Practice and Examples

2 What Does Anxiety Look Like?

Generalized Anxiety Disorder

Worry is the principal symptom of a mental health disorder called generalized anxiety disorder (GAD). According to the DSM, a professional might diagnose you with GAD if you’ve been experiencing significant distress due to worry and anxiety, including some specific symptoms like sleeplessness and irritability, for longer than six months and for reasons other than medical or substance abuse problems.

When certain fears cause you marked distress in life for a certain period of time and you meet other spe-cific criteria, a mental health professional might diagnose you with a specific phobia. This is the single most prevalent diagnosis among the anxiety disorders, affecting about one in ten American adults at any given time (Kessler et al. 1994).

Panic

Panic is a severe form of anxiety behavior that typically includes physical symptoms such as a racing heart, nausea, hyperventilation, a choking sensation, and so on. Most often these episodes are accompanied by a strong fear of losing control or even of dying. The root of panic is the fear of fear, making a person want to avoid the panic experience itself. So people with panic problems are intently focused on fear, on the bodily sensations listed above (the cues of an impending panic attack), and on being unable to protect themselves from harm in an unfamiliar or uncontrollable situation.

Panic is very often associated with agoraphobia, a strong fear of being anywhere but the safest places. People with panic worry that if they don’t stay in these safe places, they might have a panic attack— and this can seem like the worst thing imaginable.

If you have recurrent panic attacks without any obvious cause and you spend a considerable amount of time dreading and trying to avoid panic attacks, you might have panic disorder. Panic is often distinguished from other forms of anxiety because the fearful focus is on the sensations inside and not on the world outside. Somewhat less than 3 percent of the adult American population will suffer from panic disorder in a given year (Kessler et al. 1994). It stands to reason that the number of people who experience isolated or less frequent panic attacks is far greater.

Social Anxiety

One intense fear that’s distinguished from specific phobias is the fear of embarrassment and humiliation in front of others, known as social anxiety disorder or social phobia. This condition is very common, with about 7 percent of the adult U.S. population experiencing diagnosable levels in any given year (Kessler et al. 1994).

This statistic leaves out the countless individuals who typically feel shy, uncomfortable, and ill at ease in social situations but don’t meet the specific diagnostic criteria in the DSM for clinical social phobia.

For those with social phobia, parties, gatherings, meetings, and public- speaking responsibilities can be sources of considerable anxiety. Often, those with social phobia respond to this anxiety by going to great lengths to avoid situations (or the threat of situations) that trigger it. Often social phobia is accompanied by significant depression, which may be caused by lack of social contact, a necessary and basic emotional need.

Obsessive- Compulsive Disorder (OCD)

OCD is a spectrum of behaviors characterized by obsession with certain unpleasant thoughts, often alternat-ing with compulsive behaviors intended to neutralize the obsessions. Common examples of OCD behavior include the following:

• An obsession with contamination or infection paired with a washing or cleaning compulsion

• An obsession with the possibility of a catastrophic fire or burglary combined with a compulsion to repeatedly check the knobs on the stove or the locks on the doors

• A compulsive urge to hoard objects or animals

• An obsession with sin coupled with a compulsion to confess

• An obsession about the possibility of harming others with a compulsion to check repeatedly if such harm has occurred

Post- Traumatic Stress Disorder (PTSD)

This condition can arise after an experience involving either the real or perceived threat of death or serious injury to others or to the person who eventually suffers from PTSD. The sufferer also experiences feelings of helplessness, fear, and horror. Common situations that might meet these conditions are accidents; natural disasters; violent crimes such as robbery, murder, or rape; childhood abuse; and exposure to combat situations.

To be diagnosed with PTSD, you have to have been exposed to an extreme situation in which severe injury or loss of life took place or was a possibility for you or others near you. Further, you need to reexperience the events in some way, engage in active avoidance of things and situations that recall the event, and experience significant distress and disability in your life as a result. The anxiety symptoms associated with PTSD can be chronic, persisting for an entire lifetime in some cases. Research suggests that about 3 percent of American adults suffer from PTSD in a given year (Kessler et al. 1994).

4 Relaxation

Instructions for Practicing Progressive Muscle Relaxation

In order to make progressive muscle relaxation work for you, you should practice it every day for twenty to thirty minutes— even on days when you aren’t in the mood. Making a regular practice of it is most effective. Don’t be concerned if at first it takes you quite a while to get to a state of relaxation. If you keep up your rou-tine, you’ll soon be able to get into a state of deep relaxation in a shorter period of time.

Tense and relax each muscle group twice. Tense for 7 seconds, relax for 20 seconds, and repeat. Each time you tense, make the muscles as hard as you can without straining them. After the 7 seconds of tightness, release the tension all at once. Pay attention to how the relaxation stage feels. What do you feel in your mus-cles? Recognizing what a relaxed muscle feels like is an essential goal of this exercise.

Arms

1. Clench both hands tightly, making them into fists. Hold the tightness for 7 seconds. Pay attention to the sensations in the muscles as they contract. Now let go of the tension and notice the difference. Let yourself fully absorb the feeling of relaxation. After 20 seconds of relaxation, repeat the cycle.

2. Bend both arms and flex your biceps hard. Hold for 7 seconds, then relax for 20 seconds. Repeat. Absorb that feeling of relaxation. How do your muscles feel when they’re relaxed?

3. Tense your triceps (the muscles on the back of your arms, opposite your biceps) by straightening your arms and pushing them down hard by your sides. Release and notice the feeling of relaxation. Repeat.

Head

1. Raise your eyebrows high and feel the tightness in your forehead. Release after 7 seconds and let the feeling of relaxation take hold for 20 seconds. Repeat.

2. Press all your features together, tightening all the muscles in your face as you concentrate on the tip of your nose. Release, relax, and repeat the cycle.

3. Press your eyelids together and smile as widely as you can. After 7 seconds, relax for 20 seconds and repeat.

4. Tighten your jaw muscles and press your tongue against the roof of your mouth. Hold, then release. Repeat. Open your mouth as wide as you can, making your lips into an O. After 7 seconds, release and let your jaw relax. How does your face feel? Repeat.

5. Let your head fall back as far as it will go. Hold, then relax. Repeat. Tilt your head to the side, toward your shoulder. Hold the position, then relax and repeat. Next, tilt your head to the other side. Again, hold, then relax and repeat. Return your head to a neutral position and feel the absence of tension. Let your lower jaw drop slightly. Let your head fall forward toward your chest. Lift your head back up to a neutral position and feel the lack of tension for 20 seconds. Repeat.

Midsection

1. Hunch your shoulders up around your ears. After 7 seconds, let them relax back to their normal position. Repeat. Stretch your shoulders back, pinching your shoulder blades together. Relax and repeat.

2. Lift your arms out in front of you until they’re parallel with the floor. Without bending your arms or drop-ping them down, cross them until you feel a strong stretch in your back. After 7 seconds have passed, let your arms fall down to your sides and feel the deep relaxation for 20 seconds. Repeat.

3. Breathe deeply. While holding your breath, tighten the muscles of your abdomen and hold for 7 seconds. Exhale. Repeat.

4. Arch your back gently. Hold, then relax and let your back go flat again. Repeat.

Legs

1. Clench your buttocks and tighten your thigh muscles. You can increase the tension by straightening your legs and imagining energy going out through your heels. Hold for 7 seconds. Relax for 20 seconds, then repeat.

2. Press your legs together firmly to engage your inner thigh muscles. Hold, relax, and repeat the sequence.

3. Contract your leg muscles by pointing your toes. Hold, relax, and repeat.

4. Now contract your leg muscles again by flexing your toes up toward your shins. Hold, relax, and repeat the sequence.

Visualization Skills

If you have difficulty creating a vivid, peaceful scene in your mind, try adding some of these elements to your next practice session.

Focus on your senses. How would it feel if you were actually in this place? If your scene is outdoors, think about the elements. Is the air dry and warm, or misty and cool? What time of day is it? Is the sun low or high in the sky? How deep are the shadows that you see? Concentrate hard until you can imagine textures under your fingertips: the grain of wood, silky- smooth fabric, a rough stone, powdery sand.

• If there are areas of the environment that you want to fill in, enter the scene and put all your focus on that area. Let the more obvious parts of the scene fade away until the gap begins to fill. Once something begins to appear, take extra care to establish the tiny details that will help you hold this part of the scene in your imagination.

• Play with one detail at a time. Mentally trace the outlines of that mountain until every crag is embedded in your mind. Zero in on colors—is that wildflower fuchsia, magenta, or hot pink? Get as specific as you can.

• Think about where you are within the scene. Are you looking out from your own eyes, or are you viewing yourself from afar? If you are seeing yourself from afar, shift your perspective so that you’re looking out at the scene from your own point of view. This will place you inside the scene instead of outside it, allowing you to experience it in greater detail.

Examples of Peaceful Scenes

The beach. You begin by walking along a winding path that rises gradually as you go. At the crest of the path, the ocean comes into view. As you step onto the beach, you notice that it’s immaculately clean and completely deserted. The air is so fresh that you instinctively begin to breathe more deeply. The scents of salt and seaweed fill your nostrils. The warmth of the sun melts from the top of your head to your shoulders and gently down your entire body. As you walk toward the water, you notice all its many shades of turquoise, blue, and green, backlit by the sun. Sharp white crests appear and gradually build on the waves until they break and roll, over and over. Long strands of seaweed, lifted by the waves, tumble wildly in the surf. Near the edge of the water, the sand is covered in a swath of pale pink seashells. The shells and stones along the water’s edge clatter loudly as the waves break onto the shore. You sink down onto the sand and feel it cradle you gently. Burying your hands in the sand, you feel its powdery softness clinging to your skin. A deep calm washes over you.

The desert. You part the flaps of a tent to look out as dawn breaks on an April morning in the desert. The air is still a bit cool, and you pull your sleeping bag around you and settle in to watch your favorite part of the day. Wind- carved spires rise in the distance. The sand around you seems to contain every color imaginable,

from palest dun to deep red, each glowing in its own way in the soft early light. The air is so clear that it that it seems you can see forever. Birds appear all around, some soaring high above you and others hopping lightly around your camp. You watch them for a time, and finally your eyes settle on a flame- red patch of desert paintbrush, watching its colors change as it comes out of shadow and into full sunlight. As the sun climbs higher in the sky, it warms your body gently and completely. You feel safe and content.

5 Worry Risk Assessment

Risk Assessment Process

You can use the following process to make accurate risk assessments by estimating accurate probabilities and making reasonable outcome predictions. Find a notebook or use your computer to write down your work as you go through the following steps.

1. Record one of your worries in the form of a feared event. Write down the worst possible version of your worry you can think of. For example, if you worry about your teenager going out at night, imagine the worst: a head- on collision of drunk teens and a big truck, everybody dead on impact or dying in the emer-gency room after suffering horribly.

2. Then, write the automatic thoughts that typically come up: She’ll die… I’ll die… Blood and pain… Things will never be the same… Awful… Can’t stand it… Jot down whatever comes to mind, even if it is just an image or a fleeting word.

3. Next, rate your anxiety when considering this worst- case scenario. Use 0 for no anxiety and 100 for the worst fear you have ever experienced. Then rate the probability of this worst- case scenario coming to pass— from 0 percent for no likelihood at all to 100 percent for absolute inevitability.

4. Assuming that the worst did happen, predict the consequences you most fear. Then spend some time figur-ing out what you would tell yourself and what you would do in order to cope with the catastrophe. When you have a clear picture of possible coping strategies, make a revised prediction of the consequences. After these predictions, rerate your anxiety and see if it has diminished.

5. List the evidence against the very worst outcome happening. Figure the odds as realistically as you can. Then list all the alternative outcomes you can think of. Finally, re- rate your anxiety and the probability of the event. You should find that both your anxiety and probability ratings have declined as the result of your making a full and objective risk assessment.

Go through this process each time you’re confronted by a significant worry, or whenever you return to a worry more than once. It’s important to do this exercise consistently. Each risk assessment helps you change old habits of catastrophic thinking. When you’ve completed a risk assessment, keep your work. You may wish to refer to it again when confronting a similar worry.

6 Worry Time

More to Think about during Worry Time

Another kind of inaccurate thinking to watch out for is magical thinking, a pattern in which you believe that your worrying somehow works to protect you or people you care about from bad things that might happen. By worrying, you imagine yourself to be a kind of sentry, waiting and watching for the first sign of misfortune. This kind of thinking might look like prudence and due diligence on the face of it, but looks can be deceiving. How often do you engage in this kind of thinking? While our thoughts exert great influence over how we feel, they don’t have much effect at all on the world around us, as most people who’ve tried to bend spoons with their minds know. Can you catch this kind of thinking next time it pops up?

9 Relief from Panic

The Fight- or- Flight Reaction

Here’s how your fight- or- flight mechanism works: It starts with an event inside or outside your body. An exter-nal event might be a stressor or challenge at work or at school, an interpersonal conflict, or the reoccurrence of a previously panic- inducing situation. An internal event could be any of the physical symptoms that you associate with panic.

Next, the event triggers worry. Your worry thoughts might be about the situation (a crowded classroom and what it would be like to lose control there) or your physical sensations (“Uh- oh, this dizziness means another panic is coming!”).

As worry thoughts flash through your mind, priming your system for potential danger, your body starts to prepare for disaster. This part happens very quickly— so quickly that you might not even notice it because the worry thoughts flit through your mind so quickly. But your body feels it, and this step lights the match for the panic cycle to begin.

And now the fight- or- flight response kicks in. You know this one: Your body is prepared for the worst kind of danger. Your heart speeds up and pumps blood to your large muscles, getting you ready to run or fight. Your legs may feel weak and wobbly as blood gathers there to help you run and flee the threat. You start to breathe more quickly to get enough oxygen for your next move— but this may make you feel pain or tightness in your chest. This common side effect of increased respiration is actually no threat at all, but for obvious reasons it plays a key role in exacerbating panic for those who experience it.

What else happens when you’re in fight- or- flight mode? The blood supply to your brain decreases, produc-ing feelings of dizziness, confusion, and unreality. The blood flow to skin, fingers, and toes is reduced, to protect you by reducing bleeding if you are injured. This makes your extremities cold while, simultaneously, you may feel flushed.

You’ll find yourself sweating (a protective mechanism that makes it harder for a predator to keep a grip on you). As your energy is diverted for supposedly more important functions, your body slows its digestion, which may result in cramping, nausea, and other intestinal symptoms. These harmless but often dramatic symptoms lead you to the next step in the panic sequence: you start to have catastrophic thoughts about what’s happen-ing in your body. You might worry that you’ll suffocate, have a heart attack, or pass out in the middle of the street.

What happens next? These overwhelming thoughts cause your body to release adrenaline, cranking up your distressing fight- or- flight symptoms even more dramatically. You feel even worse physically, and your catastrophic thinking escalates as well. Yes, this is the part where you start to think you’re going to die, right on the spot. Though the panic cycle can keep building through this process, it doesn’t have to: you can learn new ways to interpret and work through stress symptoms. See section 10, on breath control training, and sec-tion 11, on interoceptive exposure, in the book and in this Practice and Examples file.

Sample Coping Thoughts

Here are some coping thoughts that work well for specific physical symptoms of panic or anxiety.

Light- headedness: I’m only light-headed because of hyperventilation or the release of stress hormones that cause my blood vessels to constrict temporarily. As soon as I get through the fight- or- flight reaction it will pass, and it can’t hurt me while it lasts.

Feeling faint: It might feel like I’m going to faint, but that’s unlikely. Fainting is caused by low blood pressure, and anxiety tends to make blood pressure higher.

Racing heart: Even if my heart were to beat this fast for weeks on end, it wouldn’t cause any damage. A short period of rapid heartbeat caused by stress can’t hurt me at all.

Dizziness: This is just a temporary effect of hyperventilation. When I relax, it will go away.

Weak legs: This means my body is giving me strength to run or fight by sending lots of blood to my leg muscles. It feels strange, but it means I’m stronger than usual, not weaker. I feel shaky, but that’s because I’m not using all this extra strength to run or fight.

Feeling depersonalized or not yourself: This one seems scary, but it’s just another symptom of the hyperventilation and constricted blood vessels that are part of my normal stress response. It can’t hurt me, and it will go away when I relax.

Shortness of breath: When I get anxious, my diaphragm gets tight, which means it’s harder for me to take a deep breath. But I’m in no danger of running out of air. My body knows exactly how to keep getting air, no matter how anxious I get. I’ll feel better as soon as I relax my diaphragm with deep, calm, slow breaths.

Fear of losing control: I’ve felt like this before, but I’ve never gone crazy or acted out, and it’s not going to happen this time.

Feeling hot or cold: My body’s temperature regulation feels messed up because of my stress response. This is a nor-mal part of the fight- or- flight reaction, and it can’t hurt me at all.

10 Breath Control Training

Further Help with Breath Control Training

If you have difficulty counting during breath control exercises, you can make a recording to help you learn the proper pacing. To make a twelve- breaths- per- minute tape:

1. Say the word “in” for two seconds.

2. Say the word “out” for two seconds.

3. Pause one second.

4. Continue repeating “in” for two seconds and “out” for two seconds, followed by a one- second pause.

The recording should last about five minutes. To make an eight- breaths- per- minute recording, do every-thing the same except say “in” and “out” for three seconds each.

11 Interoceptive Exposure

Interoceptive Assessment Chart

Exercise Duration Anxiety 0-100

Similarity to Panic Sensations

0-100%

Shaking head from side to side 30 seconds

Repeatedly lowering your head between your legs and then lifting it (keep repeating)

30 seconds

Running in place 60 seconds

Running in place wearing a heavy jacket 60 seconds

Holding your breath 30 seconds (or as long as you can)

Tensing major muscles—particularly in your abdomen

60 seconds (or as long as you can)

Spinning while you sit in a swivel chair 60 seconds

Very rapid breathing Up to 60 seconds

Breathing through a narrow straw 120 seconds

Staring at yourself in a mirror 90 seconds

Introceptive Hierarchy/Anxiety Intensity Chart

Exercise Trial 1 Trial 2 Trial 3 Trial 4 Trial 5 Trial 6 Trial 7 Trial 8

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Desensitization in Natural Settings

When you’ve worked through your hierarchy to the point where each exercise triggers an anxiety- intensity rating of no more than 25, you can begin desensitization in real- life settings. With medical clearance, you can begin exposure to activities and experiences you’ve avoided because you feared a panic.

More Tips for Desensitization

If you have difficulty desensitizing and lowering your anxiety during exposure, it may be because you have catastrophic thoughts that haven’t been addressed. As you begin an exposure exercise, monitor your thoughts about the bodily sensations that come up. What are you telling yourself? What terrible thing do you fear might happen? What is the worst possible outcome?

12 Fears and Phobias

Contingency Planning

It’s wise to plan for outside problems that may come up in your exposure work. Imagine that you’re attempting exposure in a public place where many different elements are outside your control. You might have to adjust your approach if things don’t go according to plan. For example, what do you do if you’re attempting exposure practice in a restaurant, but you have to wait a long time to give your order and service seems extremely slow? You might plan that you’ll continue your exposure work at a short- order coffee shop, or order just a single course.

More Tips for Exposure Practice

You may want to try using acceptance during exposure. As hard as you may try to control your thoughts, your breathing, and your reaction to your physical symptoms, you simply can’t control everything, especially once that adrenaline rush gets going. When that hormonal burst occurs, you’re going to feel it, and you might wish to use an acceptance- based coping thought to help you accept the physical feelings rather than fighting them. Try statements such as these:

• I can float past this anxiety.

• I can notice these sensations without fighting them.

• I accept what is happening in my body. It will pass.

14 Steps to Problem Solving

Problem Checklist

After each situation listed, check the box that best describes how much of a problem it is for you. If you have trouble determining whether a situation is a significant problem for you, imagine yourself in that situation. Include lots of sights and sounds and actions to make it seem real. In that situation, do you feel angry, depressed, anxious, or confused? These are red flag emotions. When you experience anger, depression, anxi-ety, or confusion, you are probably in a situation that is a problem for you— something about the way you are responding to the situation isn’t working for you.

• No problem: either minimal interference with daily life or not applicable to you

• Minor problem: some interference with daily life

• Moderate problem: significant interference with daily life

• Major problem: regular, severe interference with daily life and a major negative impact on your well- being

Health No Problem

Minor Problem

Moderate Problem

Major Problem

Difficulty sleeping

Weight problems

Feeling physically tired and run- down

Stomach trouble

Chronic physical problems

Difficulty getting up in the morning

Poor diet and nutrition

Finances No Problem

Minor Problem

Moderate Problem

Major Problem

Difficulty making ends meet

Increasing amounts of debt

Unexpected expenses

Too little money for hobbies and recreation

No steady source of income

Too many financial dependents

Living Situation No Problem

Minor Problem

Moderate Problem

Major Problem

Bad neighborhood

Insufficient money for basic necessities

Too far from work or school

Too small

Unpleasant conditions

Things in need of repair

Poor relationship with landlord

Work No Problem

Minor Problem

Moderate Problem

Major Problem

Monotonous and boring work

Poor relations with boss or supervisor

Being rushed and under stress

Wanting a different job or career

Needing more education or experience

Fear of losing job

Not getting along with coworkers

Unemployment

Unpleasant conditions

Needing more freedom at work

Psychological No Problem

Minor Problem

Moderate Problem

Major Problem

Having a particular bad habit

Religious problems

Problems with authority

Competing goals or demands

Obsession with distant or unobtainable goals

Lack of motivation

Feeling very depressed at times

Feeling nervous at certain times

Feeling blocked from attaining goals

Feeling angry a lot

Worrying

Recreation No Problem

Minor Problem

Moderate Problem

Major Problem

Not having enough fun

Ineptitude at sports or games

Too little leisure time

Wanting more chance to enjoy art or self- expression

Little chance to enjoy nature

Wanting to travel

Needing a vacation

Inability to think of anything fun to do

Social Relationships No Problem

Minor Problem

Moderate Problem

Major Problem

Timidity or shyness

Not having many friends

Too little romantic contact

Feeling lonely

Not getting along well with certain people

A failed or failing love affair

Feeling left out

Lack of love and affection

Vulnerability to criticism

Family No Problem

Minor Problem

Moderate Problem

Major Problem

Feeling rejected by family

Discord at home with mate

Not getting along with one or more of the children

Feeling trapped in painful family situation

Insecurity— fear of losing mate

Inability to be open and honest with family members

Desire for sexual contact with someone other than partner

OtherIf particular situations not listed above significantly interfere with your life, write them here and rate them:

Evaluating Consequences Chart

When working through step 4 of the problem-solving process, you may find it helpful to use the following form to evaluate the consequences of the three strategies representing your best ideas. On the form, list the negative and positive consequences you can think of for each strategy. How would putting that strategy into action affect what you feel, need, or want? How would it affect the people in your life? How would it change their reaction to you? How would it affect your life right now, next month, or next year? Take some time to get both positive and negative consequences for each possible strategy.

When you have the major consequences listed, go over each one and ask yourself how likely it is to come about. If the consequence is very unlikely, cross it out— you’re telling your self horror stories or being falsely optimistic. Then score the remaining consequences as follows:

• If the consequence is predominantly personal, give it 2 points.

• If the consequence predominantly affects others, give it 1 point.

• If the consequence is predominantly long-range, give it 2 points.

• If the consequence is predominantly short-range, give it 1 point.

Note that consequences can be both personal and long-range at the same time (total score of 4), have a long-range effect on others (total score of 3), and so on.

Add up the scores for each strategy to see whether the positive consequences outweigh the negative. Then select the strategy whose positive consequences most greatly outweigh the negative consequences.

Evaluating Consequences

Strategy:

Positive Consequences Score Negative Consequences Score

Total Total

Strategy:

Positive Consequences Score Negative Consequences Score

Total Total

Strategy:

Positive Consequences Score Negative Consequences Score

Total Total

Strategy:

Positive Consequences Score Negative Consequences Score

Total Total

15 Be Mindful

More Everyday Mindfulness

As a further mindfulness practice, you can do pretty much any daily activity as an exercise in mindfulness:

• Walking

• Doing the dishes or any other household chore

• Eating an apple (or any other food)

• Drinking a beverage, such as tea

• Looking at something beautiful

• Bathing or showering

• Driving

• Listening to a friend

• Washing your hands

• Listening to music

16 Practice Acceptance

Keeping a Log of Workable Thoughts

As you work toward staying in an accepting mode more of the time, the trick is to not be concerned with the content of your thoughts. That is, don’t spend a lot of time trying to decide whether your thoughts are right or wrong, accurate or distorted, supported or contradicted by your experience and observations. Instead, focus on whether your thoughts are workable— do they move you toward where you want to be in your life or away from that direction? Keep a log of thoughts that are workable and those that are not.

18 Label and Let Go

Putting Watching, Labeling, and Letting Go Together

When defusing from your thoughts, it’s helpful to establish a sequence of responses to use with each cognition. The simplest way to do this is to choose one labeling exercise and combine it with either a letting-go visualiza-tion or the physical dropping experience.

Mark, who ruminates about scary future possibilities, chose to respond to these thoughts with a labeling exercise (I’m having a thought that…) and a letting-go exercise using the image of leaves on a stream. Each time one of his what-if thoughts showed up, Mark carefully described it using the labeling exercise, and then imag-ined the thought as a leaf, dropping in a stream and drifting away. After a time, Mark realized that the leaves on a stream image was hard to call up when he was in social situations. So he replaced it with a covert spread-ing of his fingers that symbolized letting go. Mark found that when he used the labeling and letting-go process for each negative thought, these old cognitions felt less believable and upsetting.

19 Use Distancing Techniques

More Distancing Techniques

Negative label repetition: Edward Titchener (1916) discovered that if you keep repeating a word fifty or more times, it begins to lose its meaning. It becomes just a sound rather than a concept. Take, for example, the word “milk.” You can imagine the color and smell and the cool liquid flowing down your throat. But consider what happens if you say the word “milk” out loud over and over again. What if you keep saying it as fast as you can while still pronouncing it clearly? Go ahead and do it right now for at least sixty seconds.

What happens to the meaning of the word? Do those same sense impressions still hold, or does the word feel strangely vacuous or conceptually empty? Is it more a sound than a word?

The fact that repetition changes and diminishes meaning is very useful for defusion. You can repeat nega-tive self- judgments or feared future outcomes until they lose their sting and ability to disturb you. Try it right now. Choose a negative label you often apply to yourself. Repeat it fifty times and notice what happens to this thought.

Physicalizing thoughts: A classic way to make thoughts less important and disturbing (dating back to Fritz Perl’s Gestalt Therapy) is to physicalize them. Sticky thoughts that keep bothering you can be assigned a color. You can also ask yourself what shape the thought has, what texture, and how big it is. It’s easier to distance from a thought when you imagine that it is green, as big as a basketball, the texture of cheesecake, and the shape of a starfish.

Card carrying: Some thoughts keep showing up, like unwelcome relatives for another visit. One way to distance from these thoughts is to carry an index card, and write them down whenever they come into your mind. Then, when those thoughts reoccur, you can remind yourself, I have it on the card.

Wearing signs: Sometimes it’s helpful to openly acknowledge the most painful thoughts your mind can create. Write the thought down on a sticky note or name tag and wear it for a few hours on your shirt. You might do this in the privacy of your home, or with a few friends. You’ll find that it doesn’t take long for the power and sting of the thought to diminish once you’ve begun to wear it. Many people find this especially helpful for judgmental thoughts, such as, I’m stupid or I’m a bad parent or I’m lonely and empty. Acknowledging a thought seems to have the magical effect of making it seem further away and less important.

Example

Walker is a twenty-four- year- old draftsman who struggled for years with anxious and self- denigrating thoughts. He had judgment thoughts about his competence at work and his ability to socialize and make interesting conversation. Walker also had fear thoughts about being rejected, judged by others, and losing his job, his apartment, and his independence. Walker wanted to return to school to pursue a degree in mechanical engi-neering. However, thoughts about failure and potential financial disaster with school loans were keeping him from moving forward.

Walker chose a simple defusion process to observe and let go of difficult thoughts. As each cognition showed up, he said to himself, Now my mind’s having a (judgment or fear) thought. Then he turned his hand in a dropping motion and sometimes imagined the thought falling through the floor and out of sight.

As Walker became more skilled at labeling and letting go of thoughts, he noticed a shift in how he related to his mind. Instead of feeling that each judgment or fear thought was terribly important, he began to regard them as “mere thoughts” and part of his endless mental chatter.

Despite these positive changes, Walker still experienced some of his fear thoughts as sticky and powerful. Chief among these was the thought that he would fail if he returned to school. Walker first tried Titchener’s repetition and the card carrying strategy to distance himself from these thoughts. Finally, he committed him-self to use the distancing drill to give himself some breathing room with these cognitions. Each time one of the fear thoughts about school came to mind, Walker asked how old it was. The answer was that these thoughts had begun about the time he first entered college— more than eleven years ago. The function of the thoughts was always the same: to protect himself from failure (and anxiety about failure) by avoiding difficult challenges.

When Walker turned to the workability question, he recognized that these fear thoughts had never been helpful. During his first years in college they drove him to avoid the hard engineering courses, and ultimately to drop out. He also remembered that the thoughts, instead of protecting him from anxiety, had made his college years a nervous nightmare. And now every time he thought about going back to school his heart raced and he felt a surge of anxiety. Instead of protecting him from anxiety and failure, his thoughts were filling him with fear and guaranteeing failure.

Finally, Walker asked himself the most important question. Would he be willing to have these fear thoughts and still fill out the school applications? He decided to fill out the applications anyway, regardless of how much failure and disaster his mind predicted.

21 Work on Anxiety- Making Behavior Patterns

Monitoring Avoidance and Checking

Date Old Behavior New Behavior How Did My Anxiety Level Change?

22 Identify Trigger Thoughts

Keeping an Emotional Record

To help you recognize your emotions, it’s often helpful to say how you’re feeling out loud. This method of label-ing might sound silly at first, but the act of saying how you feel out loud will highlight your emotions for you and help you pay extra attention to what you’re experiencing. Describing your emotions aloud, especially your overwhelming emotions, can also help deflate your distressing feelings. So the more you can talk about an emotion, the less urge you might have to do something about it. You do not have to scream how you feel; it might be enough to say your emotion quietly to yourself. Just find what works best for you. Say to yourself “Right now I feel…” And remember to pay attention to your pleasant and joyful emotions too. The more you’re able to recognize them and say them out loud, the more fully you’ll be able to enjoy those feelings.

Then, in order to further reinforce the experience, record your emotions in your Emotional Record. Recording your feelings throughout the week will help you recognize, label, and describe your emotions. Photocopy the blank form and keep a copy with you in order to record your emotions shortly after you recog-nize them. Do this exercise for at least two weeks. We’ve provided an example to help you see how to fill out the form.

Example: Emotional Record

When Did It Happen and Where Were

You?

How Did You Feel? (“Right now, I feel …”)

Did You Say How You Felt Out Loud?

What Did You Do After You Recognized

How You Felt?

Thursday night, at home I feel angry. Yes I went to the kitchen and had a glass of wine.

Thursday night, at home I feel sad. No I tried to go to sleep, but I kept thinking about how sad I was.

Friday morning, on the bus

I feel agitated. Yes I tried to calm down by distracting myself and reading the newspaper.

Friday morning, at work I feel pissed off. Yes I went outside and had a cigarette.

Friday afternoon, at work I feel jealous. No I continued to ignore my friend who’s dating a woman I like.

Friday night, at home I feel lonely. Yes I decided to go to the movies by myself and have a good time.

Saturday afternoon, at the park

I feel happy. Yes I stayed at the park with my friends.

Saturday night, at Ben’s house

I feel cheerful. Yes I didn’t say much to anyone because I didn’t want to mess up my feelings.

Emotional Record

When Did It Happen and Where Were

You?

How Did You Feel? (“Right now, I feel …”)

Did You Say How You Felt Out Loud?

What Did You Do After You Recognized

How You Felt?

23 Make Room for Positive Feelings

Following is a list of over one hundred pleasurable activities you can try. Check off items you think you’d enjoy, then commit to trying them

Talk to a friend on the telephone.

Go out and visit a friend.

Invite a friend to come to your home.

Text message your friends.

Organize a party.

Exercise.

Lift weights.

Do yoga, tai chi, or Pilates, or take classes to learn.

Stretch your muscles.

Go for a long walk in a park or someplace else that’s peaceful.

Go outside and watch the clouds.

Go jogging.

Ride your bike.

Go for a swim.

Go hiking.

Do something exciting, like surfing, rock climbing, skiing, skydiving, motorcycle riding, or kayaking, or go learn how to do one of these things.

Go to your local park and join a game being played or watch a game.

Go play something you can do by yourself if no one else is around, like basketball, bowling, handball, miniature golf, billiards, or hitting a tennis ball against the wall.

Get a massage; this can also help soothe your emotions.

Get out of your house, even if you just sit outside.

Go for a drive in your car or go for a ride on public transportation.

Plan a trip to a place you’ve never been before.

Sleep or take a nap.

Eat chocolate (it’s good for you!) or eat something else you really like.

Eat your favorite ice cream.

Cook your favorite dish or meal.

Cook a recipe that you’ve never tried before.

Take a cooking class.

Go out for something to eat.

Go outside and play with your pet.

Borrow a friend’s dog and take it to the park.

Give your pet a bath.

Go outside and watch the birds and other animals.

Watch a funny movie (start collecting funny movies to watch when you’re feeling overwhelmed with anxiety).

Go to the movie theater and watch whatever’s playing.

Watch television.

Listen to the radio.

Go to a sporting event, like a baseball or football game.

Play a game with a friend.

Play solitaire.

Play video games.

Go online to chat.

Visit your favorite websites.

Visit crazy websites and start keeping a list of them.

Create your own website.

Start a blog.

Join an Internet dating service.

Sell something you don’t want on the Internet.

Buy something on the Internet.

Do a puzzle with a lot of pieces.

Go shopping.

Go get a haircut.

Go to a spa.

Go to a library.

Go to a bookstore and read.

Go to your favorite café for coffee or tea.

Visit a museum or local art gallery.

Go to the mall or the park and watch other people; try to imagine what they’re thinking.

Pray or meditate.

Go to your church, synagogue, temple, mosque, or other place of worship.

Join a group at your place of worship.

Write a letter to God.

Call a family member you haven’t spoken to in a long time.

Learn a new language.

Sing or learn how to sing.

Play a musical instrument or learn how to play one.

Write a song.

Listen to some upbeat, happy music (start collecting happy songs for times when you’re feeling overwhelmed).

Turn on some loud music and dance.

Memorize lines from your favorite movie, play, or song.

Make a movie or video with your camcorder.

Take photographs.

Join a public-speaking group and write a speech.

Participate in a local theater group.

Sing in a local choir.

Join a club.

Plant a garden.

Work outside.

Knit, crochet, or sew—or learn how to.

Make a scrapbook with pictures.

Paint your nails.

Change your hair color.

Take a bubble bath or shower.

Work on your car, truck, motorcycle, or bicycle.

Sign up for a class that excites you at a local college or online.

Read your favorite book, magazine, paper, or poem.

Read a trashy celebrity magazine.

Write a letter to a friend or family member.

Write a poem, story, movie, or play about your life or someone else’s life.

Write in your journal or diary about what happened to you today.

Write a loving letter to yourself when you’re feeling good and keep it with you to read when you’re feeling upset.

Make a list of ten things you’re good at or that you like about yourself when you’re feeling good and keep it with you to read when you’re feeling upset.

Draw a picture.

Paint a picture with a brush or your fingers.

Masturbate.

Have sex with someone you care about.

Make a list of the people you admire and want to be like—it can be anyone real or fictional throughout history. Describe what you admire about these people.

Write a story about the craziest, funniest, or sexiest thing that has ever happened to you.

Make a list of ten things you would like to do before you die.

Make a list of ten celebrities you would like to be friends with and describe why.

Make a list of ten celebrities you would like to have sex with and describe why.

Write a letter to someone who has made your life better and tell them why. (You don’t have to send the letter if you don’t want to.)

Create your own list of pleasurable activities.

Other ideas:

24 Use Distraction and Self- Soothing

Meditation Practice for Loving-kindness toward Yourself and Others

The following is a brief meditation practice to cultivate loving-kindness for yourself and for others. Practice it whenever and for as long as you like. Try it as a lead-in to any of your formal mindfulness practices.

InstructionsTake a comfortable position. Bring your focus mindfully to your breath or body for a few breaths. Open and soften as much as feels safe to you as you allow yourself to connect with your natural inner feelings of kindness and compas-sion for others.

Now shift your attention to yourself. It could be a sense of your whole self or some part that needs care and atten-tion, such as a physical injury or the site of an illness or a feeling of emotional pain.

Imagine speaking gently and quietly to yourself, as a mother speaks to her frightened or injured child. Use a phrase like “May I be safe and protected” or “May I be happy” or “May I be healthy and well” or “May I live with ease” or make up one of your own. Let the phrase you pick be something anyone would want (safety, ease, joy, and so on). Pick one that works for you. It can be a single phrase. Then put all your heart into it each time you speak to yourself. Let kindness and compassion come through you.

Practice by repeating your phrase to yourself silently as if singing a lullaby to a baby. Practice for as long as you like. It may help to practice for just a few minutes at a time at first and later build up to a longer practice.

When you like, you can shift your attention and focus to a friend or someone you know who is troubled. You can also focus on groups of people, such as “all my friends” or “all my brothers and sisters.”

When you wish, you can experiment with difficult people in your life. Try sending them kindness and your wish that they might be happy, and watch your inner response. In doing loving-kindness for a difficult person, you are not allowing them to abuse or hurt you but are making an attempt to see that they, too, are human beings who seek happiness. This can change your relationship to the situation and release you from resent-ment you may be holding.

Please note that in doing loving-kindness meditation, you are likely to experience many different feelings! Some may even be disturbing, such as sadness, grief, or anger. If this happens, you have not made a mistake. It is common for deeply held feelings to be released as one practices loving-kindness. This release is actually a kind of healing in itself. Just pay attention to all of your feelings, honoring each one, and continue your practice.

26 Insomnia and Solutions

More Tips for a Good Night’s Sleep

If you’re having trouble sleeping, try the following.

Try a hot shower or bath before bedtime.

Develop a sleep ritual before bedtime. This is an activity you do nightly before turning in.

Purchase a quality mattress. Try varying the firmness of your mattress. Invest in a new one or insert a board underneath one that sags or is too soft. If a mattress is too hard, place an egg- crate foam pad between the mattress surface and the mattress cover.

Have separate beds if your partner snores, kicks, tosses, or turns. Discuss this with your partner and decide on a mutually acceptable distance.

Have physically and emotionally satisfying sex. This often aids sleep.

See a psychotherapist if necessary. Anxiety and depressive disorders commonly produce insomnia. Talking to a competent psychotherapist can help. Getting more emotional support and expressing your feelings to someone you trust often helps too.

28 Exercise

Target Aerobic Heart Rate

The table below indicates aerobic pulse ranges for various ages:

Age Heart Rate

20– 29 145– 164

30– 39 138– 156

40– 49 130– 148

50– 59 122– 140

60– 69 116– 132

Daily Record of Exercise

Date: Time: Type of Exercise: Duration: Pulse Rate: Satisfaction Level:

Common Excuses for Not Exercising

You probably have a variety of excuses for why you avoid exercise. Here are some common ones, along with ideas on how to address them:

“I’m too busy.” It’s true that when you feel stressed and anxious, it seems like you don’t have an extra minute in the day. However, if you stick with an exercise program for just a few weeks, you’ll find that it’s mainly a matter of priorities. And, better yet, the stress relief and anxiety reduction will make you calmer and more productive all day, not just when you’re working out.

“I don’t have the energy.” It’s one of the great miracles of exercise: moving your body even when you feel tired will give you more energy. It takes time to build the habit, but once you do, you’ll find that energy devoted to exercise will pay you back many times over. If you find you’re especially tired late in the day, exercise in the morning or at lunchtime.

“It’s just too complicated.” As described earlier in this section, starting an exercise program is as simple as putting on a comfortable pair of shoes and walking out the door.

“Joining a gym is too expensive, plus, who has the extra time to go to and from the gym?” It’s pretty simple to solve this one— there are many exercises you can do at home. You can ride a stationary bike, use an elliptical trainer or treadmill, jump rope, lift dumbbells, work with a medicine ball or stability ball, or do workout videos. In even a small amount of space, you can get a vigorous workout without spending much money and without spending any time going to and from the gym. At home, you have the freedom to watch TV or listen to any music you want (as loud as you want).

“Ugh, it’s so boring.” We’d venture a guess here that you haven’t tried every form of exercise in the world. Get out there and try something new— there’s something that works for everyone. If having an exercise partner would help, turn exercise into a social event. If you have kids, play. Watch what kids do and try that: mock battles with toy swords, running like mad after a Frisbee, skateboarding, or swinging on the monkey bars.

“I’m too old.” This one is just not true— plenty of people take up exercise late in life and make it a habit. Unless your doctor says not to because of a medical problem, age is not a barrier. If you think you would be putting yourself in danger by taking up an exercise program, by all means discuss this with your doctor.

“What if exercise causes a panic attack?” If you have panic attacks, it’s natural to feel concerned. Walking and other milder forms of aerobic exercise are unlikely to cause symptoms that might lead to panic. You can test out more vigorous exercise in very short bursts to get comfortable with the sensations that you might associate with panic— call it exercise exposure therapy. The end result of regular exercise is likely to be a reduction in your susceptibility to panic attacks, not an increase.