Unified Protocol for Transdiagnostic Treatment of Emotional Disorders: Workbook (Treatments That Work) [2 ed.] 0190686014, 9780190686017

Citation preview

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Unified Protocol for Transdiagnostic Treatment of Emotional Disorders

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T R E AT M E N T S T H AT W O R K

Editor-​In-​Chief David H. Barlow, PhD

Scientific Advisory Board Anne Marie Albano, PhD Gillian Butler, PhD David M. Clark, PhD Edna B. Foa, PhD Paul J. Frick, PhD Jack M. Gorman, MD Kirk Heilbrun, PhD Robert J. McMahon, PhD Peter E. Nathan, PhD Christine Maguth Nezu, PhD Matthew K. Nock, PhD Paul Salkovskis, PhD Bonnie Spring, PhD Gail Steketee, PhD John R. Weisz, PhD G. Terence Wilson, PhD

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T R E AT M E N T S T H AT W O R K T RA N S D I A GN O S T I C P RO GRA M S

Unified Protocol for Transdiagnostic Treatment of Emotional Disorders Second Edition

WORKBOOK D AV I D H .   B A R L O W S H A N N O N S A U E R -​Z AVA L A T O D D J . FA R C H I O N E H E AT H E R M U R R AY   L AT I N KRISTEN K. ELLARD JACQUELINE R. BULLIS K AT E H . B E N T L E Y H A N N A H T. B O E T T C H E R C L A I R C A S S I E L L O -​R O B B I N S

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1 Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries. Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America. © Oxford University Press 2018 First Edition published in 2011 Second Edition published in 2018 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above. You must not circulate this work in any other form and you must impose this same condition on any acquirer. ISBN 978–​0–​19–​068601–​7 9 8 7 6 5 4 3 2 1 Printed by WebCom, Inc., Canada

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About

T R E AT M E N T S

T H AT W O R K

One of the most difficult problems confronting patients with various disorders and diseases is finding the best help available. Everyone is aware of friends or family who have sought treatment from a seemingly reputable practitioner, only to find out later from another doctor that the original diagnosis was wrong or the treatments recommended were inappropriate or perhaps even harmful. Most patients, or family members, address this problem by reading everything they can about their symptoms, seeking out information on the Internet or aggressively “asking around” to tap knowledge from friends and acquaintances. Governments and health care policymakers are also aware that people in need do not always get the best treatments—something they refer to as variability in health care practices. Now health care systems around the world are attempting to correct this variability by introducing evidence-based practice. This simply means that it is in everyone’s interest that patients get the most up-to-date and effective care for a particular problem. Health care policymakers have also recognized that it is very useful to give consumers of health care as much information as possible, so that they can make intelligent decisions in a collaborative effort to improve physical health and mental health. This series, Treatments ThatWork, is designed to accomplish just that. Only the latest and most effective interventions for particular problems are described in user-friendly language. To be included in this series, each treatment program must pass the highest standards of evidence available, as determined by a scientific advisory board. Thus, when individuals suffering from these problems or their family members seek out an expert clinician who is familiar with these interventions and decides that they are appropriate, patients will have confidence they are receiving the best care available. Of course, only your health care professional can decide on the right mix of treatments for you. The latest development in evidence-based treatment programs, based on the most up-to-date research and clinical evaluation, is found in unified, transdiagnostic interventions for disorders that share common features

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and respond to common therapeutic procedures. Deepening understanding of the nature of psychological disorders reveals that many groups of related disorders share important causes, and look very similar in terms of behavioral problems and brain function. Thinking of these disorders or problems as related, or on a “spectrum,” is the approach now taken by leading therapists and researchers as well as by the authors of the DSM-5. This is because most people with one disorder or problem also have another problem or disorder (referred to as comorbidity). If someone has panic disorder, they may also have social anxiety as well as depression; these are all emotional disorders. If someone abuses drugs, they may also abuse alcohol or cigarettes; these are all addictive disorders. Treatment programs in this series are “unified” because they share a common, unified set of therapeutic procedures that are effective with a whole class of disorders, such as emotional disorders or addictive disorders. Treatment programs are “transdiagnostic” because they are designed to be effective with all of the disorders in that class (emotional or addictive or eating disorders) that somebody might have, rather than just one disorder. Working with one set of therapeutic principles makes it easier and more efficient for you and your therapist, and should address all of the problems you may have in a more comprehensive and effective way. This particular workbook is designed to address the range emotional disorders. Generally, this group of disorders includes all of the anxiety and mood (depressive) disorders such as panic disorder with or without agoraphobia, social anxiety disorder, generalized anxiety disorder, post-traumatic stress disorder, obsessive-compulsive disorder, and depression. The program is also designed to address closely related conditions that arise from difficulty responding to strong emotions, such as health anxiety, dissociation (feelings of unreality), alcohol or substance use, and selfinjurious behavior. What all of these disorders have in common is the experience of strong emotions that is interfering with the ability to lead a fulfilling life. This program is not generally recommended for a specific phobia, if that is the only problem you are experiencing at this time. Only your healthcare professional can tell you for sure which disorders you have and which you may not have; and only your healthcare professional can decide on the most appropriate treatments for you. David H. Barlow, Editor-​in-​Chief, Treatments ThatWork Boston, MA

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Accessing Treatments ThatWork Forms and Worksheets Online All forms and worksheets from books in the TTW series are made available digitally shortly following print publication. You may download, print, save, and digitally complete them as PDFs. To access the forms and worksheets, please visit http://​www.oup.com/​us/​ttw.

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Contents

Acknowledgments   xi Chapter 1

What Are Emotional Disorders?   1

Chapter 2

About This Treatment   11

Chapter 3

Learning to Record Your Experiences   17

Chapter 4

Setting Goals and Maintaining Motivation   29

Chapter 5

Understanding Your Emotions—​What Is an Emotion?   41

Chapter 6

Understanding Your Emotions—​Following the ARC   53

Chapter 7

Mindful Emotion Awareness   61

Chapter 8

Cognitive Flexibility   77

Chapter 9

Countering Emotional Behaviors   95

Chapter 10

Understanding and Confronting Physical Sensations   111

Chapter 11

Putting It Into Practice—​Emotion Exposures   125

Chapter 12

The Role of Medication in the Treatment of Emotional Disorders   137

Chapter 13

Moving UP from Here—​Recognizing Accomplishments and Looking to Your Future   149

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Appendix A: Answers to Self-​Assessment Quizzes   161 Appendix B: Example Forms   163 Appendix C: Definitions of Key Terms   189 About the Authors   193

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Acknowledgments

The authors express gratitude to the individuals who have contributed to development of this treatment program. First, we would like to acknowledge authors of the first edition of this workbook (Tina Boisseau, Jill Ehrenreich May, Chris Fairholme, Laura Payne). Without their thoughtful contributions, this edition would not have been possible. Additionally, our thanks go to Amantia Ametaj, James Boswell, Matthew Gallagher, and Cassidy Gutner who provided invaluable feedback on necessary updates included in this edition of this program. In particular, we would like to acknowledge Laren Conklin for her very thoughtful review of early drafts of this workbook. Further, our appreciation to past and current members of our research group who have helped shape our thinking on the Unified Protocol: Jenna Carl, Johanna ThompsonHollands, Julianne Wilner, Meghan Fortune, Katherine Kennedy, Ujunwa Anakwenze, Olenka Olesnycky, Gabriela Aisenberg, Marina Ritchie, and Gayle Tan. We would also like to thank Luke J. Carl and Jason Zavala for their artistic contributions that bring the concepts described in this program to life. Finally, we wish to extend our gratitude to clinicians using the Unified Protocol who provided their cogent thoughts on useful revisions for the second edition, as well as to our patients; their willingness to share their experiences has been invaluable in developing this treatment program.

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Unified Protocol for Transdiagnostic Treatment of Emotional Disorders

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CHAPTER 1

What Are Emotional Disorders?

GOALS To describe the types of problems this program was designed to address ■ To help you determine whether your difficulties fit with this program ■

What Are Emotional Disorders? This workbook was developed to help people who are struggling with intense emotions like anxiety, sadness, anger, and guilt. A person may have an emotional disorder when her emotions are so overwhelming that they get in the way of moving forward in life. For example, feeling really sad may make it harder to reach out to friends or even get out of bed. Feeling anxious at school or work may prevent someone from finishing important tasks. You may have picked up this book because your emotions are interfering in your own life in ways that matter to you. Although emotions affect our lives in different ways, there are three features that often occur across all emotional disorders, as shown in Figure 1.1: Emotional Disorders. 1. Frequent, strong emotions: People who struggle with emotional difficulties tend to feel strong emotions quite often. This is a biological tendency to be emotionally sensitive—​some people may simply be hard-​wired to experience their emotions more intensely in response

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Avoidance backfires, leading to more intense emotions

Negative reaction to that emotion “I shouldn’t be feeling this way”

Efforts to avoid or escape emotion

You feel an emotion

anxiety, sadness, guilt, anger

Targets of this treatment

Figure 1.1 Functional Model of Emotional Disorders

to situations in their lives. It is important to point out, though, that feeling emotions strongly does not necessarily mean a person will find them overwhelming and interfering. It is how we respond to our emotions that really matters. 2. Negative reactions to emotions: People with emotional disorders also tend to view their emotions negatively. They can be hard on themselves for having certain reactions, thinking “I shouldn’t be feeling this way” or “getting upset about this is a sign of weakness.” They may also link strong emotions to bad outcomes and conclude things like “Everyone will judge me for being anxious,” “If I get angry, I’ll do something that I’ll regret,” or “If I let myself feel sad, I’ll fall into a hole that I won’t be able to get out of.” Sometimes one part of an emotional experience is particularly distressing. For example, some people may find the physical sensations associated with emotions like a racing heart, sweating, and butterflies in the stomach quite uncomfortable. For other people, intrusive, unwanted thoughts may be most difficult. Sometimes people even have negative reactions to positive emotions (e.g., “If I let myself feel excited, I’ll be even more disappointed if it doesn’t work out”). 3. Avoidance of emotions: Since people with emotional disorders view their emotions negatively, it makes sense that they would try to avoid them. The problem with avoidance is that it actually doesn’t work very well. Actively trying to push away emotions may make you feel better in the short term but generally leads to more frequent, intense emotions in the long term. It is like being stuck in quicksand—​the more

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you struggle, the more you sink. Additionally, by avoiding activities or situations because they might bring up intense emotions, life can become limited. You may find it difficult to get the most out of day-​ to-​day activities like going to work, spending time with friends, or just doing something fun. The goal of this workbook is to change the way you respond to your emotions when they occur. Specifically, you will be asked to approach your emotions in a more accepting manner instead of viewing them as something to avoid. This may seem like the opposite of what you were expecting—​perhaps you are hoping to get rid of your overwhelming emotions. However, as you progress though this workbook, you will learn more about how emotions, even negative ones, are important and that pushing them away actually backfires. Leaning in toward your emotions and responding more effectively to them may be difficult at first, but it will gradually make them more manageable. To begin to see if this program is right for you, take a look at these examples of people we have treated at our clinic. Amira

Amira is a 24-​year-​old graduate student who came to our clinic for help with a number of difficulties. First, she reported worrying for long periods of time (90% of her day) about her family’s finances, her ability to complete her school work, as well as her health and safety. To cope, Amira often put off her school work by surfing the Internet for several hours every evening. In particular, she had been putting off a large project that was important for graduating on time. She described feeling extremely guilty about her lack of progress but still felt unable to face this task. Additionally, she reported engaging in checking behaviors (e.g., going to the doctor frequently, looking up symptoms on the Internet), as well as refusing to enter crowded public spaces that she perceived might be more susceptible to terrorist attacks. These behaviors helped Amira to feel better for a little while, but the worries always returned in response to new situations and symptoms. In addition to her worries, Amira also described feelings of restlessness, difficulty concentrating, irritability, and muscle tension. Amira also noted that she was struggling to make friends since moving to the area for graduate school. She worried that her classmates would

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view her as “awkward and weird,” so she avoided class social gatherings. Although she had attended a church in her neighborhood a few times, Amira always sat in the back and left immediately following the service to avoid mingling during the coffee hour. Amira also reported that she had been holding back from asking questions in class because she was worried her professors would “regret accepting her to the program.” Finally, Amira indicated that all of these difficulties had been weighing on her and that she was feeling really down. She felt hopeless to solve her problems and had stopped engaging with her hobbies, like biking, yoga, and needle-​ point. Amira noted that she didn’t deserve to do “fun” things if she didn’t complete her school work. Kevin

Kevin is a 58-​year-​old, married male who lives with his wife of 20 years and their two teenaged children. He has been working as a lawyer for the past 25 years. Kevin came to our center experiencing intense panic attacks that consisted of racing heart rate, shortness of breath, dizziness, a frequent lump in his throat, nausea, and sweating. He had his first panic attack while he was on the highway driving to work one day. Kevin immediately pulled off to the side of the road and got out of his car. He had never experienced anything like this before, and he was terrified that he would lose control of the car; he ended up calling his wife to come pick him up. Following this first attack, Kevin started having panic attacks regularly. Most felt like they came “out of the blue,” but he noticed that he was especially likely to have them in situations where he felt trapped. Kevin was constantly worried about having another panic attack and made changes to his behavior in order to prevent them. For example, Kevin stopped driving on the highway. Instead, he added 30 to 45 minutes to his commute by taking back roads. In addition, he started leaving work earlier, in order to avoid rush-​hour traffic. He also began avoiding other situations, such as airplanes, elevators, stores, shopping malls, theaters, and crowds. Wherever he went, Kevin carried his cell phone (so he could call for help if anything happened to him) and his fast-​acting anxiety medication with him. Even though he didn’t take his medication very often, Kevin said that just looking at it made him feel more comfortable and better able to cope. Kevin had tried a number of different things to “get rid of ” his panic, including relaxation, hypnosis, and even medication that his doctor had prescribed. However, none of these things had

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helped. Kevin couldn’t shake the feeling that there was something wrong with his brain and that he was weak for experiencing these symptoms. Marco

Marco is a 41-​year-​old firefighter who lives with his wife of eight years. Shortly after an incident at work in which one of his coworkers was seriously injured, Marco noticed that his sleep had become disrupted by nightmares. These dreams usually involved not being able to help his coworker during the fire and made it nearly impossible for Marco to get back to sleep afterward. As a result, Marco spent much of his day feeling groggy and fatigued, though he often put off going to sleep because being in bed had become so unpleasant for him. In addition to being tired, Marco found that he was frequently distracted throughout the day by intrusive thoughts about his coworker. These memories would pop up unexpectedly even when he was trying to relax, and they left him feeling on edge. His wife tried to be supportive by asking him what was on his mind, but Marco preferred not to discuss these memories, thinking this would make him feel more stressed out. Around the same time, Marco’s wife noticed that his temper was shorter than usual. He seemed frequently irritable and would often snap at her over minor issues. For example, Marco was startled by their dog coming into the house and yelled at the dog to get out of the way, which he felt guilty about afterward. When Marco’s wife brought up his short temper, Marco agreed that he had been feeling irritable and restless but said that it was hard to relax at home. Marco also found that the activities he and his wife used to do with their friends, like going to movies or out to eat, didn’t hold his interest anymore. Marco decided to talk to a therapist after some encouragement from his wife, and he came in for treatment saying that everything felt harder since the fire that injured his coworker. Marco felt very frustrated by his symptoms—​in particular, he wondered why he felt so stressed in daily life after having performed well under much more stressful conditions at work. Marco found himself thinking self-​critical thoughts and asking “Why can’t I just get it together?” Rachel

Rachel is a 33-​year old stay-​at-​home mom who lives with her husband and two-​year-​old child. Rachel described herself as “a rigid person” who likes

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to follow rules and routines. She noted that she has always found it mildly uncomfortable when things don’t go as she planned. However, since the birth of her daughter, Rachel started noticing that minor deviations from her routine caused overwhelming anxiety. For example, if Rachel did not have time to put away the laundry immediately after folding it, she would begin to get the sense that something really terrible would happen. She noticed intrusive thoughts that her daughter, husband, and parents would be involved in some kind of accident. To avoid these thoughts, Rachel tried very hard to keep the same schedule every day and would become very angry if something interfered (e.g., her husband having to stay late at work). If the thoughts did pop up, Rachel would rub a worry stone she carried in her pocket while counting the floorboards in her dining room. Engaging in these behaviors made her feel like she was doing something to protect her loved ones. Rachel was frustrated with the time these behaviors were taking up in her life but was reluctant to give them up “just in case” they did keep her family safe.

You may notice that each person is experiencing different symptoms. In each of these cases, however, strong emotions are getting in the way of their ability to live the life they want. Their negative reactions to their emotions are driving them to do things they don’t want to do—​and, as we’ll discuss throughout this program, things that might make them feel better for a short time (e.g., skipping gatherings with classmates, avoiding driving, snapping at a spouse, rigidly following a routine) only lead to more problems in the long term.

What Types of Disorders Does This Program Treat? This treatment program is designed to help people like Amira, Kevin, Marco, and Rachel. By focusing on negative, avoidant reactions to strong emotions, we can help people with a variety of different problems. There are several mental health conditions that can be considered emotional disorders and would be a good fit for this treatment. As a reminder, emotional disorders occur when the way a person responds to strong emotions is taking over his life. Examples of emotional disorders include anxiety disorders such as panic disorder, generalized anxiety disorder, social anxiety disorder, and obsessive compulsive disorder. Depression is another common emotional disorder. See Table 1.1 for a description of many 6

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Table 1.1.  Emotional Disorders Diagnosis

Emotional Disorder Description

Panic Disorder (PD)

People with PD have panic attacks—​sudden rushes of intense fear with uncomfortable physical sensations (e.g., racing heart, sweating, dizziness, shortness of breath). People with PD find these experiences extremely distressing and attempt to avoid them at all costs. This avoidance may look like staying away from any place where a panic attack might happen, refraining from taking the bus or subway, and avoiding caffeinated drinks. Avoiding situations because they may lead to a panic attack is called agoraphobia.

Generalized Anxiety Disorder (GAD)

People with GAD engage in a great deal of worry about all sorts of topics (e.g., being on time, finances, health of themselves or loved ones, social issues, work/​school). Often this worry is future-​oriented and is out of proportion to the severity of the topic. Once they get started worrying, they find it very difficult to stop. People with GAD will often do things to make themselves feel better like calling to check in on loved ones, checking bank balances, overpreparing or procrastinating, and searching for information on the Internet. Unfortunately, these behaviors only make people with GAD feel better for a short time.

Social Anxiety Disorder (SAD)

People with SAD experience anxiety in situations where they might be observed or evaluated by others. In order to avoid these feelings, they might refrain from entering situations where other people are present (e.g., parties, the lunch room at work) or where they might have to speak up (e.g., classes with a public speaking component). They may also try to reduce their anxiety by avoiding eye contact or only talking about topics they know a lot about. These behaviors may make people with SAD feel better in the moment, but they lend support to the belief that others may be judging them.

Obsessive-​Compulsive Disorder (OCD)

OCD is characterized by intrusive thoughts (obsessions) that often seem nonsensical (e.g., “I’ll get HIV from touching this door knob”) but cause a great deal of distress. Often people with OCD engage in behaviors to neutralize the thoughts (compulsions). These behaviors can be time-​consuming and disruptive (e.g., repeated hand washing), but people with OCD keep doing them because they reduce the distress caused by the obsessions, at least for a little while. Unfortunately, reacting to these thoughts as if they are true (by engaging in compulsions) makes it much more likely that these thoughts will return in the future.

Posttraumatic Stress Disorder (PTSD)

Some people who have experienced a traumatic event (assault, combat, abuse) develop PTSD. This disorder is characterized by intrusive memories of the event that the individual finds quite distressing. As a result, people with PTSD avoid triggers (people, situations, activities that remind them of the trauma). They may also engage in behaviors that make them feel safe in general (e.g., having an exit strategy, always facing the door). Unfortunately, acting as though they are still in danger only increases their distress.

Depression (Major Depressive Disorder, Persistent Depressive Disorder)

People with depression report feelings of sadness and hopelessness. They often have little energy or motivation to do the things they used to find fun. Although getting active has been shown to help people with depression, it is often very difficult for people with depression to “get over the hump.” As a result, they tend to withdraw by cancelling plans and avoiding important activities. Although this avoidance brings relief in the short term, it has actually been shown to increase symptoms of depression. (continued)

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Table 1.1. Continued Diagnosis

Emotional Disorder Description

Borderline Personality Disorder (BPD)

People with BPD report feeling all of their emotions really strongly—​in fact, they are often described as moody because their emotions can change quite quickly. To manage their negative emotions, they engage in a wide range of behaviors that make them feel better in the moment but lead to even more problems in long term. These behaviors include picking fights with loved ones, seeking excessive reassurance in relationships, binge eating, drug use, reckless sex, and even hurting themselves on purpose (e.g., cutting, burning).

Eating Disorders

In eating disorders, the source of negative emotions is dissatisfaction or preoccupation with one’s shape or weight. To avoid feeling anxiety about gaining weight, a person with anorexia nervosa might restrict their eating or exercise excessively. When feeling particularly stressed out, a person with bulimia nervosa might binge eat (which usually leads to feeling numb); however, after the binge has ended, this person may feel guilt for overeating and compensate by purging.

Self-​Destructive Behavior While they do not necessarily constitute a mental health diagnosis, self-​destructive behaviors are often used to provide relief from negative emotions. These behaviors can include things like self-​injury (e.g., cutting, burning oneself on purpose), excessive drinking or substance use, lashing out or snapping at others, and other reckless behaviors (e.g., unsafe sex, overspending). These behaviors may take someone’s mind off of their emotions in the short term but can lead to negative consequences (and even more negative emotions) in the long term.

diagnoses and problems that are characterized by difficulty responding to strong emotions. You may have visited a mental health professional and received one or more of these diagnoses. In fact, it is actually quite common for people to have more than one disorder at the same time. This is because the same process—​negative reactions to strong emotions—​is behind all emotional disorders (and related problems like self-​injury and substance use). This is an important reason why we developed the treatment program here. By targeting negative, avoidant reactions to emotions, we can help you address all of the symptoms you are experiencing, regardless of the disorder. Even if you have not received one of these diagnoses, this program might still be a good fit for you. If your emotions (or the strategies you use to manage them) are interfering with living the life you want to lead, you will probably benefit from the skills taught in this workbook. For some people, strong emotions affect nearly every aspect of their lives, while

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for others, difficulties with emotions only occur in one or two contexts (e.g., public speaking, in romantic relationships). In fact, we think that everyone can benefit from learning healthy ways to respond to emotions. Either way, learning to be more accepting of emotions when they come up can help them become more manageable over time.

Is This Treatment Right for Your Symptoms? To help you think about how your own experiences might relate to what this treatment program targets, ask yourself the following questions and check the appropriate boxes. Do you often experience strong emotions in one or more situations in your life? ◻ Yes ◻ No

■

Do you find your emotions to be uncomfortable or consider them to be a sign of weakness? ◻ Yes ◻ No

■

Do you find yourself going out of your way to avoid feeling certain emotions? Is this interfering with living the life you want to lead? ◻ Yes ◻ No

■

If you answered yes to any of these questions, the program contained in this workbook may help you to feel more in control of your emotions. Although it may seem counterintuitive, by accepting emotions and facing them repeatedly over time, the intense emotions you currently experience will gradually become more manageable. By continuing to avoid emotions, they will actually occur more frequently (and intensely), and your life may become quite limited.

Summary This treatment program is designed to help people who are struggling with uncomfortable, unwanted, or overwhelming emotions. As the name suggests, people with emotional disorders experience intense emotions. They also tend to view emotions negatively, often trying to avoid them or push them away. In this chapter, we described four people who demonstrate

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some of the many ways emotions might interfere in a person’s life. There are a variety of disorders that fall into the category of emotional disorders. These include many types of anxiety disorders (social anxiety disorder, panic disorder, generalized anxiety disorder), obsessive-​compulsive disorder, posttraumatic stress disorder, and depressive disorders. This treatment program is designed to directly address the overwhelming emotional experiences at the core of all these disorders. In the next chapter, we will provide an overview of the treatment program. This will allow you to decide if this treatment is right for you.

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CHAPTER 2

About This Treatment

GOALS To provide an overview of the skills you will learn in this treatment ■ To highlight the importance of practicing these skills ■ To describe how this treatment can be used in combination with other treatments like medication and other types of therapy ■ To determine if now is the right time to begin this program ■

In the previous chapter, we discussed some of the problems that this treatment can address. Now let’s explore whether this treatment program is right for you.

Outline of the Treatment Each chapter of this workbook will teach you new skills to manage your emotions. As a reminder, the overall goal of this treatment is to become more accepting of your emotions when they come up in order to respond to them in more productive ways. You can think of building a healthier relationship with your emotions as similar to building a new house (see Figure 2.1). You have to start by laying a solid foundation. We will begin by encouraging you to identify your personal reasons for making the changes outlined in this program in order to motivate you to put your best effort into developing these skills (Setting Goals and Maintaining Motivation—​Chapter 4).

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EMOTION EXPOSURE

COGNITIVE FLEXIBILITY

COUNTERING EMOTIONAL BEHAVIORS

FACING PHYSICAL SENSATIONS

MINDFUL EMOTION AWARENESS

UNDERSTANDING YOUR EMOTIONS

SETTING GOALS & MAINTAINING MOTIVATION

Figure 2.1    

After solidifying the necessary foundation for success, the ground floor of this program involves developing a greater understanding of your own emotional experiences. Given that accepting and approaching emotions may sound very different than what you expected, we will discuss why we have emotions in the first place and how they actually help us. We will also teach you to break your emotions down into more manageable parts. Specifically, we will ask you to pay attention to your thoughts (what you tell yourself ), physical sensations (what you feel in your body), and behaviors (what you do). This will help you understand how your emotions can escalate and become overwhelming for you (Understanding Your Emotions—​Chapters  5 and 6). We will continue talking about these three components (thoughts, physical sensations, and behaviors) throughout this treatment. After we’ve discussed why it makes sense to accept emotions as they come up, we will teach you a skill that will help you relate to your emotions in

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a more accepting way. The skill is called Mindful Emotion Awareness (Chapter 7). You can think of this like going up to the second floor of the house to gain a different perspective on your emotional experiences. Specifically, we will ask you to look down on your thoughts, physical sensations, and behaviors in a nonjudgmental way. In other words, you will practice going easier on yourself for having emotional reactions because beating yourself up only makes you feel worse. The next step will be to zero in on each of the three components of an emotion: thoughts, physical sensations, and behaviors. These three components each occupy a room on the third floor of our house—​behind each door is a new coping skill. First, you will learn about how the way you think about situations in your life can really color how you feel about them. We will teach you a skill called Cognitive Flexibility (Chapter 8) that will encourage you to question your first impressions so that you can think about things in a more balanced way. Next, we will focus on a skill called Countering Emotional Behaviors (Chapter 9). Here we will ask you to begin to act in ways that approach emotions, rather than pushing them away. Finally, you will learn a skill called Understanding and Confronting Physical Sensations (Chapter 10). We will discuss the way that physical sensations contribute to how you experience emotions. We will also teach you exercises that will help you become more comfortable experiencing the physical sensations that go along with your emotions. After you have learned skills to cope with strong emotions, it is important to put them into practice. The best way to do this is by facing situations or activities that bring up strong emotions. We call these practices Emotion Exposures (Chapter 11). In addition to helping you practice your new skills, emotion exposures allow you to learn important information about emotions themselves. By facing emotions, we learn that they are temporary and that we can actually tolerate them more than we thought we could. Seeing this firsthand (versus reading about it in this workbook) is a very powerful way to develop that accepting attitude toward emotions we’ve been talking about. This is the pinnacle of treatment and occupies the attic of the house. Finally, the last chapter in the book, Moving UP from Here (Chapter 13), is dedicated to making sure you maintain the gains you made throughout your hard work with this treatment.

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How Should You Use This Treatment Manual? This program is designed for you to go through at your own pace, but we recommend spending enough time on each chapter to really get comfortable using the skills. Each chapter ends with a quiz to test how well you understood the skill introduced in that chapter. The answers to these quizzes can be found in Appendix A. If you find yourself struggling with the answers to these quizzes, go back and read through the chapter again. Each chapter also has exercises to help you practice the skills in response to strong emotions in your own life. Practice is extremely important! Reading this book is not enough—​you have to make real changes in the way you cope with your emotions in order to see improvements in how you feel. Think of it like deciding to enter a marathon. You can’t just sign-​ up and expect to be able to run 26 miles. You have to exercise a bit more every day until you finally build the strength to carry you through. That’s why we discuss Setting Goals and Maintaining Motivation (Chapter 4) to make sure you are ready to fully commit to this program.

Can You Do this Treatment at the Same Time as Other Treatments? If you are involved in another treatment program to help you cope with your overwhelming emotions, you should wait until that program is finished before starting this one. Different treatment programs can sometimes provide mixed messages about what you should be doing to manage your symptoms. If you have just started a different program, you might want to give it a chance to show results. If you are still struggling at the end of treatment, you can give this program a try. On the other hand, if you are seeing a therapist for another reason (e.g., supportive counseling, marital counseling), there is no reason why you can’t do both at the same time. If you are currently taking medications for your symptoms, you can continue to take them throughout this program. Keep in mind that certain medications are designed to dampen your emotions, including common prescriptions like Xanax or Klonopin. Since the goal of this program is to help you practice coping more effectively with emotions as you experience them, these medications may make it more difficult to get the full benefit of the program. Chapter 12, The Role of Medication in the Treatment of Emotional Disorders, will provide more information about the types

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of drugs that are often prescribed for people struggling with difficult emotions and how those medications may impact this treatment. We recommend that you work through this program with the help of your healthcare provider or therapist. However, this program can also be done on your own.

What Are the Benefits of This Program? This treatment was developed at the Center for Anxiety and Related Disorders at Boston University. Our center is dedicated to conducting cutting-​edge research on understanding how emotional disorders develop, as well as the best way to treat them. Researchers at our center have a long history of creating successful treatments for common mental health disorders. We have now used this treatment program with hundreds of patients, and approximately 70% of them experienced significant improvements. The majority of patients report being able to use the skills taught in this program to better cope with their emotions. Additionally, many patients also report significantly improved ability to achieve goals in many aspects of their lives (e.g., improved relationships, improved performance at work). You will be able to monitor your own progress throughout treatment by completing brief questionnaires each week. This progress monitoring will be described in Chapter 3, Learning to Record Your Experiences. This treatment is a chance to gain back a part of your life that may be missing now because of your symptoms. Of course, we cannot promise that these skills will lead to significant improvements for everyone. However, the biggest predictor of success is the amount of effort you dedicate to this program. The more you put into this treatment, the more you will get out of it.

What Are the Costs of This Program? Like most important goals, changing how you cope with your emotions takes work. The biggest cost of using the program in this workbook is time and effort. You should be prepared to set aside time each day to practice the skills you’re learning. Additionally, it is best if you continue to move through the skills without long breaks. Think of it like signing up for a course in school—​for the three to four months you’re enrolled,

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you are learning new concepts and regularly doing homework to practice what you have learned. If you are unable to make this commitment, it may not be the right time to try this program. In order to really give this program a chance to work, you have to be willing to see it through from beginning to end. Keep in mind that many people feel nervous about committing to confront difficult emotions. However, when they take it step-​by-​step, they surprise themselves.

Summary This chapter provided an overview of the skills included in this program to address the ways you are responding to your emotions that may be maintaining your difficulties. These skills are most helpful when practiced regularly. You can work through the program on your own, but we find that enlisting the help of a therapist can be useful. You can also continue to use medications for your symptoms and can refer to Chapter 12 for information on the role of medication in treating emotional disorders. Overall, the majority of people who complete this treatment see at least some improvement in their symptoms, with most making significant gains. In the next chapter, we will discuss monitoring your experiences so that you can get the most out of this program.

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CHAPTER 3

Learning to Record Your Experiences

GOALS To learn the importance of record-​keeping ■ To introduce you to questionnaires you’ll be using to monitor your emotions ■ To learn how to track your progress throughout this treatment ■

Key Concepts In this chapter, we will help you to understand the importance of monitoring and recording your experience. For the rest of this program, you will be asked to keep track of your efforts practicing each skill using homework forms at the end of each chapter. We will also ask you to monitor the emotions you’re experiencing week by week. Keeping ongoing records of your experiences will help you understand how changing your relationship with your emotions corresponds to the gains you’re making in treatment.

Why Take the Time to Record? There are many reasons why it is important to keep records of your experiences on a regular basis. First, intense anxiety, sadness, or other uncomfortable emotions typically feel overwhelming. Learning to be an observer

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of your own emotions is a first step toward understanding these experiences and feeling more in control. Throughout this treatment, you will be learning specific skills that will help you respond to your emotions in more helpful ways. Given that everyone has unique experiences, recording your personal examples will also help you figure out how to best apply the treatment strategies to meet your individual needs. As you practice applying your new skills, ongoing monitoring will highlight the impact they are having on your emotional experiences. You’ll be able to answer the question, “How is this new strategy helping?” Finally, monitoring your overall progress during the treatment will help you track the gains you are making.

Becoming an Objective Observer A systematic approach to monitoring your experiences provides much more accurate information than simply asking yourself, “How have I been feeling lately?” If you were asked to describe the past week, you may judge it to have been very bad even though you felt relatively good at some points. Or you might evaluate how you felt over the entire week on the basis of how you felt over just the past couple of days. Focusing on your negative emotions makes it easy to forget about the times you didn’t feel that way. Not only that, these negative judgments about how you’ve been doing in general may be contributing to your ongoing feelings of anxiety, sadness, or other distressing emotions. Keeping records of your emotional experiences helps you to recognize that your mood fluctuates. Through this process, you will begin to get a more realistic picture of what is really going on for you, enabling you to feel more in control. Sometimes people are concerned that continually recording how they’re feeling will make them feel even worse. It is important to realize, however, that the way you observe your experiences matters. For example, subjective monitoring means focusing on how bad you feel, how much your emotions are interfering in your life, and how helpless you feel to control them. In contrast, we’ll be asking you to engage in objective monitoring, which involves observing your emotions in a more “scientific” way. In this program, you will learn to record things such as how many times over the course of the week you felt a certain way, what was happening right before you felt distressed, and how you responded (what you were thinking,

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doing, and feeling). In other words, you will be recording just the facts and evidence, not your judgments or evaluations of how good or bad the experience may have been for you. At first, it may be difficult to switch from subjective to objective monitoring. As you start to use the record forms included in this workbook, you may even notice an increase in your distress because you are focusing on your emotions in the old, subjective way. However, with practice, you will begin to find switching into the objective mode easier and easier.

What Do You Record? As you go through each chapter in this book, you will be introduced to specific record forms that have been developed to help you practice each new skill. In addition, there are four forms that you will use throughout the entire program. The first two forms will allow you to objectively record how often you experienced the general anxiety and depression common to all emotional disorders over the past week, as well as how much these feelings interfered in your daily life. These forms are called the Overall Anxiety Severity and Interference Scale1 (Anxiety Scale) and the Overall Depression Severity and Interference Scale2 (Depression Scale). We will ask you to complete these two measures every week for the duration of your program. Tracking your scores on the Anxiety Scale and Depression Scale from week to week will be the main way you evaluate your progress. In addition, we have included two other forms that you may find useful for tracking your progress in treatment. First, if another emotion (beyond anxiety and depression) has been significantly overwhelming or interfering for you (e.g., anger, shame, jealousy), you can track it using the Other Emotion Severity and Impairment Scale (Other Emotion Scale). Additionally, if it has been difficult to experience positive emotions (e.g., joy, excitement), we encourage you to use the Overall Positive Emotion

Norman, S. B., Cissell, S. H., Means-​Christensen, A. J., & Stein, M. B. (2006). Development and validation of an overall severity and impairment scale (OASIS). Depression and Anxiety, 23, 245–​249. 2 Bentley, K. H., Gallagher, M. W., Carl, J. R., & Barlow, D. H. (2014). Development and validation of the overall depression severity and impairment scale. Psychological Assessment, 26, 815–​830. 1

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Scale (Positive Emotion Scale) to help you recall times when you experienced positive emotions over the past week. Keeping a record of changes in your emotional experiences is an important way to help keep yourself moving forward, especially during those times when you might feel frustrated or discouraged. Use the information gathered from the Anxiety and Depression Scales (as well as the Other Emotion and Positive Emotion Scales if you’re using them) to chart your progress week by week on the Progress Record. The Progress Record is designed to summarize your improvement so that you can easily view changes over the course of the entire program. A blank copy of the Progress Record is provided at the end of this chapter. On the bottom of the scale, you will see one number for each week you use this program. Use the numbers on the left side of the scale to plot your total score on the Anxiety, Depression, Other Emotion, and Positive Emotions Scales for each week. You may want to use a different colored pen for each scale or different shape to plot the score for each scale in order to tell the scales apart. If you are working through this program with a therapist, you might be asked to complete these scales at the start of each session, along with graphing your progress from week to week on the Progress Record. See Appendix B (p. 165) for an example of how a Progress Record might look. Generally speaking, we expect that you will experience a decrease in anxiety, depression, and other emotional distress as you begin to practice the skills included in this treatment. In contrast, you will likely experience an increase in positive emotions as you tackle the problem areas in your life. Also, notice that progress does not occur in a straight line, but instead there are some peaks and valleys along the way. This is typical for most people, and you may find a similar pattern emerges for your own progress. Oftentimes, people notice a spike in their anxiety and depression during times of increased stress. Additionally, people sometimes notice an increase in their distress as they start making meaningful and hard changes in their lives. In these cases, the increase in distress is a marker of really challenging oneself. If you find your own experience seems to be worse one week than it was the week before, challenge yourself to keep going. The goal of the treatment program is to have fewer of these “spikes” in distress. When they do occur, with practice, you’ll be able to respond differently to them so that your emotional experiences are less intense and don’t last as long.

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Summary We cannot emphasize enough the importance of record-​ keeping. Remember, there is a difference between subjective monitoring—​focusing on how bad you feel—​and objective monitoring—​looking at the features of your experience in a more “scientific” way. Completing the Anxiety and Depression Scales (as well as the Other Emotion and Positive Emotions Scales) and Progress Record weekly will help keep you keep your progress in perspective. At first, you may have to push yourself to complete these records, but it will become easier, and even rewarding, as you continue. These records not only serve to give yourself feedback, but are also very helpful to your mental health professional, if you are seeing one. In the next chapter, we will present two more important concepts that will help prepare you to start this treatment program—​setting your treatment goals and maintaining your motivation to engage in treatment.

Homework Begin to monitor your weekly experiences using the Anxiety and Depression Scales. Use these forms to get into the habit of objectively recording how often you experienced anxiety and depression over the past week, as well as how much these feelings interfered in your daily life. It may be helpful to photocopy these forms so that you have a fresh copy to complete each week. Alternatively, blank versions of these forms are available for download from the TreatmentsThatWorkTM website at http://www. oup.com/us/ttw. ■ Optional—​monitor your weekly experiences using the Other Emotion and Positive Emotions Scales. Use these forms to objectively rate how often you experienced the emotion you selected as most relevant to you (e.g., anger, shame), as well as how often you experienced positive emotions over the past week. ■ Use the Progress Record to begin charting your progress through the program, recording the total scores from the Anxiety and Depression Scales (as well as Other Emotion and Positive Emotions Scales) week by week. ■

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Self-​Assessment Quiz Answer each of the following by circling true (T) or false (F). Answers can be found in Appendix A. 1. Record-​keeping helps you have a better understanding of your emotional experience. T

F

2. Objective monitoring and record-​keeping means focusing on how bad you feel. T

F

3. You should be able to easily switch from subjective to objective monitoring without practicing it, and if you can’t you must be doing it wrong. T

F

4. Objective monitoring and record-​keeping help give you more accurate information about your experiences; for example, allowing you to see there may actually have been some good moments in a week you judged as all bad. T

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Form 3.1: Anxiety Scale The following items ask about anxiety. For each item, circle the number for the answer that best describes your experience over the past week. 1.  In the past week, how often have you felt anxious? 0 = No anxiety in the past week. 1 = Infrequent anxiety. Felt anxious a few times. 2 = Occasional anxiety. Felt anxious as much of the time as not. It was hard to relax. 3 = Frequent anxiety. Felt anxious most of the time. It was very difficult to relax. 4 = Constant anxiety. Felt anxious all of the time and never really relaxed. 2.  In the past week, when you have felt anxious, how intense or severe was your anxiety? 0 = Little or None: Anxiety was absent or barely noticeable. 1 = Mild: Anxiety was at a low level. It was possible to relax when I tried. Physical symptoms were only slightly uncomfortable. 2 = Moderate: Anxiety was distressing at times. It was hard to relax or concentrate, but I could do it if I tried. Physical symptoms were uncomfortable. 3 = Severe: Anxiety was intense much of the time. It was very difficult to relax or focus on anything else. Physical symptoms were uncomfortable 4 = Extreme: Anxiety was overwhelming. It was impossible to relax at all. Physical symptoms were unbearable. 3. In the past week, how often did you avoid situations, places, objects, or activities because of anxiety or fear? 0 = None: I do not avoid places, situations, activities, or things because of fear. 1 = Infrequent: I avoid something once in a while, but will usually face the situation or confront the object. My lifestyle is not affected. 2 = Occasional:  I have some fear of certain situations, places, or objects, but it is still manageable. My lifestyle has only changed in minor ways. I always or almost always avoid the things I fear when I’m alone, but can handle them if someone comes with me. 3 = Frequent: I have considerable fear and really try to avoid the things that frighten me. I have made significant changes in my lifestyle to avoid the object, situation, activity, or place. 4 = All the Time: Avoiding objects, situations, activities, or places has taken over my life. My lifestyle has been extensively affected and I no longer do things that I used to enjoy. 4. In the past week, how much did your anxiety interfere with your ability to do the things you needed to do work, at school, or at home? 0 = None: No interference at work/​home/​school from anxiety. 1 = Mild: My anxiety has caused some interference at work/​home/​school. Things are more difficult, but everything that needs to be done is still getting done. 2 = Moderate: My anxiety definitely interferes with tasks. Most things are still getting done, but few things are being done as well as in the past. 3 = Severe: My anxiety has really changed by ability to get things done. Some tasks are still being done, but many things are not. My performance has definitely suffered. 4 = Extreme: My anxiety has become incapacitating. I am unable to complete tasks and have had to leave school, have quit or been fired from my job, or have been unable to complete tasks at home and have faced consequences like bill collectors, eviction, etc. 5. In the past week, how much has anxiety interfered with your social life and relationships? 0 = None: My anxiety doesn’t affect my relationships. 1 = Mild: My anxiety slightly interferes with my relationships. Some of my friendships and other relationships have suffered, but, overall, my social life is still fulfilling. 2 = Moderate: I have experienced some interference with my social life, but I still have a few close relationships. I don’t spend as much time with others as in the past, but I still socialize sometimes. 3 = Severe:  My friendships and other relationships have suffered a lot because of anxiety. I  do not enjoy social activities. I socialize very little. 4 = Extreme: My anxiety has completely disrupted my social activities. All of my relationships have suffered or ended. My family life is extremely strained. TOTAL SCORE: _​_​_​_​_​_​_​_​_​_​_​_​ Reprinted from Norman, S. B., Cissell, S. H., Means-​Christensen, A. J., & Stein, M. B. (2006). Development and validation of an overall severity and impairment scale (OASIS). Depression and Anxiety, 23, 245–​249.

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Form 3.2: Depression Scale The following items ask about depression. For each item, circle the number for the answer that best describes your experience over the past week. 1.  In the past week, how often have you felt depressed? 0 = No depression in the past week. 1 = Infrequent depression. Felt depressed a few times. 2 = Occasional depression. Felt depressed as much of the time as not. 3 = Frequent depression. Felt depressed most of the time. 4 = Constant depression. Felt depressed all of the time. 2.  In the past week, when you have felt depressed, how intense or severe was your depression? 0 = Little or None: Depression was absent or barely noticeable. 1 = Mild: Depression was at a low level. 2 = Moderate: Depression was intense at times. 3 = Severe: Depression was intense much of the time. 4 = Extreme: Depression was overwhelming. 3. In the past week, how often did you have difficulty engaging in or being interested in activities you normally enjoy because of depression? 0 = None: I had no difficulty engaging in or being interested in activities that I normally enjoy because of depression. 1 = Infrequent: A few times I had difficulty engaging in or being interested in activities that I normally enjoy because of depression. My lifestyle was not affected. 2 = Occasional: I had some difficulty engaging in or being interested in activities that I normally enjoy because of depression. My lifestyle has only changed in minor ways. 3 = Frequent:  I have considerable difficulty engaging in or being interested in activities that I  normally enjoy because of depression. I have made significant changes in my life style because of being unable to become interested in activities I used to enjoy. 4 = All the Time: I have been unable to participate in or be interested in activities that I normally enjoy because of depression. My lifestyle has been extensively affected and I no longer do things that I used to enjoy. 4. In the past week, how much did your depression interfere with your ability to do the things you needed to do at work, at school, or at home? 0 = None: No interference at work/​home/​school from depression 1 = Mild: My depression has caused some interference at work/​home/​school. Things are more difficult, but everything that needs to be done is still getting done. 2 = Moderate: My depression definitely interferes with tasks. Most things are still getting done, but few things are being done as well as in the past. 3 = Severe: My depression has really changed my ability to get things done. Some tasks are still being done, but many things are not. My performance has definitely suffered. 4 = Extreme: My depression has become incapacitating. I am unable to complete tasks and have had to leave school, have quit or been fired from my job, or have been unable to complete tasks at home and have faced consequences like bill collectors, eviction, etc. 5. In the past week, how much has depression interfered with your social life and relationships ? 0 = None: My depression doesn’t affect my relationships. 1 = Mild: My depression slightly interferes with my relationships. Some of my friendships and other relationships have suffered, but, overall, my social life is still fulfilling. 2 = Moderate: I have experienced some interference with my social life, but I still have a few close relationships. I don’t spend as much time with others as in the past, but I still socialize sometimes. 3 = Severe: My friendships and other relationships have suffered a lot because of depression. I do not enjoy social activities. I socialize very little. 4 = Extreme: My depression has completely disrupted my social activities. All of my relationship have suffered or ended. My family life is extremely strained. TOTAL SCORE: ___________​ Reprinted from Barlow, D. H., Ellard, K. K., Fairholme, C. P., Farchione, T. J., Boisseau, C. L., Ehrenreich May, J. T., & Allen, L. B. (2011). Unified Protocol for Transdiagnostic Treatment of Emotional Disorders, Workbook. New York: Oxford University Press. Reprinted with permission.

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Form 3.3: Other Emotion Scale (optional) Identify an emotional experience that you’ve been struggling with (i.e., anger, shame, jealousy). Enter the emotion in the _​_​_​_​ for each question. For each item, circle the number for the answer that best describes your experience with that emotion over the past week. 1.  In the past week, how often have you felt _​_​_​_​_​_​_​_​_​? 0 = No, I did not feel this emotion in the past week. 1 = Infrequent. I felt this emotion a few times. 2 = Occasional. I felt this emotion as much of the time as not. 3 = Frequent. I felt this emotion most of the time. 4 = Constant. I felt this emotion all of the time. 2.  In the past week, when you have felt _​_​_​_​_​_​_​, how intense or severe was your _​_​_​_​_​_​_​? 0 = Little or None: This emotion was absent or barely noticeable. 1 = Mild: This emotion was at a low level. 2 = Moderate: This emotion was intense at times. 3 = Severe: This emotion was intense much of the time. 4 = Extreme: This emotion was overwhelming. 3. In the past week, how often did you have difficulty engaging in or being interested in activities you normally enjoy because of _​_​_​_​_​_​_​? 0 = None: I had no difficulty engaging in or being interested in activities that I normally enjoy because of this emotion. 1 = Infrequent: A few times I had difficulty engaging in or being interested in activities that I normally enjoy because of this emotion. My lifestyle was not affected. 2 = Occasional: I had some difficulty engaging in or being interested in activities that I normally enjoy because of this emotion. My lifestyle has only changed in minor ways. 3 = Frequent: I have considerable difficulty engaging in or being interested in activities that I normally enjoy because of this emotion. I have made significant changes in my life style because of being unable to become interested in activities I used to enjoy. 4 = All the Time: I have been unable to participate in or be interested in activities that I normally enjoy because of this emotion. My lifestyle has been extensively affected and I no longer do things that I used to enjoy. 4. In the past week, how much did your _​_​_​_​_​_​_​interfere with your ability to do the things you needed to do at work, at school, or at home? 0 = None: No interference at work/​home/​school from this emotion. 1 = Mild: This emotion has caused some interference at work/​home/​school. Things are more difficult, but everything that needs to be done is still getting done. 2 = Moderate: This emotion definitely interferes with tasks. Most things are still getting done, but few things are being done as well as in the past. 3 = Severe: This emotion has really changed my ability to get things done. Some tasks are still being done, but many things are not. My performance has definitely suffered. 4 = Extreme: This emotion has become incapacitating. I am unable to complete tasks and have had to leave school, have quit or been fired from my job, or have been unable to complete tasks at home and have faced consequences like bill collectors, eviction, etc. 5.  In the past week, how much has _​_​_​_​_​_​_​_​ interfered with your social life and relationships? 0 = None: This emotion doesn’t affect my relationships. 1 = Mild: This emotion slightly interferes with my relationships. Some of my friendships and other relationships have suffered, but, overall, my social life is still fulfilling. 2 = Moderate: I have experienced some interference with my social life, but I still have a few close relationships. I don’t spend as much time with others as in the past, but I still socialize sometimes. 3 = Severe: My friendships and other relationships have suffered a lot because of this emotion. I do not enjoy social activities. I socialize very little. 4 = Extreme: This emotion has completely disrupted my social activities. All of my relationship have suffered or ended. My family life is extremely strained. TOTAL SCORE: ____________​

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Form 3.4: Positive Emotion Scale (Optional) The following items ask about positive emotions. For each item, circle the number for the answer that best describes your experience over the past week. 1. In the past week, how often have you felt positive emotions (happiness, excitement, joy, etc)? 0 = No positive emotions in the past week. 1 = Infrequent positive emotions. Felt positive emotions a few times. 2 = Occasional positive emotions. Felt positive emotions as much of the time as not. 3 = Frequent positive emotions Felt positive emotions most of the time. 4 = Constant positive emotions. Felt positive emotions all of the time. 2.  In the past week, when you have felt positive emotions, how intense were these feelings? 0 = Little or None: Positive emotions were absent or barely noticeable. 1 = Mild: Positive emotions were at a low level. 2 = Good: Positive emotions were strong at times. 3 = Great: Positive emotions were strong much of the time. 4 = Excellent: Positive emotions were strong most of the time. 3. In the past week, how often did you engage in or maintain interest in activities because of positive emotions? 0 = None: I  had difficulty engaging in or being interested in activities that I  normally enjoy because of minimal positive emotion. 1 = Infrequent: I engaged in or maintained interest in activities because of positive emotion a few times. 2 = Occasional: I engaged in or maintained interest in activities because of positive emotions some of the time. My lifestyle includes a few activities that I enjoy. 3 = Frequent: I frequently engage in or maintain interest in activities because of positive emotions. I have made significant changes in my lifestyle to include activities that I enjoy. 4 = All the Time: Positive emotions help me to engage in or maintain interest in nearly all of my activities. My lifestyle reflects the activities that I enjoy the most. 4. In the past week, how much did your positive emotions enhance your ability to do the things you needed to do at work, at school, or at home? 0 = None: No enhancement at work/​home/​school from positive emotions. 1 = Mild: My positive emotions have enhanced some aspects of work/​home/​school. 2 = Good: My positive emotions definitely enhance enjoyment in my tasks. 3 = Great: My positive emotions have really changed my ability to get things done for the better. 4 = Excellent: My positive emotions have improved my quality of life in the best possible way. 5. In the past week, how much have positive emotions enhanced your social life and relationships? 0 = None: My positive emotions have not affected my relationships. 1 = Mild: My positive emotions slightly enhance my relationships. 2 = Good: I have experienced some enhancement in my social life due to positive emotions. I have noticed that I enjoy my relationships more and participate in more social interactions. 3 = Great: My friendships and other relationships have improved a lot because of my positive emotions. I enjoy social activities and socialize frequently. 4 = Excellent: My positive emotions have completely enhanced my social activities. All of my relationship have improved. My family life is positive. TOTAL SCORE: _______________​

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Form 3.5: Progress Record Use this form to plot your scores from the Anxiety and Depression Scales (as well as the Other Emotion and Positive Emotion Scales, if you are using them).

Scores on the Scales

Key: : Anxiety Scale : Depression Scale : Other Emotion Scale : Positive Emotion Scale

20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 1

2

3

4

5

6

7

8

9 10

11 12 Week

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CHAPTER 4

Setting Goals and Maintaining Motivation

GOALS To identify top problems to focus on during treatment ■ To set specific steps you can take to address your top problems during treatment ■ To discuss the importance of motivation for success ■ To explore costs and benefits of changing and remaining the same ■

Homework Review Did you complete your Anxiety and Depression Scales (and your Other Emotion and Positive Emotion Scales if you’ve chosen to complete them) for last week? Did you plot your total scores on the Progress Record? If so, well done! You can refer back to these first records as your starting point. In the chapters that follow, you will be introduced to more forms to help you practice your skills, so it is good that you are getting in the habit of recording now. If you did not do the record-​keeping this past week, think of what may have kept you from recording your experiences and what will help you stick to it. Is there a time each day that you can devote 10 minutes to recording? Can you leave forms somewhere that will remind you to complete them or add a reminder into your calendar to prompt you? Remember, record-​keeping enables you to develop a more objective level of self-​awareness and will help you to track your progress throughout this program. If you have not completed the monitoring for

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this past week using the Anxiety and Depression Scales, we recommend you complete these before continuing.

Key Concepts We’ve discussed the importance of monitoring your emotional experiences and progress during treatment. In this chapter, we’ll focus on identifying the ways that your emotions are interfering with your life—​the top problems you would like to change. We’ll also discuss the importance of you finding and maintaining motivation for making these difficult changes. The topics covered in this chapter form the necessary foundation for building a healthier relationship with your emotions (see Figure 4.1). The rest of the skills in this book build upon this groundwork.

SETTING GOALS & MAINTAINING MOTIVATION

Figure 4.1    

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Clarifying Problem Areas The first step in change is becoming clear on the types of problems that you have been experiencing. By having a better understanding of your current problems, you’ll know how to focus your efforts in the treatment program. It is important to define your top problem areas in a concrete, measureable way so that you can determine if you are moving toward the change that you are hoping for. It may be helpful to start with the basics:  In what ways have your emotions (i.e., feeling sad, anxious, guilty, angry) caused problems in your life? Have you stopped doing things that you use to enjoy? Are there experiences that you are missing out on because you don’t want to feel uncomfortable? Sometimes the way that people try to manage their negative emotions leads to even more problems (e.g., drinking to feel more comfortable in social situations, cutting to feel numb, checking locks repeatedly to decrease anxiety). Have some of your behaviors become problematic for you? Are your negative emotions impacting your relationships? Answers to some of these questions may help you clarify the top problem areas that you would like to work on. Use the following space provided to identify the ways in which your emotions have been interfering with the life you want to live. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_ Circle the two top problems you would most like to address with this treatment. Then transfer these problems to the first column on the Treatment Goals Form at the end of this chapter. Sometimes people notice that they feel increased distress as they sit down and think about the problems that they have been experiencing. Try not to feel discouraged. By clarifying the problem areas in your life, you are taking a step toward gaining control. Remember, once you’ve identified your top problems, you will have a much better idea of how to focus your efforts in the treatment.

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Setting Manageable Goals Now that you’ve identified how your emotions are interfering in your life, let’s think about what you would like to change. In other words, what are your goals related to each problem area you’ve identified? What do you hope will be different four months from now? Research has shown that setting specific, concrete, and manageable goals greatly improves our chances of successfully changing. So, instead of saying something general like, “I want to be less anxious,” you might say something more specific, such as, “I want to be able to take public transportation, ride elevators, and drive over bridges.” With the latter goals, it is much easier to evaluate whether you’ve achieved them. Go ahead and write down your goals associated with each top problem in the second column of the Treatment Goals Form. The next step is to think about specific behaviors that you can do to move you toward reaching your overall goals. It can sometimes be really overwhelming to imagine going from Point A (how you’re living now) to Point B (how you’d like to be). For this reason, we want to break down our larger goals into more manageable steps. For example, if your long-​ term goal is to make friends, you might start looking into group classes, community events, or social activities that you could participate in. The next step may be to actually attend the activity, even if you don’t know anyone. Additional steps could include attending the event regularly, having extended conversations with an acquaintance, and ultimately asking for contact information from this acquaintance in order to make plans. Now take some time to fill out the rest of the Treatment Goals Form on your own. Sometimes it can be difficult to complete this worksheet, as it might feel like the steps necessary to meet your goal are not manageable. When completing this part of the form, start with a step that seems doable, even if you have to push yourself a little bit. As you start to generate additional steps, try not to get hung up on whether you can accomplish them right now. Instead, ask yourself whether the steps you are writing down are specific behaviors that can be completed in a limited time period. Also, remember that you will be learning new skills as you go through treatment that will help you move forward with these steps. So, even if a step toward you goal seems impossible now, it may not feel that way in a few weeks. It is also okay if you have a hard time identifying all the specific steps to take for each of your goals. Your therapist or a trusted friend may be able to help you come up with more ideas. You can make

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copies of the Treatment Goals Form if you’d like to set goals for more than two problem areas. A completed example of the Treatment Goals Form can be viewed in Appendix B on p. 166.

Tracking Changes in Top Problem Areas Just as it is important to record the changes in your emotional experiences, it is important to keep track of changes in your problem areas. By keeping track of the steps you are taking to make changes in your problem areas, you’ll have a better, more objective understanding of your treatment gains. You will also have a better idea of what you will need to continue to work on to reach your goals. At several points throughout this treatment we will ask you to reflect on the progress you’ve made on the goals you identified.

Motivation Now that you’ve identified your top problem areas and your goals to address them, let’s think about what you’ll need to successfully change. First and foremost, the more you engage with this treatment, the more progress you will make. Second, the more motivated and committed you are to changing, the more likely you are to stay engaged in the treatment procedures. It is important to keep in mind that motivation is not fixed—​it changes over time. Some days your motivation will be high and you’ll feel ready to face the practice exercises laid out in this workbook. However, other days it might be more difficult to get yourself to complete your homework. External factors like increased stress at work or school, feeling particularly tired or sick, or having more to do than usual can all reduce your motivation for engaging in the treatment procedures. Additionally, we’ll be asking you to approach your emotions instead of trying to push them away; this may actually make you feel your emotions more strongly before you start to feel better. At some points, you might even feel like it is not worth the time and effort to make some of these difficult changes. This is completely normal! Recognizing that many factors can affect your motivation and allowing yourself to occasionally have doubts is important. Remember, it is all part of the change process. During times of lower

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motivation, it can be helpful to revisit the reasons why you set out to make these changes in the first place. If low motivation is a consistent problem for you, as is often the case for people with depression, it can be helpful to brainstorm ways of getting yourself to start working on this treatment even though you may not feel up to it. This might include talking to your therapist or a friend or family member about your goals so that they can help keep you accountable. It could also include setting specific times where, regardless of whether you’re motivated, you make a deal with yourself to work on therapy homework while learning to tolerate the feelings of low motivation. Often people make the mistake of “waiting for the motivation to arrive” before making changes. However, when you “get the ball rolling” and start moving toward your goals, motivation often improves and makes it easier to keep going.

Decisional Balance Exercise Very often, the reasons people have for making changes in their lives are fairly obvious (e.g., “I can’t keep living this way”), which leads them to conclude that they’re 100% ready to move forward with all that this program asks of them. Of course, it is very important to use your top problems and goals as a motivator. That said, it is also necessary to identify potential barriers (e.g., “change can be quite difficult and time consuming”) so that you can be proactive in overcoming them. We use the Decisional Balance Form at the end of this chapter to explore all the pros and cons you can think of both for changing (or engaging with this treatment) and for staying the same. A completed sample of the form is shown in Appendix B on p. 167. It can be helpful to think about the ways your current state is working for you—​even though it may be difficult to admit these reasons to yourself. For example, even though you may have identified perfectionistic behaviors such as triple-​checking all your emails before sending them as contributing to your distress, it may be difficult to let go of them if you think you will not perform as well at work or school. It is important to be honest with yourself and recognize all the reasons for and against both changing and staying the same. Let’s first take a closer look at the benefits of changing. This is often the easiest box on the Decisional Balance Form to complete because most

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people have given this quite a bit of thought before starting the treatment. Common benefits that people write down range from global benefits, such as “I’ll be able to live my life fully again” to more specific pros like “I’ll be able to fly to my niece’s wedding.” Many of the benefits you have identified probably match your treatment goals. It is just as important, however, to consider the costs of changing so that you have realistic expectations of barriers that may come up for you. Many people note that “change will take a lot of time,” and “it will be hard work.” It is true that this treatment will take a lot of effort and will ask you to respond to your emotions in new ways that might feel uncomfortable at first. Another common reason that people cite as a possible cost of participating in this program is the fear that if treatment doesn’t work, they will somehow be worse off than before. This belief may prevent you from putting forth your best effort in treatment—​and then, if it doesn’t work, you can blame your lack of effort instead of taking it as evidence that there is something wrong with you. Of course, everyone progresses at different rates, but no matter what, it is very likely that you’ll be better off than when you started. You will have a better understanding of how emotions become problematic, and you will have a strong set of skills to help break this cycle. Additionally, people who experience a great deal of guilt may sometimes feel as though they don’t deserve to use skills to improve their lives. Now let’s explore some benefits of staying the same. People often note that “it will be easier” to stay the same. Indeed, it certainly might seem like it would be a lot less effort to refrain from engaging in this treatment. You wouldn’t have to spend time reading this workbook, and you wouldn’t be filling out these forms. However, think about how much time and effort it takes to avoid your uncomfortable emotions. It might feel easier because it is what you are used to doing, but it takes a lot of time and energy to continue avoiding your emotions. Finally, let’s discuss cons for staying the same. The most common reason people place in this box is that they will continue to struggle with their feelings and continue to be limited in their daily lives. Take a few minutes to fill out the Decisional Balance Form with your own pros and cons before continuing. Once you’ve finished, consider whether the pros of changing/​costs of staying the same outweigh the costs of changing/​pros of staying the same. Are the goals you’re striving

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for worth the time and effort this treatment requires? Is it worth it to feel negative emotions more strongly as you learn new ways of coping that will bring you closer to your goals? Is the possibility of a better life worth the uncertainty of whether this treatment will work? Of course, the answers to these questions may not be black and white; however, if you lean toward changing, you are in a great position to begin this treatment. Also, keep in mind that your motivation is going to change (both increase and decrease) over the course of treatment. This is normal and does not mean that you are “failing” or that the treatment is not working. In fact, cultivating the ability to take steps forward—​even during periods of low motivation—​is key to making lasting changes in your life, particularly for people with depression. You can pull out the Decisional Balance Form if you notice that you are feeling less motivated to engage with the exercises in this treatment. Reviewing this form can remind you of your overarching goals and how the skills you are practicing fit into the bigger picture. You might even consider taking a picture of the form with your phone, so that your reasons for changing are always at your fingertips. Remember, decreases in motivation are only temporary, and they will pass.

Summary Clarifying the problem areas that you would like to address in treatment is an important first step in making changes in your life. Setting concrete steps you can take toward these changes (Treatment Goals Form) will help this process feel less overwhelming. Additionally, since you are setting out to make some important changes in your life, thinking about your reasons for changing will keep motivation high. Considering costs of changing will give you an idea of barriers that might get in the way of successfully completing the treatment program. Remember, motivation is not fixed, and your own motivation will change (both increase and decrease) as you progress through this program. This is a natural and normal part of the behavior change process. Revisiting the reasons for and against both changing and staying the same (Decisional Balance Form) can be helpful in reminding you how any one skill fits into the bigger picture of achieving your important goals.

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Homework If you haven’t already done so, complete your Treatment Goals Form and Decisional Balance Form. If you require additional space, consider making photocopies of these forms or visit the TreamentsThatWorkTM website at http://www.oup.com/us/ttw for downloadable versions. ■ Continue monitoring your weekly experiences using the Anxiety and Depression Scales (as well as the Other Emotion and Positive Emotions Scales, if you’re using them). ■ Remember to use the Progress Record to record the total scores from the Anxiety and Depression Scales (as well as Other Emotion and Positive Emotions Scales). ■

Self-​Assessment Quiz Answer each of the following by circling true (T) or false (F). Answers can be found in Appendix A. 1. Setting goals is more effective when they are concrete. T

F

2. Once you start this program, your motivation will remain as strong as it is now. T

F

3. Feeling both that you want to change and that you might not be ready to change is a natural part of the process of any behavior change. T

F

4. Having doubts about your ability to change means you will fail. T

F

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Form 4.1: Treatment Goals

Clarifying Top Problems

Setting Concrete Goals

Taking the Necessary Steps

In what way have your emotions (i.e., feeling sad, anxious, guilty) caused problems in your life?

What are some concrete goals for addressing your top problem? What would you be doing/​not doing if you achieved your goal?

Break your goals into several smaller steps so you’ll have a better idea of how to start moving toward your goals.

Top Problem

Concrete Goal 1

Step 1 Step 2 Step 3 Step 4

Concrete Goal 2

Step 1 Step 2 Step 3 Step 4

Top Problem

Concrete Goal 1

Step 1 Step 2 Step 3 Step 4

Concrete Goal 2

Step 1 Step 2 Step 3 Step 4

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Form 4.2: Decisional Balance Use this form to explore all the pros and cons you can think of both for changing (or engaging with this treatment) and for staying the same.

Pros/Benefits

Change

Stay the Same

Cons/Costs

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CHAPTER 5

Understanding Your Emotions—​ What Is an Emotion?

GOALS To learn how emotions are necessary and helpful ■ To break emotions down into more manageable parts ■

Homework Review Did you complete your Anxiety and Depression Scales (and your Other Emotion and Positive Emotion Scales if you’ve chosen to complete them) for last week? Did you plot your total scores on the Progress Record? If so, these records will help you track the gains you’re making in treatment. If not, it might be helpful to reread Chapter 3 to remind you why record-​keeping is so important. Perhaps you can brainstorm ways to make record-​keeping a priority while you are going through this program.

Key Concepts Given that the overall goal of this treatment is to better tolerate your emotions so you can respond to them more effectively when they come up, the ground floor of the house (covered in Chapters 5 and 6) involves gaining a better understanding of your emotions (see Figure 5.1). In this chapter, you will learn the important ways that emotions can be helpful in your day-​to-​day life and why you wouldn’t actually want to get rid of all “bad” feelings. We will also begin to break emotions down into more manageable parts so that they feel less overwhelming. 41

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UNDERSTANDING YOUR EMOTIONS

SETTING GOALS & MAINTAINING MOTIVATION

Figure 5.1    

Why Are We Focusing on Emotions? As we discussed in Chapter 1, a person may have an emotional disorder when her emotions are so overwhelming that they interfere with her ability to live the life she wants to lead. People with emotional disorders tend to view their emotions negatively (“this is so uncomfortable,” “it is bad to feel this way”) and, as a result, try to avoid them. In fact, people often seek treatment to get rid of uncomfortable emotions like anxiety, fear, anger, sadness, or guilt. These emotions can occur in people with anxiety disorders (e.g., panic disorder, social anxiety disorder, or generalized anxiety disorder), depressive disorders, posttraumatic stress disorder, and others. Unfortunately, pushing away emotions doesn’t work very well. The more energy you spend trying to suppress or avoid emotions, the less you can focus on things in your life that are important to you and the less you can move forward—​making you feel worse in the long term. Instead of getting rid of negative emotions, the goal of this treatment is to help you respond differently when they come up. In the next two chapters, we will teach you to listen to your emotions because their fundamental

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purpose is to communicate important information about the world around you. We will also help you understand how your emotions can go from providing this useful input to feeling totally overwhelming. We’ll do this by breaking emotions down into more manageable parts—​into thoughts, physical sensations, and behaviors. Then, in later chapters, we’ll zero in on each of these three parts, providing you with specific ways to make changes to your emotional response.

Why Do We Have Emotions? Imagine what it would be like if we had no emotions. How would we know if our lives were suddenly in danger without a sense of fear? How would we know to stand up for ourselves without a sense of anger? Even though these emotions may feel “bad” or “dangerous,” they actually tell us important information about our situation. They also motivate us to take action in ways that keep us safe or help us move forward with our goals. Let’s take a closer look at how our emotions, even the uncomfortable ones, are necessary and helpful. Fear

Fear is nature’s alarm system. It lets us know that we might be in danger and that we need to take steps to protect ourselves. For example, imagine you are crossing the street when you notice that a car is coming straight at you. This situation would instantly prompt fear for pretty much everyone. The feeling would be associated with physical sensations that prepare the body to flee such an unsafe situation, like an increased heart rate to pump blood to the arms and legs and pupils dilating to scan for danger. Fear also provides a sense of urgency to act—​often without thinking. In this situation, you would likely jump out of the way onto the sidewalk. If you felt nothing, you might continue to walk leisurely across the street, possibly being run over. So, as you can see here, the uncomfortable emotion of fear actually plays an important role in keeping us safe. Sadness

Sadness is the emotion that naturally occurs after a loss or setback related to something or someone that is important to us, such as a death of a loved one, a break-​up, or losing a job we enjoyed. This emotion is also really common when we notice significant differences between the way

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our life is and how we want it to be. For instance, we might feel sad about a job because we find ourselves not progressing like we had hoped, or we feel sad because we are experiencing struggles in a relationship that we really care about. Sadness is associated with physical sensations like heaviness in the body and feeling tired. Sadness signals the need to pull back so that the loss or setback can be processed. For example, feeling sad after a break-​up lets you know that the relationship (or aspects of that relationship) was important to you. Withdrawing to process what went wrong and what characteristics you want to look for in a new relationship may help you find greater success with a future partner. This information would be lost if you jumped immediately into a new relationship because you wanted to avoid feeling any sadness. This emotion also signals to others that we may need support and comfort. Humans are social animals, which means we sometimes need help to get back on our feet. Expressing sadness naturally draws others toward us. So, here again, a seemingly “bad” emotion of sadness serves an important function in our lives. Anxiety

Anxiety is the emotion that helps us prepare for the future. Anxiety alerts us to important or potentially dangerous situations that might occur. This emotion also prompts us to focus our attention on whatever is causing the anxiety so that we can prevent or decrease a negative outcome (or “threat”). For example, feeling anxiety before a big presentation at work or school lets you know that this task is important. It also prompts you to begin preparing so that you’re not caught off guard. Imagine if you didn’t feel anything as the day of this presentation approached. You probably wouldn’t feel motivated to practice and might not be prepared for difficult questions from the audience. Yet again, we see an uncomfortable emotion that serves a very clear purpose in our lives. Anger

Anger is the natural response when we feel we (or people we care about) have been wronged in some way. Anger (and the similar emotion of frustration) also occurs when we feel like we are being blocked from achieving important goals. This emotion alerts us that our boundaries have been crossed and motivates us to do something about it. For example, imagine you discover that your phone company has been charging you hidden fees for months and expects you to pay them right away or they’ll shut off your service. Feeling anger in this situation lets you know that something

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unfair has happened—​you shouldn’t be expected to pay for services you didn’t use. This anger would also probably prompt you to speak to a customer service manager to demand that the charges be reversed. Here the emotion of anger also signals to the other person that they have frustrated or wronged you. Anger has a bad reputation because it is can be associated with destructive behavior like yelling and breaking things. It is important to separate this possible response to anger from the experience of the emotion itself. It is very important to pay attention to anger when it occurs because it signals to you that you may need to defend yourself. Guilt/​Shame

Guilt and shame occur when we fall short of some standard. Specifically, guilt is the natural response when we go against society’s expectations in some way. For example, you might feel guilty if you forget to pay your friend back after borrowing money. Guilt in this situation would likely prompt you to make amends by apologizing and getting your friend the cash. Shame occurs when we fail to achieve a personal standard and feel “lesser in value.” For instance, being unable to pay a friend back because you don’t have any money may trigger feelings of shame. Shame, similar to sadness, prompts withdrawal from others. This withdrawal may give a person room to think about how they might achieve their goals going forward to feel better about themselves in the future. In both cases, these emotions motivate helpful behavior. Guilt helps people maintain important relationships by apologizing, and shame helps people achieve their goals by prompting hard work.

Note

A note about shame and abuse: Very often, people who have experienced abuse (emotional, physical, or sexual) feel ongoing shame long after the abuse has ended. Even though abuse is never the fault of the victim, people often report feeling shame while the abuse is happening. This is because shame can communicate submission to the abuser through body language (tears, head down). Submission in the moment of abuse may serve a protective role as it might prevent the abuser from hurting the person more. For example, if a person refrains from fighting back while being beaten, the abuse may stop sooner. Unfortunately, the feelings of shame can last much longer than is helpful. As we work through this treatment, we will identify ways that shame (and other emotions) are maintained in situations where they are not warranted and work to change these responses.

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Positive Emotions

Positive emotions, like happiness, excitement, and pride, also communicate important information. Positive emotions help us identify what we value in life and how we want to be spending our time. For example, if you pick up a new hobby that brings you a lot of joy, what are you likely to do? Keep doing it! Sometimes people try to avoid positive emotions because they’re afraid that once the emotion ends they’ll feel even worse than they did before. Or they’ll prevent themselves from getting excited because they worry that if things don’t work out, they’ll feel more disappointed than if they hadn’t gotten excited in the first place. Sometimes people with depression avoid positive experiences like socializing because they find it distressing that they don’t enjoy these experiences as much as they used to. Without positive emotions, though, we wouldn’t know what direction to go in our lives. It is important to allow ourselves to feel the full range of emotions, negative and positive. Summarizing the Importance of Emotions

As you can see from these examples, emotions serve a necessary role in our lives. All of these emotions communicate very important information about the world around us and motivate us to act. Without them, we’d be unable to move successfully through life. In fact, we evolved to have emotions because they’re so important for the survival of our species. Emotions are hardwired into us—​even if we wanted to, we’d be unable to push them away completely. That’s why this treatment focuses on accepting emotions and responding in more helpful ways when they come up. You may be saying to yourself: “I can see how fear can be adaptive, but what about the fear I  seem to feel for no reason when I  have a panic attack?” Or maybe you’re thinking:  “Anxiety might be useful to some people, but I can’t turn it off—​I feel it all the time!” You might also be wondering: “How does normal sadness in response to a loss turn into feeling so depressed you can’t get out of bed?” Even though we know that all of these emotions are important in the normal course of everyone’s life, sometimes they can come up in the wrong situations and they can feel too intense to be productive. So how do our emotions go from something useful to something overwhelming? The short answer is in the way that we respond to them. In order to begin to explore how this process unfolds, let’s first break down what happens when we feel a strong emotion.

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What Is an Emotion? What exactly is an emotional experience? You may feel like your emotions are a big “cloud” of intense feelings. This may make it difficult to identify what useful information your emotions are trying to tell you. One way to make something feel less overwhelming is to break it down into its main parts. Every emotional experience can actually be broken down into three components—​what we think, how we physically feel, and what we do. By paying attention to each of these parts, your emotions may begin to feel a bit less overwhelming. The three components of emotional experiences are: 1. Cognitive (What You Think): Your thinking in any given situation can really color how you feel about it. For example, if you tell yourself that you’re going to lose your job, you’ll probably begin to feel anxious. Or if you tell yourself that you don’t deserve to be in a loving relationship, you might feel ashamed or sad. The relationship between thoughts and emotions goes the other way, too. For example, when you feel sad, you’re more likely to have thoughts about the situation being hopeless, or being inadequate (“I always mess everything up”). In contrast, if you’re feeling pride, you may have thoughts about how capable you are (“I know I can do this!”). To begin to see how thoughts are important in any emotional experience, try to remember what you were thinking the last time you felt the emotions listed in the following spaces: What were some of the thoughts going through your head the last time you felt anxious? _​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_ What about the last time you felt angry? _​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_ What about the last time you felt guilty? _​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_ 2. Physiological (How You Feel): Every emotion is associated with a physiological response. In other words, your body goes through physical changes every time you experience an emotion. For example, fear is often accompanied by a faster heart rate, a tensing of the muscles, 47

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and maybe even shortness of breath. Remember, fear’s job is to protect you from danger, and these physiological changes are the body’s way of getting ready to take action. Anxiety may be accompanied by sweaty palms, muscle tension, or perhaps a knot in the stomach. These changes alert us that something important is looming and that we should prepare. Sadness may be accompanied by a sensation of extreme tiredness and heaviness in the limbs, prompting us to withdraw to process. See if you can identify the physiological sensations that might accompany the following states: What physical sensations come with feeling excited? _​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_ What about when experiencing panic? _​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_ What sensations come with anger? _​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_ What about when you are feeling embarrassed? _​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_ 3. Behavioral (What You Do): Whenever you feel an emotion, it is accompanied by the urge to act. We discussed some of the ways these behavioral urges can be helpful (e.g., jumping out of the way of an oncoming car in response to fear, standing up for yourself in response to anger). Sometimes, however, the things we do in response to strong emotions may not seem very useful. For example, someone who is extremely sad may watch television because the thought of getting out and “confronting” the day is too overwhelming. Or someone who is anxious in social settings may quickly leave a crowded party where they are expected to interact. Someone who is feeling guilty may completely avoid a loved one rather than face the interaction. Next, begin thinking about what you do (or feel like doing) in response to the following emotions: What do you do (or feel like doing) when you’re sad? _​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_

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What do you do (or feel like doing) when you’re angry? _​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_ What do you do (or feel like doing) when you’re ashamed or embarrassed? _​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_ These three components—​thoughts, physical sensations, and behaviors—​ can be found any time we experience an emotion. Sometimes one component may be easier to identify. For example, you may be very aware of physical sensations in a given situation but less aware of your behaviors or thoughts. In contrast, you might notice your thoughts more easily but be less aware of physical sensations and behaviors. It is important to take note of all three parts of an emotion because they can feed off each other. We use the Three-​Component Model of Emotions Form to break down any given emotional experience into each of these three parts. See Appendix B (pp. 168–​169) for two examples of how to use this form. In the first example, a man is hurrying to catch the bus. As he reaches the bus stop, he first notices that his breathing is heavy, his heart rate has increased, and he’s feeling a bit dizzy. Next he notices thoughts about these physical sensations: “This is so uncomfortable! I’m going to have a panic attack if I get on this crowded bus.” These thoughts lead to even more intense physical sensations because when we tell ourselves something scary is going to happen (like having a panic attack), our bodies prepare for action. His increased anxiety leads to even more thoughts: “See, I am going to have a panic attack.” Then this man decides to walk to work instead of taking the bus—​his behavior in this situation is to avoid the bus. As soon as he starts walking, he notices that his heart rate and breathing are starting to slow down and his worry thoughts are fading away. This strategy may have worked for him in the short term, but the next time he approaches the bus, he is likely to have similar worries about having a panic attack and may be more reluctant to ride the bus as a result. In the second example, a woman received a text from a friend cancelling their upcoming dinner plans. In this case, thoughts are initially the most noticeable part of the emotion. The woman thinks to herself: “Of course she doesn’t want to hang out with me, I’m so lame.” Next, she begins to notice a lump in her throat and then observes she is starting to feel really tired. This leads to another thought: “I might as well go to bed early, since

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I have nothing better to do.” Similar to avoiding the bus in the first example, going to sleep leads to an immediate decrease in negative thoughts and uncomfortable physical sensations. This relief is short-​lived, though, as sleeping too much has been linked to increased levels of depression. Paying attention to this process is the first step in understanding how the experience of an emotion can go from informative to overwhelming. We would like you to use the Three-​Component Model of Emotions Form at the end of this chapter any time you are feeling a strong emotion over the next week (at least once a day, if possible), taking note of what you’re thinking, feeling in your body, and doing (or feel like doing). Sometimes the emotions you want to work on with this program do not come up very often for you. This may occur because you’re actively avoiding activities that provoke these feelings. Or you simply might not come across situations that bring on these emotions regularly (e.g., flying in an airplane). It may be helpful to think about the activities you can do this week to get some experience with the emotion(s) you’re working on; this will allow you to practice the skill discussed in this chapter. You might look to the steps you wrote down (refer back to Chapter 4 if needed) that were associated with your goals for some ideas.

Summary In this chapter, we have discussed how all emotions, even the ones we traditionally think of as “bad,” play an important role in our lives. They prompt us to pay attention to a given situation and can motivate us to take action in helpful ways. We also saw how emotional experiences can be broken down into three main parts—​thoughts, physical sensations, and behaviors. By breaking emotions down into these parts, they may feel less overwhelming. In the next chapter, we continue to discuss how emotional experiences unfold and also discuss the consequences to our responses.

Homework Complete the Three-​Component Model Form once a day over the course of this week. Select at least one emotional experience that occurs each day and break it down into thoughts, physical sensations, and behaviors. You may want to make photocopies of the

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form so that you have a fresh copy to write on each day, or you may download additional copies from the TreatmentsThatWorkTM website at http://www.oup.com/us/ttw. This form will help you understand what exactly is happening each time you have an emotion, making it feel less overwhelming. ■ Continue monitoring your weekly experiences using the Anxiety and Depression Scales (as well as the Other Emotion and Positive Emotions Scales, if you’re using them). ■ Remember to use the Progress Record to record the total scores from the Anxiety and Depression Scales (as well as Other Emotion and Positive Emotions Scales).

Self-​Assessment Quiz Answer each of the following by circling true (T) or false (F). Answers can be found in Appendix A. 1. The goal of this treatment is to eliminate uncomfortable emotions like fear, anxiety, and sadness. T

F

2. All emotions, even ones we consider “negative,” serve an important role in our lives. T

F

3. Anxiety is never helpful or useful. T

F

4. Emotional experiences are made up of three main parts:  what you think, what you feel, and what you do. T

F

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Form 5.1: Three-​Component Model Situation:

Physical Sensations (what you’re feeling in your body)

Emotion(s):

Thoughts (what you’re thinking)

Behaviors (what you’re doing, what you feel like doing)

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CHAPTER 6

Understanding Your Emotions—​ Following the ARC

GOALS To look for patterns in your emotional triggers (what causes your emotional experiences) ■ To explore the short-​and long-​term consequences of your emotional responses ■

Homework Review Did you complete your Anxiety and Depression Scales (and your Other Emotion and Positive Emotion Scales if you’ve chosen to complete them) for last week? Did you plot your total scores on the Progress Record? Were you able to break down some of the emotions you experienced using the Three-​Component Model of Emotions Form? Perhaps you noticed that your thoughts affected the way you felt physically or prompted you to engage in certain behaviors. Maybe your physical sensations and behaviors led to more thoughts. See if you can begin to identify patterns in the way each part of the circle (thoughts, feelings, and behaviors) influences the other parts. If you did not complete the Three-​ Component Model of Emotions Form, go back and complete this form using a recent emotional experience before reading further.

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Key Concepts The goal of the previous chapter was to give you a better idea of exactly what is happening when you feel an emotion. Breaking your experience down into its three main parts (thoughts, physical sensations, and behaviors) may make your emotions feel a bit more manageable. Paying attention to how these components feed off each other may help you to see how your emotions can escalate so quickly. The goal of this chapter is to put your emotional experience in context by examining what happens before and what happens after you feel a strong emotion. First, we will look for patterns in the situations or events that trigger emotions. Being clear on what prompts your emotions will help you feel like they are more predictable and, as a result, more manageable. Next, we will look at how you respond to your emotions once they are triggered. Finally, we’ll look at the consequences for how you respond to your emotions, both in the short term and in the long term. Understanding that the way you respond in the midst of any given emotional response can have consequences for the emotions you feel in the future, and this understanding may help motivate you to make changes in the way you’re currently coping.

The ARC of Emotions We use the acronym ARC to help us keep track of how an emotional experience progresses. The word “arc” means to follow a path (see Figure 6.1: The Arc of Emotions); we think that all emotions follow the path of

Response Physical Sensations Thoughts

Antecedent

Figure 6.1 The Arc of Emotions

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Behaviors

Consequence

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Antecedent (something triggers your emotion), Response (your thoughts, physical sensations, and behaviors that occur during the emotional experience), and Consequence (what happens as a result of your emotional response). Let’s take a closer look of each part of the ARC. “A” refers to antecedent. Here we are paying attention to what comes before an emotion—​what provokes it. Sometimes emotions feel like they can come out of nowhere, but it is important to keep in mind that every emotion is triggered by some event or situation. Sometimes the trigger can be an event that has just happened (e.g., getting cut off in traffic, not getting a response to your text). Other times, it can be something that happened much earlier in the day or even last week. For example, if you get into an argument with a loved one in the morning, it may make you feel more sensitive to criticism later on. Additionally, the trigger isn’t always an external event but instead can be the way you feel physically (e.g., feeling jittery after too much coffee, feeling heavy because of lack of sleep). Finally, antecedents also can include things that make you vulnerable to experiencing emotions more strongly, such as being tired from a night of poor sleep, being hungry from not having time for lunch, or being generally stressed from a busy couple weeks at work. Finding patterns in the situations and events that prompt emotions may help you to feel less like you are on an unpredictable emotional rollercoaster. Being aware of your triggers can also help you prepare in advance when you know you might be faced with one. As you continue with this program, you will learn skills to use when you have strong emotions, and you can be prepared to use these skills if you know you will encounter one of your triggers. See Table 6.1 for a list of “A”s associated with common emotional disorders. The “R” in the ARC stands for response. This refers to the thoughts, physical sensations, and behaviors that make up an emotional response. These are same three components you tracked in Chapter 5. “C” refers to the consequences of our emotional responses. When we experience strong emotions, they leave lasting impressions. We remember what trigged our emotions (the A) and what the response felt like (the R). This information influences how we respond to similar situations in the future. As humans, we repeat things that make us feel good and try to avoid things that make us feel bad. For example, if you accidentally grab a pot handle that is very hot, you experience pain and immediately pull your hand away. When you reach for that pot handle the next time, you

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Table 6.1.  Antecedents for Strong Emotions Panic Disorder

Enclosed spaces (elevators), crowded places (movie theaters, sporting events), public transportation, caffeine, exercise

Generalized Anxiety Disorder

Making a schedule, errands, housekeeping, upcoming performance evaluations at school or work

Social Anxiety Disorder

Upcoming social events (parties, meetings, clubs), participating in classes, giving presentations, asking for help, introducing yourself, making small talk

Obsessive-​Compulsive Disorder

Touching something dirty, seeing something scary on the news, seeing/​hearing anything that reminds you of your obsessions

Posttraumatic Stress Disorder

Seeing/​hearing something that reminds you of the trauma, loud noises

Depression

Getting bad news, not feeling up to plans, taking much longer to complete tasks than before, seeing other people having fun

Borderline Personality Disorder

Disagreements with friends, family, or partner; being alone; feeling slighted; stressors at work or school

Eating Disorders

Gaining a few pounds, feeling full, clothes feeling a bit too tight, an upcoming event where you have to dress up

Insomnia

Bedtime, seeing the time on a clock, an important appointment scheduled for early in the morning

may stop yourself and grab a potholder so that you avoid the unpleasant experience of being burned again. You have learned that, in order to avoid pain, you should think twice before grabbing that pot. What’s more, we also quickly apply what we have learned to other similar situations. You not only stop yourself from grabbing the handle of the pot that burned you before but also hesitate before grabbing other pans off the stove. Even further, it’s not just pans on your own stove you hesitate to touch but pans on any other stove you may come across as well. For the most part, the ability to learn from our emotions and change our behavior based on them is helpful. So what does this have to do with your symptoms? In addition to being able to learn from our emotions after they occur, humans also have the gift of foresight. This means that we can imagine whether certain situations could possibly bring up strong emotions, and we can therefore change our behavior to prevent potential bad feelings. This may lead us to avoid situations and events that aren’t actually threatening. In fact, sometimes the

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focus becomes more about avoiding uncomfortable emotions than about preventing problematic events from occurring. For example, what if you gave up cooking altogether because you had previously been burned by the pot handle? Or never brought up disagreements with a loved one for fear that you might get angry and lose your temper? Or avoided crowded events because you might feel panicky, even if being at the event itself is important to you? Avoidance of situations and events because they might bring up strong emotions is what leads to the problematic interference in your life that may have prompted you seek treatment or to pick up this book on your own. This program will help you tell the difference between what is a real threat and what is a perceived threat, allowing you to better understand how your emotions should guide you. There are also consequences to engaging in behaviors that the strong emotion pulls you to do (e.g., running away when afraid) when such a response does not fit the situation. For example, fleeing when you feel fear in the context of a panic attack (which in itself is not actually dangerous) has both short-​and long-​term effects on your emotions. In the short term, escaping the situation usually provides some relief. Remember, humans are programed to do things that make them feel good and to avoid things that make them feel uncomfortable. Since fleeing made you feel better this time, you’re likely to do it again in order to find that same relief. However, there are also long-​term consequences that must be considered. Unfortunately, when you avoid something because you’re afraid, you are essentially telling yourself that the situation is indeed dangerous. In this case, by attempting to escape a panic attack at any cost, you confirm your belief that panic attacks are harmful (“if I’m leaving this concert to prevent it, this panic attack must be really dangerous”). The next time you start to notice the racing heart and shortness of breath that go along with a panic attack, you will still be afraid that something bad will happen if your panic escalates. By immediately fleeing, you are not able to see that panic attacks, while uncomfortable, don’t last for very long and don’t create lasting damage (e.g., heart attack). This becomes a vicious cycle—​the more you avoid now, the more likely you’ll be to feel the emotion again in the future.

Following Your ARC The Following Your ARC Form, at the end of this chapter, is a helpful way to track the ARC of your experience. This form builds upon the

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Three-​Component Model of Emotions Form from Chapter 5. In addition to tracking your thoughts, physical sensations, and behaviors (your “R”), you will also be paying attention to your triggers (“A”s) and both the short-​and long-​term consequences (“C”s) or your response. Complete this form any time you’re experiencing a strong emotion (or at least once a day). There are many different ways the ARC of an emotion can progress. See the completed Following Your ARC Form example in Appendix B on p. 170; there we highlight ARCs associated with several different emotional disorders. See if any of those “A”s, “R”s, and “C”s map on to your experiences. Across all of these ARCs, notice how engaging in responses that push away emotions only works for a short time. In the long-​term, avoidant responses to emotions backfire, making these emotions more likely to come up in the future. That’s why a goal of this treatment is approaching emotions instead of avoiding them.

Summary In this chapter, we built upon our observations from Chapter 5. In addition to tracking our emotional responses (thoughts, physical sensations, and behaviors), we discussed the importance of paying attention to what happens before (antecedents) and what happens after (consequences). Noticing patterns in what triggers your emotions, instead of viewing them as coming out of the blue, can help them feel a bit more predictable and manageable. We also discussed how our responses to any given emotional experience can impact the likelihood that we’ll experience strong emotions in the future. In particular, we tend to engage in responses that make us feel better in the short term but set us up to continue to experience overwhelming emotions in the long term. Using the Following Your ARC Form will help highlight how the things you’re doing to get quick relief from your emotions may actually be making you feel worse overall. These observations may help motivate you to start the process of changing your responses.

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Homework Use the Following Your ARC Form to track the ARC of your emotional experiences. Be sure to consider both immediate and distant triggers and consequences. Consider making photocopies of this form in your workbook so you have additional space to monitor your ARCs, or you may download additional copies from the TreatmentsThatWorkTM website at http://www.oup.com/us/ttw. ■ Continue monitoring your weekly experiences using the Anxiety and Depression Scales (as well as the Other Emotion and Positive Emotions Scales, if you’re using them). ■ Remember to use the Progress Record to record the total scores from the Anxiety and Depression Scales (as well as Other Emotion and Positive Emotions Scales). ■

Self-​Assessment Quiz Answer each of the following by circling true (T) or false (F). Answers can be found in Appendix A. 1. In the “ARC” of emotional experiences, “A” stands for what triggered the experience, “R” stands for how you respond, and “C” stands for the consequences of how you responded. T

F

2. Triggers for emotional experiences only include events or situations that just happened and not events from earlier in the day. T

F

3. Our emotions help us learn to approach or repeat things that make us feel good and avoid things that make us feel bad. T

F

4. There are usually only short-​term consequences for how we respond to an emotional experience. T

F

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Form 6.1: Following Your ARC

Date/ Time

Response

Antecedent What triggered your emotional response?

Consequence

Physical Sensations Thoughts

Behaviors

Short-term How is this response working for you?

Long-term How might this response lead to more negative emotions in the future?

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CHAPTER 7

Mindful Emotion Awareness

GOALS To understand the benefits of applying nonjudgmental present-​ focused awareness to emotional experiences ■ To encourage the practice of nonjudgmental present-​focused awareness through the use of two formal meditation exercises ■ To apply the concept of mindful emotion awareness to daily emotional experiences ■

Homework Review Did you complete your Anxiety and Depression Scales (and your Other Emotion and Positive Emotion Scales if you’ve chosen to complete them) for last week? Have you plotted your scores on your Progress Record? In the previous chapter, you were also introduced to the Following Your ARC Form. Did you track your experiences over the past week? If so, did you notice any patterns that have emerged? What events seem to be typical triggers for you? Did you notice any common thoughts, physical sensations, and behaviors that seem to crop up whenever you feel an intense emotion? Have you noticed any long-​term consequences to responding to emotions in ways that provide immediate relief? Continuing to ask yourself these types of questions will help you gain a full understanding of how your emotions become overwhelming and will give you a better idea of where to make changes. If you did not track your ARCs, we recommend

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that you spend at least a couple of days completing them and rereading the previous chapter before continuing on. Please remember that completing the exercises laid out in this program is vital to your success.

Key Concepts In the previous two chapters, we discussed how our emotions are, at their core, necessary and helpful. We also began tracking how emotional experiences unfold over time. In particular, we described how avoiding emotions in the short term can backfire, making it more likely that you will continue to experience overwhelming emotions in the future. You may have even seen this cycle occurring as you completed the Following Your ARC Form. We hope that you are starting to see that avoiding emotions doesn’t work and that you are ready to begin approaching them in a more accepting manner. The skill presented in this chapter, Mindful Emotion Awareness, builds upon the tracking you’ve been doing in the previous two chapters. You have already been paying close attention to your emotional responses—​now we will teach you to pay attention in a particular way. This is like going up to the second floor of the house you’re building to gain a different perspective on your emotional experiences (see Figure 7.1). Specifically, we will teach you how to approach your emotions in a nonjudgmental and present-​focused manner.

What Do We Mean by Mindful Emotion Awareness? Mindful Emotion Awareness is a specific way of looking in on your emotional responses. You may be thinking:  “I’ve already been paying very close attention to my emotions.” You’re right; the past two chapters have encouraged you track your emotional experiences as they unfold over time. It is not enough, however, to simply be aware of your emotions. The next step is to observe your emotions mindfully. Being mindful means paying attention to the present moment (what’s happening right now) in a nonjudgmental way. In Chapter 1, we discussed how negative reactions to emotions may be driving your efforts to avoid them. Mindful Emotion Awareness is a skill that directly addresses these negative reactions to emotions. Let’s break Mindful Emotion Awareness down into its two parts (nonjudgment and present-​focus) and take a closer look at how this type of attention can be helpful.

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MINDFUL EMOTION AWARENESS

UNDERSTANDING YOUR EMOTIONS

SETTING GOALS & MAINTAINING MOTIVATION

Figure 7.1    

Nonjudgmental Emotion Awareness

Being judgmental of our emotions can take several forms. First, we can judge ourselves for having certain emotions in the first place. This might look like telling yourself “I shouldn’t be feeling this way” or “no one else is reacting like this.” We can also judge ourselves for not feeling our emotions as strongly as we’d like (“why am I not happier about this—​I must be broken,” “I should be angrier about this problem—​I’m so weak”). We mistakenly believe that beating ourselves up for having a particular emotional response (or lack thereof ) will prompt us to feel the way we think we “should.” This doesn’t work because, as you’ll recall, emotions are normal, natural, and hard-​wired into us. It is actually impossible to change our emotions completely when the situation calls for them. For example, imagine you’re about to give a speech in front of a large audience. Most people in this situation would feel at least a little bit nervous. What might happen to that initial emotional reaction if you were to tell yourself that being nervous before a speech makes you weak? In general, being hard on yourself for feeling nervous in this situation will probably make you feel even more anxious as you struggle with the impossible task

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of pushing this emotion away. This judgmental response may also bring up additional emotions, like shame or frustration over the fact that you can’t prevent yourself from feeling nervous. Another way that we can be judgmental is to have a negative reaction to specific parts of the emotional experience itself. For example, you might believe that the thoughts, physical sensations, and behaviors you’re experiencing are bad in some way. This might look like telling yourself that your racing heart and flushing face are too uncomfortable to cope with. Or that thoughts about something bad happening (e.g., getting into a car accident) mean this event is more likely to occur. Or even that you might do something out of control, if you’re feeling a particular emotion (like anger). What might happen if you tell yourself that the emotions you’re experiencing are bad or definitely going to lead to problems for you? This negative reaction to emotions is likely to increase their intensity, as well as escalate the urgency to escape them. Nonjudgmental awareness means accepting emotional experiences as they are, instead of labeling them as problematic and immediately trying to push them away. It is important to understand that accepting emotions does not mean resigning yourself to feel uncomfortable. Instead, we will encourage you to recognize that your emotions, even the difficult ones, are trying to tell you something. This will allow you to move past your knee-​jerk reaction to change how you’re feeling and to respond to your emotions in a more thoughtful way. With practice, you will begin to tell the difference between when your emotion is an accurate reflection of the current situation and when it is a “false alarm.” For example, a nonjudgmental response to anxiety before a first date might look like: “It makes sense I would be anxious because making a good first impression is important to me. I should probably prepare by taking a shower and putting on a clean shirt, but I don’t need to give in to the urge to cancel the date because the situation is not actually dangerous.” Additionally, the more you refrain from engaging in the immediate attempts to push away emotions, the more you will be able to see that their intensity ebbs and flows naturally. As you gain more experience with your emotions, it will be easier to approach them in a nonjudgmental manner. Present-​Focused Emotion Awareness

The second goal of being mindful is to keep our emotional responses rooted in the present moment—​what is happening right now. Very often,

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our emotions in any given situation are being influenced by our past experiences or our predictions about what might happen in the future. Let’s return to the example of giving a speech in front of a large group of people. Imagine you’re feeling a little bit anxious, as most people would in this situation. What might happen to that anxiety if you start thinking about how you completely froze up and lost your train of thought the last time you spoke for an audience? Similarly, what might happen to your anxiety if you think about all the ways you might screw things up this time (“I’ll be boring,” “I won’t be able to answer questions”). In general, connecting the current situation to what went wrong in the past or what could go wrong in the future will escalate the emotion you’re experiencing—​this practice will make the current situation seem even more overwhelming. So it can feel more manageable to focus on the situation right in front of you—​the present moment—​instead of connecting it to past events and possible future outcomes. Present-​focused awareness is also a useful way to connect with positive emotions. Imagine that you’re spending time with friends but you’re caught up in thinking about how you’re going to feel lonely when you return home (future). By keeping your attention on the present moment, in this case engaging with your friends, you will allow yourself to experience pleasant emotions more fully. Similarly, predicting that you will not enjoy an upcoming event or activity (future) may prevent you from going, causing you to miss out on the positive emotions you might have experienced. Of course, we learn important information from our past experiences. Focusing on the present does not mean discounting what has happened before. Similarly, preparing for challenges that may come up in the future can also be quite useful. Unfortunately, in emotional situations, we sometimes focus on the past or the future at the expense of what’s right in front of us. The current situation will never be exactly identical to what has happened before. Similarly, we may have ideas about what might happen in the future, but we can never be 100% certain. For example, imagine your previous partner broke up with you out of the blue and now, years later, your current partner just snapped at you for forgetting to empty the dishwasher. You might immediately begin thinking about your previous failed relationship (past) and start to worry that the same thing will happen this time (future). This reaction will likely bring up strong anxiety about your current relationship and prompt you to apologize or seek reassurance. While you were being carried away by past events or possible future

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outcomes, you may have failed to notice that your partner has begun to talk about taking a vacation with you in a few months. A present-​focused (and nonjudgmental) response in this situation might look like: “Given my past experience, it makes sense that any sign of conflict with my partner would immediately bring up fears that the relationship is over. That said, there is no indication that we are breaking up right now, so I need to refocus on what we’re currently doing (planning the vacation).”

Practicing Present-​Focused, Nonjudgmental Awareness Being mindful (nonjudgmental and present-​focused) does not come naturally to most of us. In fact, we are designed to evaluate many aspects of our lives, and, in most cases, these judgments are helpful. Additionally, learning from the past and planning for the future are useful most of the time (e.g., remembering to let your spouse know you’re running late because he has gotten worried in the past). However, as discussed earlier, when these tendencies are applied to emotions, they don’t work as well. Since we have so much experience making judgments and thinking about the past/​future in our daily lives, it will take practice to apply mindful awareness to our emotional responses. You can think of this skill as developing a new muscle. The rest of this chapter will be focused on two exercises to build your Mindful Emotion Awareness muscle before putting it to work in your daily life. Practicing these exercises is essential for developing this skill.

Mindful Emotion Awareness Meditation The purpose of the first exercise (adapted from Segal, Williams, & Teasdale, 2002)  is to allow you to begin to get a sense of what mindful attention feels like. Guided meditation is a great place to start when building mindful awareness because it gives you a clear, concrete place to direct your attention, in contrast to the many demands on your attention you experience when going about your daily life. It is best to try this exercise out when you are in a neutral mood (or close to it) because it is much harder to be nonjudgmental and present-​focused when feeling a strong emotion. In fact, it is much more difficult to learn any new skill (riding a bike, knitting) when you are very emotional. Again, the purpose of this

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exercise is to get some experience with a mindful quality of awareness so that you can apply it later when you’re experiencing an intense emotion. Instructions for Learning Mindful Emotion Awareness Meditation

Read through the entire meditation script, as well as the tips in break-​out boxes, before you do the meditation for the first time. ■ Many people prefer to listen to an audio recording of this practice so they can focus their attention more fully on meditating. An audio version of this meditation is available on the TreatmentsThatWork™ Web site at http://www.oup.com/us/ttw. Alternatively, you might consider using an application on your phone (e.g., voice memos app on iOS) to record yourself reading the meditation so that you can always have it handy. ■ Practice this five-​minute meditation at least once a day for a week using the Mindful Emotion Awareness Form, located at the end of this chapter, to record your experience. ■

Goal To set the present-​focused tone for the practice by grounding yourself in the here and now (the room). Close your eyes and get settled in your chair. Begin by turning your attention to yourself in the room. Picture yourself in this space and start to take note of the places where you are coming into contact with it. Perhaps notice how it feels to be sitting in the chair, the sensations of the floor meeting your feet, or the pressure of your hands on your lap. Take a moment to ground yourself in the here and now by connecting to the room. Goal To see that focusing on the breath (because it is always with you) can quickly bring your attention to the present moment. Now bring your focus to the experience of your own breathing. Notice what your breathing feels like in your chest or diaphragm, in your mouth and nose. Focus on your breathing as it is happening right now, using your breath to help anchor you to the present moment. Your breath is always with you, so you can use it as a reminder to pay attention to what

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is happening right now. Pause for a moment, and just allow yourself to notice your breath. Goal To describe sensations matter-​ of-​ factly without judgment (“I feel heaviness in my limbs” instead of “I feel so depressed”). To focus on what you’re feeling now (tired) instead of what you might be feeling in the future (“this is going to last forever”). Now expand your attention to notice any physical sensations you are experiencing. Pause for a moment, and just allow yourself to observe any sensations present in your body without judging them as good or bad or trying to change them in any way. Simply notice what is there with openness and curiosity. Goal To understand that thoughts are not facts—​just because you think something does not make it true. To practice observing your thoughts without reacting to them as if they are true. Next bring your attention to your own thoughts. Notice how your thoughts may shift from one topic to the next. Some thoughts may pass by quickly, others may distract you, and some of them may be very hard to let go of. Simply notice what you’re thinking without trying to force a particular topic into awareness or push away another. Try not to judge your experience as bad or good. If you notice yourself getting caught up in or carried away by a thought, just acknowledge it, and gently bring your attention back to observing your thoughts as they occur. Allow yourself to watch your thoughts for a few moments. Goal To notice how the intensity of emotions ebbs and flows naturally. You may notice that you feel sad when thinking about an old friend but that this feeling goes down when you become distracted by what you might make for dinner tonight. Now start to shift your focus to explore how you’re feeling. Emotions, just like thoughts, can fluctuate. In the course of a short period you might 68

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feel anxious and then calm, angry and then loving, or sad and then joyful. Emotions come in waves, rising in intensity only to come back down. Simply acknowledge how you’re feeling in this very moment without trying to change your experience in any way. Allow yourself to observe your emotions, without judgment. Notice how they ebb and flow. Now continue to take note of your entire experience—​how your body feels, what you are thinking, any emotions that are coming up. If you notice that you are trying to change your experience in some way, take note of that, and gently guide yourself back to simply observing. If you get caught up in a particular sensation, thought, or emotion, use your breath to anchor you back to the present moment, then return to the process of noticing your experience. When you are ready, start to bring yourself back into the room. Picture yourself sitting in this room and become aware of the places you’re coming in contact with. Begin to wiggle your fingers and toes and, when you are ready, open your eyes. There are several common reactions to completing this exercise for the first time. Some people find this practice uncomfortable. It can be difficult to sit still and observe our emotions, even for a short time, if we’re used to doing something quickly to distract ourselves from them. If this was your reaction, keep practicing the exercise—​with time it will become easier to look in on your experience nonjudgmentally. Sometimes people wonder if they are completing the exercises correctly. Remember that the goal of this exercise is not to do it perfectly. If you notice that you are being judgmental or that your mind has wandered to the past or future—​good job! Noticing these patterns is the first step to changing them. Finally, sometimes people find this exercise very relaxing. Keep in mind that the goal Mindful Emotion Awareness is not necessarily to relax you. The goal is to teach you to observe what comes up in a nonjudgmental, present-​focused way. If you are completing the exercise in a neutral mood, it may very well be relaxing. But if you are looking in on an emotional experience, it may not be as calming.

Mindful Mood Induction Once you begin to get more comfortable observing your experience in a nonjudgmental and present-​focused way, the next step is to practice

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applying mindful attention when you are in an emotional state. Remember, building mindful awareness is like building a muscle—​you have to keep increasing the resistance to continue the progress. It is more difficult to be nonjudgmental and present-​focused when feeling a strong emotion. In order to practice mindful awareness in an emotional context, we use a simple method to bring up intense emotions—​listening to music. You should choose songs that are particularly meaningful to you. You can experiment with a variety of songs that bring up different emotions for you. If you have difficulty choosing a piece of music, you may want to try some of the suggestions on the list available for download from the TreatmentsThatWork™ Web site at http://www.oup.com/us/ttw. As you listen to each piece of music, practice being nonjudgmental (“it makes sense that I’d think about my ex while listening to this song”) while attempting to prevent yourself from getting carried away by the past or the future (“that was a long time ago—​I’ve made changes to my life since then”). You can use the same Mindful Emotion Awareness Form that you used for the meditation to record your experience with this exercise.

Anchoring in the Present Once you have formally practiced Mindful Emotion Awareness for at least a week, the next step is to incorporate this skill into your daily life. Again, you have been working to build your mindful awareness muscle with the previous two exercises, so now it is time to flex it in emotional situations. We call this skill Anchoring in the Present. The goal here is to hit the pause button any time you notice an emotion starting to build so that you can deliberately choose a response that is consistent with the present moment, rather than being driven by the past or the future. The first step is to pick a cue that you can use to anchor yourself to the present when you are feeling emotional. As mentioned earlier, one of the best cues is your own breath because it is with you wherever you go, but any concrete sensation will work (e.g., the feeling of your feet on the floor). By focusing on your cue for a few moments, you will pull yourself out of your emotional experience and back into the present. Once you’ve used your cue to step outside of the emotion you’re feeling, the next step is to look in on your response in a nonjudgmental manner. This is called doing a “three-​point check” to remind you to take stock of your thoughts, physical sensations, and behaviors. Once you’re aware of your response,

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you will then ask yourself whether it is consistent with the demands of the present moment. In other words, does your emotion fit with what’s going on right now? If you find that the intensity of your emotion is being driven by the past or the future, the last step is to try to adjust your response to be more in line with what’s happening here and now. Steps for Anchoring in the Present

Follow these steps whenever you notice an emotion is starting to build: 1. Use your cue (breath, feeling of the floor beneath your feet) to ground yourself in the present moment. 2. Do a three-​point check: a. What are you thinking right now? b. What are you feeling in your body right now? c. What are you doing right now? What do you feel like doing? 3. Ask yourself: a. Is my response (thoughts, physical feelings, behaviors) consistent with what is going on right now? b. Am I reacting to something from the past or a prediction about the future? 4. Bring your response in line with the demands of the present moment. Here’s an example of how this skill works: Imagine you’re out to lunch with a friend. While she is talking about her week, you notice that you are becoming more and more irritable as you are distracted by thoughts about an unreasonable deadline your boss has set for a project. Your thoughts are racing, but you are able to pull your attention to your breath for a few seconds. Then you do a three-​point check (thoughts:  “I’m never going to finish in time”; physical sensations: sweating, muscle tension; behaviors: picturing yourself telling your boss off). You are able to remind yourself that you are not interacting with your boss right now and that there’s not much you can do to work on the project while you are in this restaurant. You refocus your attention on your friend, telling yourself that you’ll dedicate time to problem-​solving your work situation once lunch is over. Keep in mind that Anchoring in the Present takes a lot of practice. You may find that you have to return your attention to the present over and over again during the course of a short period of time. Remember, Mindful Emotion Awareness is like a muscle—​every time you bring yourself back

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to the present it is like doing a bicep curl for your attention. In time, you will be able to hold your awareness in the present longer and catch yourself sooner after you’ve wandered to the past or the future. To help you learn this skill, practice anchoring yourself to the present any time you begin to feel an emotion. Record what you notice on the Mindful Emotion Awareness Form you’ve been using. Samples of completed Mindful Emotion Awareness Forms are shown in Appendix B on p. 171. Treatment Goal Check-​In Use the space to below to reflect on how using Mindful Emotion Awareness can bring you closer to the goals you set in Chapter 4. Also note any progress you’ve made toward your goals.

Summary In this chapter we discussed the importance of observing our emotions in a nonjudgmental and present-​focused manner. We noted how judging our emotional experiences usually makes them feel worse. We also discussed how our emotions are often rooted in what has happened in the past or what could happen in the future. We then practiced three exercises designed to promote mindful (nonjudgmental, present-​focused) awareness toward our emotions. The first exercise was a meditation that can be used to get a sense of what Mindful Emotion Awareness feels like. The second exercise involved practicing nonjudgmental, present-​focused attention in the context of a strong emotion—​we used a musical mood

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induction to bring on strong emotions in a controlled way. Finally, our Anchoring in the Present skill is the real-​world application of Mindful Emotion Awareness. We discussed four steps that can be used to employ nonjudgmental, present-​focused attention when strong emotions come up in our daily lives. In the next four chapters, we will be looking more closely at each part of your emotional response:  thoughts, behaviors, and physical sensations. By now you probably have a pretty good idea about how each part of your experience is escalating your emotional response. We will be teaching you specific skills for each component so that you respond to your emotions in a helpful way that, in the end, reduces your symptoms.

Homework First Week

Set aside time to practice the Mindful Emotion Awareness Meditation at least once a day for one week. Use the Mindful Emotion Awareness Form to record your experience. Again, you may wish to make photocopies of this form or download additional copies from the TreatmentsThatWorkTM website at http://www.oup.com/us/ttw. ■ Continue monitoring your weekly experiences using the Anxiety and Depression Scales (as well as the Other Emotion and Positive Emotions Scales, if you’re using them). ■ Remember to use the Progress Record to record the total scores from the Anxiety and Depression Scales (as well as Other Emotion and Positive Emotions Scales). ■

Second Week

Complete the Mindful Mood Induction at least three times by listening to songs that bring up an emotional response. Use the Mindful Emotion Awareness Form to record your experience. ■ Additionally, use the Mindful Emotion Awareness Form to practice Anchoring in the Present—​bringing your attention back the present moment any time you notice an emotional response is starting to build. ■

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Continue monitoring your weekly experiences using the Anxiety and Depression Scales (as well as the Other Emotion and Positive Emotions Scales, if you’re using them). ■ Remember to use the Progress Record to record the total scores from the Anxiety and Depression Scales (as well as Other Emotion and Positive Emotions Scales). ■

Self-​Assessment Quiz Answer each of the following by circling true (T) or false (F). Answers can be found in Appendix A. 1. In this treatment, Mindful Emotion Awareness means focusing on how bad your emotions might feel. T

F

2. In this treatment, Mindful Emotion Awareness means learning to approach your emotions in a nonjudgmental, present-​focused way. T

F

3. Accepting your emotions means resigning yourself to “grin and bear it.” T

F

4. Most of the time we are focused on the present moment, instead of thinking about the past or worrying about the future. T

F

5. Learning to be mindful is easy and doesn’t take much practice. T

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Form 7.1: Mindful Emotion Awareness Use this form to record your experience following completion of the Mindful Emotion Awareness Meditation, Mindful Mood Induction, or Anchoring in the Present. ☐​  Mindful Emotion Awareness Meditation: Listen to the five-​minute audio recording available at http://www.oup.com/us/ttw and record your experience. ☐​ Mindful Mood Induction: Choose a song that you know will bring up emotions for you and practice observing your experience in the present moment nonjudgmentally. Record your experience. ☐​ Anchoring in the Present: When you notice that an emotional response is building, complete the following four steps: (1) use your cue (e.g., breath) to ground yourself in the present moment, (2) do a three-​point check (thoughts, physical sensations, behaviors), (3) ask yourself if your response is consistent with what’s going on right now, and (4) bring your response in line with the demands of the present moment.

How effective were you at not judging your experience?

What did you notice?

Date

Practice Meditation, Mood Induction, or Anchoring?

0  -​  10 Thoughts

Physical Sensations

Behaviors

(not at all) (extremely)

How effective were you at anchoring yourself in the present? 0  -​   10 (not at all) (extremely)

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CHAPTER 8

Cognitive Flexibility

GOALS To understand how your thoughts influence how you feel ■ To identify patterns of negative thinking ■ To learn how to be more flexible in your thinking ■

Homework Review Did you complete your Anxiety and Depression Scales (and your Other Emotion and Positive Emotion Scales if you’ve chosen to complete them) for the previous week? Have you plotted your scores on your Progress Record? In the last chapter, we discussed the importance of observing our emotions in a nonjudgmental and present-​focused manner. You were introduced to three exercises designed to promote Mindful Emotion Awareness: Meditation, Mindful Mood Induction, and Anchoring in the Present. You were asked to use the Mindful Emotion Awareness Form to record your experiences with these exercises. Have you been continuing to build your Mindful Emotion Awareness muscle through these exercises? Remember, this takes a lot of practice—​it doesn’t happen overnight. It’s important to continue practicing Mindful Emotion Awareness, especially when you begin to notice strong emotions coming up in your life. It may be helpful to remind yourself that completing the exercises in this program is critical to your success.

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Key Concepts So far, you have learned to carefully track the interactions between your thoughts, physical sensations, and behaviors. In the previous chapter, you learned about a skill called Mindful Emotion Awareness. You practiced paying attention to the three parts of your emotional response in a nonjudgmental and present-​focused way. Now we move to the third floor of our house in which each room provides a coping skill that corresponds to each of the three components of an emotion—​thoughts, physical sensations, and behaviors. In this chapter, we zoom in on one specific (and very important) component of every emotional experience—​thoughts (see Figure 8.1). First, you will become more aware of how your thoughts influence how you feel. Then you will learn to identify when you may be automatically looking at emotional situations in negative ways. Last, you will learn how to be more flexible in your thinking, which we refer to as Cognitive Flexibility. This skill involves coming up with other ways of viewing situations that may be more helpful to you. Cognitive Flexibility will help

COGNITIVE FLEXIBILITY

MINDFUL EMOTION AWARENESS

UNDERSTANDING YOUR EMOTIONS

SETTING GOALS & MAINTAINING MOTIVATION

Figure 8.1    

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you respond in helpful, adaptive ways to emotion-​provoking situations. While focusing on what you think, try to use Mindful Emotion Awareness to observe your thoughts without judgment. This will help you get the most out of the skill discussed in this chapter.

Why Are Thoughts Important? Thoughts are an important part of every emotional experience. This is because the way we think about our world really influences how we feel. Most situations in our lives can be interpreted in more than one way. For example, imagine that you are texting back and forth over the course of a day with someone new you’re dating, but now you haven’t heard back from them for a few hours. How might you feel if you thought, “They must not be interested in me anymore?” Perhaps you would feel sad, ashamed, or even angry. What if, instead, you thought, “They are probably distracted by work.” You might feel more neutral or even excited to hear what they’ve been doing. As you can see from this example, how you interpret this situation (not hearing back from this person) really affects how you feel. In addition, how you feel can influence what you think. When you’re in a negative mood, you’re more likely to have negative thoughts. For example, if you’re feeling frustrated by a tough day at work, you might be more likely to make a negative assumption when you don’t hear back from the person you’re dating. On the other hand, if you had just received a promotion, you’d probably lean toward a more neutral interpretation. Can you think of a time when you felt very anxious because you thought something bad was going to happen (but it didn’t)? What about a time when you felt frustrated because you thought someone was upset with you (but they weren’t)? Or do you remember a time when you felt angry because you thought someone had done something to hurt you on purpose (but they hadn’t)? Use the following space to record an example of how your thoughts about a situation influenced how you felt about it. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

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What Are Automatic Thoughts? Another thing to keep in mind about thoughts is that they tend to come into our minds quickly and automatically. Let’s try an exercise to show this point. Take a moment to look at the picture in Figure 8.2.

Figure 8.2 Ambiguous Picture

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What was your first interpretation about what is happening in the picture? Be sure to record the first thing that jumped into your mind. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ What might have led you to your first interpretation? For example, did you focus on specific parts of the picture, like an object or the expression on someone’s face? Did a specific memory or past experience influence your first interpretation? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Try to come up with at least three other interpretations of what might be happening in the picture. If your first interpretation was negative, see if you can come up with a more positive one. If your first interpretation was positive, see if you can come up with something more negative. It’s okay if these other interpretations don’t seem as believable as your first interpretation. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ During this exercise, you may have noticed that your first interpretation came very quickly—​maybe after only a few seconds. You may have also noticed that once you landed on this first impression, it was hard to come up with other possibilities of what was happening. Perhaps you focused on key parts of the picture, making it difficult to see other important details. We all tend to interpret situations quickly and automatically. Sometimes, these automatic thoughts are helpful. Imagine a situation

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where there is immediate danger, like a car speeding down the street toward you. You would probably focus on only a couple key pieces of information, like how fast the car is going and how far away it is. You may not notice car’s color or model. In this situation, focusing on only a couple things is helpful. It allows you respond quickly, by jumping out of the way! However, when we tend to always focus only on the negative parts of certain situations, it isn’t so helpful. Getting stuck in patterns where our automatic thoughts are usually negative is common for people with emotional disorders. Because the way we think affects how we feel, it’s important to notice when we are getting stuck in negative thinking patterns.

What Are Thinking Traps? When we find ourselves stuck in these mental ruts where our first impressions are usually negative, we may be falling into a thinking trap. To show what we mean, let’s consider an example. Imagine you gave a presentation at work or in class. Later, you meet with your boss or teacher to discuss your performance. They start by praising you for doing well. Then they tell you about something you could improve on, like making better eye contact. In this situation, it would be helpful to focus on their critical feedback so you can improve your performance in the future. However, it would be problematic if you also ignored all other possible thoughts about the situation, like all the things you did well. This might lead you to feel more intense negative emotions and to have judgmental thoughts like, “I’ll never do anything right” or “There’s no point in trying.” It could also lead you to respond in unhelpful ways, like avoiding presentations in the future or sending angry emails about your boss or teacher that you regret later on. People with emotional disorders tend to experience two types of thinking traps: jumping to conclusions and thinking the worst. These thinking traps can really get in the way of seeing other possibilities. Let’s talk some more about these traps. Jumping to Conclusions

This thinking trap occurs when you jump to the conclusion that your automatic thought (e.g., something bad will happen, that you’re a failure)

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is true, even with little or no evidence. You may also ignore evidence to suggest a different possibility. For example, imagine someone who is having frequent panic attacks. When he begins to notice symptoms of a panic attack coming on (e.g., racing heart, shortness of breath), he becomes terrified that he will have a heart attack and die, even though this has never happened. This person is jumping to the conclusion that this negative outcome will happen. He is also focusing on only one possible outcome and missing other possibilities, like the panic attack passing quickly. He is also ignoring evidence that having a panic attack is not likely to result in a heart attack or death. Imagine another person who is having trouble doing her usual activities because she has been feeling depressed. She knows that she “should” get up, take a shower, and leave the house. But she has been feeling so down lately, even while doing things she used to enjoy. This person may think about how she will feel terrible all day again, no matter what she does. In this case, she is jumping to the conclusion that she will have no positive (or even neutral) feelings that day. She is also ignoring other possibilities, such as the likelihood that her mood might improve if she decides to spend time with someone she cares about. This thinking trap also makes it more likely that she will stay in bed, which is likely to make her depression worse. Jumping to conclusions can occur in the context of many different emotions. For example, thinking that a friend definitely hurt you on purpose could quickly lead to feelings of anger. Similarly, the thought that “I always screw things up” might lead you to feel ashamed and worthless. Thinking the Worst

This thinking trap occurs when you automatically predict that the worst possible scenario is going to happen. You also think that, when it does happen, you will be unable to cope with it. Imagine someone who is worried that if she doesn’t have anything interesting to say at a party, people will reject her. She also predicts that, if she is rejected, she would find this devastating. Here, this person is assuming that the result of not having anything to say will be really bad—​she will be rejected. She is also assuming that, if she is rejected, she will be absolutely devastated. This person is only focusing on one negative possibility, which makes her miss other options of what may happen. For example, other people might not reject her. She may also be ignoring evidence that she has

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been rejected before and survived. Falling into this trap would probably make this person feel more anxious and perhaps also sad. It could also make her likely to avoid talking to new people at the party or avoid going at all. Now consider someone else who is dreading going home for the holidays because he might encounter triggers (like a specific person or place) for distressing memories and flashbacks. This person may automatically assume that he won’t be able to cope (“I won’t be able to handle it” or “I’ll get so down again and never feel better”). This trap would make it hard to see other possibilities of what could happen when faced with these triggers. It could also lead to unhelpful responses—​like withdrawing from friends or family or using alcohol to cope with his negative feelings.

Identifying Thinking Traps The problem with thinking traps is they make our thinking less flexible. By only seeing the negative side of a situation, we are more likely to respond in unhelpful ways—​like doing something to avoid or push our feelings away. As we’ve discussed, this can keep us stuck in cycles of negative emotion. The first step to changing this pattern is to notice when you might be falling into a thinking trap in your daily life. Pull out the Following Your ARC Forms you completed previously. Examine the thoughts you recorded and see if you can identify whether any of them are falling into these traps. Keep in mind that negative automatic thoughts can often fall into both thinking traps at the same time—​jumping to conclusions and thinking the worst. Don’t worry about figuring out whether a thought is one trap or the other. Instead, the goal is to recognize when you are falling into a trap. Recognizing this can prompt you to question your initial, gut interpretations. You might feel discouraged by how often you find yourself falling into a trap. Remember to use your Mindful Emotion Awareness skill to look at your thinking traps in a nonjudgmental way. For example, you could remind yourself that it makes sense that you might be having a negative first impression given your past experiences. Also, your negative automatic thought may not always end up being inaccurate, but it is still

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important to get into the habit of considering other perspectives. This will help you with the next step: increasing flexibility in your thinking.

How Do We Become More Flexible in Our Thinking? One way out of these thinking traps is to consider your negative automatic thoughts not as “truths” but as one possible interpretation. Cognitive Flexibility involves coming up with other interpretations of situations that bring up strong emotions for you. Learning to be more flexible in your thinking can help you respond in more helpful ways to strong emotions. When you find yourself falling into a thinking trap, ask yourself the following questions to generate other ways of thinking about emotional situations. Questions for Negative Automatic Thoughts

Use these questions when you notice yourself falling into a thinking trap: ■ ■ ■

Do I know for certain that __________ will happen or is true? What evidence do I have for and against this thought or belief? Could there be any other explanations? How much does it feel like __________ ​is true? What is a more realistic chance that ___________ i​s true? ■ Is my negative automatic thought driven by the intense emotions I’m experiencing? ■ If __________ ​was true, could I cope with it? How would I handle it? ■ Even if ___________ ​was true, could I live with it? ■

These questions are designed to help you get your thinking unstuck. The responses to these questions make it easier to come up with other possible interpretations. Remember, your automatic first impressions happen very quickly, so you may also find it helpful to type these questions into your cell phone or take a picture of them so it’s easier to use them in the future. Let’s go through an example of what using these questions could look like. Remember the person who is concerned that if she doesn’t have anything interesting to say at a party, she will be rejected. If this were to happen, she also expects that it will be devastating for her. Imagine how she might respond to some of the questions above:

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Do I know for certain that they will reject me if I don’t have anything interesting to say? No, I do not know this for certain. ■ How much does it feel like they will reject me? A lot, especially when I’m anxious. What is a more realistic chance that they will reject me? The chance is probably smaller than I think it is—​it feels like there is 90% chance, but maybe a 40% chance is more realistic. ■ Even if they did reject me, could I live with it? I guess. I have been rejected before, like someone not calling me after a first date. Even though it didn’t feel good at the time, I don’t really think about it much now. ■

Now think back to the person who was dreading going home for the holidays. His automatic thoughts were about not being able to handle it if he had to face triggers for distressing memories. This person might try asking himself: What evidence do I have for and against this thought or belief? In the past, there have been times when going home has been way too overwhelming. But this hasn’t happened every single time. ■ Is my negative thought driven by the intense emotions I’m experiencing? Probably—​I tend to have more thoughts like these when I’m very anxious. ■ If my negative thought were true (and I became depressed again after going home), could I cope with it? Maybe . . . I’ve been depressed before—​sometimes I’ve coped better than others. How would I handle it? I could talk to my friends about it and make sure I keep doing things I enjoy. ■

The responses to these questions can be used to help you come up with other interpretations of the emotion-​producing situations you face. For example, the person going home for the holidays could think: “It’s possible that it won’t be as terrible as I’m imagining” and “Maybe I’ll feel down for a bit after but it won’t become full-​blown depression.” He may also come up with other thoughts about his ability to cope. For example, “Even if I do become depressed, I have helpful ways to cope—​like talking to my friends and therapist.” These other interpretations might help him plan ways to make his trip more manageable, such as having supportive people around and making a plan for what to do if he starts to feel unsafe. Remember, though, that the goal isn’t to get rid of negative automatic thoughts. Instead, the aim is to allow many possible interpretations to exist.

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Now try using your Cognitive Flexibility skill with the thinking traps you identified on your Following Your ARC Forms. Use the Practicing Cognitive Flexibility Form at the end of this chapter to guide you. You’ll notice that the questions to ask yourself when having negative automatic thoughts are listed at the top of the form, and you can use them to come up with other interpretations about emotional situations. This will help you to get more perspective on your negative automatic thoughts. When asking yourself these questions, use your Mindful Emotion Awareness skill to pay attention to what is actually happening in the present. For example, if your first thought is “He/​she is breaking up with me,” you could consider whether that person is breaking up with you right now. This will help you come up with interpretations that are more consistent with the present situation. A completed example of the Practicing Cognitive Flexibility Form can be found in Appendix B on p. 172. While you’re practicing Cognitive Flexibility, keep in mind that the goal isn’t to get rid of your negative automatic thoughts. Instead, the aim is to allow other possible interpretations and thoughts to exist. Additionally, you may find that working through the questions may feel like “going through the motions” because you don’t fully believe the new thoughts you’re generating. Remember that you have had a lot of practice automatically making negative interpretations, so it will take time and repetition before the new thoughts feel true. As long as you continue to generate new interpretations that are a bit more balanced and realistic (not just the most positive thoughts you can come up with for the sake of “thinking positively”), you will start to believe the thoughts more over time.

Thoughts about Emotions It is also important to try to be flexible in how you think about emotions. For example, people with emotional disorders often have negative automatic thoughts about the experience of emotion. For example, you may think “I shouldn’t feel anxious” or “I hate being sad.” Practice generating other ways of thinking about emotion, like “Anxiety can help me prepare for important things” and “Sometimes, anxiety is helpful.” The same goes for emotions like anger and sadness—​helpful thoughts about these emotions could be “It makes sense I’m angry with how unfairly my boss is treating me” or “Being sad after this loss is normal; feeling this way now will help me move on later.” Coming up with other interpretations of

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what it can mean to experience a wide range of emotions will help you approach your emotions and not push them away, which is the goal of this program.

Increasing Cognitive Flexibility with Intrusive, Unwanted Thoughts Some people have thoughts that seem to “just pop into their mind” and don’t make sense. Common examples are thoughts about harming someone they love or that some terrible but very unrealistic outcome will happen (like contracting HIV from a hand rail). If this applies to you, it can be helpful to first ask yourself: “How does having this thought make me feel? What does having this thought mean about me?” Then use the “Questions for Negative Automatic Thoughts” listed previously to come up with other interpretations about what having these thoughts may mean about you. For example, someone may think they are a “monster” or terrible person for having these intrusive and unwanted thoughts. Specifically, having an intrusive thought about their mom getting into a car accident may prompt someone to question whether this thought means they might want that to happen. Working on cognitive flexibility in this case could involve asking themselves whether there are any explanations other than “Because I  have these thoughts, I  am an awful person.” Someone with these kinds of intrusive thoughts may also ask themselves what evidence they have that they are an awful person. These questions may help them consider that they have never acted on these thoughts and that they find the whole idea of acting on these thoughts very offensive. This could help them come up with other interpretations about what these unwanted thoughts mean. For example, “Just because I have these thoughts doesn’t mean I’m a monster or I will act on them.”

What If Cognitive Flexibility Isn’t Working? You may have noticed that questioning your automatic thoughts in certain situations isn’t working very well. You may be able to come up with other interpretations of emotional situations, but you have a hard time believing them. You may also notice that it’s especially hard to consider other perspectives when you are feeling a strong emotion. This may be because of core automatic thoughts that are being triggered by a particular situation.

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Core automatic thoughts are not specific to a particular situation or event. Often these thoughts are about yourself: “I’m incompetent,” “I’m a failure,” “I’m unlovable,” “I’m bad,” “I’m worthless,” or “I’ll be alone forever.” They can also be general beliefs about the world around you: “The world is a dangerous place,” or “At the end of the day, I have no control over what happens to me.” Core automatic thoughts often hang out below the surface, like a painful bruise below your skin that isn’t easily seen. When your core automatic thoughts are activated, like someone applying pressure on your bruise, your emotions will feel much more intense. This can make it really hard to think flexibly. For many people, it can take some digging to figure out what their core automatic thoughts are. The Downward Arrow strategy can help you with this. Start by picking a negative automatic thought you had during a recent emotional situation. Then ask yourself the questions on the Downward Arrow Form at the end of this chapter: What would happen if [automatic thought] were true?”, “What would happen next?”, and “If [automatic thought] were true, what would it mean about me?” Keep going until you get to a core automatic thought that is making your emotions more intense and getting in the way of flexible thinking. Two sample completed Downward Arrow Forms are shown in Appendix B on pp. 173–​174. The good news is that you can also become more flexible with core automatic thoughts by questioning them in the same way you’ve been practicing with your negative automatic thoughts. Use the questions to help you come up with a more balanced or neutral alternative to your core automatic thought. Examples could be “I’m okay,” “I’m good enough,” “I have value,” or “I am successful sometimes.” These new core thoughts shouldn’t be overly positive (e.g., “I never do anything wrong”) because it is not helpful to try to force yourself to believe thoughts that are too positive to be realistic. Keep in mind that you don’t have to limit yourself to challenging the core automatic thought you came to at the bottom of the Downward Arrow Form. Any thoughts generated by this exercise are fair game. After you’ve generated some alternatives to your core automatic thoughts, begin looking for evidence that supports the new core thought each day. This can be things that happen to you or things that you do well. For example, someone with the new core thought “I’m good enough” might notice that a friend complimented them. Someone with the new core thought of “Sometimes I can be successful” might notice that they showered and got dressed even when they felt depressed. This is when thinking

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flexibly comes in. You will still notice negative events, but try to also look for positive things that could support your new core thought. You may find it helpful to write two or three things down each day.

Treatment Goal Check-​In Use the space to below to reflect on how using Cognitive Flexibility can bring you closer to the goals you set in Chapter 4. Also note any progress you’ve made toward your goals.

Summary In this chapter, we looked more closely at one part of our emotional experiences—​thoughts. We saw how our thoughts influence how we feel. We discussed how thoughts can become automatic and lead to thinking traps. Last, we learned how to question our thinking traps to come up with other ways of thinking about emotional situations. By using this Cognitive Flexibility skill, you will be better able to respond to your emotions in more helpful ways and without avoidance. In the next chapter, we zoom in on another very important part of our emotional experiences—​behaviors.

Homework Use the Practicing Cognitive Flexibility Form to record when you might be falling into a thinking trap and come up with other interpretations of emotional situations. Remember that the “Questions for Negative Automatic Thoughts” can be helpful in coming up with other interpretations. Try this at least once a day. If you would like more space to practice this skill, consider

■

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making photocopies of this form or downloading it from the TreatmentsThatWorkTM website at http://www.oup.com/us/ttw. ■ Continue monitoring your weekly experiences using the Anxiety and Depression Scales (as well as the Other Emotion and Positive Emotions Scales, if you’re using them). ■ Remember to use the Progress Record to record the total scores from the Anxiety and Depression Scales (as well as Other Emotion and Positive Emotions Scales). ■ Optional: If you are having trouble with Cognitive Flexibility, use the Downward Arrow Form to identify core automatic thoughts that may be making it hard to question your first automatic thoughts in some situations. Then use the Practicing Cognitive Flexibility Form to come up with alternative interpretations of your core automatic thoughts.

Self-​Assessment Quiz Answer each of the following by circling true (T) or false (F). Answers can be found in Appendix A. 1. Thoughts affect how we feel, but our emotions don’t affect how we interpret situations. T

F

2. We always have complete and conscious control over our automatic thoughts. T

F

3. In this treatment, it is not as important to figure out which of the two thinking traps (jumping to conclusions and thinking the worst) you are falling into. T

F

4. In this treatment, the goal of cognitive flexibility is to eliminate all incorrect ways of thinking. T

F

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Form 8.1: Practicing Cognitive Flexibility Use this form to help you move past your first impressions by identifying if you’re falling into a negative thinking trap and coming up with alternative ways you can think about the situation. Use the questions below to help you evaluate your automatic thoughts. ☐​  ☐​  ☐​  ☐​ 

Do I know for certain that _​_​_​_​_​_​_​_​ will happen or is true? What evidence do I have for this thought or belief? Could there be any other explanations? Even if _​_​_​_​_​_​_​_​was true, could I live with it?

Situation/​Trigger

Automatic Thought(s)

☐​  How much does it feel like _​_​_​_​_​_​_​_​is true? What is a more realistic chance that _​_​_​_​_​_​_​_​is true? ☐​  Is my negative automatic thought driven by the intense emotions I’m experiencing? ☐​  If _​_​_​_​_​_​_​_​was true, could I cope with it? How would I handle it?

Is this a Thinking Trap? YES/​NO

Other Interpretation(s) Often include “automatic thought may not be true” and “even if it is, I could cope.”

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Form 8.2: Downward Arrow: Identifying Core Automatic Thoughts Sometimes the alternative thoughts you’re coming up with don’t seem very believable. This may because there are core automatic thoughts driving your initial negative thoughts. Use this form to explore the thoughts that might be beneath the surface of your first automatic thought.

First Automatic Thought:

If this were true, what would it mean about me? Why does this matter to me? What would happen if this were true? What would happen next? Core Automatic Thought:

If this were true, what would it mean about me? Why does this matter to me? What would happen if this were true? What would happen next? Core Automatic Thought:

If this were true, what would it mean about me? Why does this matter to me? What would happen if this were true? What would happen next? Core Automatic Thought:

If this were true, what would it mean about me? Why does this matter to me? What would happen if this were true? What would happen next? Core Automatic Thought:

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CHAPTER 9

Countering Emotional Behaviors

GOALS To learn about the behaviors associated with strong emotions ■ To understand how these behaviors influence emotional experiences ■ To identify and counter different types of emotional behaviors ■

Homework Review Did you complete your Anxiety and Depression Scales (and your Other Emotion and Positive Emotion Scales if you’ve chosen to complete them) for the previous week? Have you plotted your scores on your Progress Record? Additionally, did you notice any negative automatic thoughts this past week? If so, were you able use the Practicing Cognitive Flexibility Form to generate alternative ways to interpret emotion-​ producing situations? Remember that we can get stuck in thinking ruts where we trust our (often negative) first impressions. The goal of evaluating our negative automatic thoughts is not to correct them. Instead, we want to be more flexible in allowing other, more balanced interpretations. If you have not done so, spend the next week closely monitoring and questioning your negative automatic thoughts.

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COGNITIVE FLEXIBILITY

COUNTERING EMOTIONAL BEHAVIORS

MINDFUL EMOTION AWARENESS

UNDERSTANDING YOUR EMOTIONS

SETTING GOALS & MAINTAINING MOTIVATION

Figure 9.1    

Key Concepts The next room on the third floor of our house provides skills to identify and evaluate emotional behaviors—​the behaviors that you use to manage strong emotions (see Figure 9.1). Emotional behaviors can often be helpful (e.g., running away from a snarling stray dog when feeling fear, phrasing negative feedback carefully to prevent yourself from feeling guilty about how you handled things), but sometimes these behaviors are not consistent with the situation at hand (e.g., avoiding a meeting when you feel anxious about giving a presentation). As we discussed in Chapter 5, emotional behaviors serve to avoid uncomfortable emotions in the short term but can limit our lives in the long term. In this chapter, you will first learn to identify the behaviors you use in the context of a strong emotion. Then you will work to develop new ways to act that do not interfere with your life in the long term. What Are Emotional Behaviors? The term “emotional behaviors” refers to the things we do to manage our emotions. There are several ways our actions can be affected by our 96

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emotions. First, every emotion is naturally associated with specific actions that are called emotion-​driven behaviors. In Chapter 5 we discussed how the natural behaviors linked with each emotion can be helpful. For example, sadness prompts us to withdraw to process a loss or setback. Anger motivates us to defend ourselves when we’ve been wronged. Take a moment here to remind yourself of the helpful behaviors associated with other common emotions by filling in Figure 9.2. As you probably remember, anxiety helps us to prepare for important events in the future (e.g., studying for an upcoming test, saving for retirement). Guilt may prompt us to make amends after hurting another person. Happiness lets us know what we value so we can continue to pursue it. In all of these cases, emotions communicate important information about the world around us so that we can act in ways that benefit us. However, sometimes the emotion-​driven behaviors that we engage in when feeling a strong emotion are not so helpful. For example, imagine that you snap at your significant other because you had a bad day at work. We can all relate to lashing out at someone we love when we’re stressed about something else, even though we know it won’t solve the problem. So why do we do it? Often we act in ways that reduce distress in the short term. That is, snapping at a loved one might make you feel a little better while you’re doing it—​kind of like scratching an itch. This behavior might feel like a release from the tension you’re feeling. But the relief is often short-​lived as these behaviors can lead to long-​term consequences that make you feel worse later on (e.g., more arguments with your partner, feeling guilty for lashing out).

Figure 9.2 Emotion-​Driven Action Tendencies

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Additionally, in Chapter  6, we discussed how humans’ ability to think about the future can also prompt unhelpful emotional behaviors. We can imagine whether certain situations could possibly bring up strong emotions and change our behavior to prevent potential uncomfortable feelings. For example, avoiding parties might prevent you from experiencing feelings of anxiety in the short term. But, in the long term, there might be negative consequences for your relationships if you’re never able to hang out with your friends. More importantly, avoiding parties sends the message that social situations are indeed dangerous (why else would you be avoiding them?), making it even harder to approach them in the future. Totally avoiding certain situations, events, or activities is called overt avoidance. In addition to completely avoiding certain situations to prevent feeling an uncomfortable emotion altogether, we can also engage in less obvious forms of avoidance. Subtle behavioral avoidance refers to behaviors that prevent you from experiencing the full effect of an emotion. For example, you might go to a party but play games on your phone or have several drinks before talking to someone you don’t know very well. Additionally, cognitive avoidance involves keeping your mind occupied to keep your attention off your emotions; this might look like surfing the Internet to distract yourself when feeling irritated in a meeting. Finally, safety signals are items that people carry to help them feel more comfortable in emotional situations. They can be superstitious objects like good luck charms, practical items like cell phones or water bottles, and even people we bring with us to uncomfortable places. At first glance safety signals probably don’t seem like a big deal. But the problem with relying on them is that they can prevent you from learning that you can cope with a situation on your own. Using subtle behavioral avoidance, cognitive avoidance, or safety signals is problematic because it sends the message that you couldn’t possibly cope with the full brunt of an emotional experience—​keeping you stuck in the cycle of avoidance and maintaining negative beliefs about emotions. In general, all of these categories of unhelpful emotional behaviors make you feel better (at least a little bit) in the short term but lead to more negative emotions in the long term. Each person may engage in unique, idiosyncratic emotional behaviors that relate to their lives. See Table 9.1 for some examples, and notice how each serves to avoid negative emotions in the short term but can increase them in the long term.

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Table 9.1.  Short-​and Long-​Term Consequences of Emotional Behaviors Emotion-​Driven Behaviors Behaviors driven by strong emotions that are designed to reduce the intensity of that emotion Behavior

Consequences

Leaving a situation when feeling anxious

Short-​term: Reduction in anxiety Long-​term: Begin avoiding more situations because they seem too anxiety-​ provoking, confirm to yourself that the situation is “dangerous” and continue to experience anxiety when approaching it

Lashing out at someone who made you angry

Short-​term: Release of tension, like you “taught them a lesson” Long-​term: Damage relationships, feeling guilty

Apologizing excessively

Short-​term: Feel better, might get reassurance from the other person that they are not upset Long-​term: People get frustrated with having to provide so much reassurance, confirms that you did something “bad”

Calling a relative repeatedly to check on their safety

Short-​term: Feeling relief when you hear their voice Long-​term: Relatives become annoyed by constant calls, you continue to feel anxious anytime you have a thought that loved ones might not be safe

Self-​injurious behaviors (e.g., cutting yourself on purpose)

Short-​term: Takes your mind off emotional pain, feel relief Long-​term: Scars, social stigma, reinforce the belief that emotions are more dangerous than physical pain

Drinking alcohol or using substances

Short-​term: Takes your mind off emotional pain, feel relief Long-​term: May engage in behaviors you later regret, reinforces the belief that you can’t cope with emotions without taking the edge off with substances

Overt Avoidance Outright avoidance of situations, people, etc. that bring up strong emotions Behavior

Consequences

Not attending a party to avoid anxiety in social situations

Short-​term: Steer clear of anxious feelings at party Long-​term: Friends become frustrated and they invite you to fewer events, confirms to yourself that the party is “dangerous” and you continue to feel anxious and avoid parties in the future

Not taking public transportation due to fears of having a panic attack

Short-​term: Possibly avoid having a panic attack Long-​term: Spend money on cabs, might take a long time to get places, confirms the belief that you are unable to cope with panic attacks

Avoiding situation or places that remind you of better times

Short-​term: Don’t have to think about how you’re feeling depressed now Long-​term: Confirms the belief that thinking about the past will keep you down for a long period of time (continued)

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Table 9.1. Continued Subtle Behavioral Avoidance Behaviors that prevent fully experiencing an emotion when outright avoidance isn’t an option Behavior

Consequences

Texting at a party to avoid small talk

Short-​term: Feel less awkward and anxious Long-​term: Do not meet new people or make new friends, confirms the belief that others would judge you if you didn’t “look busy”

Not drinking caffeine

Short-​term: Prevents uncomfortable physical sensations such as racing heart Long-​term: Limits your food and beverage options

Wrapping yourself in a towel at the pool so no one can see your body

Short-​term: Feel relieved that no one can see you Long-​term: Confirms the belief that your body is something to be ashamed of

Perfectionism

Short-​term: Feel stressed but prevents uncomfortable uncertainty about whether you’re doing a good job Long-​term: Continue to feel pressure for things to be “perfect,” maintains worry that people will think less of you if you make a mistake

Restricting food intake

Short-​term: Prevent yourself from worrying about gaining weight Long-​term: Reinforces the belief that you have to be a certain weight, increased anxiety if you eat something “bad”

Cognitive Avoidance Anything you might do to keep your mind off something that is distressing Behavior Distraction (e.g., reading, listening to music, watching television) Dissociation

Worry/​Rumination

Trying to push away “bad” thoughts that bring up emotions (thought suppression)

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Consequences Short-​term: Keeps your mind off a difficult situation Long-​term: Maintains the belief that you can’t cope with the situation Short-​term: Avoid feelings associated with a difficult situation Long-​term: Miss important elements of situation (e.g., questions directed at you, instructions) Short-​term: Feel like you’re working to solve the problem Long-​term: Doesn’t solve the problem, takes up a lot of time, actually increases negative emotions over time Short-​term: Relief from not having to think about these thoughts Long-​term: Thoughts rebound, are more intense than before, thoughts feel more dangerous than before

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Table 9.1. Continued Safety Signals Items people carry with them that help them feel more comfortable and/​or keep an emotion from becoming overwhelming Behavior

Consequences

Carrying good luck charms to feel comfortable in an airplane

Short-​term: Feel less anxious during the flight Long-​term: Believe you can only fly with these items, refuse to get on a plane if you forget them

Carrying items like water bottles, medication, or cell phones “just in case”

Short-​term: Feel prepared for anything Long-​term: Your bag is really heavy, you believe you can’t function without it

Bringing a “safety person” to an uncomfortable situation Carrying self-​defense items

Short-​term: Never feel bored Long-​term: Disengage from situations that makes you appear unfriendly, don’t meet new people Short-​term: Feel prepared Long-​term: Reinforces the idea that the world is a dangerous place and you cannot cope with it on your own

If Unhelpful Emotional Behaviors Have Negative Consequences, Why Do We Keep Doing Them?

As previously mentioned, unhelpful emotional behaviors provide short-​ term relief from distress. When a behavior makes you feel better, even just for a little while, it is reinforced. In other words, the relief you feel is a very powerful motivator to engage in that behavior again. Think of it like this: if you were in a great deal of pain and pushing a button administered pain medication that made you feel better, you’d probably keep pushing it. Reinforcement that is immediate, like feeling relief as soon as you perform an emotional behavior, is really difficult to break—​even when we know that it will backfire in the long term. When you enter a situation that brings up a strong emotion, the pull to do something that “worked” (reduced the negative emotions quickly) can be very strong. For example, if you usually leave crowded spaces when you begin to feel panicky, you’ll probably have the urge to engage in this behavior the next time this situation occurs. Although leaving makes you feel better immediately, you’re also confirming to yourself that crowds are

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indeed dangerous and the only reason you didn’t panic is because you left. Chances are that next time you are in a crowd you’ll feel even more anxious than before and, of course, the urge to leave. Further, continuing to avoid strong emotions keeps you stuck in a cycle where you continue to tell yourself (through your actions) that emotions are “bad,” making them more and more overwhelming each time they occur. Let’s do an exercise that further highlights the short-​term and long-​term effects of avoiding our emotions.

Think about a time you were really embarrassed. Write down the situation on the following lines. What happened? What were you doing? thinking? feeling? Try to be very descriptive. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ For the next minute, hold this memory in your mind. Really focus on it. How successful were you thinking about that memory (circle one)? Very    Somewhat    A little    Not at all Now for the next minute, absolutely do not think about the embarrassing memory. You can think about anything else, apart from that memory. Again, how successful were you at not thinking about the memory (circle one)? Very    Somewhat    A little    Not at all

Did you find it difficult to avoid thinking about the memory? A lot of people find that it is an almost impossible task! You may have been able to hold thoughts about the memory off for a little while, but it probably took a lot of effort trying to distract yourself (e.g., singing a song to 102

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yourself ). Generally, when we let our guard down, the thoughts come rushing back. By telling yourself to push away a particular thought, you’re basically confirming to yourself that the thought is bad and worthy of avoiding. In other words, avoiding these thoughts makes it seem like they are so terrible that there is no other way to manage them than to forcefully push them away. When something is really dangerous, it tends to draw our attention to it so we can cope—​that’s why suppressing thoughts makes them come up even more. How Do You Break the Cycle of Unhelpful Emotional Behaviors?

One of the best ways to break the cycle of experiencing overwhelming strong emotions is to replace a current emotional behavior with a new, alternative behavior. For example, when you’re feeling sad, you could exercise or text your friends instead of taking a nap. We refer to this skill as choosing an Alternative Action—​that is, engaging in an action that is different to what you’ve done in the past when you experience strong emotions. See Table 9.2 for examples of Alternative Actions. Approaching your emotions instead of avoiding them is an important form of Alternative Action. By “approaching,” we mean engaging in activities that bring up the emotions you are currently avoiding. Doing so will help you gather more information about your ability to cope in a given situation. Using a previous example, if you always avoid crowds out of fear that you will have a panic attack, you will assume you cannot handle being in a crowd. But if you were to approach this situation, you could learn more about how well you can manage. Over time changing how you behave can also change how you feel. As we discussed in Chapter  5, thoughts, physical sensations, and behaviors interact to produce emotional experiences. Thus changing how we respond to one of those components can change the whole experience. You might have noticed this in Chapter  8 when you learned strategies for Cognitive Flexibility. In those examples, changing how you responded to an automatic thought might have affected your subsequent thoughts, feelings, or behaviors. Let’s look at an example of how changing behavior might affect an emotional experience. If you get angry in traffic, you might yell at other drivers. As you yell, your heart rate goes up, you start to spend time thinking about how the other drivers wronged you, and you likely continue to feel angry and perhaps risk picking a fight with another driver. Further, after yelling, you might

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Table 9.2.  Alternative Actions for Emotional Behaviors

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Emotion

Emotional Behavior(s)

Alternative Action(s)

Fear

Escape/​avoid people or places Pick fights Make threats

Stay in the situation, approach Speak calmly Give compliments

Sadness

Withdraw from friends Nap Avoid enjoyable activities Listen to sad music Move slowly Do not make eye contact

Call friends, make plans to go out Schedule activities Make plans to do something fun Listen to upbeat music Be active: walk quickly, do pushups, stretch Make direct eye contact

Anxiety

Over prepare Avoid Seek reassurance Worry/​ruminate Pay extra attention to physical sensations Tap feet or hands

Set a time limit on how long to prepare, engage in a pleasant activity Face the situation Resist reassurance seeking by talking about something else Practice mindfulness or problem-​solving (i.e., make a step-​by-​step list of how to solve the problem) Maintain full contact with both feet and the floor, hold your hands together in your lap

Anger

Fight Yell Break things Clench your fists Clench your jaw Make snarky comments Vent Pace Get too close to people

Take a break before responding, go for a walk Talk in an even tone Move slowly, put items down gently Relax your hands, spread out your fingers to make it impossible to hold a fist Pay a compliment Tell a funny story, consider the other person’s perspective Stretch gently Take a big step backwards

Guilt/​Shame

Withdraw Avoid eye contact Speak softly Ruminate Maintain hunched posture Apologize excessively Deny yourself something to make up for what you did

Contact others Make eye contact Use a full voice Anchor in the present Sit/​stand up straight Apologize only once (if warranted), talk about something else Engage in an enjoyable activity (text friends, eat a favorite food, listen to music, etc.)

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feel bad about yourself. On the other hand, if you refrain from yelling and instead sing along with the radio (an Alternative Action), your behavior is less likely to fuel feelings of anger. If you engage in the Alternative Action, you avoid the potential of an altercation with another driver and might even feel proud of yourself for how you responded to the situation. As this example illustrates, Alternative Actions have different short-​term and long-​term consequences than emotional behaviors. In the short term, it can be difficult to perform these actions, especially if they are different from what you’re used to doing. But in the long term, engaging in Alternative Actions can help reduce the intensity of your emotional experience and might also make you feel proud of your ability to handle difficult situations. Now that we have discussed the rationale for engaging in Alternative Actions, let’s review some ways you can come up with actions that work for you. Alternative Action doesn’t always mean that you have to do something big like approaching a feared situation. It can be something as simple as sitting up straight instead of slouching. Another important point is that Alternative Action requires you to do something. It can be tempting to decide that the opposite of a behavior is to do nothing. For example, someone might be tempted to say that instead of reassurance seeking, they just won’t say anything at all. But we find is that it’s really hard to go from doing something to doing nothing. It is easier to go from doing something to doing something different. So instead of trying to eliminate a behavior, we try to focus on replacing it. Sometimes it can be really tough to think of an Alternative Action. If you find yourself getting stuck, it can be helpful to start by thinking of the most extreme opposite action that you can. For example, if someone’s emotional behavior when feeling sad is to spend time alone—​the most extreme opposite might be going to a huge concert or talking to every stranger they see. Those behaviors might not be feasible. But then the individual can start scaling back to get to an Alternative Action that works for them. Perhaps they talk to two strangers, or call a friend and suggest that they do something together. Thinking of the most extreme opposite can help you start the brainstorming process. At this point, it might be helpful to identify some of your typical emotional behaviors and work on developing alternative behaviors. You can use the List of Emotional Behaviors Form at the end of this chapter to note emotional behaviors that you use in your life. It’s okay if you have trouble

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identifying all of them at this point—​this form is for brainstorming. Next use the Countering Emotional Behaviors Form at the end of the chapter to come up with Alternative Actions for the emotional behaviors that you identified. You can keep working on this throughout the week. But, for right now, just note some of the behaviors you would like to change as part of your treatment, and then develop some clear Alternative Actions that you believe will be more helpful to you in the long term. Examples of completed versions of both of these forms can be seen in Appendix B (on pp. 175–​178).

Treatment Goal Check-​In Use the space to below to reflect on how using Countering Emotional Behaviors can bring you closer to the goals you set in Chapter 4. Also note any progress you’ve made toward your goals.

Summary In this chapter, we discussed emotional behaviors—​actions that we take to manage strong emotions. Emotional behaviors can be used to quickly reduce the intensity of an emotional experience (emotion-​driven behaviors) or to prevent feelings of distress (overt avoidance, subtle behavioral avoidance, cognitive avoidance, and safety signals). These strategies often lessen distress in the short term but tend to make things worse in the long term (e.g., avoiding a meeting where you have to give a presentation might make you feel relieved in the moment but get you in trouble with your boss later). However, because they bring down distress (even if just for a moment), we are likely to keep engaging in these behaviors the next time we encounter an uncomfortable emotion. Further, using emotional behaviors perpetuates the idea that we cannot handle a given situation, making us likely to rely on them again in the future. We also discussed changing unhelpful emotional behaviors by engaging in Alternative Actions such as engaging with 106

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and experiencing an emotion you usually avoid, which can help break this cycle by changing the intensity of your emotion. It can also increase your confidence that you can handle experiencing the situation/​emotion. Homework Begin identifying the emotional behaviors that apply to you using the List of Emotional Behaviors Form. ■ Use the Countering Emotional Behaviors Form to start considering new behavioral responses to your strong emotions. If you would like more space to practice this skill, consider making photocopies of this form or downloading it from the TreatmentsThatWorkTM website at http://www.oup.com/us/ttw. ■ Continue monitoring your weekly experiences using the Anxiety and Depression Scales (as well as the Other Emotion and Positive Emotions Scales, if you’re using them). ■ Remember to use the Progress Record to record the total scores from the Anxiety and Depression Scales (as well as Other Emotion and Positive Emotions Scales). ■

Self-​Assessment Quiz Answer each of the following by circling true (T) or false (F). Answers can be found in Appendix A. 1. Every emotion has emotional behaviors associated with it. T

F

2. All emotional behaviors are bad. T

F

3. Examples of emotional behaviors include outright avoidance, subtle behavioral avoidance, cognitive avoidance, and emotion-​driven behaviors. T

F

4. One way to counter emotional behaviors is to approach situations you usually avoid. T

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Form 9.1: List of Emotional Behaviors The purpose of this list is to help you identify some of the emotional behaviors you’re using to manage your emotions. We will return to this list later in treatment when we’ll ask you to face some of the situations and activities you’ve been avoiding because they might generate strong emotions. If you have trouble figuring out which columns to put a strategy in, that’s okay. The most important part is that you begin to record the variety of emotional behaviors you are engaging in.

Overt Avoidance

Subtle Behavioral Avoidance

Cognitive Avoidance

Safety Signals

Emotion-​Driven Behaviors

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Form 9.2: Countering Emotional Behaviors Use this form to help you think of Alternative Actions for the emotional behaviors you would like to change. Use the first column to identify situations that bring up strong emotions, and use the second column to note the emotions that typically come up in that situation. In the third column, write down the emotional behavior(s) you usually use. Finally, use the last two columns to brainstorm Alternative Actions and to consider the short-​term and long-​term consequences of engaging in a new behavior.

Situation/​Trigger

Emotion(s)

Emotional Behavior

Alternative Action(s)

Consequences of Alternative Actions Short term:

Long term:

Short term:

Long term:

Short term:

Long term:

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CHAPTER 10

Understanding and Confronting Physical Sensations

GOALS To identify physical sensations associated with your emotions ■ To understand how physical sensations impact your experience of emotions ■ To confront uncomfortable physical sensations through physical exercises ■

Homework Review Before you start this chapter, let’s review your homework from Chapter 9. Did you complete your Anxiety and Depression Scales (and your Other Emotion and Positive Emotion Scales if you’ve chosen to complete them) for the previous week? Have you plotted your scores on your Progress Record? Were you able to use any Alternative Actions this past week? Did you notice any effect that changing your behaviors had on your emotional experience? Did you find any opportunities to use skills from previous chapters, like Anchoring in the Present or Practicing Cognitive Flexibility? It is best to continue to use skills from each chapter in the workbook as they work together to address all aspects of your emotional experience. If you have stopped doing your homework between chapters, remember that practice is extremely important to this program. Doing your homework lets you track your progress, and it helps you get better faster.

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COGNITIVE FLEXIBILITY

COUNTERING EMOTIONAL BEHAVIORS

FACING PHYSICAL SENSATIONS

MINDFUL EMOTION AWARENESS

UNDERSTANDING YOUR EMOTIONS

SETTING GOALS & MAINTAINING MOTIVATION

Figure 10.1    

Key Concepts The final room on the third floor of the house we’re building explores the role physical sensations play in emotional experiences (see Figure 10.1). Physical sensations refer to any physical symptoms that you might experience during strong emotions (e.g., racing heart, sweating, or nausea). Look back at one of the Three-​Component Model of Emotions Forms you filled out when you learned about understanding emotions in Chapter 5. Consider how the “physical sensations” part of your emotions played a role in the whole emotional experience. Just like how we think and how we behave in a situation can influence our emotional experience, so can how we feel physically. In fact, bothersome physical sensations are often a big part of the reason people want to avoid their emotions. But, as you’ll learn in this chapter, trying to get away from physical sensations doesn’t really work—​you just end up having more physical symptoms over time. The solution is actually to get comfortable having more physical sensations. We do this by practicing exercises that get you used to feeling the physical sensations associated with your emotions so that they begin to feel more manageable. 112

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Why Are Physical Sensations So Important for Our Emotional Experiences? So far, this treatment has zeroed in on two parts of an emotional experience—​ thoughts and behaviors. As you know from Chapter 5, there is one more component to explore—​how you feel in your body. Most emotions also have physical sensations associated with them. For example, anxiety can be accompanied by a racing heart, shortness of breath, feeling dizzy or disoriented, muscle tension, tightness in the chest, and sweating. Feeling down or depressed is associated with extreme tiredness, a lump in the throat, or heaviness in our limbs. Anger can lead to muscle tension and feeling hot. Guilt or shame may produce stomach discomfort or flushing of the face. These physical responses are a normal part of feeling these emotions—​the experience of these sensations is what alerts us to what our emotions are trying to communicate, as well as what motivates us to action. Physical sensations can intensify your emotional experiences in a number of ways. First, they can make you feel like you can’t cope with the situation you’re facing. For example, you might feel like you can’t get work done when you’re feeling tense or that you’ll never make it through a presentation if you’re short of breath. Further, intense physical sensations can make you feel like something bad is about to occur. For example, some people worry that a faster heart rate will definitely turn into a full-​blown panic attack. Others worry that their physical reactions will be noticeable to others—​that people will be able to tell that they’re nervous if they blush or sweat. Sometimes people think that if they feel tense or hot when angry, they’re more likely to lose control. Others view stomach distress as a sign that their fears are valid—​thoughts that a loved one may get in accident feel more true when accompanied by nausea. Given that physical sensations can intensify emotional experiences, it is no surprise that they contribute to the urge to avoid emotions that we discussed in the previous chapter. But remember that trying to escape from strong emotions tends to backfire in the long run. That’s what happens with physical sensations too. If you try to avoid having certain physical sensations (or the situations that make you feel these sensations), they will seem more overwhelming over time. Again, this is because avoiding something teaches you that you can’t cope with it.

Context Affects How We Interpret Physical Sensations The context in which physical sensations occur is very important for how we interpret them. To illustrate this point, let’s consider the example of children 113

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having fun at a playground. When a child goes down a slide, his stomach might drop and he might feel lightheaded when he lands at the bottom. What about merry-​go-​rounds on playgrounds? Their whole purpose is to make kids dizzy—​so dizzy they can’t stand up when they get off (that’s the “best” part, if you’re a kid). What about playing tag? This can bring on a racing heart, sweatiness, and shortness of breath—​all from running around so much. When these physical feelings occur in a child on the playground, they are considered good sensations—​something kids purposely bring on! But consider this: these are the very same sensations that can feel so scary and threatening in a different context—​like, as an adult, giving a speech or entering a situation that scares you. This means that the physical sensations themselves are not the problem—​instead, it is your interpretation of these sensations that makes them so scary and uncomfortable. We take these physical sensations as evidence that something bad will happen. So if you’re someone who has panic attacks, you may view your heart rate speeding up as a sign that a full-​blown panic attack is on its way. Or if you’re someone who gets nervous in social situations, feeling hot and sweaty might mean that other people can see that you’re anxious and will judge you for it. So the context really colors your interpretation of your physical sensations. At the same time, in isolation, physical sensations don’t have to be bad or threatening. As we mentioned, physical sensations are a normal, integral part of emotional experiences. Instead, it is your interpretation of physical feelings that makes them feel that way.

Facing Physical Sensations Makes Them Easier to Tolerate Here’s the good news: your interpretation of physical sensations is something that can be changed. In fact, you can actually become more comfortable with these feelings over time. We will do this using physical exercises designed to bring on the very same sensations that come up when you have strong emotions. We will ask you to practice experiencing these sensations again and again, without doing anything to make them go away. Just like you practiced present-​focused nonjudgmental awareness in Chapter  7, you will practice using this same Mindful Emotion Awareness to observe your physical sensations without judgment. We do this for several reasons: First, we do this so that you can notice what a physical sensation feels like on its own, apart from any interpretation of what it might

■

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mean. Often, when people explore these sensations nonjudgmentally and with a focus on what they’re actually feeling in the present moment (versus what they might feel in the future), the sensations don’t seem as bad. ■ Next, by repeatedly bringing on these sensations, you will learn about your ability to cope with them, even when you don’t do anything to manage them. ■ And finally, the more you practice feeling these sensations, the more you will get used to them. They might even start to feel routine to you—​even boring! The idea is that, when these sensations come along with a strong emotion in the real world, you will know that they are safe and tolerable, even if they are uncomfortable. That way, having physical sensations come up during an emotional experience will no longer make your emotions feel even harder to handle. You can think about the exercises in this chapter like getting a vaccine. In order for your body to know how to cope with an illness, your immune system has to have some exposure to it. That’s what a vaccine is—​a small dose of the illness your body needs practice handling. These exercises work similarly: by exposing yourself to the physical sensations that make you uncomfortable, you’ll learn that you can cope with these feelings and they will feel more tolerable the next time they come up unexpectedly. If You Don’t Really Notice Physical Sensations and They Don’t Really Bother You

Some people aren’t bothered by the physical sensations that come with emotional experiences. They may even have a hard time describing any physical sensations at all. Even if you aren’t aware of your own physical sensations that happen when you experience strong emotions, they are still contributing to the intensity of your emotional experiences. You can think of physical sensations as “setting the stage” for how you think and act in emotional situations. You may be less likely to fall into thinking traps if you are calm, but you may think entirely differently about the same situation if you are feeling shaky, or heavy, or agitated. Additionally, physical sensations can contribute to the urgency you feel to engage in behaviors designed to push away emotions quickly. Thus it is important to become aware of your physical sensations in a mindful (nonjudgmental and present-​focused) way, just as you did for your thoughts and behaviors.

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Inducing Physical Sensations As mentioned, we have designed a number of physical exercises that are meant to produce physical sensations consistent with what you feel when you’re experiencing strong emotions. Your first task is to figure out which of these exercises produces physical sensations that feel most similar to what you feel in your body when you’re anxious, sad, angry, and so forth. The best exercises to practice are the ones that feel the most similar to your emotions and are at least somewhat distressing to you. It is important to note that the exercises listed here are safe for most people; however, some of them may not be appropriate for individuals with certain medical conditions (e.g., hyperventilation is not recommended for people with asthma, running in place may not be suitable right after knee surgery). Fortunately, almost everyone can find at least one exercise that is safe and useful for them (e.g., straw breathing is often used by people with asthma). If you are in doubt about any of the exercises, consult with your therapist or medical doctor before continuing. Form 10.1 contains a list of four exercises that bring on sensations commonly associated with strong emotions. In order to conduct these exercises, you will need a stopwatch or timer as well as a thin straw (a coffee stirrer will work). Try each of the exercises below for 60 seconds without stopping. After each exercise, use the Physical Sensation Test (at the end of Form 10.1) to make a note of the physical sensations you experienced. You will also be asked to rate the level of distress you experienced during the exercise on a 0–​10 scale (0  =  no distress, 5  =  moderate distress, 10 = extreme distress). Finally, you will also rate the similarity to symptoms you experience during strong emotions on a 0–​10 scale (0 = not at all similar to my emotions, 5 = moderately similar, 10 = extremely similar). Wait until the symptoms have mostly subsided before attempting the next exercise. Use the other spaces provided to be creative and come up with additional exercises that are specific to you. While you’re completing these exercises, notice how your thoughts influence the intensity of the experience. Notice also how you behave in response to this exercise. Are you sitting back relaxed? Are you sitting forward in your chair, gripping the armrests? Are you fidgeting? Notice how different thoughts and different behaviors influence the intensity of the physical sensations you experience when engaging with these exercises.

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Form 10.1: Physical Sensation Test Exercises 1. Hyperventilation Take rapid, deep breaths through your mouth, using a lot of force, as if you were blowing up a balloon. This exercise is likely to produce lightheadedness, dizziness, and feelings of unreality. 2.  Breathe through a thin straw Breathe through a thin straw or coffee stirrer while blocking air from your nose. Make sure that you’re only taking in air through the straw, without breathing around it. This exercise will make it feel like you can’t get enough air, and it is designed to make you feel anxious. You’ll get the most benefit from it if you stick with it for the full minute. 3.  Spin in circles Stand up and turn around quickly (approximately one full rotation every three seconds). You can do this with your eyes open or closed. Alternatively, you can spin in a chair that swivels. If you conduct this exercise standing, consider doing it near a chair or couch where you can sit down afterwards. This exercise is designed to produce dizziness, lightheadedness, and disorientation. 4.  Run in place Run in place while lifting your knees as high as you can. This exercise is designed to cause rapid heart rate, shortness of breath, flushed cheeks, and increased body heat. Physical Sensation Test PROCEDURE Hyperventilation (60 seconds) Breath through thin straw (60 seconds) Spinning while standing (60 seconds) Running in place (60 seconds) Other: (_​_​_​ seconds) Other: (_​_​_​ seconds) Other: (_​_​_​ seconds)

Symptoms Experienced

Distress

Similarity

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When you are done, put a star next to the exercises that produced distress and similarity ratings of at least 5.  If none of the exercises brought on sensations that feel similar and distressing, try doing the exercises again—​ this time for two full minutes. Or you might try combining two exercises, such as spinning in a chair for one minute followed immediately by breathing through a straw for one minute. Finally, you can come up with other exercises to try to reproduce the physical feelings you have during strong emotions. Try each for at least 60 seconds, and record your experience in the “Other” section of the form. Other Physical Exercises to Try

To raise your heart rate: Squats, push-​ups, walking up and down stairs ■ To feel hot and sweaty: Burpees (start by doing a push-​up then jump your feet between your hands and hop to standing. Next, bring your hands back down next to your feet and jump back to push-​up position. Repeat). Sit in front of a space heater, and/​or put on a heavy coat indoors ■ To feel dizzy: Roll your head from side to side, or sit with your head between your legs and then raise your head rapidly ■ To feel disoriented: Look into a mirror with your face just a few inches away, or stare at a bright lamp or pattern (e.g., window blinds) and then look away suddenly ■ To feel shaky: Hold books or weights straight out to the sides of your body until your arms start to shake, or hold a plank position until your body starts to shake ■ To feel heavy or tired: Wear wrist weights, ankle weights, or a heavy backpack while going about daily activities for five minutes ■ To feel nauseous or full: Drink a large quantity of water and wear a tight belt ■

Repeatedly Confronting Physical Sensations Once you find one or more exercises that reproduce the physical sensations associated with your strong emotions, the next step is to practice doing these exercises over and over again, for at least 60 seconds at

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a time. You can do this using Form 10.2 Physical Sensation Practice. Over many practices, you will notice that the sensations start to feel less distressing as you become more used to them. See Appendix B (p. 179) for an example of how this form can be completed. Remember that the point of these exercises is to bring on physical sensations, so be sure to jump “feet first” into them. Doing the exercises half-​heartedly or “tip-​toeing” through them by using emotion-​driven behaviors will not be helpful—​in fact, that would just teach you that the exercises are scary! Instead, just watch what happens to your physical sensations over time, even when you don’t do anything to make them go away. You will find that the sensations eventually decrease or become less distressing on their own. As you do each exercise, consider what is making you anxious or distressed when you’re doing it. Often what makes these exercises difficult is our expectations about what will happen if we experience sensations we are used to avoiding. For example, some people worry that they will pass out, go crazy, or have a full-​blown panic attack if they try to bring on physical sensations purposefully. Think about what outcome might be worrying you. Then, when you do the exercise, see whether it actually happens. Once you have done the exercise many times, try reevaluating your predictions about what happens when you have intense physical sensations. You can use your Practicing Cognitive Flexibility skill to generate new, flexible thinking patterns about your experience of physical sensations. For example, you might initially have the thought “I’m going to pass out if I hyperventilate on purpose” and then, after trying this exercise repeatedly, you might generate an alternative thought “I feel anxious when I hyperventilate on purpose, but it is unlikely that I’ll pass out.” Do the exercises over and over again, without taking breaks—​only pause long enough to make ratings on Form 10.2 Physical Sensation Practice. Keep doing the exercises until you no longer feel very concerned that doing the exercises will have the negative consequences you initially worried about. It’s likely that by doing the exercises repeatedly, your distress ratings will also decrease. Another rule of thumb is to continue doing the exercises until your distress reaches a 3 or less. This may not happen the first time you do a set of exercises, so come back to them another day to practice some more.

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What Do You Do if You Don’t Find These Exercises Distressing?

To make sure you get the full benefit of the exercises, make sure you do them for a full minute—​or longer—​if you’re not distressed yet. You may have the urge to stop before experiencing significant sensations, possibly because the exercise makes you uncomfortable. This is exactly when it’s important to continue doing the exercise! Feeling uncomfortable, and continuing anyway, teaches you that you’re able to handle the experiences that you’ve avoided in the past. If your distress never reaches above a 3, do anything you can to make the exercise harder. This can include combining two exercises, doing them in front of other people, or doing the exercises when you already feel anxious or upset. Some people don’t experience distress when doing these exercises in a “safe” environment, such as at home or with a friend or family member nearby. Try doing the exercises alone, outside of the house, or right before you’re going to leave the house. Even if you are not distressed by any of the physical exercises, some people find it helpful to use this as an opportunity to practice Mindful Emotion Awareness. Practice “watching” your physical sensations change over the course of the exercise and labeling these changes nonjudgmentally (e.g., “I’m noticing my heart speeding up”). You can also practice noticing thoughts that come up during the exercises, possibly as a result of the changes in your body (e.g., “I’m having the worry that I won’t have enough oxygen if I keep breathing through this straw”). Also practice noticing behaviors, or urges to do something, and label these nonjudgmentally too (e.g., “I keep looking at the clock” or “I’m noticing the urge to stop the exercise”).

Treatment Goal Check-​In Use the space to below to reflect on how using Facing Physical Sensations can bring you closer to the goals you set in Chapter 4. Also note any progress you’ve made toward your goals.

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Summary In this chapter, we explored the role of physical sensations in emotions. We highlighted how physical sensations are often a big part of why emotions are uncomfortable. We also talked about how your interpretation of physical sensations determines how distressing they are. Just as avoiding emotions causes them to continue over the long term, avoiding physical sensations ensures that you continue to find them distressing. The solution is to get more practice experiencing the physical sensations that are most distressing to you, without doing anything to manage or get away from them. By repeatedly experiencing these physical sensations, you start to get used to them and eventually find them less distressing (even boring). You now have all of the core skills to begin approaching, accepting, and tolerating uncomfortable emotional experiences. You have learned how to observe your emotions, to be more flexible in your thinking, to counter emotional behaviors, and now to get used to uncomfortable physical sensations. In the next chapter, all of these skills will be brought together and you will have the opportunity to apply them to your real-​life experiences.

Homework Continue doing the physical exercises on a daily basis and recording your progress on the Form 10.2 Physical Sensation Practice at the end of this chapter. If needed, you can make copies of this form or download more from the TreatmentsThatWorkTM website at http:// www.oup.com/us/ttw. ■ Continue monitoring your weekly experiences using the Anxiety and Depression Scales (as well as the Other Emotion and Positive Emotions Scales, if you’re using them). ■ Remember to use the Progress Record to record the total scores from the Anxiety and Depression Scales (as well as Other Emotion and Positive Emotions Scales). ■

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Self-​Assessment Quiz Answer each of the following by circling true (T) or false (F). Answers can be found in Appendix A. 1. Physical sensations may make you feel like your emotions, or emotional situations, are more threatening than they really are. T F 2. It is important to be aware of how we physically feel during an emotional experience, just as it is important to recognize what we think and what we do. T F 3. When experiencing physical sensations during an emotional experience, you should try to reduce their intensity so that you can get your emotions under control. T F 4. Confronting physical sensations repeatedly can help you learn that they are not dangerous and that they will decrease on their own. T F

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Form 10.2: Physical Sensation Practice Use this form to record your practice of the physical exercises that you find most distressing and most similar to your own experiences of strong emotion (e.g., the way you feel in your body when you are anxious, down, etc.). “Trial” is a way to keep track of how many repetitions you have done of the exercise; “Distress” is where you can record your distress on a 0-​10 scale (where 0 = no distress and 10 = extreme distress); and “Similarity” is where you can record how similar the exercise feels to your own strong emotions. Repeat each exercise at least five times in a row in one sitting. EXERCISE:_____________________​       EXERCISE: ____________________​         EXERCISE:______________________​ Trial    Distress   Similarity    Trial    Distress    Similarity    Trial    Distress   Similarity 1._____________________________    1.______________________________    1.______________________________ 2._____________________________    2.______________________________    2.______________________________ 3._____________________________    3.______________________________    3.______________________________ 4._____________________________    4.______________________________    4.______________________________ 5._____________________________    5.______________________________    5.______________________________ EXERCISE:______________________​

EXERCISE:_____________________​

EXERCISE: _____________________​

Trial    Distress    Similarity    Trial    Distress    Similarity    Trial    Distress    Similarity 1.______________________________    1.______________________________    1.______________________________ 2.______________________________    2.______________________________    2.______________________________ 3.______________________________    3.______________________________    3.______________________________ 4.______________________________    4.______________________________    4.______________________________ 5.______________________________    5.______________________________    5.______________________________

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CHAPTER 11

Putting It Into Practice—Emotion Exposures

GOALS ■ ■ ■ ■

To understand the purpose of Emotion Exposures To learn how to design effective Emotion Exposure exercises To develop an Emotion Exposure hierarchy To repeatedly practice confronting strong emotions through Emotion Exposure exercises

Homework Review Did you complete your Anxiety and Depression Scales (and your Other Emotion and Positive Emotion Scales if you’ve chosen to complete them) for the previous week? Have you plotted your scores on your Progress Record? Have you noted any changes in your responses? In the last chapter, we practiced experiencing physical sensations that are most distressing to you. Did you practice these exercises repeatedly? If not, we urge you to spend the next few days trying them. It’s important to do these exercises repeatedly so you can get used to them.

Key Concepts The main focus of this chapter is to begin practicing Emotion Exposures. During this part of treatment, you’ll be asked to tackle specific situations and activities that bring up uncomfortable emotions. There are two important 125

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EMOTION EXPOSURE

COGNITIVE FLEXIBILITY

COUNTERING EMOTIONAL BEHAVIORS

FACING PHYSICAL SENSATIONS

MINDFUL EMOTION AWARENESS

UNDERSTANDING YOUR EMOTIONS

SETTING GOALS & MAINTAINING MOTIVATION

Figure 11.1

reasons why you should complete Emotion Exposures. First, the most direct way to test out your negative beliefs about your emotions (and the situations that produce them) is to face them and see what happens. If you’re avoiding going to social gatherings because you think you won’t find anything to talk about, this is a way to test that out. Second, Emotion Exposures provide a chance to put the skills you’ve been learning to practice and to gain confidence that you can tolerate any strong emotions that might come up. Deliberately bringing up strong emotions may sound frightening, but you can do this at your own pace and we’ll take it one step at a time. This is really the pinnacle of treatment where we put everything together, so we’ve placed it on the top floor of our house (see Figure 11.1). It is very important that you commit to making time and effort during this last part of treatment, because this is the chance for the greatest change to occur.

Introduction to Emotion Exposures So far in this treatment you’ve learned to pay attention to the three components of an emotion using Mindful Emotion Awareness. You’ve also learned skills to respond differently to each of these components—thoughts (Practicing Cognitive Flexibility), behaviors (Countering Emotional Behaviors), 126

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and physical sensations (Confronting Physical Sensations). This next phase of treatment is the most important step for building upon the skills you’ve been working on. During Emotion Exposures we will ask you repeatedly face situations/activities that bring up strong emotions. This will provide an opportunity to practice your skills in the context that matters most—when you’re actually feeling an intense emotion. Think of it this way: Can you imagine learning how to ride a bike by reading a book or having someone tell you how to do it? This would be very difficult. Unless you put it all together while actually on the bike, you will never really know how to ride. The same thing applies here. You must practice the skills we have talked about in response to strong emotions in order to truly learn how to use them. The way we get you out “on the bike” in treatment is through Emotion Exposures. As we have described, Emotion Exposures are exercises that are specifically designed (by you) to provoke strong emotional responses— the same emotions you’ve been avoiding. We’ve provided you with all the skills you’ll need to face your emotions, you provide the final ingredient—willingness to step outside your comfort zone. In addition to providing a valuable way to practice the skills you’ve been learning, Emotion Exposures also allow you to confront your negative reactions to emotions head on. In order to evaluate any negative beliefs you have about emotions (e.g., they’ll last forever, you’ll lose control), you need to actually face them to see what happens. For example, if you are afraid you’ll go crazy if you have a panic attack and you avoid situations that might trigger an attack, you’ll never be able to see that your feared outcome doesn’t occur. As a result, you’ll continue to believe that you’ll do something out of control if you panic. Similarly, if you always check your stove before going out because you think you’ll worry about your house burning down all day if you don’t, you won’t be able to test whether this constant worry really happens (or whether your house actually burns down). Emotion Exposures can help you test out your beliefs about emotions. Facing strong emotions will give you the opportunity to learn 1. that any uncomfortable emotions you feel are temporary. Even without engaging in any avoidance, your negative emotions will eventually subside. 2. that you can cope with negative emotions better than you thought. 3. that you can perform tasks and activities that are important to you even when experiencing strong emotions.

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Types of Emotion Exposures There are a number of different ways to conduct Emotion Exposures. In fact, any situation or activity that brings up strong emotions will allow you to practice your skills and help you test your beliefs about emotions. Keep in mind that what constitutes an effective Emotion Exposure depends on the person doing it—you need to face the situations that bring up strong emotions for you. We next describe the different kinds of exposure exercises. Situation-Based Emotion Exposures

As the name suggests, situation-based Emotion Exposures are when you enter situations that will bring on intense emotions for you. Depending on your symptoms, these situations might include revisiting the location of a traumatic experience, putting yourself in an enclosed place for a period of time, or having a conversation with a stranger. Other ideas include making a mistake, getting started on a task even though you don’t feel motivated, touching something dirty, or giving a speech. You can also face situations that bring up positive emotions like getting together with friends or exercising. Exposure to positive emotions is particularly important if you avoid such situations because you’re afraid you’ll feel even worse when the experience is over or because you’re distressed that you don’t feel your positive emotions as strongly as you think you should. Look back at your List of Emotional Behaviors Form from Chapter 9 to help you generate ideas for situation-based Emotion Exposures. Imaginal Emotion Exposures

You can also conduct Emotion Exposures by imagining difficult situations. Imaginal Emotion Exposures are particularly useful in three instances: 1. when there are practical barriers to conducting repeated situational Emotion Exposures (e.g., taking multiple flights). 2. when you believe that simply thinking about a particular topic (e.g., memories, worries) will cause your emotion to spiral out of control. 3. when you believe that thinking about a particular topic (e.g., a loved getting into an accident) makes it more likely to come true. Imaginal Emotion Exposures are best conducted in a quiet setting, with your eyes closed. You then picture the scene (the memory or future fear)

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in as much detail as possible, while noticing any thoughts or physical sensations the exercise brings up. Sometimes it can be helpful to write out the scenario first and then record yourself reading it so you can concentrate on imagining the scenario as clearly as you can. Remember, the goal is still to bring on strong emotions, so try to fully experience whatever comes up when you imagine your situation. Physical Sensation Emotion Exposures

You may also choose to continue to conduct the physical sensation exposures you completed in the previous chapter. You can add the exercises that bring on bodily sensations to both situational and imaginal exposures to really show yourself that you can tolerate your emotions. For example, if you are nervous about participating in groups, you might first run in place to elevate your heart rate and then speak up at a meeting at work.

Practicing Emotion Exposures You may be starting to feel a bit nervous as you think about completing Emotion Exposures. That’s completely normal, as we’re asking you to face situations that you may have been avoiding for a long time. Because we know that Emotion Exposures can be difficult, we will start slowly by asking you to make an Emotion Exposure Hierarchy. A hierarchy is a list of the situations/activities that you will face, rated by the amount of distress and avoidance they produce. You will then work your way through each of these tasks in turn. You don’t need to go in order from easiest to hardest—in fact, we encourage you to mix up the order. Remember that the purpose of these exercises is to elicit strong, uncomfortable emotions. Try to begin with an exposure that you believe will evoke at least a moderate degree of emotion. Additionally, if the opportunity arises to complete a task that you hadn’t planned to complete until later, go ahead and take it! For example, even if attending a party was something you had planned to do after practicing other social interactions, you should make an effort to attend any parties that you’re invited to. See pp. 180–181 of Appendix B for examples of completed Emotion Exposure Hierarchy Forms. Tips For Building Your Emotion Exposure Hierarchy ■

If possible, plan exposures to take place in a variety of different situations (e.g., at home, at work, in public, alone, and with

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others). This can help the lessons you learn about coping with emotions really stick. ■ Try combining more than one Emotion Exposure in the same task. For example, if feeling jittery and talking to strangers both make you anxious, you might include “drink a large cup of coffee, then introduce myself to a new coworker.” Before conducting combination exposures such as this one, it can be helpful first to practice each part of the task on its own—so you might get used to drinking coffee and also practice meeting strangers separately before combining the two. ■ You can make your hierarchy longer than eight items or create a new hierarchy after you complete the tasks on your initial hierarchy. You can make copies of this form or download more from the TreatmentsThatWorkTM website at http://www.oup.com/us/ttw. Use the Record of Emotion Exposure Practice Form at the end of the chapter to record your Emotion Exposures. Again, it may be helpful to make multiple copies of this form (or download them from the TreatmentsThatWorkTM website at http://www.oup.com/us/ttw) as you will want to complete a new one for each exposure you complete. This form will walk you through how you can use all of the skills presented during this treatment while conducting these exposures. Can you use your breath to anchor yourself in the present? Can you do a quick three-point check of your thoughts, feelings, and behaviors? Try simply naming your emotions without attempting to change them. Can you identify automatic thoughts? Make a prediction about what might happen as a result of the exposure (so you can see whether it comes true). Are you noticing any urges to avoid? Can you replace avoidance behaviors with alternative actions? After you complete each exposure, reflect on what you learned. Two examples of the Record of Emotion Exposure Practice Forms can be viewed in Appendix B (pages 182–185).

Key Things to Remember about Exposure Practice 1. Practice, practice, practice! You should try to set up several exposures in a week. The more you can do, the better. It may take a couple times

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facing the same situation before you begin to feel more comfortable. After all, you are probably working against many experiences in your history where you did not face the situation—so it makes sense that it will take a while to develop a habit of facing these situations and to feel at ease doing so. 2. You might experience a setback. Sometimes when you complete an exposure, you might find the emotions too difficult to experience and stop the exposure early. Try not to get too discouraged—self-compassion is key here. You have a lot of practice avoiding your emotions, and it may take time to break that pattern. If you escape from the situation, give yourself a moment, and then get back in there. If you need to move a step down on the hierarchy, or change the exposure to make it a little easier, go ahead. It is also possible the things you worry about during an exposure will actually happen—you may have a panic attack, feel very awkward in a social setting, and so forth. We don’t consider that a bad thing. In fact, having occasional experiences where an exposure does not go as well as you would want it to actually leads to more lasting progress in the long run. 3. Make it part of your routine. Since exposures can sometimes be difficult to arrange, and if properly designed should evoke uncomfortable emotions, it’s very common to put them off. Scheduling exposures and putting them in your planner is a good way to assist you in completing these exercises. 4. Avoid avoidance. When conducting Emotion Exposures, it’s important to try to connect with the emotion and to “avoid avoiding.” It can be helpful to think ahead about the most likely emotional behaviors you’ll have the urge to engage in and plan what you will do instead. Even the attitude with which you approach the task itself can be important. Are you conducting your exposures with reluctance, white-knuckling it through the experience and wishing it was over? Or are you welcoming your own distress with courage and acceptance? Treat each exposure as an opportunity to learn that your emotions are not as uncomfortable or problematic as you previously thought.

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Note A note on motivation: In Chapter 4, we discussed the importance of staying motivated to complete this program. Starting Emotion Exposures means you’re in the homestretch now, and it is really important that you finish strong. It is important to keep in mind, though, that Emotion Exposure can be really difficult – we’re asking you to face situation, activities, and memories that you may have been avoiding for a long time. If you’re having mixed feelings about leaping into these practices, pull out your Decisional Balance Form from Chapter 4. You can remind yourself of all the reasons you started this treatment in the first place and that these pros of changing outweighed the costs (like facing your emotions head-on). Use your reasons for changing to motivate you to complete these exercises.

Treatment Goal Check-In Use the space below to reflect on how using Emotion Exposures can bring you closer to the goals you set in Chapter 4. Also note any progress you’ve made toward your goals.

Summary In this chapter, you have had the opportunity to take all the skills you have learned in this program and apply them to your real-life situations. This is the best way to learn any new skill. The best approach is learning by doing, and Emotion Exposures allow you to do just that.

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Homework Complete your Emotional Exposure Hierarchy. Generate a list of at least eight distressing situations. Choose situations that will help you achieve your treatment goals. ■ Practice engaging in Emotion Exposures. Keep track of your experience on the Record of Emotion Exposure Practice Form. ■ Continue monitoring your weekly experiences using the Anxiety and Depression Scales (as well as the Other Emotion and Positive Emotions Scales, if you’re using them). ■ Remember to use the Progress Record to record the total scores from the Anxiety and Depression Scales (as well as Other Emotion and Positive Emotions Scales). ■

Self-Assessment Quiz Answer each of the following by circling true (T) or false (F). Answers can be found in Appendix A. 1. Emotion Exposures are exercises that are specifically designed to provoke strong emotional responses. T

F

2. It is unlikely that negative automatic thoughts about emotions are modified as a result of Emotion Exposures. T

F

3. During an Emotion Exposure, it is important to identify emotional behaviors so that these behaviors can be modified. T

F

4. Maintaining control over emotions during exposures is a good strategy for gradually and systematically easing into emotionally provoking situations. T

F

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Form 11.1: Emotion Exposure Hierarchy Describe situations you are currently avoiding in order to prevent uncomfortable emotions from occurring. Think of this form like a ladder with less challenging situations at the bottom, working your way up to more challenging situations at the top. Rate the degree to which you avoid each of the situations you describe and the degree of distress they cause. For each, write the applicable number in the space provided.

Do Not Avoid

Hesitate To Enter But Rarely Avoid

Sometimes Avoid

Usually Avoid

Always Avoid

5

0 No Distress

Slight Distress

Definite Distress

Description 1 WORST 2

3

4

5

6

7

8

10 Strong Distress

Extreme Distress

Avoid

Distress

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Form 11.2: Record of Emotion Exposure Practice Date: Exposure Task (Briefly describe the activity you have chosen to bring up an emotional response)

Preparation Before the Exposure Negative Automatic Thoughts (List the thoughts you have about completing this exposure)

Other Interpretations (Are there ways you can think more flexibly about this exposure?)

Emotional Behaviors (List emotional behaviors that might prevent you from fully experiencing the emotions brought up by the exposure)

Alternative Action (Identify other behaviors that will allow you to fully engage with the emotions brought up by the exposure)

Mindful Emotion Awareness Remember to take a nonjudgmental, willing stance toward the emotions generated by the exposure Remember to stay anchored in the present during the exposure.

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Debriefing After the Exposure What emotions did you experience? __________________________________________ Break down of your emotional experience into its three parts

Thoughts Physical Sensations Behaviors Mindful Emotion Awareness How willing were you to experience your emotions (0 [not at all] – 10 [extremely])? ______ How effective were you at anchoring yourself in the present (0 [not at all] – 10 [extremely])? _____ Cognitive Flexibility How effective were you at thinking flexibly during the exposure (0 [not at all] – 10 [extremely])? _____ Countering Emotional Behaviors How effective were you at engaging in alternative actions during the exposure (0 [not at all] – 10 [extremely])? _____

What did you learn by engaging in this exposure? What did you learn about the task/situation you faced? What did you learn about your emotions? Did your negative predictions occur? What did you learn about your ability to cope?

What can you do differently in your next exposure? How can you use your skills to fully approach the emotions brought up by these exercises?

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CHAPTER 12

The Role of Medication in the Treatment of Emotional Disorders

GOALS To learn about medications that are commonly prescribed for emotional disorders ■ To answer frequently asked questions about medications ■ To provide recommendations for how to discontinue your medications under the supervision of your doctor ■

Overview Medication can serve an important role in treatment, and many people with emotional disorders are prescribed medication to help manage their symptoms. The decision to take medication or to stop taking medication is often a personal choice. Some people may feel that medication is the best treatment for their symptoms, whereas others would prefer not to take medication if possible. There are many factors to consider when making any decisions about medication, including your individual needs and evidence from clinical research trials. For example, in some cases psychotherapy alone has been shown to be more effective than medication and in other cases a combination of medication and psychotherapy is most effective. One factor to consider is that most medications are not effective in the long term unless you continue to take them. Sometimes people find that their medications become less effective over time. Other people find that taking medication no longer fits their needs, such as

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women who want to become pregnant or people who are experiencing severe side effects. The purpose of this chapter is to help you make an informed decision about how medications can be used to achieve your goals. We will review some of the most commonly prescribed medications for emotional disorders. We then address some frequently asked questions about medications and treatment. If you are interested in stopping your medication, we will also provide some general recommendations on how to do so safely. However, it is important to remember that any changes to your medication plan should always be made under the direct supervision of your prescribing physician.

Anti-​Anxiety Medications There are a number of anti-​anxiety medications that are used to help reduce symptoms of anxiety. These medications are occasionally used for sleep difficulties as well. What Are Anti-​Anxiety Medications?

The most commonly prescribed anti-​anxiety medications are benzodiazepines, which are also referred to as sedatives. Benzodiazepines work by slowing down the nervous system, which helps people to feel more relaxed both emotionally and physically. Benzodiazepines are typically prescribed for short-​term relief of anxiety because they work much quicker than other medications, normally in less than an hour and sometimes as quickly as within 20 minutes. For this reason, they are often prescribed to use on an “as needed” basis for panic attacks or intense anxiety episodes. Beta blockers are a type of medication that are traditionally used to treat heart pain and high blood pressure but are sometimes prescribed for anxiety. Beta blockers work by blocking stress hormones that are involved in the flight-​or-​fight response. As a result, they help decrease physical symptoms of anxiety like rapid heart rate, shaky hands, and sweating. Since beta blockers only help with the physical symptoms of anxiety, they are most often prescribed for use in specific situations like public speaking. Similarly to benzodiazepines, beta blockers are taken on an “as needed” basis. Buspirone is a less commonly used anti-​anxiety medication that is

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Table 12.1.  Anti-​Anxiety Medications Medication Type

Examples

Common Side Effects

Conditions Treated

Benzodiazepines

Lorazepam (Ativan), Diazepam (Valium), Alprazolam (Xanax), Clonazepam (Klonopin)

Most common side effects are drowsiness and dizziness, but some people also experience confusion, headaches, blurred vision, or nausea

Short-​term treatment of anxiety or insomnia symptoms

Beta blockers

Atenolol Compared to benzodiazepines, beta (Tenormin), blockers have fewer adverse side effects, Propranolol (Inderal) but some people do report feeling sleepy, light-​headed, or dizzy

Performance anxiety

Other

Buspirone (BuSpar)

Generalized anxiety disorder

Fewer side effects and less severe withdrawal symptoms compared to benzodiazepines, but some people do report nausea, dizziness, headache, drowsiness, or lightheadedness

taken every day instead of on an “as needed” basis and takes up to two weeks to work. Table 12.1 provides examples of each of these types of medications. We list the generic name for the medication and then the brand name in parentheses. We also list some of the most commonly reported side effects for each medication type. How Do People Respond to Anti-​Anxiety Medications?

Unlike many medications, benzodiazepines and beta blockers can provide almost immediate relief from anxiety symptoms. However, there are often unpleasant side effects associated with benzodiazepines (see Table 12.1), particularly when taken at higher doses. An important concern with benzodiazepines is that people often develop tolerance, which means that they need higher doses to obtain the same effect as when they first started the medication. People can also develop physical dependence, which means that they experience withdrawal symptoms when they stop taking the medication. Tolerance and physical dependence occurs quickly with benzodiazepines, normally in a few months, which means that they should only be used for a short period of time. It is also important to remember that combining benzodiazepines and alcohol is very dangerous because each drug enhances the effect of the other, which can result in loss of consciousness or death.

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Beta blockers are less likely to result in physical dependence because they are typically used only in performance situations. Although beta blockers can be helpful in reducing physical symptoms of anxiety, they do not affect the psychological symptoms. That means that beta blockers may minimize symptoms like sweating and a racing heart before giving a speech, but they won’t help with anxious thoughts about forgetting the material or being able to answer questions from the audience. There are some studies that have found that your emotional state has a stronger impact on performance quality than physical symptoms, and others have found that some people perform better at moderate to high levels of anxiety. Buspirone is considered safer than benzodiazepines because it is slower acting, which means people are less likely to develop tolerance or to become physically dependent on it. Studies suggest that buspirone is an effective treatment for generalized anxiety, but it doesn’t seem to help with other anxiety symptoms.

Antidepressant Medications Antidepressant medications are used to treat depression and other emotional disorders. A summary of antidepressant medications can be seen in Table 12.2. There are several classes of antidepressants, including selective serotonin reuptake inhibitors (SSRIs), serotonin-​norepinephrine reuptake inhibitors (SNRIs), tricyclic and tetracyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), and atypical antidepressants. What Are Antidepressant Medications?

SSRIs are the most commonly prescribed antidepressants because they tend to have fewer side effects than earlier generations of antidepressants (i.e., MAOIs and TCAs). SSRIs increase the amount of the neurotransmitter serotonin in the brain by blocking its absorption, but it still isn’t known precisely how increasing serotonin levels improves depression. SNRIs work very similarly to SSRIs. They increase the amount of both serotonin and norepinephrine in the brain. There are also other antidepressants that are considered “atypical” because their chemical structure is different from SSRIs and SNRIs. TCAs were the first generation of antidepressants that were developed. TCAs also increase levels of serotonin and norepinephrine in the brain

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Table 12.2.  Antidepressant Medications Medication Type

Examples

Common Side Effects

Conditions Treated

Selective serotonin reuptake inhibitors (SSRIs)

Fluoxetine (Prozac), Sertraline (Zoloft), Paroxetine (Paxil), Escitalopram (Lexapro), Citalopram (Celexa), Fluvoxamine (Luvox)

The most frequently reported side effects of SSRIs are weight gain, nausea and vomiting, diarrhea, fatigue, and sexual problems (difficulty maintaining an erection or achieving orgasm, reduced sex drive)

Depression, anxiety disorders, some eating disorders

Serotonin-​ norepinephrine reuptake inhibitors (SNRIs)

Venlafaxine (Effexor), Duloxetine (Cymbalta)

Similar to SSRIs

Depression, anxiety disorders, insomnia, chronic pain

Tricyclic antidepressants (TCAs)

Imipramine (Tofranil), Clomipramine (Anafranil), Desipramine (Norpramin), Nortriptyline (Pamelor), Amitriptyline (Elavil), Irtazapine (Remeron)

Common side effects include constipation, drowsiness, dry mouth, blurred vision, urine retention, weight gain, and lightheadedness

Depression, obsessive-​ compulsive disorder; occasionally used for eating disorders and panic attacks

Monoamine oxidase inhibitors (MAOIs)

Tranycypromine (Parnate), Isocarboxazid (Marplan)

The most common side effects are dry mouth, dizziness, lightheadedness, drowsiness, insomnia, nausea, constipation

Depression

Atypical

Bupropion (Wellbutrin)

Commonly reported side effects include dry mouth, insomnia, agitation, headache, constipation, nausea, dizziness, ringing in the ears, stomach pain, loss of interest in sex, vision problems, muscle pain, increased sweating, frequent urination, sore throat

Depression, seasonal affective disorder, smoking cessation; occasionally used for attention deficit hyperactivity disorder

Atypical

Trazodone (Desyrel)

Common side effects muscle aches, headache, nausea, vomiting, constipation or diarrhea, dry mouth, dizziness or loss of balance, loss of interest in sex

Depression; occasionally used for insomnia, schizophrenia, and anxiety symptoms

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but tend to have more severe side effects than the newer antidepressants such as SSRIs and SNRIs. MAOIs are another type of first-​generation antidepressants that increase levels of serotonin, norepinephrine, and dopamine in the brain. MAOIs require severe dietary restrictions in order to prevent dangerous blood pressure levels. For example, you can’t eat cheese or chocolate, and you also can’t drink alcoholic beverages. Due to these restrictions and the side effects, MAOIs are used infrequently. How Do People Respond to Antidepressant Medications?

Compared to anti-​anxiety medications, antidepressant medications take a longer time to product an effect, normally four to six weeks. Research has shown that all antidepressants produce similar effects. In other words, it doesn’t seem like one type of antidepressant is more effective than another type. However, studies do show that antidepressant medications work best for moderate to severe depression. For some people, it is necessary to try several medications in order to find one that works well and has minimal side effects. Other people find that their medication works for a period of time, but then their symptoms return.

Other Commonly Prescribed Medications for Emotional Disorders Mood Stabilizers

Mood stabilizers are medications used most often to manage symptoms of bipolar disorder and to prevent episodes of mania and elevated mood. Sometimes mood stabilizers are also prescribed to strengthen the effect of an antidepressant medication. Lithium (Eskalith) is the most commonly prescribed mood stabilizer. It is prescribed to treat symptoms of mania, and many people continue to take it after manic symptoms subside to prevent future episodes from occurring. Common side effects of lithium include stomach pain, weight gain, increased thirst, more frequent urination, dry mouth, diarrhea, and mild hand tremors. Anticonvulsant medications are sometimes also used as mood stabilizers, such as lamotrigine (Lamictal), carbamazepine (Carbatrol, Epitol, Tegretol), and oxcarbazepine (Trileptal).

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Antipsychotic Medications

Antipsychotic medications are primarily used to treat symptoms of psychosis, but they also can be prescribed for mania, anxiety disorders, eating disorders, and severe depression. Commonly prescribed antipsychotic medications for emotional disorders include quetiapine (Seroquel), aripiprazole (Abilify), and Luasidone (Latuda). Common side effects include weight gain, drowsiness, dizziness, dry mouth, nausea, vomiting, and restlessness. Other Sedatives

We have already discussed the use of benzodiazepines, which are a type of sedative medication prescribed to manage anxiety symptoms. There are other types of sedatives that are referred to as hypnotics or “Z-​drugs,” and are commonly prescribed for insomnia. Examples include zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta). These sedatives produce a similar effect to benzodiazepines, but because they bind to a different receptor in the brain, there are fewer side effects and they are less likely to cause changes to the stages of sleep. The mostly commonly reported side effects with Z-​drugs are headaches, daytime drowsiness, and difficulty concentrating. However, many studies have shown that the use of Z-​drugs is associated with abnormal behavior during sleep, like sleepwalking and difficulties with concentration the following day. Z-​drugs are often considered to be safer than benzodiazepines due to less perceived risk of physical dependence, but research suggests that this is not the case. For these reasons, it is recommended that Z-​drugs only be used for short-​ term management of insomnia (two to four weeks).

Frequently Asked Questions about Medication Is Medication More Effective than Psychotherapy?

The purpose of this chapter is not to argue that medication is more or less effective than psychotherapy. Even though there are clinical research trials that compare the effectiveness of one treatment to another treatment, these studies report which treatment, on average, worked better. Therefore, we cannot know for certain which treatment will necessarily

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work better for you as an individual, although researchers are working on ways to make more personalized treatment recommendations. There are many benefits to medications, including that most medications start to help with symptoms in a relatively short period of time, whereas a psychological treatment may take longer. This is especially true for benzodiazepines, which can often reduce anxiety symptoms within an hour. However, there are also downsides to medications, like unpleasant side effects and the need to continue taking them to manage symptoms. In general, medications can be helpful in controlling the symptoms of emotional disorders, but they do not “cure” them. One notable exception is for benzodiazepines and other sedatives because of the danger associated with their long-​term use. These medications should only be considered a short-​term strategy for coping with anxiety or insomnia and are not effective for long-​term symptom management. Do Medications Correct a Chemical Imbalance in the Brain?

It is often suggested that emotional disorders, especially depression, are caused by a chemical imbalance in the brain. Even though antidepressant medications increase the levels of certain neurotransmitters in the brain, there is no evidence that depression is caused by a shortage of those neurotransmitters. This is also the case for headaches—​an aspirin can help with symptoms of a headache, but a headache is not caused by an imbalance of aspirin in the brain. The truth is that we still don’t know exactly how antidepressant medications reduce symptoms of depression. The causes of depression (and other emotional disorders) are complex, and there are many factors that contribute to it. Our genes play a small role in our vulnerability for developing an emotional disorder, but studies show that the majority of our vulnerability is related to the way we interpret and respond to events. Do I Need to Stop Taking My Medication before Beginning this Treatment Program?

As we mentioned in Chapter 2, it is not necessary to stop your medication before starting this treatment program. In fact, we do not recommend that you stop your medication before beginning treatment. One reason is because it can be hard to stop using a medication before learning

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skills to cope with your symptoms. For some people, it may be necessary to use medication to be able to attend treatment sessions or to have the energy to actively participate in the treatment. Depending on the medication, you may experience some temporary withdrawal symptoms that are unpleasant and may feel similar to anxiety when you begin to taper off of your medication. For these reasons, it is helpful to wait until you feel more confident in your ability to cope with these uncomfortable physical symptoms. People using fast-​acting medications to manage anxiety, such as benzodiazepines or beta blockers, often end up stopping those medications by the end of this treatment program. Others decide to begin the process of tapering off their antidepressant medication after finishing our program, and some chose to remain on their medication. Will My Medication Interfere with this Treatment Program?

There are a few situations where the use of medication can interfere with treatment. One situation is the use of benzodiazepines or other fast-​acting anti-​anxiety medications during exposures. If you take your anti-​anxiety medication before an exposure, you may prevent yourself from experiencing the full benefit of the exercise. Specifically, studies have shown that people who use benzodiazepines during exposures have poorer outcomes over the long term. In other words, people who use benzodiazepines during exposures are doing just as well as those who didn’t at the end of treatment, but these positive effects don’t last as long. Even if you don’t take your anti-​anxiety medication but you keep it with you, you may be minimizing the effectiveness of the exposure. Keeping your medication with you “just in case” during an exposure is an emotion-​driven behavior that prevents you from learning that your strong emotions will decrease naturally. Will I Be Able to Stop Taking My Medications after Completing this Treatment Program?

Some people find that they are able to successfully manage their symptoms after mastering the skills taught in this workbook, but others may want or need to continue on their medications. It can be very difficult to cope with effects of withdrawing from a medication, and it may take some people multiple tries before they are able to completely stop their

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medication. There are also some disorders, such as bipolar disorder, that are more likely to benefit from the long-​term use of medication to prevent future episodes. It is important to remember that the purpose of this treatment program is not to get you to stop taking your medications. The goal of this treatment is to help you learn more useful ways of responding to intense emotions so that they feel less overwhelming and interfering.

Recommendations for Discontinuing Medications As we mentioned at the beginning of this chapter, any changes to your medication should always been done in consultation with your prescribing physician. The following are some recommendations for safely discontinuing your medication if you choose to do so. Take it slow. Stopping your medication suddenly can produce significant withdrawal symptoms and can be very dangerous. This is especially important for discontinuing benzodiazepines, which can result in such strong withdrawal symptoms that people decide to begin the medication again to get rid of the symptoms. Your prescribing physician will be able to provide you with a safe schedule for gradually reducing your medication. The process may take several months depending on the type of medication and your current dosage, so be patient. ■ Remember that withdrawal symptoms may mimic other symptoms. Some people misinterpret withdrawal symptoms as a return of original symptoms and think that it is necessary to start the medication again or increase the dosage. Although slowly tapering off of your medication will help to minimize withdrawal symptoms, you may still experience an increase in physical symptoms or a temporary increase in anxiety or depressed mood. This is a normal experience and simply means that your body is going through an adjustment period. ■ Plan a time that works for you. For some people, discontinuing their medications is a primary goal of treatment, and they are eager to begin immediately after completing this treatment program. However, it is helpful to choose a time when you will not be under a lot of stress or going through a major life change. ■

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Use the skills you learned in this workbook to cope with withdrawal symptoms. At this point, you have learned skills to change the way that you relate to your emotions. If you experience an increase in emotions or unpleasant symptoms while tapering off of your medication, you can apply the skills to cope more effectively with these symptoms.

■

Summary It is very common for people with emotional disorders to take medications to help manage their symptoms. The purpose of this treatment program is to teach you some new, more helpful ways of coping with your emotions. Some people are interested in discontinuing their medications after they complete this program. If you are taking medications and would like to stop, it is important that you only do so under the direct supervision of your prescribing physician. Many people who discontinue their medications experience temporary increases in physical symptoms or symptoms of anxiety and depressed mood. This temporary increase in symptoms is normal while your body adjusts to the changes. You can apply the skills you learned in this workbook to help manage these uncomfortable symptoms.

Self-​Assessment Quiz Answer each of the following by circling true (T) or false (F). Answers can be found in Appendix A. 1. Medications are necessary to correct a chemical imbalance in the brain. T

F

2. If you decide to discontinue your medication, it is essential that you do so gradually and under the direct supervision of your prescribing physician. T

F

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3. If you experience an increase in symptoms when tapering off your medication, it is a sign that you need to go back on it. T

F

4. It is helpful to use anti-​anxiety medications during exposures to manage the intensity of your emotions. T

F

5. If you decide to continue taking your medication after completing this treatment program, it means that the treatment failed. T

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CHAPTER 13

Moving UP from Here Recognizing Accomplishments and Looking to Your Future

GOALS ■ ■ ■ ■

To review the important takeaway message of this program To evaluate your progress To revisit your treatment goals To develop a practice plan

Homework Review Did you complete your Anxiety and Depression Scales (and your Other Emotion and Positive Emotion Scales if you’ve chosen to complete them) for the previous week? Have you plotted your scores on your Progress Record? Now that we have reached the end of this program, we’ll be using it to evaluate how your ratings on these scales have changed throughout treatment. In the last chapter, we discussed the importance of conducting Emotions Exposures. Did you create a hierarchy of emotion-​ producing situations/​activities? Have you been facing these situations/​ activities and writing your experiences down on the Record of Emotion Exposure Practice Form? If so, great! The purpose of these exercises is to learn that you can tolerate strong emotions and to practice your skills in response to them. If you haven’t been completing your Emotion Exposures, you should return to Chapter 11 to familiarize yourself with why this skill is so important to lasting improvement.

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Key Concepts The main purpose of this chapter is to review the key concepts from this treatment program and to prepare you for what comes next. We will review strategies that will help you continue to strengthen the skills you’ve been practicing. You’ve reached the point in this program where you have learned a new way to relate to your emotions when they come up. Without spending so much energy judging your emotional experiences and/​or pushing them away, you may be able to pursue new directions in your life. You’ve reached the top floor of the house you’ve been building to create a healthy relationship with your emotions (see Figure 13.1).

MOVING UP FROM HERE

EMOTION EXPOSURE

COGNITIVE FLEXIBILITY

COUNTERING EMOTIONAL BEHAVIORS

FACING PHYSICAL SENSATIONS

MINDFUL EMOTION AWARENESS

UNDERSTANDING YOUR EMOTIONS

SETTING GOALS & MAINTAINING MOTIVATION

Figure 13.1    

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Important Takeaways from This Program This treatment program contains a great deal of information on how to develop a more accepting attitude toward your emotions. Here are some of most important takeaway messages: All emotions, even the ones that feel negative or uncomfortable, are providing you with important information that can motivate you to take action in helpful ways. ■ Staying present in the moment and taking a nonjudgmental view of your emotions can help to prevent emotions from increasing in intensity. ■ The way you think about a situation influences how you feel, and how you feel affects the way you interpret a situation. ■ Although avoiding uncomfortable emotional experiences can work well in the short term, it isn’t an effective long-​term coping strategy. ■

To help you remember all of the skills contained in this program, we have summarized them in the UP Skills Action Plan that you can use whenever you notice an emotion starting to build (see Box 13.1). The UP Skills Action Plan is rooted in the three-​components of an emotion to help you remember it.

Box 13.1  UP Skills Action Plan

Do a quick three-​point check. Use your breath or other chosen cue as an anchor to help bring you out of your head and to anchor yourself in the present moment. What are you thinking right now? What negative automatic thoughts are you having right now? Are you jumping to conclusions or thinking the worst? Are you responding to a past concern or future worry? Ask yourself whether there are any other ways to interpret this situation that may be more helpful and what are some ways you can cope. What are you feeling in your body right now? What physical sensations are you noticing? Are you tired, hungry, or rundown? Are your physical sensations intensifying your emotions, or vice versa? Try to stay in the present moment with your physical sensations without trying to control them or to distract yourself. What are you doing now, or what do you feel like doing right now? Are you avoiding a situation that may trigger an uncomfortable emotion? Remember that countering an emotional behavior involves provoking emotions and engaging in helpful Alternative Actions.

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To keep your UP Skills Action Plan handy, you can make a photocopy of these steps or download a printer-​ friendly version from TM the TreatmentsThatWork website at http://www.oup.com/us/ttw. Alternatively, some people find it helpful to take a picture of the UP Skills Action Plan with their cellphone so that it is easily accessible anytime they are experiencing uncomfortable emotions.

Evaluating Your Progress As you approach the end of this treatment program, you may be feeling excited because you’ve seen improvements in your symptoms. You may also be feeling disappointed that you haven’t seen as much improvement as you had hoped. It is important to remember that the goal of completing this treatment program is to teach you skills for responding to your emotions in a more helpful way. Although it is very common for people to feel that they have made some noticeable progress in addressing their symptoms, there is often still room for improvement following this short-​ term treatment. This is because it takes time after learning the skills to see the full effect. As we mentioned in Chapter 2, we have used this treatment with hundreds of patients and over 70% of them saw significant improvements in their symptoms. Our studies on this treatment have also shown that patients continue to see additional improvements in their symptoms for up to a full year after completing it. It is helpful to keep this in mind as you reflect on how your symptoms have changed over the course of this program. There are several ways that you can evaluate the progress that you’ve made since you first began this program. One option is to take a look at your Progress Record. If you’ve completed the Anxiety and Depression Scales (as well as the Other Emotion and Positive Emotion Scales) from week to week, and logged the data onto your Progress Record, it can be a nice visual representation of how some of your symptoms changed. If you are like most people who complete this program, there were probably some ups and downs from one week to the next. However, if you compare your scores at the beginning of the program to now, have there been any decreases in your overall levels of anxiety and feelings of depression? Have you seen decreases in the personally relevant emotion that you tracked? Have you noticed an increase in your experiences of positive emotions?

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Perhaps some of these changes (e.g., feeling less anxious) have impacted the top problems you identified at the start of treatment. You can use the Progress Evaluation Form to reflect on the progress you have made toward learning new ways of coping with intense, uncomfortable emotions. It is important to set aside time to complete this evaluation thoughtfully. By generating specific examples of how each skill has been helpful, you will be reinforcing the connection in your brain between using the skills and positive changes in your life. We will also ask you to consider where there are opportunities for continued improvement for each skill, which will be helpful in creating your Practice Plan later in this chapter. See Appendix B (p. 186) for a completed example of a Progress Evaluation Form.

How to Maintain Your Progress and Your Momentum As you approach the end of this treatment program, you may find yourself looking forward to taking a break. After all, treatment is hard work! However, consider Newton’s first law of motion—​an object at rest stays at rest and an object in motion stays in motion. Right now, you are an object in motion! In other words, it is much easier to maintain all of the positive momentum that you’ve worked so hard to accumulate over these past few months than it is to get back on track after taking a break. Next we recommend strategies for maintaining your progress and continuing to benefit from treatment. Revisit Your Goals

In Chapter 4, you came up with some goals for treatment. Setting goals is a critical part of making changes to your life and maintaining your motivation. Take a look at the Treatment Goals Form you completed at the start of this program. Now that you have completed this treatment, you may have made significant progress on some of the goals you set. In order to stay motivated, it can be helpful to take a moment to revisit your goals and update them if necessary. Now that you’re feeling better, more possibilities may seem open to you (e.g., starting to date, going back to school, looking for a new job). When updating your goals, remember that people tend to feel most motivated when working toward something that is important to them. So

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choose goals that are personally meaningful to you. Once you have your updated goals in mind, ask yourself the following: Are my goals specific and concrete enough for me to easily measure my progress? ■ Are my goals manageable and realistic? Remember that the purpose of goals is to motivate you. If you set goals that are unrealistic, you will most likely end up feeling defeated. ■ Is the ability to achieve my goals within my control, or is it possible that I fail for reasons beyond my control? For example, if you set a goal to go on two job interviews next month, there are many reasons why you may not be able to achieve your goal that you can’t control. However, if you revise your goal to submitting two job applications every week, you can control whether you achieve that goal. ■

Create a Practice Plan

The single most effective way to maintain the progress you have made in this program and to keep improving is to continue to practice the skills you’ve learned. Keep in mind that even if you have made significant progress so far, these are newly learned behaviors that will require time and effort in order to “stick.” The Practice Plan Form is designed to help you come up with specific strategies for practicing each of the core skills. Studies have shown that people are more likely to take action when they plan it out in advance. First, the Practice Plan Form asks you to think about how each of the treatment skills relates to your long-​term treatment goals. For example, if your long-​term goal is to improve your relationships with your friends, practicing Cognitive Flexibility may stop you from jumping to conclusions when a friend doesn’t respond to your text message. The Practice Plan Form also asks you to come up with a plan for how you can practice each skill. Even with the best of intentions, it is hard to follow through with a practice plan unless you get specific about exactly how and when you will practice. For example, someone may plan to work on countering emotional avoidance by not using distraction as a coping strategy during the commute to work. However, that practice plan doesn’t specify when or how this person will stop using distraction. Here is a better practice plan: “When I take the subway to and from work, I won’t listen to music or read on my phone to distract myself. At each subway

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stop, I will take a deep breath to anchor myself in the present moment and do a three-​point check.” Lastly, the Practice Plan Form asks you to come up with a way of holding yourself accountable for following through on your plan. There are many ways that you can hold yourself accountable. You can enlist the help of a friend or family member—​sometimes just knowing that someone is going to ask you whether you followed through with your practice plan can motivate you to do it. You can also link your practice plan to other daily behaviors. For example, you could say that you aren’t going to brush your teeth in the morning until you complete your straw-​breathing exercises. You can also consider whether there are any steps you can take to make it easier to stick with your practice plan. For example, for the person who is planning to not listen to music or read on the phone, it may be helpful to leave headphones at home and to keep the phone powered off for the commute. A completed example of the Practice Plan Form can be seen in Appendix B (p. 188). If you would like additional space to develop your practice plan, you can make photocopies of this form or download it from the TreatmentsThatWorkTM website at http://www.oup.com/us/ttw. Be Your Own Coach

Whether you completed this treatment program on your own or with the help of a therapist, it is important that you take ownership over your continued progress. Many people find it helpful to schedule time to review their progress and revise their practice plan on a weekly basis. We recommend blocking out this time on your calendar the same way you would for a doctor’s appointment or a work meeting. If you use an electronic calendar on your phone or computer, you can even set automatic reminders. It is often said that the best offense is a strong defense, and the same is true when it comes to monitoring your symptoms. Many people wait until their symptoms start to disrupt their lives again before they make time to address them. However, if you establish the routine of checking in with yourself each week, you will be able to notice any changes in your symptoms before they get out of hand. For example, if you notice that you are starting to avoid situations that trigger intense emotions, you can proactively address it using your practice plan. It can also be helpful to consider whether there are any upcoming situations that may be particularly challenging for you. You can anticipate

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some of the negative automatic thoughts that are likely to arise and generate more flexible interpretations ahead of time. You can even review these new interpretations right before entering the challenging situation. You can also predict which emotional behaviors you will be tempted to use in order to lessen the intensity of your emotions and plan which Alternative Actions to use instead. When your emotions are likely to be especially intense or overwhelming, planning out your coping strategy in advance can make it easier to actually use it in the moment.

Anticipating Difficulties and Managing Setbacks Regardless of the gains you have made in treatment, it is very likely that you will experience intense or uncomfortable emotions at some time in the future. Emotional ups and downs are part of everyday life. You may notice that when you are under stress, your symptoms tend to flare up. This is very normal and similar to the way stress can affect your immune system. In the same way that you are more likely to get sick when you are under a lot of stress, you are more likely to fall back into old patterns of avoiding your emotions. Sometimes, however, it may seem like your symptoms flare up when there hasn’t been an increase in stress. Even though this can be very distressing, these fluctuations in symptoms are perfectly natural and normal—​they do not necessarily mean that you have relapsed. The skills that you’ve learned to manage your emotions in more helpful ways are also applicable to coping with the inevitable ups and downs that will happen over time. For example, responding to an increase in symptoms with criticism and judgment will only intensify the symptoms. It is very easy to start jumping to conclusions and thinking the worst when symptoms flare up. You may find yourself thinking that treatment failed or that you’ll never be able to cope with intense emotions. Your Mindful Emotion Awareness and Cognitive Flexibility skills can be very helpful in these moments.

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Summary It takes both time and effort to change the way you respond to your emotions, and it is hard work! It is important to remember that you didn’t learn these unhelpful ways of coping with intense emotions overnight. It is unrealistic to expect that these learned behaviors will be completely eliminated in a few months. However, with consistent practice, you will be able to replace unhelpful coping strategies with more useful ones and change the way you respond to your emotions. The end of treatment is just the beginning of making more substantial changes in your life. To quote Michelangelo, “Every block of stone has a statue inside it and it is the task of the sculptor to discover it.” You are the sculptor and you now have the tools—​all that’s left is to carve the stone.

Self-​Assessment Quiz Answer each of the following by circling true (T) or false (F). Answers can be found in Appendix A. 1. If you are still struggling with symptoms at the end of treatment, it means that treatment did not work for you. T

F

2. It is natural and normal to experience fluctuations in your symptoms; it does not necessarily mean that you have relapsed. T

F

3. Once treatment is over, you don’t need to practice the skills on a regular basis. T

F

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Form 13.1: Progress Evaluation Use this form to identify the specific ways in which each skill has been helpful to you. Mindful Emotion Awareness What are some specific improvements you’ve noticed in your ability to stay present in the moment instead of getting caught up in the past or worrying about the future? What are some specific improvements you’ve noticed in your ability to nonjudgmentally observe your emotions and your reactions to them? In what ways have you found this skill helpful? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ ​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​​_​_​_​_​_​_​_​_​__​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Where do you see room for continued improvement? Are there situations where you find it more difficult to stay in the present moment or to not judge your emotional experiences? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Cognitive Flexibility What are some specific improvements you’ve noticed in your ability to be more flexible in the way you think about situations? Are you jumping to conclusions or blowing things out of proportion less often? How has this skill been useful? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Where do you see room for continued improvement? Are there situations where you find it more difficult to be flexible in your thinking? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

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Confronting Physical Sensations What are some specific improvements that you’ve noticed in the way you respond to the physical sensations that are associated with your intense emotions? Are you doing activities that you previously avoided due to uncomfortable physical sensations? How has this skill been useful? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Where do you see room for continued improvement? Are there certain physical sensations that you still find highly distressing? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Countering Emotional Avoidance What are some specific improvements that you’ve noticed in your ability to identify your unhelpful emotional behaviors and replace them with alternative actions? How has this skill been useful? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Where do you see room for continued improvement? Are there specific emotional behaviors that are more difficult to replace with alternative actions or certain situations where you find it more challenging to use an alternative action? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

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Form 13.2: Practice Plan Use this form to generate a plan for continuing to practice these skills after you’ve completed this program.

Mindful Emotion Awareness

How will practicing this skill help you achieve your long-​term goals?

What is your specific practice plan for this skill?

How can you hold yourself accountable to your practice plan?

Cognitive Flexibility

Confronting Physical Sensations

Countering Emotion Driven Behaviors

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Appendix A Answers to Self-​Assessment Quizzes Chapter 3: T, F, F, T Chapter 4: T, F, T, F Chapter 5: F, T, F, T Chapter 6: T, F, T, F Chapter 7: F, T, F, F, F Chapter 8: F, F, T, F Chapter 9: T, F, T, T Chapter 10: T, T, F, T Chapter 11: T, F, T, F Chapter 12: F, T, F, F, F Chapter 13: F, T, F

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Appendix B Example Forms Example Form 3.5: Progress Record Example Form 4.1: Treatment Goals Example Form 4.2: Decisional Balance Example Form 5.1a: Three-​Component Model Example Form 5.1b: Three-​Component Model Example Form 6.1: Following Your ARC Example Form 7.1: Mindful Emotion Awareness Example Form 8.1: Practicing Cognitive Flexibility Example Form 8.2a: Downward Arrow: Identifying Core Automatic Thoughts Example Form 8.2b: Downward Arrow: Identifying Core Automatic Thoughts Example Form 9.1a: List of Emotional Behaviors Example Form 9.1b: List of Emotional Behaviors Example Form 9.2a: Countering Emotional Behaviors Example Form 9.2b: Countering Emotional Behaviors Example Form 10.2: Physical Sensation Practice Example Form 11.1a: Emotion Exposure Hierarchy Example Form 11.1b: Emotion Exposure Hierarchy Example Form 11.2a: Record of Emotion Exposure Practice Example Form 11.2b: Record of Emotion Exposure Practice Example Form 13.1: Progress Evaluation Example Form 13.2: Practice Plan

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Accessing Treatments ThatWork Forms and Worksheets Online All forms and worksheets from books in the TTW series are made available digitally shortly following print publication. You may download, print, save, and digitally complete them as PDFs. To access the forms and worksheets, please visit http://​www.oup.com/​us/​ttw.   

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Example Form 3.5: Progress Record Use this form to plot your scores from the Anxiety and Depression Scales (as well as the Other Emotion and Positive Emotion Scales, if you are using them).

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Example Form 4.1: Treatment Goals

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Example Form 4.2: Decisional Balance

Use this form to explore all the pros and cons you can think of both for changing (or engaging with this treatment) and for staying the same.

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Example Form 5.1a: Three-​Component Model Use this form whenever you are feeling a strong emotion to help you break it down into its three parts. You can also use this form after an emotional experience to review how your emotion progressed. Situation: Late for the bus

Physical Sensations (what you’re feeling in your body)

Emotion(s): Anxiety

Heavy breathing Faster heart rate Dizzy

Thoughts (what you’re thinking)

Behaviors (what you’re doing, what you feel like doing)

This is so uncomfortable If I get on this bus, I’m going to have a panic attack It's happening—I’m definitely going to panic

Walking to work instead

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Example Form 5.1b: Three-​Component Model Use this form whenever you are feeling a strong emotion to help you break it down into its three parts. You can also use this form after an emotional experience to review how your emotion progressed. Situation: Friend cancels plans

Physical Sensations (what you’re feeling in your body)

Emotion(s): sad, embarrassed

Lump in my throat Fatigue

Thoughts (what you’re thinking)

Of course she doesn’t want to hang out with me— I’ am so lame I might as well go to bed early

Behaviors (what you’re doing, what you feel like doing)

Ruminate about what I did to upset my friend Go to bed at 8 

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Example Form 6.1: Following Your ARC

Date/ Time

Response

Antecedent What triggered your emotional response?

Consequence

Physical Sensations Thoughts

11/15 7:30am

Cut off in traffic

Behaviors

Feeling hot & sweaty, clenched jaw Yell at the other driver, tailgate, tighten hands on wheel

It was on purpose, I’m going to be late now

11/20 4pm

11/21 6:15pm

Feeling really tired

Looking in the mirror before a big event

Heaviness in my head I getting depressed again, I won’t feel up to my plans tonight

Cancel plans, take a nap Pit in stomach, sweating

I look so fat, people are going to judge me for gaining weight

Try on multiple outfits, ask partner for reassurance, urge to not eat all day

Short-term How is this response working for you?

Long-term How might this response lead to more negative emotions in the future?

Release tension, feel “in the right”

Continue to believe people are out to get me

Feel relief canceling, feel nothing while sleeping

Feel guilty for not getting anything done and ditching friends

Release tension, feel “in the right”

Reinforce belief that how I look will affect others’ opinions of me

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Example Form 7.1: Mindful Emotion Awareness Use this form to record your experience following completion of the Mindful Emotion Awareness Meditation, Mindful Mood Induction, or Anchoring in the Present.

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Example Form 8.1: Practicing Cognitive Flexibility Use this form to help you move past your first impressions by identifying if you’re falling into a negative thinking trap and coming up with alternative ways you can think about the situation. Use the following questions to help you evaluate your automatic thoughts.

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Example Form 8.2a: Downward Arrow: Identifying Core Automatic Thoughts

Sometimes the alternative thoughts you're coming up with don't seem very believable. This may because there are core automatic thoughts driving your initial negative thoughts. Use this form to explore the thoughts that might be beneath the surface of your first automatic thought. First Automatic Thought: My boss will find the mistake I made and be upset at me

If this were true, what would it mean about me? Why does this matter to me? What would happen if this were true? What would happen next? Core Automatic Thought:

I’m going to get fired

If this were true, what would it mean about me? Why does this matter to me? What would happen if this were true? What would happen next? Core Automatic Thought:

I’m bad at my job

If this were true, what would it mean about me? Why does this matter to me? What would happen if this were true? What would happen next? Core Automatic Thought:

I’ll never be successful

If this were true, what would it mean about me? Why does this matter to me? What would happen if this were true? What would happen next? Core Automatic Thought:

I’m incompetent

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Example Form 8.2b: Downward Arrow: Identifying Core Automatic Thoughts

Sometimes the alternative thoughts you're coming up with don't seem very believable. This may because there are core automatic thoughts driving your initial negative thoughts. Use this form to explore the thoughts that might be beneath the surface of your first automatic thought. First Automatic Thought: My partner forgot our anniversary; I must care more about our relationship than they do

If this were true, what would it mean about me? Why does this matter to me? What would happen if this were true? What would happen next? Core Automatic Thought:

They don’t love me anymore

If this were true, what would it mean about me? Why d oes this matter to me? What would happen if this were true? What would happen next? Core Automatic Thought:

We’re not going to last

If this were true, what would it mean about me? Why does this matter to me? What would happen ifthis were true? What would happen next? Core Automatic Thought:

I’m going to end up alone

If this were true, what would it mean about me? Why does this matter to me? What would happen if this were true? What would happen next? Core Automatic Thought:

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I’m unlovable

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Example Form 9.1a: List of Emotional Behaviors

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Example Form 9.1b: List of Emotional Behaviors

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Example Form 9.2a: Countering Emotional Behaviors

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Example Form 9.2b: Countering Emotional Behaviors

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Example Form 10.2: Physical Sensation Practice

801

Example Form 11.1a: Emotion Exposure Hierarchy

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Example Form 11.1b: Emotion Exposure Hierarchy

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Example Form 11.2a: Record of Emotion Exposure Practice

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813

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814

Example Form 11.2b: Record of Emotion Exposure Practice

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815

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816

Example Form 13.1: Progress Evaluation

186

817

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Example Form 13.2: Practice Plan

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Appendix C Definitions of Key Terms Anchoring in the present. The act of pausing to nonjudgmentally observe experience in the present moment and deliberately choosing a response consistent with current needs, goals, or values. ■ Anxiety Scale. Overall Anxiety Severity and Interference Scale (OASIS). Weekly monitoring questionnaire for anxiety. ■ ARC of emotion. Antecedents—​Response—​Consequences of an emotional experience. ■ Antecedents are triggers, conditions, or situations that bring up certain emotions. They may be proximal (immediate) or distal (in the past). ■ The response is the three components of emotion—​ thoughts, physical sensations, and behaviors. ■ Consequences are the resulting effects of the emotional response, which may be short term or long term. ■ Automatic thoughts. Thoughts that occur immediately and involuntarily in response to a situation. ■ Cognitive challenging. An exercise designed to increase flexibility of thinking habits by using challenging questions to examine whether thoughts are realistic and helpful, then generating more useful appraisals. ■ Cognitive flexibility. The practice of deliberately considering multiple interpretations or predictions about a situation, instead of assuming that the first thought is accurate and helpful. ■ Core automatic thoughts. Also called core beliefs. Central beliefs that an individual maintains about themselves, others, and the world that come up involuntarily but that are not specific to any one situation. ■ Depression Scale. Overall Depression Severity and Interference Scale (ODSIS). Weekly monitoring questionnaire for depression. ■ Emotion avoidance. Things an individual may do to prevent uncomfortable emotions from happening or prevent them from getting stronger. This may include ■

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Situational (overt) avoidance: Avoiding situations that trigger strong emotions. ■ Subtle behavioral avoidance: In an uncomfortable situation, doing things to avoid facing strong emotions (e.g., not making eye contact). ■ Cognitive avoidance: Avoiding thinking about things that will bring up uncomfortable emotion (e.g., distracting oneself during an anxiety-​provoking situation). ■ Safety signals: Talismans, people, or other things that make a person feel “safer” in uncomfortable situations (e.g., carrying medication, only talking to strangers at a party when accompanied by a friend). Emotion exposure. An exercise designed to increase tolerance of uncomfortable emotions by entering situations likely to produce uncomfortable emotion without engaging in avoidance or escape. Emotional behaviors. Includes emotion avoidance and emotion-​ driven behaviors. Behaviors that are used to control strong emotions, which may be adaptive or maladaptive. Emotion-​driven behaviors (EDBs). Behaviors that occur in response to emotions. These behaviors can be hard to resist (or change) in the presence of strong emotions. EDBs can be helpful and adaptive (e.g., jumping out of the way of a car due to feeling fear), but they can also be maladaptive (e.g., leaving a party early because of anxiety, staying in bed when feeling tired and depressed). Emotional disorders. Psychological disorders, such as anxiety or depression, characterized by (1) frequent, strong emotions, (2) negative reactions to these emotions, and (3) avoidance of emotional experiences. These difficulties cause interference in important areas of functioning. Interoceptive. Referring to physical sensations. Jumping to conclusions. Also called probability overestimation. Overestimating the likelihood of a negative outcome. Mindful emotion awareness. A way of paying attention to emotional experiences that emphasizes the importance of focusing on the present (including how an individual is currently feeling) in a nonjudgmental way. Objective monitoring. Observing “just the facts” of an experience without evaluation or judgment. ■



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Other Emotion Scale. Weekly monitoring questionnaire for other emotions a patient may be struggling with, such as anger, shame, or jealousy. ■ Positive Emotion Scale. Weekly monitoring questionnaire for positive emotions. ■ Present-​focused nonjudgmental awareness. Sometimes called mindfulness. A way of interacting with emotional experiences that involves observing components of the experience without trying to push emotions away or change them, and without judging oneself for the emotions that are present. ■ Progress record. A chart for visually representing scores from the Anxiety Scale, Depression Scale, Other Emotion Scale, and Positive Emotion Scale. ■ Subjective monitoring. Observing experiences in a way that adds evaluation or judgment; e.g., focusing on how awful one feels or criticizing oneself for feeling a certain way. ■ SUDS. Subjective Units of Distress Scale. A way to measure uncomfortable emotion ranging from 0 (no discomfort) to 8 (extreme discomfort). ■ Thinking the worst. Also called catastrophizing. Thinking that if a negative outcome does occur, it will be extremely bad or the person will be unable to cope with it. ■ Thinking traps. Thinking habits in which people repeatedly interpret or predict situations in a negative way. Include jumping to conclusions and thinking the worst. ■ Three-​component model of emotion. The three parts of any emotional experience: thoughts (what you’re thinking), physical sensations (what you’re feeling), and behaviors (what you’re doing). ■

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About the Authors

David H. Barlow, PhD, is Professor of Psychology and Psychiatry Emeritus and founder of the Center for Anxiety and Related Disorders at Boston University. He is editor-​in-​chief for the Treatments That Work series of therapist manuals and patient workbooks, as well as editor of The Oxford Handbook of Clinical Psychology. Dr.  Barlow has published more than 600 articles and chapters and more than 80 books and clinical manuals, mostly in the area of the nature and treatment of emotional disorders and clinical research methodology. Todd J. Farchione, PhD, is a Research Associate Professor in the Department of Psychological and Brain Sciences, Center for Anxiety and Related Disorders, Boston University. Dr. Farchione’s research focuses on the nature, assessment, and treatment of anxiety, mood, and related disorders. He has published more than 60 articles and chapters in this area.  Shannon Sauer-​Zavala, PhD, is a Research Assistant Professor in Boston University’s Department of Psychology, as well as the director of the Unified Protocol Training Institute. Her research is focused on identifying factors that maintain symptoms across broad classes of psychological disorders and using this information to streamline treatment for commonly co-​occurring diagnoses. Dr. Sauer-​Zavala has more than 60 peer-​ reviewed publications in this area and is currently funded by the National Institute of Mental Health to continue this work. Heather Murray-​Latin, PhD, is a Research Assistant Professor in the Department of Psychological and Brain Sciences at Boston University. Jacqueline R. Bullis, PhD, is an instructor in the Department of Psychiatry at Harvard Medical School and a clinical researcher in the Division of Depression and Anxiety Disorders at McLean Hospital. She completed her doctoral training in the clinical psychology program at Boston University Kristen K. Ellard, PhD, is an instructor in psychology, Harvard Medical School, and an Assistant in Psychology and Clinical Research Fellow at

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the Massachusetts General Hospital Department of Psychiatry’s Dauten Family Center for Bipolar Treatment Innovation and Division of Neurotherapeutics. Kate H. Bentley, PhD, is a Clinical and Research Fellow at the Massachusetts General Hospital/​Harvard Medical School and previously completed her doctoral training in the clinical psychology program at Boston University. Hannah T. Boettcher, MA, is a predoctoral intern at the VA Medical Center in Lexington, Kentucky, and completed her doctoral training in the clinical psychology program at Boston University. Clair Cassiello-​Robbins, MA,  is an advanced doctoral student in the clinical psychology program at Boston University.

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