232– 237 CBT model of worry, 199–208, 200f content, 188–189 Control Pie Chart (Worksheet 8.10), 218, 219 decatastrophizing intervention and, 225–228 detached worry intervention, 237–239 directed worry exposure intervention and, 228–231 Harmful/Helpful Worry Quiz (Worksheet 8.2), 192 helpful versus harmful worry, 186–188, 189–193, 190t, 194 making anxiety helpful and, 50–52 mental fitness and, 19 My Cognitive Characteristics of Harmful Worry (Worksheet 8.4), 196–199 My Daily Uncertainty Record (Worksheet 8.12), 234 My Tolerance Fitness Form (Worksheet 8.13), 236 My Worry across Life Domains (Worksheet 8.3), 194 overview, x, 2, 12, 184, 185–186, 239, 269–270 practice and, 31 problem-solving approach to, 213, 215–225 resources regarding, 334 thought processes in, 203–208 triggers and intrusive thoughts and, 199–201 Type of Worry Checklist (Worksheet 8.9), 216 types of, 215–216 using this workbook, 12–15, 13t–14t what makes worry harmful, 193, 195–199, 195t When My Anxiety Was Helpful (Worksheet 3.4), 51 Worry Beliefs Checklist (Worksheet 8.5), 202 Worry Diary (Worksheet 8.7), 211 Worry Exposure Form (Worksheet 8.11), 231 worry postponement technique and, 231–232 Worry Profile (Worksheet 8.8), 212, 214 Worry Wart Checklist (Worksheet 8.6), 209 Worry postponement technique, 231–232

about the authors David A. Clark, PhD, is Professor Emeritus of Psychology at the University of New Brunswick, Canada, and has had a private practice in clinical psychology since 1985. Dr. Clark is a widely recognized authority on cognitive behavior therapy for anxiety, depression, and obsessive–­compulsive disorder. He is a Fellow of the Canadian Psychological Association and a Founding Fellow of the Academy of Cognitive and Behavioral Therapies. Aaron T. Beck, MD, until his death in 2021, was Professor Emeritus of Psychiatry at the University of Pennsylvania and President Emeritus of the Beck Institute for Cognitive Behavior Therapy. Internationally recognized as the founder of cognitive therapy, Dr. Beck has been credited with shaping the face of American psychiatry and was cited by American Psychologist as “one of the five most influential psychotherapists of all time.”

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