The Cognitive Behavioral Workbook For Anxiety PDF
The Cognitive Behavioral Workbook For Anxiety PDF
The Cognitive Behavioral Workbook For Anxiety PDF
of anxiety. Uniquely emphasizes the links between anxiety and common co-occurring conditions,
such as procrastination and indecision. The book shows how to combat anxiety cognitions, build
emotional tolerance, use imagery for relaxation, engage in problem-solving behaviors, and apply
tested techniques for solving more than one emotional problem simultaneously. It features self-
contracts at the end of each chapter to reinforce change.”
—Janet Wolfe, PhD, former executive director of the Albert Ellis Institute and staff
psychologist for thirty-five years, as well as author or coauthor of multiple books,
including What to Do When He Has a Headache
“This book is brilliant! Scientifically sound, user-friendly, compassionate, and deeply understand-
ing of the anxiety disorders—I will insist that many of my patients read it. In fact, regular use of
Knaus’s workbook may actually shorten the length of time required for some anxiety sufferers to
remain in therapy.”
—Barry Lubetkin, PhD, ABPP, director and founder of the Institute for Behavior
Therapy, New York City
“Knaus has an amazing capacity to simplify and clarify complex scientific ideas and to incorporate
them into an accessible, pragmatic text. This workbook can greatly benefit lay people afflicted
with excessive anxiety and commonly associated disturbances. He has added a section on medita-
tive practices, which greatly enhances the appeal and utility of this workbook. I recommend it
heartily.”
—Joseph Gerstein, MD, FACP, founding president of the SMART Recovery
Self-Help Network
“As we strive to navigate the waves of change, push ourselves to constantly do better, and struggle
to accomplish a sense of balance, we can fall prey to the ravages of fear, anxiety, and depression.
Knaus impresses once again by providing a highly practical, research-based methodology to tackle
these psychological demons. Readers will come away with useful tools and strategies that will allow
them to take charge of their lives, restore their well-being, and advance their health and productiv-
ity. Practitioners will also find this workbook a valuable and indispensable resource.”
—Sam Klarreich, PhD, C Psych, president of The Berkeley Center for Effectiveness
and The Center for Rational Emotive Therapy, and coauthor of Fearless Job Hunting
“One of the foundational tenets of the cognitive behavioral therapies is that personal change does
not take place in the therapist’s office. Rather, a patient can only make desired change by
practicing—yes, practicing—the insights and strategies the therapist provides in the context of his
or her daily life. Bill Knaus’s The Cognitive Behavioral Workbook for Anxiety is a rare gem in this
regard; it is both a reference for the therapist to guide the patient through the anxiety-defeating
change process and also a suitable resource for the layperson to independently obliterate anxiety
on his or her own. I will treasure it for my own personal use, keep copies on hand for my anxious
patients as an adjunct for their therapy, and make participants aware of it at my self-help
workshops.
—Russ Greiger, PhD, clinical psychologist in private practice in Charlottesville,
VA, and coauthor of Fearless Job Hunting
“Working through each page of The Cognitive Behavioral Workbook for Anxiety will empower any
reader who is truly ready to get down to the heart of the matter! In this excellent and comprehen-
sive collection of our current understandings and research-driven techniques, Knaus reveals a full
and user-friendly plan for the great defeat of anxiety-feeding beliefs and habits!”
—Pam Garcy, PhD, psychologist in Dallas, TX, and author of The REBT Super
Activity Guide
“Knaus’s step-by-step approach to conquer anxiety is written in a manner that gives the reader a
handle on the source of his or her anxiety and spells out a plethora of sensible, evidence-based
solutions. I heartily recommend The Cognitive Behavioral Workbook for Anxiety to anyone strug-
gling with worry, anxiety, procrastination, and depression. If getting a better handle on emotions,
giving up perfectionism, and defeating social anxiety are your goals, Knaus’s book will seem as
though he wrote it with you in mind.”
—Joel Block, PhD, assistant clinical professor, Hofstra, North-Shore/LIJ School
of Medicine
“A fantastic tool for all those who struggle with anxiety and want to learn how to reduce it once
and for all. Knaus has compiled a very practical, clear, and effective workbook, complemented by
catchy, easy-to-remember tips and a very comprehensive coverage of anti-anxiety strategies and
techniques following in the footsteps of Dr. Albert Ellis’s theory of rational emotive behavior
therapy. I will recommend this workbook to all my anxiety patients.”
—Roberta Galluccio Richardson, PhD, clinical psychologist, Sloane Medical
Practice, London
“In this recent revision, Knaus has provided the reader with an up-to-date and comprehensive
description of anxiety and the role it can play in our now all-too-complicated and demanding lives.
More importantly, he gives the reader those essential and valuable tools he or she needs to better
cope with and reduce modern day stress and anxiety. I strongly recommend this book to the lay
reader and professional alike. This book is truly a gem!”
—Allen Elkin, PhD, in private practice in New York, NY, and author of Stress
Management for Dummies
“Knaus has given us an extensive new edition of his highly successful The Cognitive Behavioral
Workbook for Anxiety. From direct observation, we know that the completion of this project has
been a labor of love. Knaus has a strong scientist-clinician’s grasp of the topics he covers in this
revised edition, and it shows! Throughout the book, he shares his clinical insights and thorough
understanding of the anxiety research. This book effectively summarizes many approaches to
coping with anxiety and offers help to those who needlessly suffer its effects. It is a goldmine of
proven ways and innovative methods to cope with the many faces of anxiety. The self-helper who
chooses to reduce or end needless anxieties and fears, regardless of the form that they take, will
find an organized approach for developing the skills needed to manage anxiety or make it go
away.”
—Leon Pomeroy, PhD, author of The New Science of Axiological Psychology and
Wendy Pomeroy, MD, US Department of Justice, retired
“Knaus’s The Cognitive Behavioral Workbook for Anxiety is a well-constructed, thoughtful explora-
tion of both the causes of and approaches to overcoming or minimizing anxiety and its effects. His
book clearly illustrates the principles and particular steps involved in overcoming anxiety. In addi-
tion, each chapter provides clearly delineated, practical steps to address the principle causes of
anxiety as the subject of each chapter. I have found the approach to addressing ‘double trouble’
particularly useful with clients and friends alike. Oftentimes, simply pointing out how ‘awfulizing’
about having anxiety brings almost immediate relief and allows the person to focus on the circum-
stances and causes of their anxiety. It is clear to me that fully deploying the exercises found in his
workbook will bring benefit to almost anyone struggling with the ill-effects of anxiety.”
—James W. Thompson, PhD, MBA, business psychologist
“Knaus’s excellent book on overcoming anxiety just got even more versatile with this new improved
edition. A virtual one-stop supermarket of information, techniques, case illustrations, top tips, and
exercises for overcoming debilitating anxiety and worry, this fully revised and updated resource
serves multiple purposes. From the unhappy traveler of life looking to feel and do better, to the
therapist in search of an innovative and creative cognitive behavioral approach, this book serves
them all—and incredibly well. Knaus has truly outdone himself on this one!”
—Elliot D. Cohen, PhD, author of What would Aristotle Do? Self-Control through
the Power of Reason
“Anxiety is so common that almost everyone experiences it from time to time. It can interfere with
fully living the only life you have to live. Knaus, a renowned cognitive behavioral therapist and
author, has summarized the cutting-edge knowledge and provided practical steps for you to follow
to deal with anxiety. By following this precious wisdom, you can gain relief from the suffering
caused by anxiety.”
—Sanjay Singh, MD, DNB, PhD, REBT and REE representative in India, professor,
Department of Dermatology, Institute of Medical Sciences, Banaras Hindu
University, Varanasi, India.
“If you want to reduce and control your anxieties, worries, fears, etc., Socrates’s advice still holds:
‘Know yourself!’ But how do you do it? Even small steps can help, and this workbook by veteran
psychotherapist Knaus will guide you along the way with a variety of practical tools you can imme-
diately apply for observing and managing your thinking-feeling-acting. Alfred Korzybski, an early
pioneer in what is now called cognitive behavioral therapy, said fears and defensiveness are no
defense. You can learn how to manage yours.”
—Bruce I. Kodish, author of Korzybski: A Biography and Drive Yourself Sane: Using
the Uncommon Sense of General Semantics, coauthored with Susan Presby Kodish
“Freud distinguished between fearing what is harmful and threatening to our survival (realistic
anxiety) and all other fears (neurotic anxiety). Knaus offers systematic ways to reduce self-
handicapping unrealistic anxieties with a series of exercises and written progress reports. Building
on decades of work in cognitive behavioral therapy, he presents highly practical and creative ideas
for educating oneself against anxiety and toward a calmer, more comfortable, and productive life.
His is a valuable, no-nonsense approach to self-help.”
—Richard L. Wessler, PhD, emeritus professor of psychology and codeveloper
of cognitive appraisal therapy
“Knaus has done it again with an important update to his best-selling book The Cognitive Behavioral
Workbook for Anxiety. Not only is this a self-help manual, but it could also be used as a college
textbook in a counseling psychology course. It is astonishingly well written, and the coverage is
detailed and thorough. As a self-help manual it offers a clear, step-by-step solution to the dilemma
of depression and anxiety. It gets the reader moving and changing, because it demands that the
reader be involved enough to take active steps. This is not for the passively disengaged, but for
those who are willing to participate in their own recovery process (which is essential to the overall
healing). As a textbook it is a foundational source for a true understanding of cognitive behavioral
therapy, which has been proven to be today’s most effective therapeutic technique. And in this
case you will be reading words from the master, as Knaus himself has contributed greatly to the
creation of this important therapeutic breakthrough.”
—Richard Sprinthall, PhD, emeritus professor at American International College
“This revision of Knaus’s Cognitive Behavioral Work Book for Anxiety is no less than a milestone in
the CBT self-help movement. It is both a compassionate and scholarly reach-out to all those suf-
fering from anxieties that thwart their well-being and development. I am sure, given my personal
acquaintance with the founding fathers of CBT, such as Albert Ellis, that they also would applaud
the publication of this helpful volume.”
—René F.W. Diekstra, PhD, emeritus professor of psychology at the University
College in Roosevelt Middelburg, the Netherlands, and professor of youth and
development at the University of Applied Sciences at The Hague, the Netherlands
The
Cogni t i ve
Behavi o r a l
Work bo o k
for
An xi e t y
S ECOND ED I TI ON
A S T E P - B Y- S T E P P R O G R A M
WILLIAM J. KNAUS, E d D
16 15 14
10 9 8 7 6 5 4 3 2 1 First printing
Contents
Acknowledgments v
Foreword vii
Introduction 1
PART I
Basic Techniques to Defeat Anxiety and Fear
PART II
Cognitive, Emotive, and Behavioral Ways to Defeat Anxiety
PART III
How to Address Special Anxieties and Fears
PART IV
Your Personal Anxieties and Fears
References259
Index 277
iv
Acknowledgments
I’d like to acknowledge the following people for their marvelous contributions and helpful tips to
the readers of this book:
Dr. Bob Alberti, Dr. Irwin Altrows, Dr. Judith Beck, Dr. Joel Block, Dr. Elliot Cohen, Dr.
Daniel David, Dr. Pam Garcy, Ed Garcia, Dr. William Golden, Michael Gregory, Dr. Russ Grieger,
Dr. Steven Hayes, Dale Jarvis, Dr. Howie Kassinove, Dr. Sam Klarreich, Dr. Cliff Lazarus, Dr.
John Minor, Dr. George Morelli, Dr. Ron Murphy, Dr. John Norcross, Dr. Rick Paar, Dr. Vince
Parr, Will Ross, Dr. Jeff Rudolph, Justin Rudolph, Dr. Jack Shannon, Dr. Susan Krauss Whitbourne,
and especially my wife, Dr. Nancy Knaus who reviewed this book as it was in process and who
contributed a tip on preventing anxiety.
Foreword
My grandparents, who emigrated directly from Sweden, used to tell me, “Worry gives a small thing
a big shadow.” Many habits of the mind are transferred to us through this kind of transgenerational
learning. Some learnings help us to cope with life, while others—including fears, anxieties, and
phobias—tend to be destructive.
Alfred Adler explained that anxiety has a purpose: it is a safeguarding mechanism that causes
us to frighten ourselves out of doing things. We could simply decide not to do these things, but
then we might have to face our complexes and admit to having them. With anxiety as a mecha-
nism, we claim we are too afraid to try (Carlson, Watts, and Maniacci 2006). These patterns fre-
quently arise without our direct awareness or conscious intent.
Anxiety affects one-third of the population at one time or another. A web search turns up
nearly 60 million entries for anxiety alone. The various listings describe the many strategies pur-
ported to provide relief. These range from drugs to biblical passages to diets to folk cures.
This best-selling book stands out in that it offers strategies that have been researched and
proven effective. They do not promise a quick fix but rather teach us how to take responsibility for
our own lives. Too many people blame others for their personal challenges. As Bill Knaus states,
“Blame, like the air, is everywhere.” This book provides three basic prescriptions to help conquer
the problem of anxiety:
1. Educate your reason to oppose parasitic thinking and reacting. (Change your thoughts.)
3. Behaviorally engage the fear and desensitize yourself to it. (Take action.)
The fact that these interventions integrate thinking, feeling, and acting modalities allows
readers to utilize their unique strengths and preferences.
The quickest way to clear anxiety out of your body is to take a few deep belly breaths. Chest
breathing seems to be wired into anxiety production, while belly breathing is connected to anxiety
The Cognitive Behavioral Workbook for Anxiety
reduction. If you are anxious, you can wait until you are not anxious, and your breathing will slow
down. But if you are in a hurry to clear out the anxiety, you can consciously slow down your
breathing and watch the anxiety go away.
By concentrating on our breathing, we create a sense of serenity. We can learn to accept the
fact of fear, learn to feel fear fully, and learn to thrive by acting in a manner that prevents fear from
interfering with life choices. As David Richo (2008, 21–22) states, “We all feel afraid sometimes.
This is an appropriate feeling and can be a signal of real danger and threat. At the same time, we
sometimes feel afraid without reason. Our guesses and fantasies about what might happen keep us
afraid of events and experiences that may never befall us. It is useless to attempt to eliminate fear
altogether, whether it be ritualistic or imagined.”
This revised book adds to the original impressive collection of techniques that can be used to
provide the courage necessary to face anxieties and fears. Dr. Knaus also offers thirty-two “quick
tips” contributed by today’s leading anxiety experts. All of the strategies have their roots in the
work of the great psychologists Alfred Adler, Aaron Beck, Albert Ellis, and Arnold Lazarus and
have withstood the test of time. They can change transgenerational learning patterns by helping
readers develop courage and self-control.
The profession of psychology has advanced in the short time since the original edition of this
book appeared. The completely revised book remains a most valuable resource for therapists and
their clients who wish to learn cutting-edge methods of anxiety treatment. This new edition is
more than a self-help book for anxiety. Readers will learn to not only eliminate anxieties and fears
but also prevent their return. Additionally, the book provides a program for developing the self-
efficacy, serenity, confidence, and control needed for living a satisfying life overall.
As I read through this exceptional resource book, I am reminded of the power of the mind. Bill
Knaus has clearly presented many effective strategies that will allow readers to solve their own
problems. This type of solution will lead to the greater psychological hardiness and self-efficacy of
the population. It is now possible to go beyond our many self-imposed prisons. Eleanor Roosevelt
said it best: “You must do the things you think you cannot do.”
—Jon Carlson, PsyD, EdD, ABPP
Distinguished Professor
Division of Psychology and Counseling
Governors State University
viii
Introduction
Do you sometimes feel overwhelmed by your anxieties and fears? Does one misery follow another?
Do you hold to lofty ideals and feel anxious about falling short? Do you actively avoid whatever you
fear even when you know the fear is silly?
Few go through life without having their share of irrational anxieties and fears; some have
more than their fair share. Some of these anxieties are like reoccurring storms. But unlike weather
patterns that you can’t change, you can do many things to change the intensity, duration, and
course of your anxieties and fears.
You are not crazy for having anxieties. You may have a sensitive fear signaling system and
startle easily. You may feel anxious or fearful about having sensations such as an increased heart
rate, sweating, and tension headaches. The issue isn’t whether you have fears or anxieties; the issue
is, what can you do to liberate yourself from needless fears and anxieties? Cognitive behavioral
therapy (CBT) methods are effective for curbing both.
Here’s the idea. Your cognitions (thoughts, mental images, memories), emotions, and behaviors
blend together. Changes in one of these areas affect the others. Thus, if you no longer see a situa-
tion as threatening, your anxiety drops. You may approach what you formerly feared. That’s the
anxiety solution. The cognitive behavioral changes that you make are relatively durable (Gloster
et al. 2013).
Here is a question you should be asking yourself: Where’s the evidence that CBT is effective
against anxiety?
CBT RESEARCH
Over the past forty years, CBT has amassed strong evidence to show effectiveness for reducing and
ending disturbing conditions, such as anxiety and depression (Öst 2008).
The Cognitive Behavioral Workbook for Anxiety
Meta-analyses affirm CBT’s general effectiveness (Butler et al. 2006) and specifi-
cally for combatting anxiety (Olatunji, Cisler, and Deacon 2010).
A survey of 269 CBT meta-analyses shows that the system is effective for people
suffering from a broad range of problems, such as substance abuse, depression, and
anxiety. The results point to CBT as a consistently strong method for reducing
anxiety (Hofmann et al. 2012).
Specific studies demonstrate that you can use CBT for decreasing anxious rumi-
nations (Reinecke et al. 2013), for reducing panic (Rayburn and Otto 2003), for
overcoming social anxieties (Furukawa et al. 2013), and for toning down those parts
of your brain’s artificial anxiety and fear generating network (Kircher et al. 2013).
CBT is a brain training method. Healthy brain function and brain structural
changes are observed after CBT (Collerton 2013).
The CBT system is a strong alternative to the anxiolytic and hypnotic drugs used
to medically treat anxiety. This class of drugs is addictive and associated with
increased mortality (Weich et al. 2014).
CBT is viewed as the gold standard for treating anxiety (Otte 2011).
Throughout this book you’ll find references to articles and research studies. They are illustra-
tive, not exhaustive, which means you could have long lists of studies for most referenced topics.
They help answer the question, “Where’s the evidence?”
2
Introduction
psychological self-help approach lies in deepening your self-knowledge by taking action to solve
your problems.
3
The Cognitive Behavioral Workbook for Anxiety
practice—a transdiagnostic technique that may be especially useful when it comes to combatting
your anxieties and fears. For example, if you suffer from panic and agoraphobia, doing homework
assignments to face what you fear frequently reduces both conditions (Cammin-Nowak et al.
2013). Following through on psychological homework assignments correlates with self-improvement
(Lebeau et al. 2013).
If you set weekly goals and give yourself assignments for meeting these goals, and you make a
good-faith effort to follow through, the odds are that you’ll get better results and improve more
quickly than if you simply stay on the sidelines wringing your hands.
4
Introduction
I divided this workbook into four parts. Part I introduces the world of anxieties and fears. It
will show you how to separate real from imagined fears and how to use basic cognitive, emotive,
and behavioral ways to overcome these conditions. It will show you how to break a vicious cycle of
anxiety using objective self-observation skills, how to stop escalating your anxieties, how to make
progress using a self-management approach, and how to get past procrastination barriers that can
interfere with positive change.
Part II shows how to use nature scenes to achieve serenity, how to relax your body, how to
regulate emotions that are triggered by cognitions, how to use a classic ABCDE model to combat
anxiety, and how to use key behavioral methods for overcoming fear.
Part III explores how to break patterns of worry, manage anxiety over uncertainty, calm
unpleasant physical sensations, overcome panic, combat phobias, and mount a multimodal attack
against anxiety and fear.
Part IV looks at how to defuse anxiety-evoking expectations, defeat harmful inhibitions, over-
come anxieties you may have about yourself, earn freedom from painful social anxieties, and
overcome mixed anxiety and depression. The final chapter will help you learn how to preserve the
gains you’ve made.
How fast can you proceed with your anxiety solution program? Your pace will depend in part
on where you are on this healing path. You may have already started to address your anxieties. It
also will depend on your network of complications (we all have them); these networks sprout from
core issues, such as a vulnerability to anxiety that is reflected in negative thinking and worry. Your
pace will also depend on whether you tend to procrastinate. For example, you may wait for motiva-
tion to come out of the blue. If so, you’ll be waiting a long time.
Luckily, even the most complex and painfully recurring anxieties and fears have simple and
manageable features. Start with what you can manage. Build from there. But don’t put off
starting.
5
The Cognitive Behavioral Workbook for Anxiety
There is no one psychological antianxiety intervention that works for all people under all con-
ditions. As you go through this program, you’ll find many ways to address anxiety problems.
Choose and use the best approaches for you to develop self-mastery, which can be the biggest
payoff.
6
PA R T I
Take a test and discover your anxiety hot spots (and where to go to get solutions).
Learn to separate real anxieties and fears from the fictional or exaggerated kind.
Start yourself on a cognitive, emotive, and behavioral path to calm your anxieties.
Follow a six-phase approach for getting control over your anxieties and fears.
When fear causes you to escape a life-threatening danger, it is your friend. But some fears have this
sordid tale to tell.
I am fear. I make your mind spin out of control. I wind your body tight as a drum.
You try to hide from me. I will find you. Look over your shoulder. I am behind you. Look forward.
My shadow crosses your path. Look into a mirror and you see me sneering back at you.
Your exaggerated anxieties and fears drain your time and resources and offer nothing of positive
value in return, which is why this book refers to them as parasitic. As Mark Twain once said, “I am
an old man and have known a great many troubles, but most of them never happened.”
When you suffer from fear and anxiety, it can be hard to imagine a different way of being. But
eliminating fear and anxiety is something you can progressively do. It may help to start this journey
through the eyes of some people who turned their own anxieties and fears into fading memories.
Anxiety is a common worldwide debility that cuts across national, racial, and eco-
nomic boundaries. Studies of people with anxiety from Qatar, Turkey, Nepal, Chili,
sub-Saharan Africa, Morocco, China, and other nations contribute to this conclu-
sion. Indeed, every continent has anxiety hot spots. The Arkhangelsk region of
Russia, for example, is a high-stress location. Sixty-nine percent of the women living
there and 32.3 percent of the men report high levels of anxiety, depression, and
sleep problems (Averina et al. 2005).
If you are female, you are at a greater risk for anxiety than if you are male (McLean
et al. 2011).
Being young is no buffer against anxiety. Anxiety is common among preadolescent
children (Perou et al. 2013) and adolescents (Kessler et al. 2012). Anxiety increases
in the middle years of life (Scott et al. 2008). Rosy numbers on lower levels of
debilitating anxiety among the elderly may be a myth (Wolitzky-Taylor et al. 2010).
John’s Panic
John was a frequent panicked visitor to his local hospital emergency room. Whenever he
gasped for air and felt chest pains, he dialed 911. He believed that he was having a heart attack
and was about to die. After more than twenty visits to the ER, and on the recommendation of his
primary care physician, John joined a psychological treatment group. After three group sessions,
John came to see his breathing difficulties and chest pains as symptoms of panic. He felt relieved
to learn that most people with panic who learn to use exposure, relaxation, deep breathing, and
other cognitive and behavioral methods make meaningful and durable progress (Sánchez-Meca et
al. 2010). John aimed to join that club.
Elaine’s Silence
Elaine was the group’s silent member. She felt petrified at the thought of saying something
foolish. After eight weeks of saying very little, she confessed that if the group leader and members
really knew her, they’d kick her out of the group. The question, “Where is the evidence for that
conclusion?” started Elaine thinking differently. She calmed down when she learned that her fear
of rejection reflected her self-doubts and not the views of the other group members. Based on
10
Welcome to the World of Anxieties and Fears
group feedback, she figured out that what she’d thought others were thinking about her could not
possibly be true. The group did not necessarily have the same impressions of her that she had
about herself.
Larry’s Stress
Larry told the group that he became stressed easily. Like John, he had moments of panic where
he had trouble breathing, he felt dizzy, and his heart beat like crazy. He said that this panic
occurred when he was “stuck in one place with a lot of people in a small area.” Larry went on to
say that he had bad headaches. He was afraid that he might have a brain tumor.
Larry wanted to deal with his problems, but as soon as he would begin to address one anxiety
or fear, he would move on to another problem without resolving the first one. He was in a revolving-
door pattern of procrastination. Because his problems kept returning, he felt overwhelmed. He
said, “This is too much for me to handle.” His too much was part of an internal monologue in
which he exaggerated the fearsomeness of his tensions. At the same time, Larry minimized his
abilities to cope. Once he began to deal with one fear at a time, however, he found he was able to
whittle down the number of his anxieties and fears. He began to feel like an emotionally freer
human being.
Joy’s Apprehension
Joy felt anything but joyful. She told the group that she was a dimwit in a brightly lit world of
intelligent people. She argued that she made many mistakes. She dreaded the thought that people
would catch on to her and discover that she was a fake.
Joy was finishing her second year of graduate school. She reported that she compulsively
studied until she thought she’d have a reasonable chance of succeeding. She said, “It takes me
three times as long as anyone else to pass the courses.” She went silent when John asked, “How do
you know how much time others spend studying? Did you take a survey?”
Although Joy received praise from her professors for the quality of her work, she claimed that
she had fooled them all. The question “How can someone who sees herself as a dimwit fool others
whom she sees as bright lights?” stumped her. Then Elaine pointed out that the main reason Joy
felt like a dimwit was because she held a dimmer switch and turned down her own light. Joy said,
“I never thought that way before.” With a changing self-view, she was in a better position to cele-
brate her achievements. She no longer felt like a fraud.
Tom’s Complacency
Tom believed that he was productive only because his fears drove him to perform. Without
them, he’d be complacent. Tom feared complacency.
11
The Cognitive Behavioral Workbook for Anxiety
Tom hated being driven by his fears, but if he eased up, he believed that he would fail, and he
couldn’t stand failing. Tom’s all-or-nothing thinking about the driving force of fear meant that he
was controlled by either fear or complacency. He began to rethink this position when he was
asked, “What lies in between the extremes?”
John, Elaine, Larry, Joy, and Tom participated in a supportive group where they felt free to
explore their thinking, feelings, behaviors, and relationships with each other. This atmosphere
promoted conditions for positive change. The following section will help you explore how to take
a similarly supportive approach with yourself.
12
Welcome to the World of Anxieties and Fears
How might you break the connection between blame and anxiety? First, use blame strictly as
a means of establishing accountability. Hold others responsible for damages that they cause. Accept
responsibility for your own mistakes and accidents. Then concentrate on developing greater toler-
ance for your errors and working to strengthen your will to take corrective actions.
13
The Cognitive Behavioral Workbook for Anxiety
Prepare for the unexpected crisis by having rational mantras on your person.
A wallet-sized card with rational expressions targeting anxiety about anxiety
will do. If a crisis arises, pull out the card and repeat coping ideas, such as,
“Anxiety is unpleasant, but I’ll live through it. If life is not as I expect it to be,
I can accept it as it is.”
By routinely working to improve your emotive, cognitive, and behavioral skills, you’ll have
less to feel anxious about, because you’ll know that you have a tested way to face them.
14
Welcome to the World of Anxieties and Fears
Core Interventions
At a core level, you deal with deeper and more personal issues that connect to unproductive
patterns in your life. For example, you might stymie yourself because of core problems, such as self-
doubt, equivocating, and living in dread of making a mistake. If your anxieties are connected with
self-doubt, examine the personal situations where you doubt yourself and why it is you do. Which
situations are anxiety related?
If you feel both anxious and depressed, look for powerlessness thinking, where you think that
you are helpless to do anything differently. Just as negative feelings can influence what you think
about, your thinking processes can worsen feelings of distress. If you have multiple anxieties, are
they linked with beliefs that you can’t cope or won’t cope adequately enough? Do you worry too
much, ruminate, and procrastinate when it would be wise for you to start taking corrective actions?
Empirical Interventions
At an empirical level, you put on your scientist’s hat. Say that you believe you can never over-
come your anxiety. Will recognizing and labeling this defeatist view as an erroneous expectation
help put this problem into perspective? Often, labeling an anxious thought can give you a sense of
control over it. Now, what evidence-based interventions support what you want to accomplish?
Start thinking this way, and you are on an empirical path.
Practical Interventions
At a practical level, you use common sense techniques to produce the changes that you want
to make. For example, you acquire more information about the form of anxiety—and its antidotes—
that you most want to control. You keep a log of your anxious thoughts to help reveal patterns in
your anxiety thinking. You test practical solutions, such as imagining an anxious thought vapor-
izing like a puff of steam. You exercise to relieve tension.
15
The Cognitive Behavioral Workbook for Anxiety
16
Welcome to the World of Anxieties and Fears
“I’m uncomfortable about Not you Somewhat Often like 14, 6, 7, 10, 21
making changes.” like you you
“My anxious thoughts won’t Not you Somewhat Often like 11, 2, 4, 5, 9, 10, 13
stop.” like you you
“I need to calm down.” Not you Somewhat Often like 9, 8, 12, 15, 17
like you you
“I need to take better care of Not you Somewhat Often like 24, 3, 4, 15
myself.” like you you
“My anxieties and fears are Not you Somewhat Often like 18, 10, 11
complicated.” like you you
“My anxiety is about as bad Not you Somewhat Often like 1, 3, 5, 16, 23
as it gets.” like you you
After taking inventory, focus your attention on the anxiety or fear issues that are most prob-
lematic for you. The numbers on the right refer to chapters in this book where you will find practi-
cal interventions for your issues; the numbers in bold refer to chapters with the most information
on these topics.
You may want to make copies of this inventory for future use. You can use it again to measure
your progress. Completing the inventory once a month is a good idea. The results can serve as an
early warning system to prevent a recurrence of parasitic anxieties and fears.
17
The Cognitive Behavioral Workbook for Anxiety
What are three key ideas that you took away from this chapter?
1.
2.
3.
What top three actions can you take to combat a specific anxiety or fear?
1.
2.
3.
What did you gain from taking action? What would you do differently next time?
1.
2.
3.
Doing this exercise at the end of each chapter will help you concentrate on the CBT methods
that work best for you. By identifying personally relevant ideas, thinking out what to do, and
testing ideas through action, you are likely to get further faster in your campaign to conquer your
anxieties and fears.
18
CHAPTER 2
In Greek mythology, terror and dread are the handiwork of two gods of war who are twin brothers,
Phobos and Deimos. Phobos is in charge of real and present danger. He shocks the mind with
terror, panic, and flight. Deimos uses apprehension to fill minds with dread for what was to come.
The ancients got it right. Fear and anxiety share many common connections, but they operate in
different ways (Perkins et al. 2010).
Fear is on a proximity dimension. When in proximity to what you fear, you try to escape.
Anxiety is on a time dimension. You dread a future event. You take steps to avoid it. Knowing this
relationship can help you decide on which strategies to use for your anxieties and what to do to
quell your fears.
However, your reactions are also a matter of perception and perspective. If you face a known
danger that can strike from a great distance, the rules change.
Acquiring Fears
You can develop new fears through either direct or indirect experience:
You learn not to touch a live wire because you know it would shock you. You’ll learn
this lesson fast, either from direct experience or knowledge that shock is painful.
You witness a coworker getting mangled in some machinery. Later, you flinch when
in that area. This a fear caused by direct observation.
You observe how others respond to what they see as a danger (Olsson, Nearing,
and Phelps 2007). A person frantically yells, “Watch out for the snake!” You never
saw a live snake before, but the yell nevertheless instills fear. Later you see a snake
and flinch or panic.
You have a direct and frightening experience. You are driving in the rain and have
a skidding accident near a bridge. Later, when you are driving in the rain and
approaching a bridge, you fear that your vehicle will skid out of control. You grasp
the wheel tightly.
These are just a few examples of how you can develop new fears.
20
Anxieties and Fears as Friends and Foes
and the office where you would be working is in a skyscraper. It’s impractical to walk the stairs. So
what do you do? You overcome your fear of elevators by gradually exposing yourself to being in one.
You may start with entering and exiting an elevator with its doors open. You would do this several
times until you no longer are afraid of being in an open elevator. The next step may be riding to
the first floor. And so on. Eventually, with exposure, your fear of elevators goes away.
By correcting faulty thinking, you can decrease anxiety complications that come about as a
result of it:
False assumptions. You live in dread of something horrible happening. You’re not
sure what will happen, but you assume it will be catastrophic. You can learn to
21
The Cognitive Behavioral Workbook for Anxiety
reverse alarmist assumptions, however. Try asking yourself, What is the best possible
scenario?
Faulty expectations. You act as if you believe that the disasters that you expect to
happen will inevitably happen exactly as you expect. As an alternative, you can
create hypotheses that contradict the inevitability of your prediction.
Magnification. You dramatize every possible danger. As an alternative, magnify
every bit of information that suggests the opposite conclusion. Then ask yourself,
What lies in between these magnified extremes?
Possibility thinking. You make a magical jump from the possible to the probable. It’s
possible that your tension headache means that you have a brain tumor. To counter
this thinking, ask yourself if you get this type of headache when you feel stressed.
If so, what’s a more logical explanation for the headache you’re having?
Powerlessness thinking. You believe that you can’t change because you are helpless.
This thinking is not only pessimistic but also a formula for giving up before you
start. To break this destructive pattern, act as if your mind were free of such nega-
tive thoughts. If so, what would you do? Then, take the first step.
Emotional reasoning. You ignore facts and ruminate on how nervous you feel. You
act as if your anxious emotions verified your negative thinking and as if your nega-
tive thinking verified your anxious emotions. To get away from this circular reason-
ing trap, consider how a scientist would separate facts from fiction and then execute
solutions that are plausible or factual. This question aids this scientific process:
Where does the evidence lie?
Fear of the feeling. You dread feeling frustrated, uncomfortable, or afraid. You go
out of your way to avoid tension, but this has a boomerang effect: you feel frus-
trated, uncomfortable, or afraid anyway. Allow yourself to live with the tension
until you can see for yourself that these feelings can change for the better.
Loss of perspective. You focus on the worst-case scenario and ignore possible posi-
tive alternatives. To give yourself a new perspective, imagine an equally powerful
positive scenario or result.
False associations. You know that home invasions are dangerous. You hear a creak-
ing sound in your abode. You panic at the thought that someone has entered your
home and intends to harm you. To counter this thought, you can ask yourself, Does
a creaking sound invariably prove that a home invasion is underway? Do you then find
yourself in a better position to judge what is actually going on?
22
Anxieties and Fears as Friends and Foes
For every anxiety-provoking thought, there is an available alternative that can decrease your
feelings of anxiety.
The Amygdala
Your sensory system transmits threat information directly to your amygdala. This almond-
shaped area of your brain is a center for fear and for some forms of anxiety (Debiec and LeDoux
2009). Your amygdala has a simple mission: avoid harm. When it comes to danger, the amygdala
represents your reptile brain. Shadowing your senses, the amygdala alerts you to danger.
23
The Cognitive Behavioral Workbook for Anxiety
Your amygdala doesn’t wait for a complete picture to develop before it excites stress hormones.
You automatically freeze when in an enclosed place where you can’t retreat. (In prehistoric times,
freezing was the best survival tactic, because predators pay attention to movement.) You are super-
charged to flee when that response gives you your best chance.
The amygdala is capable of learning new fears. If you were ever assaulted, for example, you
might later feel tense when in an environment that reminds you of the assault.
The amygdala contributes to negative feelings by increasing your perceptual sensitivity for
negative stimuli (Barrett et al. 2007). If you have a sensitive amygdala, you’ll have lots of false
alarms. You are more likely to overreact to things when they are not where you expect them to be,
as well as to strange sounds, quick movements, or unexpected changes in emotions. In prehistoric
times, those who were most sensitive to changes in their environment and sounded the alarm may
have aided the survival of the group.
24
Anxieties and Fears as Friends and Foes
25
The Cognitive Behavioral Workbook for Anxiety
Context is important. If the bully is your employer’s mate or best friend, and you want to keep
your job, some of the above solutions may not work well. Other solutions would work regardless.
How to respond
Imagined or
invented
problem
How to respond
26
Anxieties and Fears as Friends and Foes
Mapping out these different emotions can be useful in helping you recognize whether real or
invented emotional stresses are operating and how you can respond to each.
27
The Cognitive Behavioral Workbook for Anxiety
What are three key ideas that you took away from this chapter?
1.
2.
3.
What top three actions can you take to combat a specific anxiety or fear?
1.
2.
3.
1.
2.
3.
What did you gain from taking action? What would you do differently next time?
1.
2.
3.
28
CHAPTER 3
The worst kinds of anxieties and fears are the ones that you create for yourself. Fortunately, you
have a powerful four-pronged solution:
1. Learn to recognize and defuse different forms of anxious thoughts and beliefs.
This chapter will continue the process of exploring these cognitive, emotive, and behavioral
ways to execute the anxiety solution. These issues will be expanded on throughout this book.
What-If-Thinking Review
You may worry: What if an undetected asteroid threatened life on earth? You fret about this pos-
sibility as if it were a certainty. It takes effort to break this habit of mind, but you can gain relief by
accepting that you could be wrong.
The Cognitive Behavioral Workbook for Anxiety
First, you’d wisely recognize that this form of what-if-thinking contains erroneous information.
If you believe that because the world could end in your lifetime, it will end, think again. By looking
at the probabilities (not possibilities), you can reduce the uncertainty, helplessness, and vulnerabil-
ity that accompanies worrying about remote possibilities. For example, what are the odds that the
world will come to an end in the next year? Accept only those probability estimates that fit with
known scientific facts.
30
Your Anxiety Solution
31
The Cognitive Behavioral Workbook for Anxiety
5. Implement the action plan that you have developed. If unsuccessful, instead of giving
up, renew your problem solving by starting to redefine the problem, and brainstorm
again. You probably will have new information and may be able to identify some new
alternatives. Don’t be afraid to ask other people you know and trust for their ideas.
Sometimes another person can see an alternative that you missed.”
The only thing that feels overwhelming is the amplification of your anxious feelings.
By quelling scary ideas about tension, you’ll have more time to manage the ordinary and the
extraordinary stresses of life.
Emotional tolerance starts with accepting reality. If you’re tense, you’re tense. That’s it! This
does not mean capitulation to anxiety, nor does it mean that it’s okay to be complacent about
ruminating over what pains you.
When you dwell on discomfort, you magnify feelings that you don’t want to experience and
you are likely to rehash the conditions you associate with these feelings. This rehashing (negative
repetitive thinking) accelerates your misery. It cuts across different forms of anxiety and other
unpleasant emotional states, such as depression (McEvoy et al. 2013). If you break a rumination
pattern in one area, you may automatically reduce it in another.
Although unpleasant anxious sensations sometimes do go away on their own, dwelling on a
threatening situation usually makes the feelings more intense. If you no longer fear the sensations
of discomfort associated with terrifying beliefs, you will be less likely to magnify them. If you don’t
magnify them, you’ll experience less stress.
With this new level of emotional tolerance, you can begin to approach situations that trigger
your anxieties and fears, which will bring about a deeper change in how you think and feel.
32
Your Anxiety Solution
2. You imagine yourself as a fly on the wall listening to people’s comments about your work.
For every negative comment that you imagine, you balance it with a corresponding posi-
tive comment.
3. You come up with five sound reasons why people have different aesthetic preferences and
may not see your work in the same way. For example, some think that Leonardo da Vinci’s
Mona Lisa looks washed out or that Mona Lisa was not beautiful enough to warrant da
Vinci’s efforts. Yet this work is one of the most renowned paintings of all time. Here’s the
message: you can’t please everyone. Indeed, you can’t achieve perfection, and some people
won’t be pleased with what you do even if your work was perfect. Instead of worrying about
the other guy, do the best you can.
4. You accept the validity of a pluralistic perspective (meaning that the same situation can be
seen in different ways) and accept that in the case of your sketches—which will vary in
quality—you have no good realistic reason to fear negative criticism from everyone, nor
should you expect universal acclaim.
In phase 2, you move from this mental rehearsal to doing a behavioral exercise:
1. Hang your favorite sketches in your residence where they will be in plain view.
2. Invite people over. If you hear a negative comment, work to accept the statement without
deflating yourself. (See phase 1.)
33
The Cognitive Behavioral Workbook for Anxiety
3. Remind yourself that everyone has different aesthetic preferences and may not see your
work in the same way.
4. Recognize that you have no realistic reason to fear negative criticism from everyone.
As a next step, you might enter your favorite sketch in a contest and see what happens.
Emotive What can I do to tolerate What actions (thoughts, What are my options
the physical feelings of behavior) can I take to when it comes to
anxiety that I do not like? cope when anxiety blends accepting the tension of
into fear? fear?
Behavioral What specific behaviors What behavioral actions What behavioral actions
can I test in advance to can I take to face a fear at can I take to avoid
prepare myself to cope the point of convergence, retreating and reinforcing
effectively? where anxiety merges into fear?
fear?
34
Your Anxiety Solution
Emotive
Behavioral
35
The Cognitive Behavioral Workbook for Anxiety
My change team keeps a positive focus and reminds me of my progress (despite the
slips).
When asked, they offer change tips and specific advice.
We buddy up in our respective goals and even have friendly competitions to succeed.
36
Your Anxiety Solution
What are three key ideas that you took away from this chapter?
1.
2.
3.
What top three actions can you take to combat a specific anxiety or fear?
1.
2.
3.
1.
2.
3.
What did you gain from taking action? What would you do differently next time?
1.
2.
3.
37
CHAPTER 4
Developing Your
Self-Observation Skills
Anxiety is a self-absorbing process where you come to know more and more about increasingly
minute issues but little about what you can do to liberate yourself from your anxiety. Paradoxically,
by learning more about what you can accomplish, you learn more about your true self. So how do
you get out of a myopic rut? You practice self-observation. With a self-observant approach, you take
extra steps to examine your anxieties and fears as though you were watching yourself from a dis-
tance. By tracking what happens when you go through an anxiety cycle, you can discover where
to intervene to change the process.
might name the evocative event, your beliefs about the event, your emotions, and your behavioral
responses.
The following chart shows how to organize journal information. The example comes from a
client named Bob who persistently worried. Bob started by mapping the connection between his
worry situations, threat cognitions, emotions, and behaviors.
Registered letter notice Something dreadful is Anxiety and panic, Avoid the notice. Swig
about to happen. I’m and more worry and down a glass of wine.
going to be sued. The panic as the dreaded
IRS wants to audit my possibilities keep
taxes. coming to mind
These three examples were sufficient to convince Bob that he tended to jump to conclusions.
He noted that he drank excessively to smother his tensions when he was worried. He definitely
needed to address that problem habit. His record-keeping exercise opened his eyes to what he
needed to change.
40
Developing Your
Self-Observation Skills
Mapping your processes can help you get a better picture of the patterns you want to break.
41
The Cognitive Behavioral Workbook for Anxiety
What are some alternative hypotheses? A registered letter could be a public notice that a
nearby neighbor has applied for a variance to build a garage. Perhaps you forgot to update your
pet’s license and are being notified. The letter could be from the executor of the estate of a long-
lost relative, informing you of an unexpected inheritance.
Getting the facts to see which hypothesis, if any, is correct, is the next step. You open the letter
and read it. Once you know what’s happening, you are in a position to decide a course of action.
The example of the registered letter shows how to identify whether you have a problem or not.
Suspending judgment until you get the facts is usually a good thing to do in areas of uncertainty
where you have no clue as to what’s ahead—even a long time ahead.
42
Developing Your
Self-Observation Skills
Suppose you don’t pass an important test. You might tell yourself that your life is ruined. You
might imagine that people who know of this failure will run from you as if you had a contagious
disease. But is any of this true?
Take the general statement, “My life is ruined.” If this is what you say to yourself, you can ques-
tion your thinking by asking, “And then what?” You might conclude, I’ll be miserable. And then
what? I’ll likely get back to my normal life. And then what? You might conclude, I’ll study and retake
the test. If retaking the test is the bottom line, then why not go directly to that solution and bypass
the catastrophic part of the process?
Step back and look at your thoughts. Nonjudgmentally observe (what’s happening), qualify (what’s
ruminative, what’s not), and quantify (how often, how intense, how durable) your ruminative
thoughts. This examination can help to moderate rumination and worry.
Rather than look at the glass as half empty, explore what’s in the other half. The world of
rumination is filled with could haves, what you could have done or said or thought. Balance it out
with memories of what you did do and are pleased with.
Reflect on the problems that you face. You can help yourself by asking productive questions and
seeking verifiable answers. What are the facts in this situation? What are your options? How will
you go about executing your best option? By asking and answering productive questions, you are
likely to be better positioned to pursue your most promising options.
Deal with the here and now. Oscillating between regretful remembrances and anticipated dreads
detracts from the present moment. Right now there is no guilt, for guilt reflects the past. Right
now there is no frightful event, for anxiety is about the future. If you can’t think of anything else
43
The Cognitive Behavioral Workbook for Anxiety
to think about, just look at the back of your hand. What you see is what is happening right now.
Not too scary, is it?
44
Developing Your
Self-Observation Skills
Having a higher purpose for survival, such as living for your family or fulfilling an important
mission in life, immensely improves your chances of survival in dangerous circumstances. Such a
purpose gives you the persistence to tolerate extreme emotional discomfort. If you are clinging to
a tree in a flood, your will to endure can make a big difference. However, minor stress events are
far more common.
When you are beset by anxieties and fears, you do not lose your intellect, ingenuity, or will, but
sometimes these precious faculties can be misused. You use your intellect to invent excuses. You
find ingenious ways to duck the discomfort of fear. You will yourself to avoid your fears. Fortunately,
you can teach yourself to question excuses, put up with stresses, and come up with novel ways to
address your fears.
45
The Cognitive Behavioral Workbook for Anxiety
What are three key ideas that you took away from this chapter?
1.
2.
3.
What top three actions can you take to combat a specific anxiety or fear?
1.
2.
3.
1.
2.
3.
What did you gain from taking action? What would you do differently next time?
1.
2.
3.
46
CHAPTER 5
Have you ever felt like you were in a rotating door of escalating anxieties? If so, you may have
double troubles, which is when you make two or more problems out of one.
Here’s how double troubles work. You have a problem, such as new and unexplained physical
symptoms. You have a legitimate cause for concern and should go see a doctor. That’s bad enough.
The first layer of extra troubles comes when you read too much into the symptoms and believe that
you must have a dreaded disease. Then you start worrying that you are worrying too much. You
blame yourself for worrying. Because you blame yourself, you become angry at yourself. You start
thinking, I’ve got to get rid of this feeling, I’ve got to get rid of this feeling, and you can amplify the very
feelings you want to avoid. As you might guess, this problem amplification can extend into
catastrophizing.
I can’t change.
The Cognitive Behavioral Workbook for Anxiety
Problem Magnification
In problem magnification, you concentrate too much on the feared situation or tension. For
example, if anxiety keeps you awake, you will have multiple double troubles if you worry about
feeling tired the following day, press yourself to fall asleep, and blame yourself for feeling tense and
not able to sleep. You are better off accepting that if you are anxious, you are anxious. And even
if you don’t fall asleep, you still can have a more restful night than if you were to wallow in dis-
tressed thinking about staying awake.
Overgeneralization
An overgeneralization is where you draw too broad a conclusion. Double troubles can reflect
overgeneralizations, when you tell yourself, I can’t change or My fears will go on forever. If you don’t
have a crystal ball, then how can you know these predictions will come true?
Urgency
Double troubles have an underlying message of urgency, such as I must stop feeling anxious now.
The intolerance for tension in the message is unmistakable. However, a clarifying question can
shift your attention. Ask yourself, What is the worst thing that could happen if I don’t stop feeling tense
immediately? Among the various possible answers, here is a rational one: you’ll likely feel anxious
in the next minute and survive what you are surviving now.
Helplessness
Helplessness is a belief that you can’t do anything about your situation. Sometimes you can’t.
For example, you might want to play center for a National Football League team, but you weigh
48
Defusing Double Troubles
only 135 pounds. On the other hand, believing that you can’t change is worth a second look. Such
beliefs can be altered by new information and experience. Can you think of times when you made
improvements in your life?
Circular Thinking
In most double-trouble patterns, you think in circles. Here’s an example: Because I cannot
change, my fears will go on forever. Because my fears will go on forever, I cannot change. Here’s another:
Anxiety feels awful, and because it feels awful, anxiety is awful. You can step out of a double-trouble
circle by looking at each double trouble as an assumption. In the first example above, “I can’t
change” is an assumption. So is the second circular assumption that “fears will go on forever.”
49
The Cognitive Behavioral Workbook for Anxiety
forever” is a theory, not a fact. To properly test this theory, you would look for exceptions to the
statement.
You would start by defining your key terms: What does “change” mean? What does “cannot”
mean? What does “forever” mean? Once the key words in a circular statement are mapped, you
are in a stronger position to end double-trouble circular thinking by seeing the fallacies in the
extremes.
Are all forms of circular reasoning irrational? No! Some circularity can resist falsification: “I
am changing in appearance as I grow older, and as I grow older, I change in appearance.” Also, not
all fears are fictional, such as a feeling of fear if someone threatens you with a knife.
1. Describe your primary double-trouble circle of tension (a statement you make to yourself):
Faulty thinking is at the heart of much amplified human misery. Being able to stop and iden-
tify faulty thinking will help you avoid it.
50
Defusing Double Troubles
How does all of this add up? Any progress you’ve made suggests that you’re on your way toward
dropping double troubles.
51
The Cognitive Behavioral Workbook for Anxiety
S M T W T F S
Accept troubling thoughts.
As you check off the items, you’ll get a double reward. You will experience fewer double trou-
bles, which is one benefit. You will also have a visual means of seeing your progress. That’s a plus!
52
Defusing Double Troubles
What are three key ideas that you took away from this chapter?
1.
2.
3.
What top three actions can you take to combat a specific anxiety or fear?
1.
2.
3.
1.
2.
3.
What did you gain from taking action? What would you do differently next time?
1.
2.
3.
53
CHAPTER 6
Self-Efficacy Training
to Defeat Anxiety
How do successful people meet challenges and overcome adversity? Their actions express what
they believe about their capabilities. This is called self-efficacy, or the belief that you have the
power to organize, regulate, and direct your actions to achieve mastery over challenges (Bandura
1997). The importance of self-efficacy in overcoming anxiety cannot be overstated.
Self-efficacy plays a central role in reducing anxiety (Benight and Bandura 2004).
You can enhance self-efficacy by gathering information, by mastering new experiences, through
imitating others’ effective behaviors, through persuasion, and by developing different psychological
and emotional responses. As you gather new information, you learn about the mechanisms for
anxiety and how to take corrective actions. Mastering new experiences means engaging your fear
in a step-by-step fashion and rewarding yourself for each significant accomplishment. Observation
means watching what other people do to overcome anxiety; we learn by imitation, and you may be
inclined to copy what you see. You also may benefit from the persuasion of a friend. In addition to
encouraging you, a friend can accompany you when you face your fear.
If you’ve had bad experiences in a specific situation, such as speaking up in public, you may
have developed a low self-efficacy in this area. But you can develop different psychological and
The Cognitive Behavioral Workbook for Anxiety
emotional responses, by learning new ways to interpret your experiences. For example, you can
come to view overcoming a public-speaking anxiety as a challenge rather than a threat.
What external situations are likely to activate your anxiety and fear? An external event might
be a public-speech assignment, an opportunity to ask a question, or the task of making small talk
at a social gathering.
What do you tell yourself about these situations that intensify your anxiety and fear? Like the
Amazon River, thinking flows uninterrupted. You will practically always be thinking about some-
thing. (Try to stop thinking for the next five minutes and see what happens.) Think about your
thinking. Do you hear yourself saying something like Failure would be horrible when you anticipate
speaking?
What adds to your anxiety? Anxieties and fears rarely occur independently of other conditions,
such as perfectionism, blame, procrastination, insecurity, and inhibition. For example, if you
believe that you must give a perfect talk, one in which every statement is unassailable, you are
living an impossible dream.
How can you develop a challenge outlook? Approaching public speaking as a challenge is
remarkably different from retreating from the same situation that you define as a threat. When you
56
Self-Efficacy Training to Defeat Anxiety
gain mastery over public speaking, your heart pumps more efficiently because your blood flows
with less resistance. On the other hand, a threat outlook about public speaking leads to vascular
constriction. The heart pumps harder to get blood through the system (Blascovich et al. 2011). In
giving speeches, students whose physiological measures were consistent with a challenge outlook
got higher course grades (Seery et al. 2010).
1. What external situations are likely to activate your particular anxieties and fears?
2. What do you tell yourself about these situations that evoke or intensify your anxiety and
fears?
4. What basic steps can you take to overcome your anxieties and also defuse coexisting
conditions?
Doing this analysis gives you a way to organize your thinking around a challenge approach.
As you switch from a threat outlook to a challenge outlook, you will stop avoiding threats and
begin approaching beneficial situations.
57
The Cognitive Behavioral Workbook for Anxiety
Setting Goals
To reach your mission, you need relevant, measurable, and achievable goals.
If your goal is relevant and consistent with an objectively positive personal and
social outcome, it’s probably worth stretching to achieve. Being able to speak in
public is a concrete goal that is relevant if you want to stop feeling afraid of speak-
ing up in groups.
If your goal is measurable, you can track your progress. Identifying and changing
fear thinking about public speaking is a measurable goal.
Knowing that a goal is achievable can motivate you to pursue it. Progressively mas-
tering ways to develop effective public-speaking skills is an achievable goal.
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Self-Efficacy Training to Defeat Anxiety
Planning Action
An action plan defines the steps that you will take and the order in which you will take them.
Action plans typically answer three questions: Where are you starting from? Where are you
heading? What do you need to do to get there?
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The Cognitive Behavioral Workbook for Anxiety
The answer to the first question is simple. You start with an anxiety or fear, such as a public-
speaking anxiety, that you want to minimize or eliminate.
Where are you heading? If public speaking is your issue, you are ultimately heading toward speak-
ing before groups with little more than normal apprehension or stage fright and maybe with a posi-
tive anticipation of being able to convey your ideas to the audience.
What do you need to do to get there? Your plan would naturally involve meeting objectives to
fulfill goals that support your mission. For example, you’d develop cognitive skills to reduce nega-
tive forecasting; build emotional tolerance for distress; and take behavioral steps to manage, mini-
mize, or overcome your public-speaking anxieties and fears. And you’d distinguish between what
is relevant and what is unfounded in your automatic negative thoughts. People who follow this
self-observant approach show significant improvement (Philippot, Vrielynck, and Muller 2010).
Recognizing Barriers
Distractions and detours are bound to get in the way of even the best-laid plans, so prepare for
possible obstacles. Good plans take potential barriers into account. Thus, it’s important to learn to
recognize and cope with anything that could get in your way. If you know the barriers you face,
you can do something about cutting through them. Here are some possibilities:
Ambivalence. You want the change but not to experience the doubts and the
tension associated with it, so you take no action. To overcome ambivalence, look for
a balance-tipping idea or reason to get going on addressing your anxieties. Perhaps
you want liberation from the anxiety.
Reactance. You view taking action to change as interfering with your freedom to
stay in a safe haven. To overcome this barrier, do a cost-benefit analysis. Perhaps
acting to overcome anxiety competes with avoiding anxiety. But where do you get
your biggest payoff, from retreating or advancing?
Emotional reasoning, where you believe you have to feel comfortable before under-
taking something uncomfortable. Overcoming anxiety is ordinarily not a comfort-
able process. If you can accept discomfort as part of the process, you are moving
in the right direction.
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Self-Efficacy Training to Defeat Anxiety
your sensations of fear until they subside. That’s a feature of change that many hate to hear.
However, by allowing yourself to live through the feelings that you’d ordinarily avoid, you’ll have
shown yourself that you can survive them. You’ll likely find that your anxious feelings fade over
time.
Does your plan contain sufficient details and directions to accomplish your mission?
If the answer to each of these questions is yes, then you know you are moving in the right
direction. If the answer to any is no, then go back and look at what may be getting in your way.
Once you execute your plan, you can continue to evaluate how you are doing. There are three
classic ways to measure mastery over anxiety or fear:
You are thinking more clearly.
After evaluating how you are doing, you may decide that you are on the right track, or that you
need to modify your approach or try a different way.
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The Cognitive Behavioral Workbook for Anxiety
What are three key ideas that you took away from this chapter?
1.
2.
3.
What top three actions can you take to combat a specific anxiety or fear?
1.
2.
3.
1.
2.
3.
What did you gain from taking action? What would you do differently next time?
1.
2.
3.
62
CHAPTER 7
Breaking the
Anxiety-P rocrastination Connection
Procrastination is a major transdiagnostic issue that can spread like an out-of-control weed. It’s a
habit of missing deadlines and avoiding problems. It’s a symptom of anxiety, depression, or other
emotional conditions. It’s a defense against facing a specific issue such as intolerance for uncer-
tainty or fear of failure. It can include all of the above and more.
PROCRASTINATION IS A PROCESS
Procrastination is an automatic problem habit of needlessly delaying a timely, relevant, priority
activity until another day or time. But to understand how procrastination works, you need to see
it as a living process with specific stages.
You can break the process of procrastination down into commonly observed phases. The left
column of this chart gives a sample procrastination process, with stages moving from the top
down. Sample interventions for each stage are given on the right.
2. You evaluate this timely activity as Negative evaluations about the threats or
uncomfortable, inconvenient, threatening, tediousness of a priority activity may be true.
tedious, boring, or frightening. But it doesn’t follow that you have to avoid
timely and relevant activities because you
don’t like or want to do them. Add a
countermanding comment, such as “Life has
some unpleasant duties and obligations and
responsibilities. I’ll act responsibly whether I
like the task or not, or whether I fear the task
or not.” (This is a position of maturity.)
3. You always substitute something safer, less Remind yourself that diversions are the sine
threatening, or less timely for what you are qua non of procrastination. If you don’t divert
putting off. You text a friend to ask about your attention, you’ll engage your priority,
the weather. You read a novel. You wash which is what is in your best interest to do.
your car. You feel relief from this retreat
and are likely to repeat what you did to
obtain relief.
4. You’ll practically always justify the delay Tune in to your justifications, such as This is
by advancing an argument to yourself too tough. I can’t take the anxiety. Label such
that you are too tired, too weak, too evaluation as exaggerations that amplify anxious
disinterested, or too anxious to follow emotions and refuse to accept it as factual.
through.
5. Procrastination practically always includes Listen for procrastination thinking, such as
procrastination thinking. You make I’m too tired or I’ll do this tomorrow. Revise
promises to yourself that you rarely keep: these procrastination decision thoughts to
I’ll do better next time. I’ll start later when I’ll start something now. Then I’ll judge the
I feel better. I need to let the issue season. difficulty. Then I’ll decide what I’ll do next.
6. You may feel relief (and off the hook) by Live through the discomfort as you engage
making a decision to delay. This relief the task. Your important reward comes
serves to reinforce future procrastination later, when you’ve progressed with your
decisions. self-improvement initiative; and still later,
when you gain mastery over this
anxiety-procrastination process.
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Breaking the Anxiety-Procrastination Connection
2.
3.
4.
5.
6.
Once you see what’s happening, you can take steps to change this process and benefit from timely
actions.
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The Cognitive Behavioral Workbook for Anxiety
SECONDARY PROCRASTINATION
When procrastination is a basic habit of delay, it is known as primary procrastination. Scattered acts
of primary procrastination may not amount to much, but patterns do! You may feel anxious and
overwhelmed over a pileup of tasks that you’ve put off. Although primary procrastination doesn’t
automatically lead to anxiety, delaying often leads to feeling pressured, feeling anxious, complain-
ing that you have too much to do, and running out of time. And of course, a pattern of delay can
prove disadvantageous in other ways when you lose opportunities by letting them slide by.
When procrastination is a symptom of anxiety, it is secondary procrastination. The anxiety is
primary. Procrastination is a symptom of anxiety.
When anxiety and procrastination coexist, you’re in a cycle of misery: you automatically avoid
what you fear, you put off actions to end your avoidance cycle, and you put off efforts to start over-
coming the fear. Unless you take corrective action, you’ll lose opportunities to self-improve. You’ll
repeat the cycle. Here, procrastination is an impediment to overcoming itself as well as to combat-
ting anxiety.
Anxiety and procrastination can overlap. For example, both anxiety and procrastination may
arise from self-doubts, fear of uncertainty, or a sense of lack of control.
When contending with an anxiety-procrastination connection, you have at least two chal-
lenges: combatting your initial procrastination on addressing anxiety (getting information about
anxiety and applying what you learn) and combatting procrastination that shadows anxiety (failing
to follow through on activities because you associate them with feeling anxious).
The next section uses anxiety over failure as an example of how to apply cognitive, emotive,
and behavioral methods to break this anxiety-procrastination connection.
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Breaking the Anxiety-Procrastination Connection
Anxiety you put off facing: Anxiety over failing an academic test.
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The Cognitive Behavioral Workbook for Anxiety
EXERCISE: YOUR
ANXIETY-P ROCRASTINATION CONNECTION
Use this format to break your own anxiety-procrastination connection. Fill in the blanks, first by
writing down the anxiety you put off facing. Then map out your cognitive, emotive, and behav-
ioral procrastination diversions, productive alternatives, your action plan for each, and the results
of executing these plans.
Emotive
Behavioral
It’s a paradox that a habit of avoiding work takes work to correct. Nevertheless, in the long
term, this is the best way to get out of a pattern where you keep cycling through anxiety and pro-
crastination over and over and get nowhere.
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Breaking the Anxiety-Procrastination Connection
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The Cognitive Behavioral Workbook for Anxiety
bring relief from anxiety. You’ll be operating with an “I want relief now” view. But where does that
get you?
Whenever your mind says to take time to solve a problem, and your gratification instincts pull
you in the other direction, you have a Y decision to make, in which one branch of the Y points
toward going for what is quickest and easiest and discounting future consequences. The other
branch of the Y points toward restraining impulses so that you can have later, greater gains. Thus,
the crux of the Y decision is whether to follow the path of least resistance or to follow the path of
productive actions in which you combat and overcome what you fear.
Taking Charge
Fear, anxiety, and procrastination share a common feature: an impulse to dodge discomfort.
Building emotional resilience and stamina is a by-product of allowing yourself to experience dis-
comfort as you choose to do a timely priority activity.
There are many ways to take charge. Psychologist John Dollard (1942, 22) writes, “When
afraid, stop and think. Examine the feared situation. See if there is any real danger in it. If not, try
just that act to which the fear is attached.”
Thinking things through and acting on your analysis can be challenging to do, and you may
put this off for many reasons. Here are a few examples:
You want to avoid stirring up unpleasant emotions. For example, you have a
public-speaking anxiety, so you feel anxious when you think about giving a talk.
Therefore, you avoid both thinking about speaking and thinking about overcoming
your anxiety.
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Breaking the Anxiety-Procrastination Connection
You want to leave your current job and get a better one, but you procrastinate
because you are afraid that you may look like a jerk during a job interview. To avoid
that anxiety, you stay in a job that you hate.
You want to avoid having to choose the lesser of two evils. You are in a relation-
ship with a person who acts destructively, but because you are anxious about living
alone, you put off thinking through and acting upon your enlightened options.
Keep a procrastination log. In the log, describe your anxiety situation, procrastination thinking,
and how you are feeling. Examine the contents of your procrastination log. Use this information
to forge a strategy of positive change.
When a fearsome situation looms, think about your thinking. What do you tell yourself about
the situation you’re avoiding? What do you tell yourself about the emotions that you feel? What
would Chiron say to do?
Execute an antihelplessness exercise for thinking things through. If you believe that you are
helpless and therefore can do nothing to stop feeling anxious, use the impossibility exercise. Instead
of saying, “I can’t act,” say, “It’s impossible for me to take any action whatsoever to either do or get
better.” All you need is one contrary example to falsify a procrastination-provoking assumption
like this one.
Do a benefits analysis. Ask yourself about the short-and long-term benefits of bolting and avoid-
ing vs. the short-and long-term benefits of pushing yourself to meet the challenge. Does this analy-
sis help?
Use the mnemonic EMOTION to remind yourself to follow through: Energize your priority
efforts by addressing the most important first. Move yourself toward achieving productive out-
comes. Operate by keeping your focus on long-term advantages. Tolerate but don’t give in to emo-
tional signals for needless delays. Integrate realistic thinking with self-regulated actions to achieve
stated objectives. Overcome diversionary unstated agenda urges with “do it now” actions. Nudge
yourself in the direction of Y decisions that lead to productive results.
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The Cognitive Behavioral Workbook for Anxiety
Avoidance of needless stress and behavioral consequences that can come from
excessive delay
More free time created for pleasurable pursuits
The self-confidence that comes from directing your actions to achieve positive
results
Tolerance for frustration as a buffer against needless distresses
By playing the procrastination endgame, you can quickly discover that unpleasant avoidance
feelings ebb as you work through them. That’s how to beat secondary procrastination due to
anxiety.
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Breaking the Anxiety-Procrastination Connection
What are three key ideas that you took away from this chapter?
1.
2.
3.
What top three actions can you take to combat a specific anxiety or fear?
1.
2.
3.
1.
2.
3.
What did you gain from taking action? What would you do differently next time?
1.
2.
3.
73
PA R T I I
Control your anxieties and fears with a special five-step metacognitive plan.
Discover how to stop thinking in circles about your anxieties and fears.
Learn how to use an ABCDE method to overcome your anxieties and fears.
Practically everybody has a favorite natural landscape that they associate with tranquility. You
may appreciate ocean waves along a beach or a sunset over a distant mountain. By viewing scenes
that you associate with thriving and surviving, you can create a tranquil effect within yourself.
This chapter offers a number of methods for incorporating scenic views into your daily life: from
looking at photographs of beautiful landscapes to getting exercise on a nature walk to enjoying
scenes of serenity while listening to relaxing music.
EVOKING TRANQUILITY
For many reasons, being out in nature or simply viewing a nature scene can have a calming effect.
What landscapes you choose to view can influence the type of mood or emotion that you want to
produce (Sabatinelli et al. 2011). Tranquil scenes connect you to an ancient calling for safe, secure,
pleasant habitats. Green areas with water seem to have strong positive impact (Barton and Pretty
2010). Clear water scenes are highly desired and include mountain waterfalls, oceans, rivers, lakes,
and ponds (McAndrew et al. 1998). Receding paths and rivers appeal to our curiosity, interest in
mystery, and sense of fascination (Dutton 2003). Open spaces may be more important than places
(Kravitz, Peng, and Baker 2011). A combination of openness and complexity (a scene that includes
a stream) can trigger an urge to explore. Out-of-place objects can be distracting (Walther et al.
2009). If you observe a beautiful natural landscape cluttered by beer cans, you may feel disgusted.
Dark shadows that seem foreboding can disrupt the tranquility of a scene. Nature gets the edge
over viewing human-built structures (Ulrich 1977). However, looking out at open scenes from
human-made structures is a preferred vantage point (Stamps 2008).
Being out in nature can have a calming effect on the nervous system. Five minutes of exercise
in a park, working in a garden, kayaking, or walking a nature trail can be relaxing if you have been
feeling stressed. But simply viewing a photograph or a painting of a nature scene can also have a
calming effect. Experiment. Discover what works best for you.
The Cognitive Behavioral Workbook for Anxiety
Aesthetic and pleasing nature scenes can reduce feelings of stress and promote well-being
(Velarde, Fry, and Tveit 2007). In comparing nature to urban scenes, exposure to nature paintings
in office settings decreases stress and anger (Kweon et al. 2008). Nature scenes are associated with
a faster recovery from stress than urban scenes are (Brown, Barton, and Gladwell 2013). For those
living in poverty areas, viewing open green environments is associated with reduced mental fatigue
(Kuo 2001). Interestingly, tranquility scenes are relatively constant across places and cultures.
Variations are based in region and enculturation (Falk and Balling 2010).
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Scenes for Serenity
window, make a point of looking outside each day. If you are surrounded by concrete or wooden
structures and there are no open green spaces, put pleasing-looking plants on your windowsill.
Exercise in itself is a good way to relieve tension. Getting exercise in a beautiful space outdoors
can be even more beneficial.
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The Cognitive Behavioral Workbook for Anxiety
Decorate your work area at home or at your workplace with tranquil landscape
scenes. Place them prominently, where you can frequently see them.
Practice visualizing landscape scenes that appeal to you. Visualizing such scenes
can have a calming effect.
By looking at natural scenery on a daily basis, you may have pleasing experiences that accu-
mulate over time. Although there is no longitudinal research on the long-term effects of experi-
encing open landscape scenes, it’s noteworthy that people pay premiums for living in scenic areas.
APPROACHING OPPORTUNITIES
If you feel anxious about an approaching opportunity and want to motivate yourself, try repeating
activating phrases while imagining or looking at views of calming nature scenery, then launch
yourself into the activity.
2. Decide on the first step that you will take, such as opening a book to study.
3. Select a visual image that evokes tranquility, such as your favorite ocean scene.
4. Come up with three activating phrases that give directions for achieving your goal. Examples
would be “I have passing the test in mind,” “I feel relaxed and ready to act,” or “I’m opening
the book to study.”
5. Think about or look at a picture of the visual image that you chose in step 3 until you feel
tranquil.
6. Keep the tranquil image in mind and repeat each of your activating phrases six times.
7. Launch action by opening the book.
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Scenes for Serenity
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The Cognitive Behavioral Workbook for Anxiety
With a relaxed body, you are likely to have thoughts that fit the mood. This experience has a
restorative value. When relaxed, you are less likely to worry, and that is a good thing.
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Scenes for Serenity
What are three key ideas that you took away from this chapter?
1.
2.
3.
What top three actions can you take to combat a specific anxiety or fear?
1.
2.
3.
1.
2.
3.
What did you gain from taking action? What would you do differently next time?
1.
2.
3.
83
CHAPTER 9
Although CBT is normally more effective for anxiety than relaxation methods (Cuijpers et al.
2014), relaxation training helps improve your mental flexibility (Lee and Orsillo 2014) and may
serve as an effective part of your CBT program. By themselves, relaxation methods have mild to
strong effects on reducing anxious tensions (Manzoni et al. 2008) and seem effective for reducing
generalized anxiety (Siev and Chambless 2007). When it comes to developing assertiveness skills
and controlling phobias, relaxation can be useful in conjunction with exposure methods. This
chapter introduces several relaxation methods, including diaphragmatic breathing, visualization,
meditation, and mindfulness practices.
Follow this breathing sequence for two to four minutes, or longer. Some recommend exhaling
over eight seconds. Experiment with each step to see what timing and techniques work best for
you.
• Can you imagine a yellow kite floating high in the bright blue sky?
• Can you picture the sight and sounds of a narrow woodland brook running under the
boughs of dark green trees?
• Can you see yourself reclining restfully in a rocking chair in a quiet room?
• Can you imagine an aquarium with brightly colored tropical fish swimming about?
• Can you imagine your body feeling like a limp rag doll?
• Can you imagine dusting of mist hovering over a green summer meadow?
• Can you imagine a falling leaf gently rocking downward in the air?
• Can you imagine the word RELAX written in soft green letters?
Can you feel the sensations of inner peace? If certain suggestions especially appeal to you, then
spend more time with the related imagery. Don’t concern yourself with how well you are doing as
you do this exercise. There is no right way to do it. Let the results be your guide.
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Relax Your Body, Relax Your Mind
Another way to use your imagination to relax is the quartz stone technique.
2. Hold your stone tight. Then very slowly loosen your grip on the stone until you are cradling it
in your hand. As you slowly ease your grip, imagine your tension flowing into the stone.
3. Imagine that as the stone draws the tension from your body, it stays trapped in the stone.
4. After about two minutes, toss the stone with its stored tension.
As an alternative to imagining tension flowing from your body to the stone, you can imagine
the stone gradually drawing the flow of your anxious thoughts to itself.
MEDITATION
Among the different relaxation techniques, meditation methods generally pull the strongest relax-
ation effects (Manzoni et al. 2008). Meditation is a traditional Buddhist way of feeling in harmony
with yourself and the world around you. Straightforward meditation methods are generally more
effective than the more complex, ritualistic variety (Eppley, Abrams, and Shear 1989).
Psychologically stressed persons who participated in an extensive eight-week mindfulness-
based stress reduction (MBSR) program based on Jon Kabat-Zinn’s (1990) work showed improved
memory, learning, emotional regulation, and perspective; also increased brain gray matter associ-
ated with brain regions responsible for these functions (Hölzel et al. 2011). Loving-kindness medi-
tation (LKM) also showed increases in gray matter in brain areas related to empathy and emotional
regulation (Leung et al. 2013). People use LKM to deepen a sense of unconditional kindness to all
people.
Mindfulness-based therapy may be as effective as cognitive behavioral therapy in reducing
anxiety, depression, and stress (Khoury et al. 2013). However, mindfulness meditation methods
might be inflated by other conditions (Eberth and Sedlmeier 2012). For example, a nonjudgmental
approach may contribute to a tranquility effect.
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The Cognitive Behavioral Workbook for Anxiety
2. Breathe in slowly and then slowly exhale. As you breathe in, think “ohhhhh” in a sort of
humming tone. As you exhale, extend this to “mmmmmmm.” Continue this sequence every
ten to fifteen seconds for this ten-minute period.
3. If your mind drifts, go back to repeating your word.
It can be challenging to concentrate on one word without your mind drifting to other thoughts.
Don’t try to force other thoughts out of your awareness. Your only task during this time is to repeat
the word.
If you choose to practice meditating, plan to do this exercise twice a day for the next eight
weeks. Pick a time that works for you, such as early morning and late afternoon. See what happens.
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Relax Your Body, Relax Your Mind
2012). You can engage a mindfulness view whenever unwanted thoughts are going through your
mind. Here are five acceptances that support this process:
1. Accept that anxious exaggerations are mental events that do not define your global self.
2. Accept that anxious thoughts and feelings are transitory events. Like storms, they pass.
3. Accept that anxious thoughts that exist in the present moment do not guarantee what will
happen next.
4. Accept that life includes unpleasant events and sufferings that come and go like passing
winds.
5. Gestalt therapy founder Fritz Perls (1973) taught that instead of defining certain thoughts
or feelings as alien parts of your being, you accept them rather than disown them. Your
thoughts and feelings come from you. They are part of you for the moment. But they are
not the whole of you.
1. Imagine yourself at a very young age. Picture that child in front of you, and when you
have that image clear, have the child say the difficult thought out loud. How would
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The Cognitive Behavioral Workbook for Anxiety
you show compassion for a child of that age who thought such a painful thing? How
can you show the same compassion for yourself now when you have such a thought?
2. Form the difficult thought clearly in your mind and then sing the thought to the tune
of ‘Happy Birthday.’ As the tune carries the thought along, consider whether this old
automatic thought is really your enemy or whether you can let it sit there like you might
an old song.
3. Think the thought again, but add these words at the beginning: ‘I’m having the
thought that…’ If you notice reactions that follow (additional thoughts or emotions),
label them too (for example, ‘I’m having the feeling of sadness’).
4. Distill the thought down to one or two words (for example, if the thought is I’m a
loser, distill it down to “loser”). Now say that thought as fast as you can out loud for
thirty seconds. As the word begins to lose meaning, and you begin to notice how it
sounds and what it feels like to say it, gently consider whether it works to let what is,
at its base, a sound and a movement run your life.
“Once you see how the mind pulls off the illusion of literal meaning, you can make up
your own methods to put your own mental machinery on a leash. These methods work best if
they are used as ways of helping you to see how the mind uses sleight-of-hand tricks to pull off
its central illusion. If they are used as a means to eliminate, ridicule, or subtract your difficult
thoughts, they tend not to work as well, and the reason is this: it means you are buying into
another thought (the one that says that this other thought needs to go away!). Defusion is not
about winning a mental war; it’s about stepping off that field of battle.”
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Relax Your Body, Relax Your Mind
What are three key ideas that you took away from this chapter?
1.
2.
3.
What top three actions can you take to combat a specific anxiety or fear?
1.
2.
3.
1.
2.
3.
What did you gain from taking action? What would you do differently next time?
1.
2.
3.
91
C H A P T E R 10
How to Break a
Cognition-A nxiety Connection
Las Vegas psychologist Jon Geis (personal communication) tells a story of identical twins on an
ocean beach. One jumps up and down with glee. He speeds toward the waves yelling “Whoopee!”
The other clings to his mother. She holds his hand and tries to bring him to the water. His eyes
well up with tears, and he digs his heels into the sand.
Why the difference in how the twins react to the water? One boy sees the water as fun whereas
the other sees it as a threat. How we perceive things affects how we feel. Geis is not alone in
making this point:
The Greek philosopher Aristotle said that people think themselves into superiority,
anger, and shame (Jebb 1909).
The ancient Stoics viewed emotional distress as triggered by false judgments
(Epictetus 2004).
Psychologist Magna Arnold (1960) proposed that emotion arises from appraisals of
events.
Psychologist Richard Lazarus (Lazarus and Lazarus 1994) viewed emotions as trig-
gered by appraisals where we take our well-being into account.
Emotions from our prehistoric past remain while other emotions reflect our modern social
learnings, beliefs, and appraisals. When it comes to coping with anxieties and fears, it’s important
to take both our primitive emotions and our modern appraisal-based emotions into account.
The Cognitive Behavioral Workbook for Anxiety
2. Reflect on what you are perceiving or believing. Do you exaggerate a danger like the fright-
ened twin at the ocean?
3. Separate fiction from fact. You may see an upcoming situation as something that can over-
whelm you. Write down what you have to be telling yourself to feel overwhelmed. Are you
telling yourself that This is too much for me? If so, what is too much? Is it the tension?
4. Reappraise your situation from a coping perspective. This is where you look at reasonable
and realistic alternative possibilities that counteract parasitic anxiety beliefs.
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How to Break a Cognition-Anxiety Connection
• Ken’s Story
A client named Ken suffered from anxiety after his long-term girlfriend broke up with
him. Ken felt devastated and depressed by the loss. He felt anxious that he would never
find anyone to love. He used a five-step metacognitive approach to defuse his anxiety over
the loss and to free himself from needless anguish.
1. Identify anxiety activator. The love of Ken’s life broke up with him and went off to
date someone else.
2. Reflect on cognitive Ken wrote out his thoughts, and this exercise helped him
triggers and amplifiers. hone in on a dire prediction. He worried that he would
never find anyone else. This thought of growing old was
more than worrisome. It became his reality.
3. Separate fiction from fact. Ken separated the parts of his thinking that were factual
from the parts that he exaggerated. Fact: He felt upset about
the betrayal and that he didn’t see it coming. Losses of this
sort are rarely welcome. However, thinking that he would
never find another person to love and would grow old alone
was dramatic and unprovable.
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The Cognitive Behavioral Workbook for Anxiety
4. Reappraise your situation Ken first reappraised his status by looking at alternative
from a coping perspective. possibilities: (1) Is it possible to accept the sadness of the
loss and to live beyond it? (2) Is it possible to think clearly
about a loss and betrayal and still feel emotionally
saddened? (3) Is it possible to eventually get beyond the
feeling of loss and to find someone to both trust and love?
5. Develop tolerance tactics. (1) Ken picked an hour each day for five days in a row when
he allowed himself to feel the loss. He was less likely to
dramatize the loss when he chose to disentangle himself
from the complications of the betrayal and accept his
sadness. (2) He came to accept that his sadness arose from
his memories. He had a lot of different memories that fed
into his sense of loss and sadness. (3) With each memory, he
implanted a realistic, moderate affective label to describe
the experience, such as “I enjoyed that experience and can
still enjoy the memory despite the loss.” This form of
affective labeling doesn’t soft-pedal the betrayal or diminish
the sadness of loss. Rather, it’s an acceptance that both
experiences are part of the same memory picture.
Betrayals and losses are complex. Anger, anxieties, self-doubts, and recriminations were part
of Ken’s bundle of emotions. But time does heal most wounds. Situational emotions that were once
live issues eventually fade. Torments become tolerable. Lessons learned carry over to the next situ-
ation. Life goes on.
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How to Break a Cognition-Anxiety Connection
2. Reflect on cognitive
triggers and amplifiers.
Emotions may be natural, they may trigger thoughts about themselves, or they may emerge
based on how you appraise a situation. Cognitive appraisals and emotions may also feed off each
other. Let’s turn to that matter next.
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One way to break out of the circle is to pause long enough to notice that your thinking is circular.
If you preface your conclusion with the phrase “I assume” (Because I feel fear, I assume there is a ghost
under my bed), you may be able to prevent the idea from becoming an uncontested conviction.
By confronting your anxieties in this way, you can gain a different perspective. You can also
use your imagination to give the voice of reason a bigger role. If you evoke the image of reason
when you experience anxiety and fear thinking, you may find it easier to change your anxiety
script.
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How to Break a Cognition-Anxiety Connection
when happy, and happy when successful (Lyubomirsky, King, and Diener 2005). That’s because
you are inclined to approach opportunities that you associate with thriving and happiness. You
would be likely to avoid these same situations if you viewed them as threats.
When you fear what you want, you may feel caught between a rock and a hard place. For
example, you want something, but you associate discomfort with approaching what you want, and
you want to avoid feeling uncomfortable. Now you have an approach-avoidance conflict. If you
can teach yourself to approach worthy challenges that you’d ordinarily avoid, you will increase
your chances for success and happiness. There are many ways to do this. One way is to weigh your
options.
Approach Avoidance
1. 1.
2. 2.
3. 3.
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The Cognitive Behavioral Workbook for Anxiety
4. 4.
5. 5.
6. 6.
7. 7.
8. 8.
9. 9.
10. 10.
In this exercise, the benefits of approach outweigh the benefits of avoidance. It’s fair to stack the
deck in this way, especially if you’ve stacked it against yourself in the past. Does this image give
you a different perspective on how to gain justice for yourself?
Whenever you prioritize avoidance over approaching a goal, keep the scale of justice image in
mind. However, you won’t get far beyond this intellectual perspective unless you take the necessary
steps toward success.
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What are three key ideas that you took away from this chapter?
1.
2.
3.
What top three actions can you take to combat a specific anxiety or fear?
1.
2.
3.
1.
2.
3.
What did you gain from taking action? What would you do differently next time?
1.
2.
3.
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C H A P T E R 11
When you feel anxious, you’ll have interconnecting negative thoughts. For example, you may
worry about feeling fatigued from losing sleep. That worry may link to anxiety about your fatigue.
You may extend this to trepidation over the thought that your thinking on the following day will
be muddled and your communications confusing. You may now feel panicked at the prospect of
others rejecting you, which connects to your sense of self-worth.
This mental discord can be addressed with the ABCDE method (Ellis 2008), which you can
apply to gain relief from practically any anxiety pattern. This chapter offers Fred’s anxiety predica-
ment as an example of how the ABCDE method can be used to resolve a complex anxiety problem.
• Fred’s Story
Fred was a forty-eight-year-old widower with two grown children. As a successful inventor,
he retired with ample financial resources. After his retirement, he spent several hours
weekly in volunteer work. He was strongly family oriented. Whenever he had the
opportunity, he would spend time with his children and his grandchildren. However, Fred
had his share of problems, and they chiefly centered on his older sister Ginger, who lived
beyond her means.
Ginger’s life revolved around one financial crisis after another. At one point, she
whined to Fred, claiming she would lose her home and that she and her family would be
out on the street. Fred wrote a check to pay off her second mortgage. Next, her daughter’s
college tuition was overdue. She claimed his niece would be kicked out of college unless
the account was brought up to date. Fred wrote the check. Then her son needed to get a
car so that he could deliver pizza. She told Fred that she feared that her son would go back
to using cocaine unless he got the job. Fred bought the car.
Fred tried to downplay the extent of his relatives’ problems by saying to himself that
everyone would eventually come to their senses. This hope was an illusion.
The Cognitive Behavioral Workbook for Anxiety
Fred’s relationship with his sister and her family was not entirely negative. When his
wife was alive, the two families had gone on vacations together. He had good memories of
his sister’s children growing up and the birthdays and holidays the family had shared
together. His children and his sister’s children continued to enjoy positive relationships.
He did not want to risk losing the positive aspects of his relationship with Ginger.
When Fred and Ginger were children, Ginger was the dominant sibling. Taking
advantage of being older, she micromanaged Fred. When Fred was in high school, if
Ginger did not like one of his girlfriends, he dropped her.
Ginger did not approve of Fred’s new fiancée. This time, Fred decided to take a stand.
He refused to leave the woman he loved. Fred hated confrontation of any sort. He entered
therapy when his confrontation anxieties felt unbearable.
SETTING GOALS
As you gain perspective on your anxieties, you may realize that you need to make some changes in
how you go about your life. Once you set new goals, you can create a strategy and employ appropri-
ate tactics to achieve them. Fred, for example, realized that he was far from taking charge of
himself. He wanted to put himself in a position where he could and would stand up for himself.
That was his goal. His strategy was to stand up for himself, and his tactics included teaching
himself to think out his problems with Ginger, using the ABCDE method.
Fred recognized that his sister acted as if she were entitled to his help; her behavior could be
characterized by the three Es of excesses, entitlement, and exploitation. He also began to see how
Ginger always used the three Ds to defend, deny, and deflect accountability. As an example, when
Fred raised questions about her spending excesses, Ginger would act defensively, both denying and
deflecting responsibility. Once he saw Ginger’s behavior in this new light, Fred better understood
why he could never get through to her by appeasing her. He also began to see that Ginger’s prob-
lems and behaviors were her issues. How he responded was his issue.
Fred’s most pressing concern was his own anxiety. He hated feeling tense over his tension. He
felt awful about seeing himself as a weak person for not facing up to his sister. Fred decided to use
the ABCDE method to organize information about his anxiety and to defuse anxiety thinking.
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B stands for your beliefs about the adversity. These beliefs can range from weakly held ones to
strong convictions. They can be reasonable or erroneous or somewhere in between. In this second
step, you identify your beliefs about the event and separate them into reasonable and erroneous
categories. (Step D gives you criteria for separating reasonable from erroneous beliefs, in a way that
can help you develop a realistic perspective about your anxiety situation and gain relief.)
C stands for the emotional and behavioral consequences of having beliefs. In this step, you list
the consequences of both your reasonable and your erroneous beliefs. For example, a consequence
of the belief that you are in threatening emotional circumstances where you are helpless might be
one of panic. Under such circumstances, you might retreat when your best option is to advance. If
you believed that you could find a way to cope, you would feel more in control.
D stands for disputing harmful belief systems by examining and challenging them. In case you
are new to this process, this step includes six perspective-generating questions to help you dispute
your beliefs. You supply the answers: (1) Does the belief fit with reality (that is, is the belief con-
firmable through experiment, or is it fact-based)? (2) Does the belief support the achievement of
reasonable and constructive interests and goals? (3) Does the belief help foster positive relation-
ships? (4) Does the belief conform to a measurable reality? (5) Does the belief seem reasonable and
logical in the context in which it occurs? (6) Is the belief generally helpful or generally detrimental?
Once you’ve mastered this six-step questioning method, you can customize your questions. (See
chapters 16 and 22 for further examples of how to dispute anxiety thinking.) This process can lead
to a perspective that is relatively free of erroneous beliefs and exaggerations about the evocative
situation.
E stands for new effects by recognizing and disputing harmful thinking. Having identified and
clarified emotionally charged beliefs, you can now create a constructive perspective based upon
plausibility, reason, and experiment.
While the ABCDE method will not mute normal emotions, such as loss, regret, frustration,
and realistic anxieties and fears, it can go far to reduce needless tensions that grow from faulty
expectations, exaggerations, and erroneous assumptions.
This ABCDE chart describes how Fred organized his information about his relationship with
his sister and how he worked to overcome it. Fred’s most pressing concern was his own anxiety. He
hated feeling tense over his tension. He reported feeling awful about seeing himself as a weak
person for not facing up to his sister. Thus he focused first on standing up to his sister.
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Reasonable beliefs about the event: I don’t like being put into a corner where I capitulate to
my sister’s insistence and demand for money to bail her out from the consequences of her own
excesses.
Emotional and behavioral consequences of the reasoned belief: Regret, disappointment with
sister’s behavior, and dislike of the situation.
Potentially erroneous beliefs about the events: I can’t stand up to my sister. Belief that
appeasement will eliminate anxiety.
Emotional and behavioral consequence of the potentially erroneous beliefs: Self-loathing for
capitulation. Intolerance for tension and retreat from tension.
Disputing potentially erroneous beliefs: Fred reminded himself of his basic family values. He
recognized that he would want to help his sister if she were ill or if she had no control over
adverse events, but he did not want to help her repeat what were actually self-destructive
habits. With that in mind, Fred asked and answered six questions:
1. “Does my belief that I cannot stand up to my sister fit with reality?”
Answer: “No. There are exceptions. I married my wife, despite my sister’s strong protests,
and had a wonderful marriage. I have the power to say no.”
2. “Does my belief that I must avoid conflict with my sister over money help me achieve my
constructive interests and goals?”
Answer: “No. It actually defeats my interest in overcoming anxiety related to her demands.”
3. “Does my belief in avoiding conflict by capitulation foster a constructive relationship with
my sister?”
Answer: “No. This aspect of my relationship with her is dysfunctional and likely will
continue to be as long as she believes she can get whatever she demands from me.”
4. “Does my belief that I can’t defend myself conform to reality?”
Answer: “No. The belief that I’m too weak and will be overwhelmed by her if I defend my
position is a fear, not a fact.”
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5. “Does my belief in capitulation seem reasonable and make sense in the context in which it
occurs?”
Answer: “No. My sister’s excesses, entitlement beliefs, and exploitive manipulations are
unreasonable. To avoid conflict, I allow myself to deflate my own sense of self-worth by
labeling myself weak and inept. That conclusion is based upon a magical view that my
worth depends upon her approval.”
6. “Is my appeasement belief generally helpful or detrimental?”
Answer: “In this case, it is generally detrimental. It costs time, emotional energy, and
money, with no benefits in return.”
Effects of the disputation exercise: A better perspective on the issues. A resolve to refuse
Ginger’s urgent pressures to bail her out of her financial troubles. A recognition that self-worth
does not depend upon capitulation to another’s expectations and demands. Self-acceptance
with or without sister’s approval. Recognition that working on tolerance for tension will help
build a sense of inner control.
Using this ABCDE method of analysis gave Fred clarity about his situation. As a result, he took
action and stopped capitulating to Ginger’s financial demands. He reported feeling relief as a
result. He noticed that Ginger started to live within her means. His newfound courage was helpful
to her as well.
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1. Does the belief fit with reality? (Is the belief confirmable through experiment? Is there
evidence to support the belief? Is it or is it not fact based?)
2. Does the belief support the achievement of reasonable and constructive interests and goals?
5. Does the belief seem reasonable and logical in the context in which it occurs?
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What are three key ideas that you took away from this chapter?
1.
2.
3.
What top three actions can you take to combat a specific anxiety or fear?
1.
2.
3.
1.
2.
3.
What did you gain from taking action? What would you do differently next time?
1.
2.
3.
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CH A P T ER 12
Exposure is a critical part of a cognitive, emotive, and behavioral approach to overcoming fears,
phobias, and panic. This is a form of learning where you repeatedly put yourself in proximity to a
feared situation. Through this habituation process, you retrain your brain to stop being so overre-
active to nondangerous situations.
This chapter looks at the exposure programs of Judy, Dell, and Sandra, all of whom had crip-
pling fears that they were able to overcome. You can use aspects of these programs that you believe
will work for you.
OVERCOMING PHOBIAS
Phobias, like fear of heights or fear of the dark, can start at any point in life, but often they start in
childhood, when we cannot discern rational from irrational beliefs and fears. If these fears con-
tinue into adulthood, then you may realize that your fear is irrational but maintain the fear by
continuing to avoid any situation that triggers it.
• Judy’s Story
Ever since she was a child, Judy had a morbid fear of darkness. She thought it started from
a story her uncle told her about “the bogeys.” These were apparitions who flew invisibly
through the darkness to steal the souls of little children who misbehaved. After hearing
that story, she recalled feeling petrified of the dark. She knew she wasn’t perfect, and she
figured the bogeys would come to get her.
To help quell her fears, her father suggested that she keep a light on in her room. Her
mother said, “The bogeys can’t get you in the light.” This calmed her. But she continued
to have a morbid fear of being in the dark and of having her soul torn away by invisible
bogeys.
The Cognitive Behavioral Workbook for Anxiety
Judy worried about what would happen if the lights went out and she had no safe place
to hide. She solved this problem by having backup systems. She kept candles and a
battery-operated lantern in her bedroom. Her parents thought this was excessive. They
also believed she would grow out of her fears, but Judy’s fear of darkness continued into
adulthood.
Of course, the bogey story was silly. Judy figured this out around the same time she
stopped believing in the tooth fairy. Yet her fear of the dark continued. Her fear affected
her social life. As a young teen, Judy refused to go to summer camp, because she knew
that there would come a time when the lights would go out. She wanted to avoid
panicking and being ridiculed by her peers. For the same reason, she refused to go to
sleepovers with her friends. As a young adult, she missed going to her best friend’s wedding
reception because it was held at night. She wanted to avoid panicking and being ridiculed
by her peers.
Her fear generalized to other conditions of darkness, such as driving at night or
through dimly lit tunnels. She believed she’d be safe with the dome light on in her car.
When asked out on dates, she automatically refused. She feared that she’d expose her fear
of darkness to her date. Judy likened her fear of darkness to an alien force that overcame
her at night. As a twenty-six-year-old, Judy continued to sleep with a lamp on.
To the outside world, Judy looked as though she lived a normal life. If you didn’t know
about her fear of the dark, you’d think she was a lovely, upbeat young woman without a
care in the world. She had attended day college and received a degree in journalism. She
did freelance editing for a major publication house. Meanwhile, Judy continued to live
with her parents, who encouraged her to get help for dealing with her dread of darkness.
She decided to see if she could find a way to break free from her fear.
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quickly vanished. Instead, she came to view her fear of darkness as highly unpleas-
ant. This description better fit with reality.
Judy had been blaming herself for losing opportunities because of her fear. Blame, in
this instance, added surplus meaning to an already unfortunate situation. Damning
herself about lost opportunities was like living life in reverse gear. The past wasn’t
going to change. Judy realized that although the past was gone, she could reexam-
ine and reinterpret events. Although she couldn’t go back to do things differently,
she could start today to live her life differently.
Working to diminish her double troubles, Judy learned that she felt more tolerant of herself and
less worried about feeling fearful. It was time to apply her new beliefs to the challenge of addressing
her fear of darkness.
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After ten days of progressively dimming the light, Judy could turn out the light and stay in
darkness for a minute before she started to feel tense. She increased the amount of time she stayed
in darkness in three-minute increments. When Judy achieved the milestone of remaining six
minutes in darkness, she began using a dim night-light in her bedroom instead of the higher inten-
sity lamp that she was accustomed to using. After three weeks, Judy shut off the night-light and fell
asleep in darkness. Thereafter, she could have the night-light on or keep it off.
Through exposure, Judy showed herself that her fear sensations were time limited and tolera-
ble. She learned she could stand experiencing fear sensations. She felt a huge sense of
accomplishment.
Start with the least intense phase and stick with it until mastered. Then move on
to the next.
Pace yourself. There is no hurry. It takes time for the brain to integrate new infor-
mation from experience.
If you have a setback, try again, perhaps with a modified plan.
You can follow these basic steps as you outline your own exposure programs.
What can you do with your time and your life after you are no longer limited because of your
fears? In Judy’s case, she dated. She attended night courses in journalism. She obtained a master’s
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degree. She went on vacations, something she had not done before. She had her share of setbacks
and losses. Nevertheless, she experienced her life as exciting and meaningful.
2. You imagine a range of proximities to that location, from the safest to the most dreaded
proximity.
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5. You sort the cards to develop a list of ranked items from least to most fearsome.
You now have a map set out in graduated steps—from least to most fearsome—that you can
follow to progressively master your fear of being in “unsafe” locations.
• Del’s Story
Del was a thirty-five-year-old undergraduate biology major. He panicked if he went into a
classroom where he did not have the seat closest to the classroom door. He wanted to be
close to the door so that he could quickly exit the building should he suffer a panic
reaction during the class. His primary fear was that of not being able to escape if he
panicked. The farther he was from the exit, the greater his fear.
To avoid panicking over not getting “his seat,” Del habitually arrived twenty minutes
early for class. Proximity to the door was critical to him. That was his safety blanket.
Being close to an exit was only the tip of the iceberg, however. His fears increased on
higher floors. Thus he selected a local college based on the height of the buildings. The
science building, where his major subjects were taught, had three stories. When the classes
he needed to take were scheduled on the first floor, he’d take them. Otherwise, he’d wait.
With a small family inheritance, Del originally had no need to work. But his
inheritance would eventually run out. That reality, along with being fed up with his fears,
prompted a decision to act to stop feeling afraid.
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1. First floor 1. Two seats away from door in row closest to door
2. Second floor 2. Two rows from the door in seat closest to the door
3. Third floor 3. Five rows from door in seat closest to door
Del started his behavioral card-sort exposure sessions in the spring semester. That spring, he
took four courses on the first floor of the same building. This provided ample learning opportuni-
ties; he could repeat the card-sort plan daily. He started with the first location and proximity
condition and mastered it at his own pace. When he felt reasonably comfortable with step 1, he
took the second proximity step, which was to sit two rows from the door in the seat closest to the
door. By the end of the semester, Del could comfortably sit anywhere in the first-f loor classroom.
He was pleased with the results of his exposure program.
For the summer semester, Del enrolled in courses taught on the second and third floors. He
decided to use the break between semesters to address his fears of being in the classrooms on these
higher floors. The first challenge was to get up the stairs to the second and third floors. For this
purpose, Del hired a psychology graduate student as a helper. The student first walked with him
up the stairs, providing a sense of security. Next, the student followed thirty seconds behind Del,
then one minute behind him, then two minutes, and then not at all. Del repeated this time-lag
technique going from the second to the third floors. Within a week, he found that he could walk
on his own up to the third floor.
As an experiment, Del entered the second-and third-f loor classrooms when they were empty.
Starting with the second-f loor room, he switched seats according to the card-sort plan. Then he sat
in every seat in the room (about thirty) for about a minute each. He repeated this exercise on the
third floor. He reported feeling bored with the redundancy, but he also reported an absence of fear.
When he began his classes, he did so with some trepidation. The presence of a professor and
students in the classroom had a greater impact than he’d expected. It was in these circumstances
that he most feared having a panic attack.
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To face his fear of panic, Del thought through his fears of what others might think if they saw
him panicking. He faced an incongruity: if different people can view the same situation in differ-
ent ways, why would the members of his class see him only as he saw himself? He accepted that
many of his classmates would likely not notice him even if he did feel panicky and that, if the worst
happened (if he panicked in the class and was unable to exit), he could still unconditionally accept
his fallible self. That insight gave him a positive new perspective.
A week after classes started, Del reported that he could comfortably sit anywhere in either
class. He had gotten past a significant hurdle toward finishing his degree.
His least worrisome condition was sitting close to the door when the restaurant was nearly
empty. The most worrisome condition was sitting in the farthest seat from the door when the
restaurant was crowded. Interestingly, Del expressed no fear of going to the counter to order food.
The counter was far from the door, but he believed that being on his feet made a difference.
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Otherwise, he had no explanation. However, the fact of his ease at the counter caused him to
rethink his assumption that he needed to be close to the door.
Within three weeks of this graduated exposure experiment, Del stopped worrying about where
he sat in the restaurant.
Using the card-sort technique allowed Del to concentrate his efforts on establishing control
over different location, proximity, and people conditions. As a by-product of his success, he no
longer felt panicky about panicking.
The card-sort technique works best when you have a specific fear that you can rank in terms
of least to most intense conditions.
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• Sandra’s Story
Sandra was on the third floor of a college dormitory that caught fire. She exited coughing,
gasping for air, and teary eyed from the smoke. She later thought a lot about the fire and
her close call. For several years after the event, Sandra felt panicky when she smelled
smoke. She wouldn’t go near a third floor. It got to the point where she worried her
anxiety could eventually affect her health.
Ordinarily, the more you engage a conditioned stimulus in short-time intervals, the
more likely your fear will weaken and be extinguished (Golkar, Bellander, and Öhman
2013). However, in Sandra’s case, longer intervals were necessary. She went to a restaurant
with a wood-burning fireplace and obtained a table at the farthest point from the fire. She
went with her favorite friends. She ordered her favorite food. Over a two-month period,
she progressively sat at tables closer and closer to the fire. Her fear of the smell of smoke
dropped to nearly zero. However, she still did not like the smell of smoke.
To overcome her fear of third floors, she intentionally pushed the third and fourth
floor button on an elevator. When the elevator reached the third floor, the door opened.
At first, she stayed at the back of the elevator. When she felt comfortable, she moved
toward the middle of the elevator. Eventually, she walked out of the elevator and then
back inside before the door closed. Soon she was able to get off at the third floor without
trepidation. She repeated this exposure experiment by walking down the stairs—the
condition that most closely approximated what had happened in her college dorm—until
she no longer felt afraid.
Should Sandra have spent time and energy dealing with panicky situations that she
could normally avoid and that didn’t interfere in any significant way with her life? She
wanted to stop ruminating about the fire. She wanted to stop feeling afraid of safe
situations. Afterward, she no longer felt panicky with the smell of smoke, she no longer felt
panicky about being on a third floor, and she no longer ruminated about the fire.
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In some cases, addressing one fear has a transdiagnostic effect on others. Sometimes, there is
no such effect. Nevertheless, you can apply what you learned in one anxiety-fear situation to
another. Judy, Del, and Sandra experienced significant fears that generalized to other areas of their
lives. In addressing these primary fears, they were each able to transfer what they’d learned to
other related fears. Knowing what to do, and knowing that you can do it, is advantageous!
What are three key ideas that you took away from this chapter?
1.
2.
3.
What top three actions can you take to combat a specific anxiety or fear?
1.
2.
3.
1.
2.
3.
What did you gain from taking action? What would you do differently next time?
1.
2.
3.
122
PA R T I I I
Worry is a form of mental uneasiness about negative possibilities that rarely happen. It’s a verbal,
ruminative, language-rich process. How often do you worry in images? Probably not much!
Our ability to fret about frightening possibilities has been around for a long time. The Old
English word wyrgan meant to choke or strangle. In the seventeenth century, the word “worry”
meant to stress, trouble, or prosecute. In the nineteenth century, the word took on its current
meaning: a feeling of apprehension, trouble, and unease about a possible event.
You also can view worry as repetitive negative thinking that cuts across many conditions such
as phobias, panic, and social anxieties (Olatunji, Naragon-Gainey, and Wolitzky-Taylor 2013).
Worry—the brooding and uncontrollable variety—is a cardinal symptom of generalized anxiety,
but not all people who worry have general anxiety (Penney, Mazmanian, and Rudanycz 2013). By
reducing worry, you can diminish undesirable conditions that link to it (Kertz et al. 2012).
True False
1. “I often think of bad things that can happen.”
If you checked “false” to every item, you probably don’t worry much. If you checked “true” to
most items, you probably worry a lot, and this is a problem for you. If you are somewhere in
between, some worries may matter a lot while some issues barely concern you. In some instances,
the numbers don’t matter as much as the meaning that you place on a future possibility.
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There is some good news. The ruminative, brooding nature of worry is a transdiagnostic issue.
Change the process and you can break a network of related conditions. The first step is to explore
whether what you are feeling is worry or anxiety.
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“When we’re threatened, a little structure in the limbic system called the amygdala
screams out in fear, sending its signals upward to the cortex. However, the interaction
between the limbic system and the cortex works in both directions. Your limbic system
informs your cortex, but your cortex can also control your limbic system. It takes effort, but
you can put your cortex to work to override those worry signals from the amygdala.
“Worries in daily life often take the form of subconscious, irrational ruminations over
possible threats to our well-being. For example, you may worry that you’ll make a terrible
mistake the next time you get into a new relationship. If you let that worry dominate, you’ll be
so reluctant to take the plunge that you may miss out on great opportunities to meet new
people.
“Sometimes it’s actually good to worry, especially if there’s a real danger lurking in the
shadows. You should worry about losing your job if you’re continually late for work or about
losing your partner if you’re unfaithful. In these situations, worry is a signal that something’s
wrong. Once you address these realistic worries by changing your behavior, you’ll have no
need to fret because you will have made the problem go away.
“Some may argue that the fact that we are hardwired to worry is evolutionarily based.
However, what makes us distinctly human is precisely our ability to use our cortex to override
the emotional storms that brew in our subcortical brain regions. By controlling your worries,
you’ll not only make better decisions but also feel better because you do.”
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If you flip a coin, it’s nearly 100 percent certain that it will come up either heads or tails. It’s highly
unlikely the coin will land on its edge. Unlike a coin toss, where the odds are known, it’s highly
improbable that your recurring worries will always and accurately predict the events that consume
your attention.
Recurring worries are driven by psychological factors, including magical beliefs that by worry-
ing you can avert disaster. Rather than let these ruminations go unchecked, use the previous
exercise to stop jumping to conclusions about remote possibilities. You may worry less.
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woven together, impede the flow of productive thought. Whenever you are tangled in worry, a first
line of defense is to think about your thinking and separate speculation from fact.
You can learn to stop making a case in support of your worries. All it takes is recognizing and
examining speculative thoughts. When you put worry in perspective, you are free to address the
objects of your anxiety.
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When unlikely possibilities translate into worry feelings, you’ve created a certainty out of a
fiction. You’ll then fill in the gaps to support the worry. This kind of thinking can be a habit, a
defense, or both a habit and a defense. If you find yourself in such could-be-thinking traps, figure out
what is going on.
The old adage “Don’t sweat the small stuff” takes on a new meaning when worrisome small
stuff detracts from the big stuff, or what you are putting off in your life that’s really important to
you. However, there are many other ways to create a crisis, including ballooning something fic-
tional into something big.
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Examining your worry thinking by asking “If not, then what?” will help you undo this thinking
trap. As an alternative, devising strategies to cope with remote possibilities may make you feel
better, but you may soon discover that you spend a lot of time planning solutions for disasters that
never happen.
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3. Sometimes people have too many actions steps to do. If you fall into this trap, ask your-
self, ‘What’s next?’ Focus only on this one thing. Breathe slowly in and out as you go.
When you complete this action, reward yourself with a short break and then ask, ‘What’s
next?’
4. Still stuck? Try a focus-changing technique. Start by making a table with two
columns. At the top of the table, write out what you’re worrying about. In the first
column, write out everything that is out of your control about the situation (such as
another person’s behavior, another’s opinion, or what someone else says). At the
bottom of this column, write down how you feel when you focus upon the aspects of
the problem that are out of your control. In the second column, write down every-
thing that is in your control about the situation (such as how you think, what you say
or don’t say, or whether or not you act in one way or another). At the bottom of this
column, write down how you feel when you focus upon the aspects of the problem
that are in your control. This will help you to gain clarity about what you can do and
where you want to place your emphasis.”
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Group your worries. By dividing your worries into two different groups, what you can do some-
thing about and what you can’t do anything about, you can dismantle this thinking trap. If you
can’t do anything about a possible outcome, why worry? If you can do something about it, then
devise a coping strategy.
Nip worry in the bud by naming the process. Start by describing worry as automatic verbal
ruminations that kick up emotional dust. Labeling worry in this way can help put this thought
pattern into perspective.
Plot a mindfulness course. This can be as simple as thinking about a worrisome thought running
on a treadmill and getting nowhere. Such changes in thinking responses to anxiety are associated
with reductions in worry (Querstret and Cropley 2013).
Ask the simple question “Do I feel like continuing?” This question implies that if worry think-
ing is no longer enjoyable or profitable, you can terminate it (Davey et al. 2007).
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Separate concern from worry. When you have concern for yourself, someone else, or a situation,
you care about what is happening. Because you care, you want to act responsibly. Next time you
worry, ask yourself, “How can I act responsibly about worry?”
Flip perspectives. Say a friend is late and you start to worry. You don’t know what’s happening.
You can’t control what you don’t know. So ask yourself, if you were late and knew what was hap-
pening, would you want someone else to worry about you? If not, why not?
Play with paradoxes. Daily, schedule ten minutes of time to worry. At that time, think about what
you have to worry about. Under controlled worry conditions, you may find your mind drifting from
the worries.
Wear an elastic band on your wrist. When you start to worry, snap the elastic band. Do it hard
enough to be uncomfortable without breaking the skin. Instead of being rewarded for worry, you
thus experience this immediate mild punishment. You could also use a thought-stopping tech-
nique. When you start to worry, silently shout, Stop, stop, stop! in your mind.
Give the word “worry” a new meaning. Use it as an acronym to stand for these corrective
actions: Will yourself to act against worry. Organize to address worries; test your plan whenever you
are caught off guard. Reflect productively by separating facts from fiction. Respond with active
measures to control what you can and to accept what you can’t. Yield to the reality that worries will
recur; you don’t have to take them seriously.
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Second, you cannot control everything, so you should stick to addressing what you can
control, which includes how you think about things but not external events, such as other
people’s actions, economic conditions, the existence of evil in the world, and so forth. Third,
you should accept the veritable fact that the world is imperfect and that there is therefore no
perfect solution to the problems of living. Fourth, it is unreasonable to demand certainty in
making your decisions, so you should live by probabilities, not certainties. Fifth, you do not
have a moral duty to worry. In fact, worrying and ruminating do not solve problems; instead
they defeat your ability to act proactively in addressing your problems. Sixth, when you do
have a real problem (one for which you do have adequate evidence), you should act proactively
to resolve it. Devise a plan of action and stick to it. Worry and rumination just get in the way
of resolving your problems of living.”
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What are three key ideas that you took away from this chapter?
1.
2.
3.
What top three actions can you take to combat a specific anxiety or fear?
1.
2.
3.
1.
2.
3.
What did you gain from taking action? What would you do differently next time?
1.
2.
3.
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C H A P T E R 14
When you feel threatened and anxious, security is important and change is disruptive. With this
mind-set, you may believe that you dare not stray from familiar paths. The truth is that planned
deviations could be an antidote to your anxieties over uncertainties, but you also don’t know for
sure what will happen if you try. As a result, you may make special efforts to keep things
predictable.
Awareness
If you think you have more than your share of anxieties and fears, you may be reluctant to risk
feeling even greater tension by engaging what you fear, especially if you are unsure of what to
expect. Indeed, the thought of change—even a positive one—can stir up doubts that you can
handle any more tension. However, building greater awareness is a critical first step in the process
of making positive voluntary changes.
What is this phase in the process of change that we call “awareness”? It means engaging your
consciousness about what is taking place within and around you. It involves knowing the makeup
of your anxieties and what you can realistically do to overcome them. By testing your growing
knowledge and resources, you increase your awareness even further as you develop into a stronger,
more confident you. As an example, a client whose anxiety was chiefly triggered by social situa-
tions filled out this questionnaire.
Awareness-of-Uncertainty Questionnaire
2. When you experience intolerance for Worry. Give up. Make up excuses. Avoid the
uncertainty, what do you normally do? occasion.
3. What conditions amplify your risk for Being overweight and lack of exercise do it for
intolerance for uncertainty? Ambiguous me. Unexpected inconveniences, such as my car
circumstances? Mood? Conflicts? breaking down, an overdue water bill, gloomy
Finances? Health? weather. Drinking too much at times.
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4. What cognitions, emotions, and behaviors Cognitions: Change is too risky. Can fail.
do you associate with intolerance for Can look awkward. Will embarrass self.
uncertainty? Will fail. Worry that I will never get over
these feelings.
Emotions: Anxiety. Irritation. Anger at times.
Depressed.
Behaviors: Eat, drink, and smoke to calm
nerves.
5. What increases your anxieties about Increases: Fatigue. Lack of sleep. Wintertime.
uncertainties? What decreases them? Boring job.
Decreases: Exercise. Sleeping well. Doing
something to address anxieties: challenging
worry talk.
6. What are the consequences of living with Have abilities and a college degree, but take
intolerance for uncertainty? low-level repetitive jobs. Quality work is missing.
Vehicle is a clunker; prefer a new car. Lacking
feeling of stability and self-worth.
7. What works best for you to combat your Sit back, reflect, figure out what to do, and then
intolerance for uncertainty? try to do it. But some things happen fast and take
quick decisions. Mostly retreat, but when trying
to sort things out on the spot, can sometimes
work “miracles.” Avoiding hesitations and delays
seems to help. It’s the anticipation of something
awful about to happen that feels crushing.
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Now that you know what works best for you, why not do what you know works?
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Managing Anxiety over Uncertainty
Action
To change, you have to do something different. If you want to cross the street in a different
way, you’ll have to take new steps. If you want to build self-confidence, you’ll have to start thinking
and acting like a self-confident person.
Action is the process of taking steps to achieve the goal of ridding yourself of burdensome
anxieties and fears. Thus, if you feel anxious about uncertainty, you’d be wise to enter that zone of
uncertainty for the greater purpose of obtaining clarity and direction. Clarity born from experi-
ence adds a dose of realism to awareness.
Hypothesis 1: All reasons for intolerance for uncertainty are valid. Examine this hypothesis to see if
you can falsify it. Instead of looking to prove that your fear of uncertainty reflects real threats, find
ways to poke holes in your anxiety thinking.
Hypothesis 2: It’s impossible to build emotional tolerance for uncertainty. Test this hypothesis by
acting to substitute emotional tolerance for the intolerance of uncertainty. First allow yourself to
feel the feeling of anxiety, but in a different way. Isolate the location of the tension sensations.
Mark their locations (for example, stomach, shoulders, neck). Isolating areas of tension is a step in
the direction of tolerating anxiety. By isolating tension zones, you open new options. For example,
you can accept each as a symptom of tension. This acceptance—along with relaxing each tension
zone—can reduce the physical effects of anxiety.
Hypothesis 3: Facing conditions of uncertainty is a formula for resolving situations that you associate
with distress. To test this proposition, enter your region of uncertainty to determine if you can find
answers, make discoveries, and develop tolerance.
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Few things in life go as smoothly as we hope or as badly as we might expect. Undertakings that
include uncertainties—even those with reasonable positive expectancies—can have unexpected
complications or result in happy accidents. Expect variations and fluctuations in life and you won’t
be disappointed.
Accommodation
Accommodation means adjusting to new ways of thinking and acting. For you, accommoda-
tion might mean reconciling conflicting thoughts, say, about an intolerance toward uncertainty,
and the reality that life is filled with ambiguities.
This is an intellectual-integration phase of change, where you put your anxiety over uncer-
tainty into perspective. By placing yourself in conditions of uncertainty, you can come to know the
problem better, and this awareness can reduce uncertainty. You’ll often find that what you feared
wasn’t as bad as you expected it to be. If what you hope to happen doesn’t pan out, you can make
adjustments in your thinking and actions.
Our inner struggles frequently involve conflicts between our negative and positive self-views.
We have conflicts between anxiety and self-mastery, doubts and self-command, certainty and
uncertainty. Through accommodation thinking, you can see which has the greater validity. Suppose
you think poorly of yourself and feel anxious because you believe that others think as badly of you
as you do of yourself. Yet you routinely receive positive feedback from others. How do you reconcile
this difference? Perhaps part of the answer lies in recognizing that you can change unwanted parts
of your thoughts, feelings, and actions, even if changing is difficult and you have no guarantees.”
How do you resolve this disparity between what you think of yourself and what others are
telling you? If you cling to negative information that you believe about yourself, then you are
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resolving uncertainty by confirming a negative self-view. If you take positive new feedback into
account, then you are accommodating to positive feedback about yourself.
Examining disparities between anxiety beliefs and observations that contradict those beliefs
can prompt conflict, and conflict correlates with an unpleasant feeling of tension.
But how bad is the feeling of tension? Can you accommodate it? Would you accept $10,000 a
day for living with one hour of tension as you sought ways to resolve a conflict between an old
anxiety-ridden self-view and an adaptive new self-view? You might if you believed that tension over
uncertainty is a time-limited experience. And it is!
You may believe that you are helpless to change your anxieties about uncertainties even though
you have evidence that you can make voluntary changes. How do you reconcile this incongruity?
Perhaps the answer is to recognize that you can change unwanted parts of your thoughts, feelings,
and actions even if changing is difficult.
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By doing a benefits analysis, you can see how the results of challenging anxiety about uncer-
tainty differ from the results of maintaining your anxiety. Now you can do your own benefits
analysis.
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Although you may not relish approaching uncertain circumstances, feeling free to engage
them is a far better position than dodging uncertainty because of excessive wariness and fear of
the feeling of anxiety.
Acceptance
The next step is acceptance, which involves emotional integration. The spirit of acceptance is
that of resigning yourself to outside realities that are not going to change. For example, you would
acknowledge that rivers sometimes flood or recognize that you can have different political views
from your cousin. At the same time, you don’t have to like the fact that rivers flood, especially if a
flooding river swept your house away. You may not like your cousin’s political perspective. But such
things are as they are.
There can be many things that you’d like to control but can’t, and you need not distress your-
self over such matters. Knowing that you can’t control the speed of the sun is unlikely to bother
you. However, in situations where control can make a difference, and that control is in doubt, the
picture can change. You may want your neighbor to live according to rules you find worthwhile,
such as keeping her dog off of your lawn, but your neighbor doesn’t have the same beliefs as you.
In this case, acceptance doesn’t mean that you are stymied. You could ask your neighbor to keep
her dog off your lawn. You could put up a fence.
When you look back over your life, you will find good times and bad times and many in-
between times. Some of life’s events will truly be regrettable, and it’s impossible to do anything to
change what has happened. You have the choice of acceptance. Now what about acceptance of
what is happening in the present?
Acceptance doesn’t mean you are passively bound to a turnstile. In an acceptant state of mind,
you can do the following:
See events as having potential for evoking different perspectives.
See events for what they are and not as what you would like them to be.
In an acceptant state of mind, you focus on what you can develop, improve, cope with, change,
or accomplish. In short, if you don’t like a situation, you can take action to effect a change. If you
can’t change a negative situation that is already in process, you find a way to adjust.
Not everything in the present moment or future is clear. Ambiguity and uncertainty are a part
of the present and future. But you can work on incorporating these five points of uncertainty into
your life:
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Accept that you can progressively master methods for overcoming uncertainty fears.
Actualization
Actualization means stretching your abilities to discover what you can do in areas that are
important to you. Instead of absorbing yourself in worries and troubles over uncertainties, you
absorb yourself in what you are doing. In that way, you learn more about what you can
accomplish.
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A prime actualization objective is to decrease negatives by striving for positive results. As you
move in this direction, you no longer avoid uncertainties just because they stir discomfort. By
striking out in a positive direction, you reach beyond your uncertainties. You move toward gaining
clarity and making gains. You feel much more in command of yourself and in charge of your life.
3. Outline what you can and will do to address anxiety over uncertainty as you stretch for your
goal.
With awareness, action, accommodation, acceptance, and actualization, you can increase your
tolerance for anxiety from uncertainty. It’s not even necessary to follow the steps in this exact
order. Voluntary personal change doesn’t have to follow a specific sequence. You may develop new
ideas and insights from the results of your actions. You may experience a radical shift in your views
through accommodation. By stretching your resources, you can favorably influence the other
stages in this process.
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What are three key ideas that you took away from this chapter?
1.
2.
3.
What top three actions can you take to combat a specific anxiety or fear?
1.
2.
3.
1.
2.
3.
What did you gain from taking action? What would you do differently next time?
1.
2.
3.
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CH A P T ER 15
Slight but sudden physical changes can trigger negative thoughts. These changes include sweating,
an uptick in your heartbeat, increases in your breathing pattern, or muscular tension. If you associ-
ate such physical sensations with negative consequences, such as looking like a nervous wreck in
front of others, this sensation detection, magnification, and interpretation process reflects an
anxiety sensitivity (Reiss and McNally 1985). This anxiety sensitivity—what you think about your
sensations—increases your risk for various forms of anxiety (Mantar, Yemez, and Alkin 2011).
There is no end to how far people will go to avoid unexplained and unpleasant sensations.
While at a shopping mall, a client named Don felt dizzy and had a quickened heart rate. He felt so
anxious about this happening again that he went on Valium and stayed on it even though the
medication fogged his mind, sapped his energy, and increased his anxiety. When he did feel good,
Don tried so hard to cling to feeling good that he felt tense.
Ducking and hiding from unpleasant sensations rarely turns out well. Psychiatrist Abraham
Low (1950) points out that the more you anticipate the discomfort you fear, the greater the fear
that you will feel. Your fear of the feelings of anxiety and fear sensations can be so great that you’ll
repeat a cycle of sensing tension, magnifying the tension (with helpless thoughts), and scrambling
to avoid unpleasant feelings. There must be a better way.
The Cognitive Behavioral Workbook for Anxiety
A Theory of Labeling
Psychologists Stanley Schachter and Jerome Singer (1962) thought that physical sensations
and a cognitive label together describe an emotion. That is, when you become aroused, you’ll tend
to look for reasons to explain what is going on, and you may use an emotional label to explain the
feeling.
Schachter and Singer’s theory of emotions is imperfect, because you can have a sensation or
emotion without labeling it. For example, infants don’t label their emotions. However, when you
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come to an age where you can interpret experience by using analytic skills and language, your
world changes. You may look for causes and apply labels to unexplained sensations. Depending on
the context, the same sensation may be labeled anger, happiness, or fear. The label becomes your
reality.
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Top Tip: Slow Down, Dig In, and Live the Big Picture
Multimodal therapist Dr. Jeffrey A. Rudolph is a licensed clinical psychologist who practices
in Manhattan and Ridgewood, New Jersey. Rudolph shares this tip that he uses with his
clients:
“Anxiety is rooted in the false perception of threat and loss of control, muting your
natural need to feel challenged and masterful. Unfortunately, many of us who view ourselves
as sensitive by nature are prone to be seduced by it, getting stuck in the moment and trapped
by the discomfort it elicits.
“Anxiety speeds you up. When you speed up, you lose perspective. This fuels your
tendency to rush through experiences, leaving you feeling drained. Thus, dodging your
anxieties can lead to seeing your cup of experiences as depleted, or half empty. Avoid
lamenting lost opportunities. Remind yourself that whether your glass is half empty or half
full, what is most important is the quality of the contents inside.
Here are two steps to add quality content to the mix:
1. Down shift to first gear, catch your breath, and take a moment to break down what
feels overwhelming into distinct ‘smaller pieces.’ You are now employing what you
already have—your natural ability for perspective, reasoning, and problem solving.
2. Follow my 10/40 rule: it takes just 10 percent of purposeful effort, or a 10 percent
reduction of a threatening situation, to produce a 40 percent drop in your anxiety.
Apply that rule to meeting a challenge that includes getting past an anxiety that is in
your way.”
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To end this review, consider that tension means you are alive and are surviving.
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2.
3.
Of course, simple is not always the same as easy. Nineteenth century Prussian general Carl
Von Clausewitz (1982) observed that we can make simple actions difficult by burdening ourselves
with misgivings, complications, and meaningless fears. He thought that while preparation was
important, action was preferable to theoretical contemplation about the uncertainties and ambi-
guities of situations.
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From a mindfulness-based lens, you can view LFT thinking as you might watch clouds float
by. You can’t control the direction of the clouds, so why upset yourself over what you can’t control?
Is it possible for you to let it be?
If you can’t let it be, then what? You can actively question and change dramatized thinking
that escalates anxiety.
Dramatized distress thinking includes such beliefs as These feelings are too much for me to take
and I can’t cope. This verbal chatter is like taking an uncomfortable feeling and twisting it into a
major upset. Here are some examples of LFT distress beliefs, six questions you could ask to chal-
lenge this thinking, and sample answers showing how to remedy this LFT thinking process:
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I won’t be able to survive. You’ve survived this tension I definitely can survive what
before, so what makes you I don’t like, and I can thrive by
think that you won’t live accepting the proposition that
through it again? I can control my thoughts and
actions to both cope and
prosper.
2.
3.
4.
5.
6.
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By questioning your thinking process whenever you have uncomfortable physical sensations
and jump to negative conclusions about them, you can gain clarity and perspective on what is
going on.
What are three key ideas that you took away from this chapter?
1.
2.
3.
What top three actions can you take to combat a specific anxiety or fear?
1.
2.
3.
1.
2.
3.
What did you gain from taking action? What would you do differently next time?
1.
2.
3.
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C H A P T E R 16
Vanquishing Panic
There is no mistaking panic. You gasp for breath. You tremble. You sweat, feel numb and unreal.
You feel dizzy. You fear fainting, losing control, and going crazy. You think you are going to die,
and this belief escalates the panic. You feel so frightened that you cry.
Although the physical symptoms of panic can seem sudden and uncontrollable, panic is a
definable, explainable, and highly correctable condition. You can draw from a variety of CBT
techniques to overcome panic, such as building self-efficacy beliefs for controlling panic (Gallagher
et al. 2013) and using a combination of relaxation, breathing, and exposure techniques (Sánchez-
Meca et al. 2010). Knowing how to defuse panicked thinking can quickly ease your panic. About
two-thirds of those who combat panic make durable improvements (Gloster et al. 2013). You can
do better!
PANIC FACTS
If you’ve gone through one or more panic episodes, you are not alone. Annually, between 3.5
percent and 10 percent of people between the ages of fifteen and sixty have serious persistent or
isolated panic reactions (Barlow 1988; Katerndahl and Realini 1993; Kessler et al. 2012). As many
as 40 percent of people over their lifetimes have some lower-grade symptoms or major panic symp-
toms (Bystritsky et al. 2010). If you have one of these subthreshold panic patterns, don’t brush it
aside. Minor panic is a risk factor for depression and other quality-of-life robbing conditions, such
as substance abuse (Pané-Farré et al. 2013). Fortunately, CBT self-help manuals on panic can be
helpful for those who suffer from panic (Lewis, Pearce, and Bisson 2012).
The Cognitive Behavioral Workbook for Anxiety
Panic Symptoms
The physical symptoms of panic can feel so severe that you may think you have a medical
problem, but panic is usually psychologically addressable. Panic consists of not only physical symp-
toms but also cognitive triggers, emotional intolerance, and behavior avoidance issues. Muscular
tension, chest pains, and gastrointestinal problems can be symptoms of anxiety as well as triggers
for panic. Since these physical symptoms could reflect a medical problem, it would be wise to have
a medical checkup, if you haven’t already done so, to assure yourself that any persistent anxieties
don’t have a medication or disease connection. For example, a hyperactive thyroid condition can
stimulate anxious feelings and thinking.
Panic Duration
Panic has a beginning, a middle, and an end. It doesn’t go on forever. And, more often than
not, it has a short duration. Panic can range from a short, unpleasant jolt of tension to a sudden
and intense wave. Panic symptoms last usually between two and thirty minutes and closer to the
two-minute mark. In rare instances, panicked feelings can last an hour or more. But even a few
minutes of panic can seem like an eternity.
Panic typically follows a process that includes a sensation awareness phase, a cognitive trigger
phase, a panic escalation phase, and a resolution phase. The good news is that you can attack
negative panic thinking at any stage in this cycle, which will help you overcome it.
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2. Exercise emotional tolerance through an acceptant attitude. Acceptance can take this
form: If I panic, I panic. Tough. It’s not the worst thing in the world.
3. Engage behavioral measures to address panic, including breathing exercises, measuring the
length of time that panic lasts, or making a mental note of the physical symptoms.
4. When you are in a calm state of mind, rehearse cognitive, emotional tolerance, and behav-
ioral methods for dealing with panic, so you’ll know what to do if panic returns.
You can use these same methods to cope with cued panic.
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Similarly, you may also fear any number of consequences—such as that you’ll pass out, lose
bowel control, or vomit—but these are rare events. You have about a 3 percent chance of any of
these things happening while you are panicking (Green et al. 2007).
MANAGING PANIC
Accepting panic moderates the intensity and duration of panic. The trick is to get from panicking
over panicking to acceptance and emotional tolerance of what you can honestly view as a highly
unpleasant experience.
Might some people view you with sympathy because they’ve experienced panic too?
Replace automatic negative cognitions with more positive realistic ideas about what might
happen, and you will no longer avoid places that could conceivably cue panic.
Gaining Perspective
In situations where you experience a panic reaction for the first time, you can gain perspective
by asking yourself if something has recently changed in your life situation. Stress accompanies life
changes, including positive ones. Have you gone on a diet? Have you started taking a new medica-
tion? Have you had a recent trauma?
If you know the triggers, signs, and causes of panic, self-observation can replace a panicky
reaction with a reflective response. Taking self-observant actions can be helpful: check your watch
to see how long the panic reaction lasts. Make mental notes of the various aspects of the reaction:
your thoughts, feelings, and behaviors.
Perhaps one of the best ways to understand and manage panic is to look at how a knowledge-
able professional coped with this condition. Here’s what Donna, a psychologist, did to address her
panic.
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• Donna’s Story
Donna experienced a panic reaction following the recent deaths of three people she felt
close to. When her panic started, she first felt sudden disturbing symptoms in her body.
She described them as “waves of hot and cold spreading through my chest and down my
arms and legs, tingling in my limbs, my heart beating fast, a feeling like I couldn’t breathe,
and sudden sweating. It hit me seemingly out of nowhere. Bam! My body was on red alert,
and it felt awful.”
She first thought she was having a heart attack: “I felt a new spurt of hot and cold
pour through my skin. I took my pulse, and it was fast but steady. I have a home blood-
pressure kit and took my blood pressure. It was a little high, but still normal. I did a
symptom check. I found no pressure in my chest or any pain in chest or arm or jaw. The
symptoms were on the surface, on my skin. I’d experienced such feelings before from
adrenaline overload. I told myself I was likely having an anxiety attack, not a heart attack.
If I couldn’t abate the symptoms with a couple of minutes of REBT, I’d call an ambulance
just in case it was a heart attack. But I was pretty certain it wasn’t.
“My first step was to attend to my breathing. It was shallow and fast. I spent sixty
seconds taking slow deep breaths. Since the symptoms lessened when I breathed correctly,
I became more certain it was anxiety and not a heart attack. What had I been thinking?
Then I tried to uncover the thoughts that had triggered the physical symptoms.
“The first thought that came to mind was that Tim was dead. Lou was dead. My
brother had died two years ago. Everyone was dead, leaving behind relatives that I was
supposed to support and help through their grief. That grief went on for months and
months. It took so much out of me that I heard myself say, ‘This was awful. I can’t stand it
anymore.’
“As I thought about the people around me, I thought, I’ve had enough. They should not
make any more demands on me. I should not have to deal with any of this awful stuff. They
won’t leave me alone to attend to my own life. All this death was awful. My husband has been
having some health problems lately. He could be next. I can’t stand the idea of being without
him.”
Donna recorded her thoughts as she sat by her computer. Then she started to reflect
on her thinking. “The thought of my husband dying (when in fact he’s no more close to
dying than any of us) and me being a young widow was the tripping point for my anxiety
attack. I realized that the thought had streaked through my mind like a meteor in
daylight. I almost didn’t register it consciously. But that was the final straw. It had triggered
a fight-or-f light panic reaction in my body. My physical symptoms of anxiety were still
intense but slightly less than a few minutes earlier.
“While still attending to my breathing, making sure I was not edging toward
hyperventilation, I proceeded to rationally dispute each of my irrational beliefs. The ‘I can’t
stand it’ thoughts seem to be an especially strong trigger for me. My physical symptoms
began to abate within seconds of identifying and then disputing this irrational self-talk.
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1. She assessed her symptoms and came up with a plan for dealing with them.
2. She made a rational effort to distinguish anxiety from a more serious heart ailment.
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3. She monitored her breathing, using a breathing technique to prevent an escalation of more
unpleasant symptoms that can be brought on by shallow, fast breathing and/or
hyperventilation.
4. She identified the irrational self-talk that had triggered the fight-or-f light response, and she
replaced the irrational statements and beliefs with rational statements.
5. Because she had practiced recognizing and challenging anxiety-evoking beliefs in calm
circumstances, she found it easier to automatically use Albert Ellis’s ABCDE method (see
chapter 11) in a stressful circumstance.
7. She accepted that her body would need several days to fully recover from the adrenaline
overload.
8. When she suffered gastrointestinal distress the next day, she accepted it as a normal con-
sequence of adrenaline overload. She did not make a federal case over a minor discomfort.
Thus, she avoided rekindling her panic through anxiety sensitivity.
9. She actively engaged in behaviors that made her life more enjoyable and manageable.
10. She continued to monitor herself for shallow breathing and took a metacognitive approach
to monitor her thinking for signs of irrational self-talk.
There are times when multiple pressures can get to even those who know better. But the real
message from Donna’s experience is that through knowledge and know-how, she brought this
pattern of panic to a relatively quick end. She acted to prevent panic from coming back. You can
employ the same techniques in overcoming panic reactions.
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Activating event (experience): Experiencing physical sensations you associate with the onset
of panic.
Reasonable beliefs about the event: “I’ve experienced these sensations before. They’ll remain
the same for a while, escalate, or diminish and disappear. The outcome is whatever the
outcome is.”
Emotional and behavioral consequences of the reasonable beliefs: A sense of emotional
acceptance and tolerance about the experience. Possibly making adjustments in breathing or
breathing into cupped hands to help recalibrate the CO2 sensor in the brain.
Erroneous beliefs about the event: “Oh my god. It’s happening again. I can’t stand it. I’m
about to die.”
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3. The hormone storm passes without any durable ill effects; the same will happen if you panic
again.
4. You still don’t like feeling panic. Who would? But you now have more compelling evidence
that the catastrophic prediction of dying is no more than a mental myth attached to panic
sensations.
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Effects of disputes:
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2. Wait out the physical symptoms and sensations of panic until the sensations subside. This can
be tough to do. However, trying to escape the feelings reinforces escape. You are going through
an anxiety cycle. You might as well accept it.
3. Take behavioral actions, such as taking your pulse rate and timing how long the panic takes
to subside. However, you use this distraction to gather information—not as an escape.
You may discover that what you have been dramatizing makes an unpleasant situation worse.
When your dramatize a situation, it is not as bad as you think.
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What are three key ideas that you took away from this chapter?
1.
2.
3.
What top three actions can you take to combat a specific anxiety or fear?
1.
2.
3.
1.
2.
3.
What did you gain from taking action? What would you do differently next time?
1.
2.
3.
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C H A P T E R 17
Karen has a morbid fear of germs and goes to extremes to avoid contamination. Abby panics about
snakes and refuses to go outside when there is any possibility of encountering one. Lloyd is afraid
of dogs. When his best friend got a pet dog, Lloyd refused to go anywhere near it. What do Karen,
Abby, and Lloyd have in common? They all have a serious specific phobia, or a persistent fear of
an animal, situation, object, or other event that they go out of their way to avoid.
Phobias are common. In any one year, 8.7 percent of the US population will have a serious
phobic reaction to one thing or another. The lifetime prevalence estimate is 12.1 percent (Kessler
et al. 2005). Phobias include fears of natural disasters, animals, insects, injections and blood, flying,
public speaking, and social events, such as attending parties, family gatherings, or weddings.
Some phobias are more of a quirk than a handicap. For example, you may have a phobia of the
number thirteen (triskaidekaphobia). Whatever the reason, you may avoid living on the thirteenth
floor of a building, or flinch a bit on Friday the thirteenth, but otherwise this fear is no big deal to
you. Even the great Babylonian King Hammurabi avoided labeling his thirteenth law with the
number thirteen. He skipped over it, going from twelve to fourteen. However, if you have a debili-
tating fear of the number thirteen, it’s not silly. Any phobia that interferes with the quality of your
life merits attention.
You can sometimes overcome a debilitating phobia in a surprisingly short time and get a trans-
diagnostic bonus. By acting to overcome your phobias and fears, you can buffer yourself against
other anxieties (Indovina et al. 2011).
network of complications interconnecting with your phobia. If you don’t know whether what you
have is a fear or a phobia, it may not matter. Both fears and phobias tend to follow similar neuro-
logical paths (Schweckendiek et al. 2011). The same CBT methods that are effective for overcom-
ing fears are effective for overcoming phobias.
Exposure-based CBT is the gold standard for addressing phobias and fears. Here are some basic
steps in this process:
1. Educate yourself. Learn about common causes for phobias and evidence-based solutions.
2. Agree with yourself that you’ll learn to tolerate tension until you no longer fear the feeling
of fear that you associate with your parasitic fear situation.
3. Put yourself in proximity to what you fear, in tolerable chunks, one step at a time.
4. You will have a natural impulse to avoid what you fear. This avoidance rarely does more
than reinforce itself and perpetuate the fear. Resist it!
5. Persist until you have control over yourself in the proximity of what you fear.
These basic steps will help you overcome any phobia. This chapter elaborates on how to use
them in different ways and in different situations.
• Karen’s Story
Karen had a morbid fear of germs. This ordinarily friendly social scientist believed that
unless she was extraordinarily cautious, she would contract a deadly disease and possibly
die. As a result, she panicked whenever she believed that she’d been exposed to germs.
Her presenting problem was not only her fear of germs. Her friendships were strained,
and she wanted to know how to communicate better. It was clear, however, that her
refusal to join her friends at restaurants and gatherings because she was afraid of germs
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had alienated the people whom she loved best. Her germ phobia was interfering with her
relationships and her peace of mind.
When gently approached about this matter, Karen snapped, “Germs Kill!” When it
became plain enough to Karen that she going nowhere by denying her problem, she put on
her scientist’s hat and experimented her way out of her problem.
She worked—uncomfortably at first—at taking away one safety behavior a week. For
example, to protect herself from germs, she had been wearing Teflon gloves everywhere
she went. As a condition for removing the gloves, she first used an antibiotic hand cleaner
every hour. Then she scaled this back until she washed her hands before and at other
appropriate times. She substituted a short-sleeved blouse during summertime for the heavy
sweaters she’d been wearing. She had originally thought that long sleeves protected her
from germs.
By making problem-related behavioral changes and becoming comfortable with these
changes, Karen shed her fear of dying from germs. She rebuilt her friendships. This process
took about six months.
For Karen, the process of overcoming her phobia involved a series of turning points. Her first
turning point was seeing the contradiction between her scientific training and her unscientific
acceptance of the belief that she was in imminent danger of being killed by germs. Her second
turning point was acceptance of her panic feelings. Her third turning point came when she saw
that she was not a slave to her fear and could overcome it if she tried.
• Abby’s Story
Abby was housebound because of her fear of snakes. She wouldn’t go to her daughter’s
school events. She arranged to have teacher conferences on her computer through
FaceTime. Her therapy sessions were by telephone. Her reason for these restrictions was
that she might be attacked and bitten by a poisonous snake. Her daughter’s excuse for her,
“that’s just Mom being Mom,” had an unsettling effect on her. She wanted relief from this
burden. The time had come to take action.
Abby decided to use exposure to defuse her snake phobia. She decided to take a
graduated approach. She liked the idea of training her primitive brain to stop overreacting
to her images of snakes.
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Her goal was to feel free to leave her home without dreading snakes. She believed that
her phobia of snakes was the cause of her panic. Arguably, it was her fear of losing control
and panicking that was the primary issue, but her exposure program would help her
overcome this fear as well. Specifically, Abby believed that if she could walk daily through a
local park, she could go just about anywhere, so walking through a local park was her goal.
Abby’s first step was looking at pictures of nonpoisonous snakes at a comfortable
distance in the confines of her home. She used the family room because she found that
room relaxing and pleasant. She would move a foot at a time, from one end of the room to
the other, where her daughter had put a snake picture. She proceeded until she could hold
the snake picture and look at the snake up close.
She went to a reptile exhibit at a museum to observed stuffed snakes behind a glass
exhibit. She planned to use the same procedure as she did with the picture. However, she
had to get to the museum. During the trip, she suffered high anxiety as her husband drove
her. Her two daughters, who were accompanying her, offered encouragement. By design,
her husband dropped her and the two girls at the stairs in front of the museum entrance.
She briskly walked through the door and to the exhibit cases. She put herself within three
feet of the snake exhibit case. She looked at all the snakes, including the poisonous
variety. By the time her husband joined her, she was giddy. Approaching the snake exhibit
was manageable.
Next, Abby drove with her family to observe snakes in the local zoo reptile exhibit.
The live snakes were housed in glass cases. As before, she briskly moved closer to the case.
She wanted to finish the exercise quickly. She found she was interested in the colors of the
snakes and reported learning a lot from what was written about them. She struck up a
conversation with a fellow visitor who had a few pet snakes. She found her fears
manageable and also found that they decreased the longer she stayed at the zoo. When
she felt relaxed, she left.
Her next step was to wear tall leather boots and walk around her lawn. She did this
with her family. She felt safe from a snake with the boots protecting her legs. She felt she
could handle the tension, so she walked around her block by herself.
Next, she wore ankle-high boots as she walked around her lawn and then around the
block. Once she felt relaxed with this process, she repeated the exercise wearing sneakers.
Finally, on her own, she walked through the park, wearing boots. Thereafter, she
walked in sneakers with her family around the park.
How long does exposure take to work? For Karen, it took six months. For Abby, it was over and
done in a few days. Everyone is different. The answer to how long it takes to stop feeling phobic is
that it takes as long as it takes.
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Set Up a Hierarchy
Identify mild, moderate, and severe fear situations and arrange them from least to most scary.
If you were afraid of dogs, the least scary image might be a small dog who acts friendly; you might
imagine a twinge of anxiety if you saw this dog at the end of your driveway lying down and being
held on a leash by its owner. This image will be the first step on your hierarchy. Create a second
item for your list. This might be the same dog, same situation, except this time the dog is sitting.
This image should be slightly more tension producing than the first one. The final step on your
hierarchy may be you holding the small dog. In setting up your hierarchy, it’s good to keep the
degree of tension about equal between steps.
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Imagine Exposure
In a relaxed state of mind and in a relaxed position, imagine the first step on your hierarchy.
Think of your coping statement. Repeat this relax–image–coping statement process until you feel
comfortable with the image. Then move on in your mind to the next step on your hierarchy.
How often should you practice this visualizing technique? Your best gauge is what you can
comfortably do each day. When you are comfortable with the top image on your hierarchy, you can
move on to live exposure.
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• Lloyd’s Story
Lloyd’s neighbor had a small friendly dog. She knew Lloyd was afraid of dogs because Lloyd
would duck into his house whenever she went outside with the dog. Otherwise, Lloyd and
his neighbor enjoyed a good relationship. He sometimes joked with her that he’d someday
pet her dog. She invited him—on numerous occasions—to approach the dog.
When Lloyd decided he wanted to overcome his fear of dogs, he explained to his
neighbor what he was trying to accomplish. His goal was to be able to pet a small friendly
dog. His neighbor was delighted to help. The following day, he gave her a copy of the
exposure steps to his hierarchy, explaining that he would have to prepare himself mentally
before taking each step.
His plan was to take eight minutes for each exposure step. He would use two minutes to
conjure the image of the first exposure step while pairing it with deep breathing. At the end
of that time, he would repeat the coping statement three times in his mind. Then he would
take the first step for five minutes of exposure. After that he would allow a minute to wind
down. If he felt okay with this step, he’d take the next step, and so on. If not, he’d repeat
the step.
Lloyd succeeded in overcoming his dog phobia from small dogs. Despite this initial
success, Lloyd wasn’t done with his program. He visited and observed several dog obedience
classes and attended dog shows. He’s still vigilant when it comes to meeting a strange dog
that growls, as he should be. Otherwise, he’s comfortable around companion dogs of any size.
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2. Deep breathing Same small, friendly “This dog is friendly Your neighbor brings her
neighborhood dog on and doesn’t bite.” dog to within one foot of
leash nearby you at your house.
3. Deep breathing Same small, friendly “This dog is friendly Your neighbor walks her
dog at your house off and doesn’t bite.” dog to your house and
leash takes him off the leash
for one minute.
4. Deep breathing Same small, friendly “This dog is friendly You take the dog for a
dog; you take it for a and doesn’t bite.” walk of five minutes
walk around your around your house
house, on the leash. several times until you
feel relaxed.
5. Deep breathing Take a walk around “These dogs are on Walk around the
your neighborhood leashes or fenced in neighborhood with a
with a friend. Keep and can’t hurt me.” friend for at least a half
walking until you see hour.
at least one dog.
6. Deep breathing Repeat step 5 by “I’ve already done Walk around your
yourself. this easily with my neighborhood by yourself
friend. I can do it on for at least a half hour or
my own.” until you see several
dogs and still feel
relaxed.
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2.
3.
4.
5.
6.
7.
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What are three key ideas that you took away from this chapter?
1.
2.
3.
What top three actions can you take to combat a specific anxiety or fear?
1.
2.
3.
1.
2.
3.
What did you gain from taking action? What would you do differently next time?
1.
2.
3.
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C H A P T E R 18
A Multimodal Attack on
Anxiety and Fear
Rutgers University professor emeritus Arnold Lazarus pioneered a multimodal therapy approach to
help people combat anxiety and other undesirable conditions. Lazarus uses the acronym BASIC
ID to describe seven modalities, or aspects of a problem condition, for understanding and overcom-
ing anxiety: behavior, affect, sensation, imagery, cognitions, interpersonal, and drugs/biology
(Lazarus 1992).
This chapter first introduces the BASIC-ID approach and then shows how to apply it to in a
situation where your anxiety signals that you need to make some changes.
7. Drugs/biology includes medications you are on, substances you may abuse, health concerns,
or biological tendencies toward anxiety or depression. This modality also includes brain
issues.
From person to person, these modalities can vary in their order of importance. For example,
you may be especially sensitive to your sensations. If you have a surprising increase in your heart
rate, this sensation can trigger a panic cognition: I’m having a heart attack, and I’m going to die. You
can then have an image of yourself in an ambulance heading to the hospital. This image can add
to the increased heart rate and breathing problems. The above combination would be an S-C-I-D
(sensation, cognition, imagery, and drugs/biology) pattern. Whatever your anxiety pattern, the
BASIC-ID is a framework to break it down by priority issue and address it.
• Diana’s Story
Diana was a twenty-three-year-old single woman who complained of severe anxiety and
panic. Dwelling on her worries, she often had trouble falling asleep. She lacked exercise and
often found herself gasping for air when climbing stairs. Otherwise, she was in good health.
She did not use drugs or alcohol to deal with her tensions. She was not on any medications.
Her weight was normal. Her appearance was attractive, her demeanor warm and engaging.
Diana said her anxieties controlled her life. She frequently panicked. She feared losing
control and going crazy. She dreaded such feelings and said she would do practically
anything to make them go away. She reported that often her muscles felt tense and her
stomach was tied in knots. She couldn’t think straight. She had difficulty concentrating.
She was forgetful. She feared doing the wrong thing and being criticized. She was afraid to
offend anyone. She felt insecure and riddled with self-doubts. She described herself as a
fearful person. Where did her anxieties start? Diana described her early childhood as filled
with pleasant memories and largely anxiety-free. Her description of that period seemed
reasonable.
When she was a young adolescent, her anxiety had escalated. She was hypersensitive
about making mistakes, looking like a fool, and getting rejected. During this period, she
had an insight. She thought that to be liked, she would need to cater to other people’s
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interests. Perhaps then they wouldn’t pick up on her imperfections. Perhaps she could
avoid conflict.
After a brief relationship and on her twenty-third birthday, she became engaged to
Jack. Around that time, her anxieties jumped through the roof. Diana said that prior to
the engagement, Jack seemed solicitous and attentive, and maybe a little jealous, at times,
but in a charming way. Sure, he drank a tad too much. He said he needed to knock down
a few cool ones to relax. She told herself, That’s a guy thing.
Once she announced a wedding date, Diana moved into Jack’s apartment. At that
point, his jealousy increased. He demanded that she tell him where she was going and
keep in constant touch with him by cell phone. He literally followed her around the
apartment. Jack’s drinking also increased. After three months of living with Jack, Diana
felt confused about her feelings toward him.
Shifting Perspective
When there is more than one way to view a situation, an incongruity intervention can help
cause a shift in thinking, as you contrast an anxiety perspective with a realistic alternative view.
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For example, Diana feared that others would see her as a failure if she broke off her engage-
ment. She understood that she would never be happy with Jack, but she felt socially embarrassed
at the thought of cancelling the wedding. She had already announced to her family and friends
that Jack was a wonderful man and that she was very lucky to have found him. Would she sound
like a hypocrite if she cancelled the wedding? She imagined her friends and family rolling their
eyes in disapproval.
Shifting perspective, Diana recognized that if her best friend left an unhealthy relationship,
she’d see this as a mark of courage. If she could accept that her friend could exit an unhealthy
relationship without being a hypocrite and a failure, then why would she see herself as a hypocrite
and a failure? As she faced this cognitive incongruity, she concluded that the fear that everyone
would see her as a failure was a figment of her imagination.
Diana also did a reality check. She asked her mother and two close friends to give her their
honest opinion of Jack. Her mother was blunt. Jack’s drinking pattern was obvious and serious. She
worried about Diana’s future with Jack. She had planned to tell her daughter to delay the wedding
and preferably break off the engagement. Both of Diana’s friends said she should drop Jack. That
ended her fear of public embarrassment about cancelling the wedding.
Diana considered her dating history before Jack entered her life. She was physically attractive.
She had an engaging personality. She had dated often. Now she faced another incongruity. How
could she be doomed to a life of spinsterhood when she’d previously had many suitors? Diana
quickly saw that the spinster image didn’t jibe with experience.
Taking Action
Even when you know what is best for you, it may take a while before you act on that knowl-
edge. For example, Diana had accepted that she could never be happy with Jack, but she waded
through several weeks of viewing herself as a bad person if she were to hurt Jack’s feelings. She
feared that Jack would get angry with her, resent her, and reject her if she called off the wedding.
She imagined him towering over her shouting, “How could you do this to us? You promised to
marry me.” As a result, she continued to work on the relationship, hoping she could get through
to Jack about her wishes to be an independent partner, but he didn’t listen.
Diana faced another incongruous situation: if she couldn’t get through to Jack, and he had
already rejected her ideas and wishes for an equal partnership, what she feared most had already
been realized. She decided that she could not control Jack’s thoughts about her. She could proba-
bly never please Jack, however hard she tried, and especially when he prioritized drinking over
their relationship.
Through exploring her fear of rejection, Diana came to realize that she probably had a strong
fear of confrontation. Her strategy had been to duck conflict through appeasement, but that was
about to change. At a crowded restaurant, Diana told Jack that the wedding was off. She picked a
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public setting because she knew that Jack would not make a scene. However, Jack persuaded her
to give him a second chance. She suggested that he seek counseling, and he agreed.
For a short while, Jack was on his best behavior. He cut down on his drinking. He was less
inquisitive about her whereabouts. Within three weeks, however, he had dropped counseling and
resumed his old patterns. Diana’s anxiety escalated, but this time she recognized that her anxiety
was about her future with Jack.
Once she cleared through her mental anxiety clutter, Diana was better able to trust her real
feelings. She accepted that her anxiety was a signal that the relationship was not right for her. She
made the final break, and she had fewer anxieties to contend with.
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Behavior: What are you doing to impede your own health and happiness? Write it down. What
you would like to start doing? For example, would you like to act more assertively?
Affect: What negative emotions impact your psychic life? What generates these negative affects?
Is it cognitions, imagery, interpersonal conflicts, or what? How do you act when you feel anxious?
Sensation: What sensations do you associate with your anxieties and fears? For example, do you
tend to panic when you feel irregularities in your heartbeat?
Imagery: How do you picture yourself when you are in a state of distress? Do you have a negative
self-image?
Cognition: What are your main anxiety or fear beliefs? For example, do you believe your problems
will never end?
Interpersonal: How do you manage relationships? Do you place demands on others? Do you avoid
social contacts?
Drugs/biology: What do you do to quell your tension? Do you smoke or drink when tense? Do you
take a walk to calm down?
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Now using the BASIC-ID framework, organize your information in the middle column under
“problem assessment” in this worksheet. Since the same problems can appear in more than one
modality, you’ll have to make judgment calls about what information goes where. The important
thing is to put key components of your anxiety or fear into an organized framework. Next, devise
and record prescriptive plans for each modality problem, using techniques from this book or of
your own invention.
Affect
Sensations
Imagery
Cognitions
Interpersonal
Drugs/biology
If you wish, number the modalities in their order of importance to you, so you can prioritize
what to address first, second, and so on. Based on your readiness level, execute your program, step
by step.
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1. Respect and honor your basic needs. The best way to fight anxiety is to seek out what
gives you emotional fulfillment. You are most anxiety prone when your helpless beliefs
disconnect you from your beliefs in your ability to execute your positive capabilities.
Remember: stop protecting and start expressing.
2. Reflect by taking a step back to regain your perspective and to reconnect to your
ledger of affirmative experiences where your persistence paid. Tune into your natural
strengths.
3. Select the most powerful tools particularly molded to your needs. Plan your approach
and remember your options.
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What are three key ideas that you took away from this chapter?
1.
2.
3.
What top three actions can you take to combat a specific anxiety or fear?
1.
2.
3.
1.
2.
3.
What did you gain from taking action? What would you do differently next time?
1.
2.
3.
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PA R T I V
Exercise your free will and free yourself from needless inhibitions.
Fortify yourself to build resilience against needless anxiety and to prevent relapses.
C H A P T E R 19
If you expect yourself to be flawless and make your value as a person dependent on meeting perfect
standards, then you are falling into a contingency-worth trap. In this world of fixed convictions, it
is not enough to do well; you have to do perfectly well. It’s not enough to have typical perfor-
mances; your performances must be exceptional. You have to avoid mistakes at all cost, lest others
evaluate and reject you.
Fear of making mistakes cuts across conditions where perfectionism is maladaptive (Sassaroli
et al. 2008). This negative perfectionism weaves through different forms of anxiety. Depression
and perfectionism can coexist (Clara, Cox, and Enns 2007). Anger and perfectionism can coexist
(Saboonchi and Lundh 2003). Substance abuse and perfectionism can coexist (Holle and Ingram
2008). Intolerance for uncertainty and perfectionism can coexist (Reuther et al. 2013). Because
perfectionism weaves through so many distressing conditions, it’s not surprising that perfectionism
is an important transdiagnostic factor (Egan, Wade, and Shafran 2011).
If you’ve locked yourself into a perfectionism trap, you can use CBT to exit this self-imposed
misery. CBT is effective for perfectionism (Riley et al. 2007). There is compelling evidence for
favorable neural-biological changes following the use of CBT for perfectionism (Radhu et al. 2012).
These favorable changes will buttress you against the fallacy that through achieving infallibility,
you’ll gain complete control over your emotions, others, and life.
PERFECT-PERSON TRAPS
Ordinarily, you can change perfectionist thoughts and beliefs that interfere with leading a quality
life. These thoughts occur in different contexts and come in several different, overlapping forms.
The Cognitive Behavioral Workbook for Anxiety
Self-Perfectionism
Self-perfectionism reflects a philosophy that says, “I must behave in a certain way or I am
unworthy. I must not make mistakes. I must have approval to feel worthy. I must maintain my
image and appearance at all costs.” Who wouldn’t feel anxious under these conditions?
To question these ideas, you can focus on what you can do rather than theoretical ideas about
who you should be and what you must do.
Social Perfectionism
Social perfectionism is the view that others should comply with the way you see the world.
This usually backfires. Other people typically have their own notions of reality, and these notions
may fit with your views only some of the time.
To build emotional tolerance, you can learn to accept—not like—that others don’t have to
think and feel as you do. In this enlightened state, you are likely to avoid people whose character-
istics you don’t like. You are likely to pick your friends among those who share your interests and
values and trust. You’ll feel less emotionally rattled when things don’t go your way.
Learning Perfectionism
Learning perfectionism is when you are your own worst critic when it comes to learning a new
skill. You may be able to accept awkwardness in others’ efforts that you can’t accept in yourself.
The fact is that anyone can experience awkwardness when building a new skill. Some failure
is instructive. How else can you learn? Accept that learning and frustration go hand in hand, and
you may feel less self-conscious when it comes time to learn something new. Instead, you may feel
curious.
Performance Anxiety
Performance anxiety may trap you when you believe that you must succeed in whatever you
undertake. There can be no mistakes. A writer keeps revising a book. The work never gets done
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because it is never perfect. The inventor abandons a promising idea because she has no guarantee
of success.
To exit this trap, teach yourself to recognize that the development of complex ideas and things
is a process. For example, a great invention rarely starts out perfect.
You can then perform to the best of your abilities and keep chipping away until you meet
reasonable-quality standards.
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If you like the feel of an aspiring philosophy, the next time you start to use a requiring-
philosophy word, stop and see if you can switch it to an aspiring-philosophy word.
While there is no law that says you must choose an aspiring philosophy over a requiring phi-
losophy, doing so is likely to have positive consequences.
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Contingency 1: “I have to be a winner.” You may think that you have to win all the time, but
this belief will make you feel like a loser whenever you don’t measure up to your own expectations.
It’s important to question the idea that not winning all the time makes you a loser. It is helpful to
remember that you are the same person whether or not you find yourself successful in all the big
and small things that you undertake. Winning can yield advantages, but doing less well sometimes
than you’d prefer makes you no more of a loser than misspelling a word makes you incompetent.
Contingency 2: “I have to be in control, or else I will feel helpless.” With this contingency in
place, you can make yourself feel extra anxious over the idea that without perfect self-control, you
are powerless. You may also think that you can’t make self-improvements unless you have all the
power you think you need. But if being in perfect control is the only solution for overcoming a
feeling of powerlessness, and you also believe that you are powerless to change, then how can you
ever be in control? One way out of this dilemma is to accept that perfect control is a myth, that
partial control is better than no control, and acceptance of what you can’t control is a form of
control where you’ve chosen reality over despair.
Contingency 3: “I must be comfortable to feel secure.” If you think that to feel secure, you have
to be comfortable, what happens when you start to feel uncomfortable? Will telling yourself that
you must be comfortable help? You now have another dilemma. You can’t escape discomfort. For
example, facing uncertainty can feel uncomfortable. Conflicts are inevitable, and they can feel
uncomfortable. Thus, if your freedom from anxiety depends upon consistently feeling comfortable,
and some discomfort is part of living, you can’t win. Accepting this reality is a step in the direction
of relief from fear of discomfort.
Contingency 4: “I must have universal approval to feel worthwhile.” It is usually a good idea
to get along with others. Approval is beneficial. But what if you can’t be loved by everyone, and yet
you think you need everyone’s love? This contingency for happiness is a formula for anxiety, par-
ticularly if you doubt that you can get the approval that you think you need. Preferring approval
to disapproval is normal. However, you can’t please everyone. Keep that in mind and you are less
likely to torment yourself over what you can’t control.
You may be afraid of making mistakes and try to avoid making them. You can use behavioral
exposure interventions to overcome the kind of fear that you experience when you are in a situa-
tion where erring is possible.
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Ending Perfectionist Thinking
What are three key ideas that you took away from this chapter?
1.
2.
3.
What top three actions can you take to combat a specific anxiety or fear?
1.
2.
3.
1.
2.
3.
What did you gain from taking action? What would you do differently next time?
1.
2.
3.
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CHAPTER 20
In The Glass Menagerie by Tennessee Williams (1974), shy Laura Wingfield lives a quiet, isolated
life with her collection of glass animals. Having a slight limp, she magnifies its significance, identi-
fies herself with it, and limits herself because she sees herself as an unwanted invalid. Desiring love
and companionship, she also fears exposing her inadequacies and getting rejected. She inhibits a
normal desire because of her fear.
If, like Laura, you hold yourself back in areas where self-expression and assertion are highly
appropriate, what can you do to liberate yourself? You have choices. You can do nothing and stay
stuck in patterns that you want to escape but are afraid to abandon. You can wait until the time is
right, but chances are you’ll be waiting a long time. You can take corrective actions starting now.
If it is important enough to do, avoid letting your excessive inhibitions stand in the way.
The acronym PURRRRS stands for pause, use your resources, reflect, reason, respond, review,
and stabilize. You can use the PURRRRS method to exercise your free will to reduce needless
inhibitions. PURRRRS will also help you combat feelings of inadequacy associated with an inhib-
iting anxiety. You’ll also learn to develop the kind of patience that comes from working out prob-
lems in lieu of automatically withdrawing and avoiding healthy challenges.
Pause: When you suspect that you are excessively inhibiting yourself, pause and consider what is
happening. Are you feeling tense, tight, and restricted? These emotional cues can connect to
inhibiting thoughts.
Use your resources: What resources can you use to resist falling down the slippery slope of inhibi-
tion? How about patience? As a start, you can agree with yourself to suspend judgment about your
inhibitions until you’ve worked through the problem situation.
Reflect: Most excessively inhibited people are skilled at finding examples to support their inhibi-
tory beliefs. At this stage, agree with yourself to take a self-observant view. Step back and map out
your thoughts and beliefs.
Reason: You’ll often find incongruities between your inhibitory beliefs and your emotional and
social capabilities. Contrast your inhibitory beliefs with an adaptive perspective. First identify
examples of skills showing that you possess competency (you can think; you can reason; you have
accomplishments and achievements). Next, contrast examples of inhibitory thinking with these
examples of competency. You now have an incongruity. Which is right? Finally, ask yourself what
behavioral steps you can take to build upon your capabilities and decrease your needless inhibi-
tions. These steps form your action plan.
Respond: Armed with a reasoned way to address your inhibitions, you now take action. You follow
the steps that you outlined in your action plan.
Review: After taking action to contend with an excessively restricting inhibition, you can look at
results and then decide if you can improve upon what you’ve done. What actions bear repeating?
What seems promising that you can modify? What actions merit ditching?
Stabilize: How do you stabilize your self-improvements? Every new situation has its own unique
features. By creating experiences to defuse behavioral inhibitions, you learn what you can do in a
given situation. You learn how to give yourself the confidence that you can dispatch needless
inhibitions.
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PURRRRS Actions
Pause: Stop and prepare for action.
After reading the rest of this chapter, you may want to return to this PURRRRS exercise to
include other coping strategies that you’ve learned.
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OVERCOMING INHIBITION
Live a life of overly restrictive rules, and you’ll feel bound by excessive restraints. Living your life at
self-restricting extremes, you’ve lost sight of the Aristotelian golden mean. This is the desirable
range between excesses (when actions are driven by impulse) and deficiencies (when actions are
driven by inhibition). Buddhist philosophy also includes the concept of the middle way.
Go to a museum by yourself and ask total strangers what they think about the exhibits.
Go to lunch with someone who’s typically loud and boisterous. Does that person
draw attention in the restaurant? Who is the attention directed toward? How does
that matter?
As you do this exercise, you may want to keep a journal of the results. Review what happened.
What did you learn?
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How to Stop Inhibiting Yourself
By experimenting with activities that you would characteristically avoid, you position yourself
to overcome inhibiting anxieties. The next time you feel a surge of inhibition and you recognize
that your inhibition is unreasonable and excessive, you can remind yourself that you can overcome
inhibitory feelings.
Getting over feeling uncomfortable about using positive expressions may help you build an
adaptable and uninhibited outlook.
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When you are not listening to yourself, your ears can pick up sounds that otherwise might
have gone unnoticed. Your other senses are sharpened as well. Going back to your sensory roots
can get you out of an inhibitory mind-set.
ASSERTING YOURSELF
Alfred Adler (1927) thought that every change brings up apprehension and fears. Fears result from
how we evaluate the change. His solutions involve recognizing how you suffer interpretation errors
and educating yourself to remove these errors.
The conditioned-reflex therapist Andrew Salter (1949) took a more behavioral approach to
defeating inhibition. He recommended disinhibiting yourself by expressing yourself even if you
insult others. He believed such actions are preferable to an obsequious, inhibited manner. Salter
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How to Stop Inhibiting Yourself
went on to say that if you take extreme positions that oppose your inhibitions, you are eventually
likely to strike a balance. Salter is credited with starting the assertiveness movement.
Assertiveness in the aggressive sense that Salter suggests is currently out of vogue. Psychologists
Robert Alberti and Michael Emmons (2008) describe assertiveness as self-expression directed
toward equalizing relationships with others. Empathy, honesty, straightforwardness, and omitting
needlessly harmful statements characterize a healthy assertive style. For example, most people
regret holding back and are quite acceptant of negative results when they believe that they did the
best they could; some situations won’t work out, but you won’t know if you don’t try.
You could be both self-restrained and self-expressive at the same time. You understand the
value of holding back needlessly hurtful comments, and so you act with restraint. You also under-
stand that expressing your views is the very thing to do. A flexible balance between reasonable
inhibitions and honest self-expression is a worthy antidote to inhibitions that drive anxiety and
anxieties that drive inhibitions.
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How to Stop Inhibiting Yourself
What are three key ideas that you took away from this chapter?
1.
2.
3.
What top three actions can you take to combat a specific anxiety or fear?
1.
2.
3.
1.
2.
3.
What did you gain from taking action? What would you do differently next time?
1.
2.
3.
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C H A P T E R 21
Most people spend over half their waking hours reflecting and thinking about themselves (Morin
and Hamper 2012). It’s what and how you think that can make a difference in the quality of your
life. For example, how you think about yourself and about what you can do is central to your sense
of well-being and to whether or not you suffer from anxiety.
If you worry a lot about yourself, you are likely to be excessively sensitive to threats to your
sense of worth. You also are likely to exaggerate threats.
However, by addressing your needless anxieties and fears about yourself, you can forge a strong
and realistic self-concept that is based on your ability to meet worthy challenges.
Your Self-Worth
Whatever you believe about yourself represents your concept of your self. This concept may be
tied to your theory of worth, or how you judge your general sense of self.
Do you base your self-worth on your performance, appearance, mood, or other specific factors,
such as your contributions to your society? If so, you have a theory of worth that is based on con-
tingencies. For example, with a perfectionist mind-set, if you do well, you are worthy. If you don’t,
you are unworthy. If your group makes loyalty a criterion for worth, you are worthy if you are loyal
and unworthy if you fall short of this standard.
Contingency-worth theories are hotbeds for self-anxiety, or a general sense of uneasiness, vul-
nerability, and insecurity that you feel about yourself. For example, if you believe that you can’t
measure up to your own or others’ standards, you may feel anxious when you anticipate being in a
situation where you may expose your vulnerabilities. When exaggerating the risk of putting your-
self in an unfavorable light, you may cover up what you think you lack by even avoiding reasonable
opportunities to thrive that most others would undertake.
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Overcoming Self-Anxiety
worthwhile situations as risky and necessary to avoid. Sadly, your self-protectiveness is a poor secu-
rity blanket. For example, by masking your anxieties and fears from others and by avoiding chal-
lenges, you are maintaining your anxieties and fears. Can you break this pattern? You bet!
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dictionary (Allport and Obert 1936). A considerable number of words that describe the self, such
as worthy, significant, and insignificant, are linked to social cognition. But you are even more
complex than that.
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Overcoming Self-Anxiety
3. Figure out how the dots connect. Think of a circle filled with so many dots that they
merge together. The circle represents all your actions, qualities, and possessions. A
good dot may very well pay off, but it doesn’t generalize to making you a good person.
A bad dot may produce negative consequences, but it doesn’t make you all bad. By
separating ego (the dots) from the circle (the self), you can see that you can rate the
dots. Rating the self from a biased selection of dots is arbitrary.”
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To change your anxiety-thinking script to a positive one, you can create a pretend person, give
the person a name, and keep it to yourself. This pretend person can do what you’ve seen others do
effectively in similar circumstances; such actions are likely to have a positive impact.
After giving your pretend person a name, you design a new script to describe measurable and
achievable changes in your behavior. For example, instead of being tongue-tied around authority,
the pretend person may speak naturally, as if talking to a friend. Instead of habitually taking
blame, the pretend person assesses situations to determine where accountability lies. The pretend
person accepts conflict and deals with it.
In creating your script, you can turn a contingency-worth problem into a constructive alterna-
tive. Instead of defining your worth based on contingencies, you can turn these contingencies into
worthwhile goals. For example, improving your grades can remain a goal after you no longer see
your self-worth as tied to making straight As. If you want to improve your relationships with the
significant people in your life, work at achieving this goal. See what your pretend person can
accomplish!
1. Describe how you tend to anticipate acting in certain situations when you feel driven by anxi-
eties and fears. This is what you want to change. Write this in the third person (use “he” or
“she”).
2. Draft the new script to include the changes that you want to make. Describe what your pretend
person does in targeted situations. Consider how your pretend person would act without the
burden of fear: how would this person think, feel, and act differently? Describe your pretend
person’s approach.
3. When writing the script, define how you can have a positive impact on other people while you
are advancing your own interests. Consider how your pretend person will project his or her
voice, use body language, determine types of risks, and choose how to express ideas and
feelings.
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Overcoming Self-Anxiety
Test the script for about two weeks. At the end of that time, you’ll have figured out what to
drop, what to modify, and what feels right. If part of the role seems especially promising from the
start, extend it. If part of the role falls flat, modify it or drop it.
Try it out. See what you can accomplish. If you interpret a positive change in your behavior as
“faking it,” your self-view could be governed by this negative interpretation. However, whatever
you accomplish is within your ability to do: if you can fake acting nonanxiously, you can act
nonanxiously.
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What are three key ideas that you took away from this chapter?
1.
2.
3.
What top three actions can you take to combat a specific anxiety or fear?
1.
2.
3.
1.
2.
3.
What did you gain from taking action? What would you do differently next time?
1.
2.
3.
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CH A P T ER 22
You want to stop feeling self-conscious, insecure, and socially inhibited. You want to stop worrying
about making social blunders and looking like a jerk. You’re tired of receding into the background
at social gatherings, hoping no one will see you. You’re tired of your heart pounding and of feeling
flush and stiff in social situations.
Can you change a pattern of social anxieties and fears to one of confident composure? Knowing
what to do and taking action can help you to get past trepidations about going to weddings, joining
colleagues for lunch, meeting someone whom you’d like to date, or other social-anxiety conditions
that affect you. Using tested cognitive, emotive, and behavioral methods, you can face and resolve
your social fears in the context where they occur.
Cognitive behavioral therapy approaches for social anxiety disabilities are highly effective
(Butler et al. 2006). Neuroimaging studies show positive brain changes following the use of CBT
interventions for social anxieties (Galvao-de et al. 2013).
The psychological core of social anxiety includes at least three primary parts. You feel out of
emotional control in the social situations where you feel fearful. You anticipate being evaluated,
judged, disapproved of, and rejected. You dread the unpleasant physical and emotional sensations
that you anticipate will come about in social situations that you fear. With all this mental and
emotional commotion, you are likely to avoid social circumstances where you anticipate feeling
self-conscious and awkward.
Control is a transdiagnostic factor that cuts across different social anxieties and is a prime
target for cognitive behavioral therapy (Gallagher, Naragon-Gainey and Brown 2014). For example,
if you believed that you could exercise control over yourself, accept yourself with or without the
approval of a few others, and tolerate the physical sensations of tension, you might test social situ-
ations that you’d normally avoid or suffer through. This assertion of control coping belief can dra-
matically ease your social anxieties and fears.
Coexisting Conditions
Social fears and anxiety practically always have coexisting complications. Depression is
common (Ingram et al. 2005). Perfectionism is common (Ashbaugh et al. 2007). Alcohol and drug
abuse are common (Baillie and Sannibale 2007).
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19. “I feel very ill at ease around people I don’t know well.” 1 2 3 4 5
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From Social Anxiety to Social Confidence
30. “I have more courage after a few drinks (or getting high).” 1 2 3 4 5
Statements rated 4 or 5 suggest a problem area for you. If you rated ten or more items as 4 or
5, you could have a general social anxiety issue to resolve. However, its something you can address.
The core transdiagnostic issues may be as straightforward as anxiety over feeling out of control,
evaluation anxiety, or anxiety over feeling awkward and fearful. By overcoming a core feature of
social anxiety, such as evaluation anxiety, you may teach yourself to feel at ease in social
situations.
You face a special challenge when you have social omissions in your life. You may be missing
out on opportunities to establish desired social relationships, pick up on positive social cues, make
community contributions, and follow a satisfactory career track. An anxiety-avoidance process
can be so automatic that your discomfort-dodging efforts are obscured from view as they are
silently woven into the fabric of your life.
Using your personal observations, an examination of social omissions in your life, and the
results of the inventory, what is your most significant social anxiety or fear? Write it down. Work
at whittling it down.
After you’ve worked for a while to reduce your social anxieties, retake the inventory to check your
progress.
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SOCIAL AWKWARDNESS
Some people suffer from social awkwardness, and because of this, they often procrastinate by
diverting themselves to safer behaviors and situations. Social awkwardness can take many forms.
• June’s Story
June has a warm, personable quality and feels at ease meeting new people. Despite her
comfort with meeting and talking to people in social situations, June has an extreme
public-speaking anxiety. Because she is afraid to speak before staff and customer groups,
she refuses job promotions. She imagines herself turning red, becoming tongue-tied, and
then running from the stage in disgrace. She says she’d rather spend a year in a dungeon
than deliver a talk.
• Don’s Story
Don and Ellen have an intimate date at their favorite restaurant. Ellen feels happy about
the occasion and is animated and expressive. Don finds her too loud. He believes that she
must be disturbing the other patrons. He criticizes Ellen for her loudness. Ellen suggests
that he has a warped sense of values: she’s the one he’s going home with, not the strangers
at the next table.
What do Tom, Bob, June, and Don have in common? Each acts self-consciously. Each expects
to be evaluated. Each expects rejection. Each feels unpleasant physical fear sensations associated
with social anxiety.
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Keep fighting fear. Fear of fear feeds on itself. Plan to survive this temporary discomfort. You’ll
find that you can survive it. Emotional tolerance is a prelude to feeling more comfortable with
yourself in social situations.
Maintain perspective. Avoid focusing on your fears. Instead, ask others questions about them-
selves. You’ll find that people are more than happy to talk about themselves.
Watch the worry. You fret about possibly acting inept. Correct this worry by instructing yourself
to suspend judgment. Then act as if you were capable of communicating well with most others.
Give up playing Nostradamus. Predicting the world will crash down on you if you make a social
blunder is an imaginary crisis. The anxiety from such false predictions is real enough. But you can
work on changing your crooked thinking.
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Avoid anticipatory anxiety. If you catastrophize about future dangers to your ego, picture yourself
breaking a magnifying glass, and then imagine that your catastrophizing vision is shattered.
Level your language. Hyperbole, such as “I will disgrace myself forever if I make a social misstep,”
is an egregious overgeneralization. Intentionally make a minor misstep to show yourself that it’s not
the end of the world.
Beware of your definitions. Define a type of social event as a staging ground for looking like a
fool, and you are likely to feel the way that you think. Redefine the event in a more positive light,
and you will feel better.
Accept feeling awkward. Your feelings may be factual, but they are not the same as facts. If you’re
anxious about being socially awkward, realize that some people will find your manner charming.
Try to take an “it is as it is” acceptance view.
Handle self-handicapping. Don’t avoid a social gathering with the excuse that you will fail.
Instead, imagine yourself cordially communicating.
Defeat your needless inhibitions. Practice doing something as basic as introducing yourself to
people in a group.
Pen yourself in. Instead of waiting for someone to rescue you, push yourself to participate.
Bring yourself into the fold. Make a comment about something in the immediate area, such as
the weather.
Address your ambivalence. Asking yourself Should I or should I not say something? is a formula for
letting a conversation float past you. Assume that you should, and you are likely to be right.
Think less doubtfully. Abandon second-guessing yourself about what you should say. When in
doubt, speak up.
Don’t let your mind go blank. You can always say, “Hello.”
Retreat from rejection. Fear of rejection is ordinarily a fictional fear. If someone justifiably rejects
an idea of yours, you can still accept the parts of your idea that remain valid.
Use bashfulness as a positive signal. Instead of looking aloof, look at others as potential friends.
Manage your modesty. Get into the habit of daily sharing a positive attribute that characterizes
you. You may blush less.
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Watch your wariness. Don’t take a backseat. Assume that some of the people whom you meet will
be friendly. See if you can find them.
Accept feeling shy. If you are naturally shy, you won’t eliminate this natural tendency. However,
you can choose to manage your shyness. Try to discover other people’s special interests by asking
them questions. Do this and you may be seen as a brilliant conversationalist, even if you say little
about yourself.
Don’t expect immediate jubilance. If you warm to new social situations slowly, know that you are
not alone and not odd.
Avoid blaming your amygdala. Social anxieties correlate with a sensitive amygdala. Nevertheless,
you can buffer yourself from needless stress by habituating to it. That means practice, practice,
practice communicating to others until you are no longer afraid.
Downplay listening to your heart. Attending to your heartbeat shifts your focus from what you
are doing to how tense you feel. Participate. Your heart will take care of itself.
Mind your body language. Habitually gaze downward and you’ll look insecure. Hold your head
up. Glance around without staring. This signals confidence.
Nod your head “yes.” Nodding signals approval. Most people like approval.
Try to smile. Think of something pleasing and let your smile extend from the thought.
Don’t read too much into facial expressions. Assumptions about the causes and meanings of
others’ facial expressions are risky. We do have an inborn tendency to read faces, but not all faces
are easy to read.
Attend to the facts. Shift from self-absorbing thoughts to objective observation of what is going
on. Respond based on an objective awareness.
Reevaluate. To avoid rejection, you believe you must make a great first impression. Plan to make
a reasonable impression, and let the chips fall where they may.
Ditch your false expectations. You don’t need to be the life of the party if that is not your style.
Flip things around. If you fear total rejection, so you wither in silence in the corner, instead
pretend that you’ll get a million dollars to engage 10 percent of the time. I’ll bet you can do it.
Don’t think you must dominate. Show interest. Share a few thoughts. Let others talk. Put in your
two cents’ worth when a topic appeals to you.
Prepare to be pleasantly surprised. You may make serendipitous connections with people.
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Don’t wait to say only perfect things. Accept the concept of the cocktail party syndrome. People
will rarely stay on topic and will invariably introduce their own agendas into a discussion.
Avoid conditionals for socializing. Waiting to feel comfortable before venturing out rarely works
well. It’s a form of procrastinating. Test the waters and see if social comfort follows.
Quell your self-consciousness. You are probably more aware of your state of mind than anyone
else is.
Separate anxiety from context. If you act socially fearful in some situations but not others, how
does what you tell yourself differ in these contexts?
Challenge feeling inferior. Instead of concentrating on what you think you lack, play on the
strengths that you have.
Exercise your strongest social skills. List what they are. Use one each time you are part of a social
gathering.
Ditch the shame. You’re not globally worthless for being you. You just think you’re something that
you are really not.
Derail irrational guilt. It’s silly to condemn yourself for errors that only you observe.
Don’t defect-detect. For every fault you find in yourself, find a positive attribute that others may
observe.
Think ahead. Plan to live through social tensions. Eventually you’ll have fewer to live through.
Resist withdrawing into a bottle of wine. Alcohol-dulled senses are a staging ground for prob-
lems and for tensions that are catalysts for further drinking.
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From Social Anxiety to Social Confidence
theory of mind (Krause et al. 2012). Theory of mind also takes into account that some people have
interests, beliefs, and motives that are different from yours and different from what you expect
them to be.
Rather than embrace the looking-glass effect, you may correctly infer that some people think
differently from what you expect them to think. With that perspective, you may be less inclined to
jump to conclusions about what other people think of you. Instead, by exploring where you may be
right, wrong, or unsure about others’ impressions of you, you can stop looking through a distorted
looking glass and see more clearly through the lens of reality.
Reasonable beliefs about the event: “I’d like to have done better, but you can’t win them all.”
Variability—not perfection—typifies life.
Emotional and behavioral consequences: Disappointment and unhappiness with the result.
Review feedback and take advantage of the information to improve future performances.
Awfulizing beliefs about the event: “This is awful.” “I’m a failure.” “People hate me.” “I’ll
never live this down.”
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You can use the ABCDE method to combat awfulizing or any other irrational belief that fuels your
social anxiety.
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From Social Anxiety to Social Confidence
Effects of disputes:
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What are three key ideas that you took away from this chapter?
1.
2.
3.
What top three actions can you take to combat a specific anxiety or fear?
1.
2.
3.
1.
2.
3.
What did you gain from taking action? What would you do differently next time?
1.
2.
3.
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CHAPTER 23
Do you feel like you are going through life mired in misery? Do you see yourself as a poster child
for Murphy’s law, where if something can go wrong, it will go wrong? Do you spend a lot of time
either worrying or in a depressive funk? Perhaps you suffer from mixed anxiety and depression.
When anxiety and depression combine, you may feel distraught and think, I feel like a hopeless
mess. Your tolerance for inconvenience and discomfort is likely to be unusually low. If left unad-
dressed, mixed anxiety and depression can linger. That doesn’t have to be. (For more on how to
cope with depression, see The Cognitive Behavioral Workbook for Depression, listed in suggested
reading.)
Whether you seek professional help, engage in self-help, or do both, it is useful for you to know
that you can address anxiety and depression simultaneously with evidenced-based methods. You
have reason to be optimistic. This chapter will first explore research findings on mixed anxiety
and depression. It will then help you work on recognizing and combatting powerlessness thinking
in anxiety and depression.
2011). But regardless of which came first, you can develop the use of CBT methods to gain relief
from both conditions (Norton, Hayes, and Hope 2004).
Actions to reduce anxiety can carry over to reduce depression. For example, CBT and related
evidence-based methods appear effective for people with depression and anxiety in medical set-
tings (Campbell-Sills et al. 2012). If you have a mixed anxiety and depression, by acting against
your anxiety, you may not have to deal directly with an accompanying depression (Fergus et al.
2013). If you also suffer from panic, neither anxiety nor depression need impede coping with that
condition (Allen et al. 2010).
Bibliotherapy is helpful to a subgroup of people with depression (Gregory et al. 2004). If you
specifically address depression, you can use CBT methods to effect changes in higher brain func-
tions that are associated with a reduction in depression (Goodapple et al. 2004).
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Coping with Mixed Anxiety and Depression
double trouble of distress, where you lament over lamenting. You may view yourself as powerless to
stop feeling depressed, but you can change this thinking. Coming to terms with what has hap-
pened involves developing a sense of acceptance. In time, you can turn the jolt of a loss into a sad
remembrance.
Having solutions available and using them are two different things, however. When anxious,
you may procrastinate on testing promising solutions. You may tell yourself that you are too over-
whelmed. When powerlessness thinking dominates, you may not want to try. But thinking you are
powerless to change doesn’t make that true.
Does it help to look for incongruities in your thinking? For example, you may think that you
are powerless to cope, but can you think of a time when you coped effectively and thought of
events differently? If so, the fact that you can change your thinking suggests that you can’t be
powerless over your thoughts.
You can feel powerless over your emotions when you believe you are under the thumb of
outside forces that you can’t control: “Jack made me mad.” But if Jack makes you mad, and you
can’t control Jack, what can you do? You can own responsibility for your part of the problem: What
do you tell yourself about Jack’s behavior that evokes anger? What are the flaws in your
thinking?
By flipping things in your mind, you may come to see that the feeling of being powerless is a
temporary state. If you have the power to create fearsome images, you can use imagery to alter
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powerlessness thinking. Although your thoughts may appear like dark clouds on the horizon, you
can judge them without judging yourself.
You may believe that you are helpless to change even though you have evidence that you can
make voluntary changes. How do you reconcile this incongruity? Perhaps the answer is to recog-
nize that you can change unwanted parts of your thoughts, feelings, and actions even if changing
is difficult.
Pause: If you are feeling powerless to change, take time out to work out this problem.
Use your resources: Put yourself into a problem-solving mind-set. The problem, in this case, is
powerlessness thinking. Write out your thoughts or record them using a tape recorder so that you
can review them.
Reflect: Look at or listen to your recorded thoughts, and then think about your thinking. What
part of this thinking represents an assumption? For example, do you tell yourself that you can do
nothing to improve your ability to cope? Does this translate into a core belief that you are power-
less to change? If so, then move on to reasoning it out.
Reason: Look for exceptions to powerlessness thinking. Have you ever thought of yourself as pow-
erless and then found something you could do to make a difference? Do you have the power to
accept reality even though you may not like it?
Respond: What steps can you now take to deal with powerlessness thinking? What step will you
take first? What step will you take next? Can you act to change your thinking through doing an
ABCDE analysis (see chapter 11)?
Review: What if you devise a good plan and then you procrastinate? When you are engaged in
this behavioral procrastination process, does powerlessness thinking contribute to subverting per-
sistence? For example, is it that you expect yourself not to finish, and then you do what you expect?
But how can you be powerful enough to prepare, to start, to move forward, but not powerful
enough to finish? This type of review can be revealing. Now armed with this new information,
reconsider what is happening. Try again.
Stabilize: Routinely take self-directed efforts to challenge powerlessness thinking in all its forms.
Review what works for you, and redo it. Practice, practice, practice strengthening your reason to
buffer yourself against the fictions of powerlessness thinking.
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Coping with Mixed Anxiety and Depression
Target thinking:
PURRRRS Actions
Pause: Stop and prepare for action.
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Top Tip: How to Talk and Walk Your Way Out of Anxiety
Dr. Clifford N. Lazarus, multimodal therapist, author of Don’t Believe It for a Minute: Forty
Toxic Ideas That Are Driving You Crazy, and the cofounder of the Lazarus Institute in
Skillman, New Jersey, describes two common thinking errors that occur in both anxiety and
depression. Lazarus shares this tip:
“As is often the case with depression, it is challenging to talk yourself out of anxiety. To
truly conquer a mixed anxiety and depression, you need to take specific steps, such as
recognizing and combatting two common thinking errors. As anxiety often precedes a major
depression, I’ll tell how to combat anxiety before it spreads into depression.
“Anxious people greatly overestimate the chances of a dreaded event happening and the
seriousness of the consequences of the bad event if it actually happens. First, anxious people
often confuse low possibility calamities (i.e., very unlikely bad events) with high probability
occurrences (i.e., very likely events). In other words, they confuse the possible with the
probable. The second common cognitive error is to overestimate the impact of bad events. In
other words, anxious people usually believe that if something bad happens, it will produce a
dramatic or even devastating consequence that might be too much to handle.
“Once you contain and correct these mental miscalculations, you can more easily begin
to face and overcome the situations that trigger your anxiety. Indeed, exposure to anxiety
triggers is the most important part of the anxiety solution.
“To understand why exposure is such a key part to this process, it helps to think of
anxiety as a psychological allergy. If someone suffers from environmental allergies (like pollen,
ragweed, or pet dander), it’s because his or her immune system is overly sensitive to those
triggers (technically called allergens). Instead of having a minor reaction or no reaction when
exposed to certain allergens, an allergy sufferer’s immune system launches a dramatic reaction
resulting in the misery of an allergy attack.
“In anxious people, it’s not their immune systems that overreact to the trigger of a
psychological allergen (some perceived threat or danger) but a vulnerability in their nervous
systems, which often leads to the misery of anxiety. And just as allergy sufferers can be
successfully desensitized by exposure to gradually increasing doses of the very stuff they’re
allergic to, people who suffer from the psychological allergy of anxiety can be desensitized,
too.
“You can help yourself to stop overreacting by gradually exposing yourself to the very
situations that evoke your anxiety. For example, if you feel anxious about making a mistake,
intentionally make mistakes under controlled conditions. As with allergy desensitization, over
time your nervous system tones down and eventually stops overreacting to the stuff that used
to set off an anxiety reaction.”
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Coping with Mixed Anxiety and Depression
What are three key ideas that you took away from this chapter?
1.
2.
3.
What top three actions can you take to combat a specific anxiety or fear?
1.
2.
3.
1.
2.
3.
What did you gain from taking action? What would you do differently next time?
1.
2.
3.
243
CHAPTER 24
However great your progress, anxiety thinking and negative feelings may not entirely disappear.
You lose a few nights of sleep, and an old maladaptive anxiety habit can creep back.
However, lapses don’t have to be as intense, durable, and frequent as they were before. You can
recover more quickly. If you are not perfectly consistent in managing your worries and troubles,
you don’t have to look at yourself or the situation negatively. As the saying goes, if you fall off a
horse, get back on again.
When it comes to reversals, it helps to look at the big picture. With a little perspective, you can
see that you can avoid double troubles over lapsing and relapsing if you keep yourself from magni-
fying setbacks into catastrophes. You also can see that you have cognitive, emotive, and behavioral
tools to assert control over new or older anxieties. You can see that you can tolerate tensions,
which is not the same as liking them. And most importantly, you can see that life is more than just
contesting anxieties. It’s what you choose to make it. This big-picture thinking gives you a legiti-
mate form of control over anxieties if they recur.
If you assume that change is a process and not an event, it is easier to accept the ups and
downs of self-improvement and personal growth. Looking at change this way is far less taxing than
thinking that if you slide back, everything you’ve done so far is worthless.
Each new anxiety event gives you an opportunity to hone your cognitive, emotional-tolerance,
and behavioral skills. But you don’t have to wait for anxiety to spontaneously recur in order to
practice. You can use these skills regularly to actualize your finest qualities.
The Cognitive Behavioral Workbook for Anxiety
RALLY YOURSELF
Here are five quick steps to rally yourself against an emerging anxiety. You can use them in any
order:
Review the key ideas, action plans, and exercise sections in each chapter of this book. This is
a quick way to access what you found most important to think about and to do. As a maintenance
measure, review this written record whenever you face an anxiety situation. As a prevention
measure, review this record monthly.
Deal with double troubles. When anxieties and fears return, double troubles typically follow.
This secondary distress comes in different forms: blaming yourself for backsliding, worrying about
worrying, feeling disturbed about feeling disturbed, and getting depressed about feeling depressed.
You’ll do much to prevent adding to your distress if you deal with these double troubles when they
arise.
Do a BASIC-ID review for diagnostic, prescriptive, and maintenance purposes. What’s going
on with each of the modalities? If there is a hot spot, ask yourself what you can do about it. Then,
act! The system’s pioneer Arnold Lazarus (1992) recommends a monthly BASIC-ID review as an
early warning system (see chapter 18).
Invoke PURRRRS to engage your self-observant abilities. When you control your anxiety through
PURRRRS, you position yourself to control the outcome (see chapters 20 and 23).
Use your ABCDEs to challenge anxiety thinking. As you practice the ABCDE method (see
chapters 11, 16, and 22), you will get better at using it. As you get more skilled, you will find less
need to use it.
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Preventing Anxiety and Fear from Coming Back
and other stress responses increases your risk for hypertension, coronary heart disease, and diabe-
tes (McEwen 1998). The abuse of tobacco, high caffeine intake and amphetamines, and alcohol
abuse to ameliorate stress does nothing to alleviate long-term stress and much to compromise your
health.
You can reduce psychological stresses by developing and strengthening your ability to cope
with real and imagined threats and adversity (Holden 1992). Indeed, developing and applying
effective problem-solving and coping skills is a way to assert control. Actions to reduce stress and
improve your health involve engaging in a healthy form of stress (Nelson and Cooper 2005). This
propellant stress (p-stress) results from efforts to solve problems (Knaus 1994). But what do you
target to solve?
The rest of this chapter concentrates on three main areas—liberating your mind, fortifying
your body, and using your intellect, ingenuity, and will—to lighten your allostatic load, stabilize
gains, and get ahead.
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The Cognitive Behavioral Workbook for Anxiety
Practice a nonjudgmental view. Anxiety thinking has consequences; you can eval-
uate and debunk the thoughts to eliminate the consequences. Judging anxiety-
evoking beliefs, without judging yourself, is a responsible action.
Look for incongruities in your thinking and act to resolve the incongruity. For
example, if you label yourself a loser for backsliding, does that mean that everyone
else is also a loser for having the same human tendency? If so, why? If not, why not?
The chances are that you will see your original thought as an overgeneralization
and possibly laugh when you do.
Construct a picture in your mind where you view yourself as steady on your feet
when facing adversity. Under adverse conditions, imagine asking yourself, What is
the problem here that I can solve? Imagine yourself solving the problem. Then do
what you imagine.
Remind yourself that anxiety and fear thoughts are simply passing thoughts. They
are part of how you are thinking at the moment. They neither last forever nor
define the global you.
By drawing on your experiences and using your insight and practical judgment to clarify what
is going on in and around you, you can continue to make positive changes.
Physical Exercise
Although there is some evidence that exercise is helpful for reducing anxiety (Berk 2007),
getting regular exercise is probably more of a general health initiative than it is a tool for reducing
anxiety. Aerobic exercise helps to reduce your allostatic load, and as a by-product you may find
that your heart rate and blood pressure will go down and your immune system will strengthen
against disease. Even moderate exercise—walking four days a week for thirty minutes a session—
can have a positive effect. Exercise also has short-term benefits. You are likely to feel better, pay
better attention, and be able to concentrate better following physical exercise.
How you exercise is up to you. You have an obvious range of possibilities, from running in
place, kayaking, riding a bike, working out at a gym, or walking on an inviting nature trail along
a river, which can increase a sense of tranquility (see chapter 8). Activating music increases length
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Preventing Anxiety and Fear from Coming Back
of stride, vigor, and speed in synchronized walking (Leman et al. 2013). Consider transmitting this
music through earphones as you walk.
Quality Sleep
Sleep loss is common among people with anxiety—perhaps as high as 70 percent (Belleville et
al. 2010). Poorer sleep quality impairs your ability to regulate and reduce negative emotions (Mauss,
Troy, and LeBourgeois 2013).
Without enough sleep, you may have problems concentrating on tasks and monitoring your
anxiety-related thoughts and performances. Fatigue and being easily distracted can result in the
pressure of running out of time on important tasks. Furthermore, worrying about getting things
done can interfere with sleep. CBT delivers empirically supported methods for improving sleep
patterns (Yang and Hsiao 2012).
Difficulty sleeping can result from such a wide range of causes that there is no one perfect
system to relieve this state. Nevertheless, CBT techniques are especially useful for sleep problems
related to worry and other stressful cognitions.
Say you feel stressed about work. It’s midnight. You’d like to settle down and sleep. However,
you lament yesterday’s mistakes. You worry about tomorrow’s problems. You are mindful of the
sleep that you expect to lose. You don’t want to feel fatigued tomorrow. You want to stop worrying
so you can fall asleep. You tell yourself, I have to stop worrying. I have to fall asleep. Now you feel
more awake than you did before. You want to stop fretting and free yourself from this emotional
turmoil. You struggle to rid yourself of unwanted negative thoughts. You tell yourself, I’ve got to fall
asleep. I’ve got to fall asleep! The harder you try, the more distress you feel.
Similarly if someone were to tell you not to think of a pink elephant, you would likely think of
a pink elephant. To rid yourself of the pink elephant, you might try to distract yourself. You might
think of a purple fox. Nevertheless, the pink elephant would remain on your mind. The harder you
try to snuff out the image, the brighter it shines.
When you are emotionally charged, you are less likely to fall asleep. So how do you fall asleep?
Start with a passive volition exercise, in which you practice an attitude of allowance. It boils down
to this: If I think of a pink elephant, I think of a pink elephant. So what? By giving up the struggle, you
may no longer have the pink elephant on your mind. Similarly, by allowing yourself to stay awake
without trying not to, you might find that you are able to sleep after all.
Here are some other cognitive, emotive, and behavioral techniques for improving sleep
patterns:
Follow a regular sleep schedule. Go to bed when you are likely to feel sleepy.
Recognize that even if you worry about staying awake, you will get rest of some
kind if you lie still. You probably will slip into and out of sleep and get more rest
than you think.
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Try white noise to muffle outside sounds. A good example of white noise would be
the sound produced by a nonoperating television channel. Turn down the volume
and put on the TV timer so that the set shuts off, say, in sixty minutes.
Avoid associating your bed with wakefulness. When you are unable to sleep, get out
of bed. Return in a few minutes. You may feel more ready to sleep.
Do moderate aerobic exercise during the afternoon every day.
If you know or suspect that you have a medical condition affecting your sleep, make a medical
appointment.
Eating Sanely
Active efforts to exercise and maintain a healthy weight reduce cardiac risk up to 79 percent
(Völler 2006). When you are overweight, weight loss appears to improve health across the board
(Foreyt 2005). There is an obesity paradox worth noting: you can have a normal weight but carry
excess fat, and this increases your risk for coronary heart disease (Chaikriangkrai et al. 2014).
There is currently no definitive study on whether being overweight causes anxiety (self-
consciousness about body image) or whether anxiety causes you to be overweight (using food for
comfort). The key word, however, is “sometimes.” Sometimes it is one way, sometimes another.
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Preventing Anxiety and Fear from Coming Back
Whether excess fat is a result of anxiety or a cause, the extra stress on the body is an allostatic load
factor.
Habits of eating excessively or inadequately do not easily yield to the intellectual decision to
adopt sane eating habits. This is especially the case when anxious and you use food for comfort,
or when you starve yourself because you are anxious over your appearance and obsessed with
losing weight.
Setting weight goals that you need to stretch to achieve may be a wiser course of action than
setting them too low (De Vet et al. 2013). However, it’s the process of how you go about making and
sustaining healthy eating changes that makes the difference. The no-diet-diet plan is an example of
a process goal that you can stretch to achieve (Knaus 2012). With this plan, you attend to both the
process—how you go about fortifying yourself by eating sanely—and the outcome of minimizing
excess fat. Use it to shed fat if you carry too much or to put on weight if you are too lean:
Set a desirable weight—something you can stretch for but also achieve.
Plan to consume daily the number of calories you need to reach and maintain your
desired weight.
Eat appealing food in proper proportions with the necessary nutrients for a bal-
anced diet.
Suppose you are a five-foot-five forty-year-old woman who weighs 150 pounds, and you want
to weigh 125 pounds to prevent future health problems associated with carrying too much fat. You
exercise moderately.
With moderate exercise, it takes about 2,100 calories a day to maintain your weight at 150
pounds. If you want to weigh and stay at 125 pounds, it would take about 1,919 calories per day.
There are many free calorie calculators on the Internet to figure out your daily calorie require-
ments to reach and maintain your desired weight given your activity level. Some calculators will
give you a time frame for how long it will take to reach your goal. As a rule of thumb, you lose a
pound for each 3,600 fewer calories you consume or burn off by exercising. You gain a pound for
every 3,600 extra calories you consume.
If you are like most people, you won’t establish perfect control over the no-diet process. Expect
variability in both the process and the result, and you won’t be disappointed. Adjustments are typi-
cally necessary. If you have an illness, you may not be able to moderately exercise. Don’t look for
perfection; rather, work at improving the process. By the time you reach your desired weight, you
will have developed eating habits that are commensurate with that weight.
It would be challenging to measure every food item for its caloric value and then to count them
up each day. Instead, educate yourself on foods that are calorie rich and those that have greater
nutritional value without the extra calories. You might try a substitution technique in which you
replace a fattening food with a more nutritious and lower calorie food. For example, if you pack on
fat by consuming a calorie-rich brownie a day, replace it with a healthier alternative, such as a
square of dark chocolate.
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The Cognitive Behavioral Workbook for Anxiety
Note that you needn’t give up chocolate. In fact, cocoa has been shown to have a calming
effect on nonanxious folk, and the next wave of research will be to see whether cocoa polyphenols
can have a calming effect on folks with higher levels of anxieties (Pase et al. 2013). In a small-scale
study, nursing students who consumed fifty grams of dark chocolate a day reported reductions in
anxiety and depression within three days (Lua and Wong 2011).
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Preventing Anxiety and Fear from Coming Back
Emotional
tolerance
Behavioral
253
The Cognitive Behavioral Workbook for Anxiety
There are two natural areas that most people can benefit from addressing. The first is to
reduce the negatives in your life. The second is to stretch for positive experiences that are in your
enlightened interest. Once you’ve progressed in these two directions, continue with your preventa-
tive maintenance plan.
Self-improvement comes down to this: Stay focused on the big-picture prize, the enjoyment of
your life. Maintain a self-observant perspective. Stretch to see how far you can advance your
enlightened interests. Look for opportunities where you can contribute to the welfare of others.
Through this process, you will do more than emotionally survive; you’ll thrive.
254
Preventing Anxiety and Fear from Coming Back
What are three key ideas that you took away from this chapter?
1.
2.
3.
What top three actions can you take to combat a specific anxiety or fear?
1.
2.
3.
1.
2.
3.
What did you gain from taking action? What would you do differently next time?
1.
2.
3.
255
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William J. Knaus, EdD, is a licensed psychologist with more than forty years of clinical experi-
ence in working with people suffering from anxiety and depression. He has appeared on numerous
regional and national television shows including Today, and more than one hundred radio shows.
His ideas have appeared in national magazines such as U.S. News and World Report and Good
Housekeeping, and major newspapers such as the Washington Post and the Chicago Tribune. He is
one of the original directors of training in rational emotive behavior therapy (REBT). Knaus is
author of twenty books, including The Cognitive Behavioral Workbook for Anxiety, The Cognitive
Behavioral Workbook for Depression, and The Procrastination Workbook.
Foreword writer Jon Carlson, PsyD, EdD, ABPP, is distinguished professor in the division of
psychology and counseling at Governors State University, IL.
Index
31–32; procrastination connected to, 63–72; behavioral card-sort technique. See card-sort
psychological homework assignments for, technique
3–4; real vs. imagined threats and, 24–27; behavioral inhibitions, 205
restraining with relaxation and reason, 78; behavioral methods, 111–122
safeguarding mechanism of, vii; self-help behavioral prevention patterns, 253
approach to dealing with, 2–3; social, beliefs: disputing harmful, 105, 234; reasonable
223–236; structured approach for vs. erroneous, 168
controlling, 56–61; survival circuit and, belly breathing, 85–86
23–24; transdiagnostic approach to, 3; benefits analysis, 71, 146
uncertainty related to, 139–149; what-if- bibliotherapy, 2, 238
thinking and, 29–30; worry distinguished blame, 12
from, 127. See also fears; phobias; worry Block, Joel, 202
anxiety activator, 94, 95 breathing: anxiety related to, vii–viii; relaxing
anxiety thinking, 51 through, 85–86; square method of, 13
approach-avoidance conflicts, 98–100;
happiness vs. anxiety and, 98–99; scale of C
justice exercise on, 99–100 card-sort technique, 116–120; case description
Aquinas, Thomas, 247 of using, 117–119; coping with other factors
Aristotle, 93 using, 119–120; exercise on using, 120
Arnold, Magna, 93 Carlson, Jon, 85
aspiring philosophy, 199, 200 catastrophizing, 42–43
asserting yourself, 98, 210–211 CBT. See cognitive behavioral therapy
avoidance: approach vs., 98–100; problem change: anxiety as signal for, 186–189;
with, 31 BASIC-ID prescriptions for, 185–186;
awareness-of-uncertainty questionnaire, interventions and levels of, 14–15
140–142 change team, 36
awfulizing, 42, 109, 233–234 Chiron, 69, 70
awkwardness, social, 228 chocolate, 252
circular thinking: breaking patterns of, 97–98;
B double troubles and, 49–50
barriers, recognizing, 60 cognition-anxiety connection, 93–101
BASIC-ID approach, 185–193; anxiety and, cognitions modality, 185, 189
189–191; exercise on using, 191–192; cognitive behavioral therapy (CBT):
modalities in, 185–186, 189–191; bibliotherapy approach to, 2; exposure-
prescriptions for change, 185–186; relapse based, 176; psychological homework
prevention and, 246; tip on using, 193 assignments in, 3–4; research on
Beck, Aaron, viii effectiveness of, 1–2; self-help approach to,
Beck, Judith, 49 2–3; transdiagnostic approach of, 3
behavior modality, 185, 190 cognitive defusion. See defusion
cognitive prevention patterns, 252
278
Index
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280
Index
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282
Index
283
The Cognitive Behavioral Workbook for Anxiety
284
Index
285
From our puBlisher—
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