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Practice and Examples

What Does Anxiety Look Like?
Generalized Anxiety Disorder
Worry is the principal symptom of a mental health disorder called generalized anxiety disorder (GAD). According
to the DSM, a professional might diagnose you with GAD if youve been experiencing significant distress due
to worry and anxiety, including some specific symptoms like sleeplessness and irritability, for longer than six
months and for reasons other than medical or substance abuse problems.
When certain fears cause you marked distress in life for a certain period of time and you meet other specific criteria, a mental health professional might diagnose you with a specific phobia. This is the single most
prevalent diagnosis among the anxiety disorders, affecting about one in ten American adults at any given time
(Kessler et al. 1994).

Panic is a severe form of anxiety behavior that typically includes physical symptoms such as a racing heart,
nausea, hyperventilation, a choking sensation, and so on. Most often these episodes are accompanied by a
strong fear of losing control or even of dying. The root of panic is the fear of fear, making a person want to
avoid the panic experience itself. So people with panic problems are intently focused on fear, on the bodily
sensations listed above (the cues of an impending panic attack), and on being unable to protect themselves
from harm in an unfamiliar or uncontrollable situation.
Panic is very often associated with agoraphobia, a strong fear of being anywhere but the safest places. People
with panic worry that if they dont stay in these safe places, they might have a panic attackand this can
seem like the worst thing imaginable.
If you have recurrent panic attacks without any obvious cause and you spend a considerable amount of
time dreading and trying to avoid panic attacks, you might have panic disorder. Panic is often distinguished
from other forms of anxiety because the fearful focus is on the sensations inside and not on the world outside.
Somewhat less than 3 percent of the adult American population will suffer from panic disorder in a given year
(Kessler et al. 1994). It stands to reason that the number of people who experience isolated or less frequent
panic attacks is far greater.

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

This statistic leaves out the countless individuals who typically feel shy, uncomfortable, and ill at ease in social
situations but dont meet the specific diagnostic criteria in the DSM for clinical social phobia.
For those with social phobia, parties, gatherings, meetings, and public-speaking responsibilities can be
sources of considerable anxiety. Often, those with social phobia respond to this anxiety by going to great
lengths to avoid situations (or the threat of situations) that trigger it. Often social phobia is accompanied by
significant depression, which may be caused by lack of social contact, a necessary and basic emotional need.

Obsessive-Compulsive Disorder (OCD)

OCD is a spectrum of behaviors characterized by obsession with certain unpleasant thoughts, often alternating with compulsive behaviors intended to neutralize the obsessions. Common examples of OCD behavior
include the following:
An obsession with contamination or infection paired with a washing or cleaning compulsion
An obsession with the possibility of a catastrophic fire or burglary combined with a compulsion to
repeatedly check the knobs on the stove or the locks on the doors
A compulsive urge to hoard objects or animals
An obsession with sin coupled with a compulsion to confess
An obsession about the possibility of harming others with a compulsion to check repeatedly if such
harm has occurred

Post-Traumatic Stress Disorder (PTSD)

This condition can arise after an experience involving either the real or perceived threat of death or serious
injury to others or to the person who eventually suffers from PTSD. The sufferer also experiences feelings of
helplessness, fear, and horror. Common situations that might meet these conditions are accidents; natural
disasters; violent crimes such as robbery, murder, or rape; childhood abuse; and exposure to combat
To be diagnosed with PTSD, you have to have been exposed to an extreme situation in which severe injury
or loss of life took place or was a possibility for you or others near you. Further, you need to reexperience the
events in some way, engage in active avoidance of things and situations that recall the event, and experience
significant distress and disability in your life as a result. The anxiety symptoms associated with PTSD can be
chronic, persisting for an entire lifetime in some cases. Research suggests that about 3 percent of American
adults suffer from PTSD in a given year (Kessler et al. 1994).

Instructions for Practicing Progressive Muscle Relaxation
In order to make progressive muscle relaxation work for you, you should practice it every day for twenty to
thirty minuteseven on days when you arent in the mood. Making a regular practice of it is most effective.
Dont be concerned if at first it takes you quite a while to get to a state of relaxation. If you keep up your routine, youll soon be able to get into a state of deep relaxation in a shorter period of time.
Tense and relax each muscle group twice. Tense for 7 seconds, relax for 20 seconds, and repeat. Each time
you tense, make the muscles as hard as you can without straining them. After the 7 seconds of tightness,
release the tension all at once. Pay attention to how the relaxation stage feels. What do you feel in your muscles? Recognizing what a relaxed muscle feels like is an essential goal of this exercise.

1. Clench both hands tightly, making them into fists. Hold the tightness for 7 seconds. Pay attention to the
sensations in the muscles as they contract. Now let go of the tension and notice the difference. Let yourself
fully absorb the feeling of relaxation. After 20 seconds of relaxation, repeat the cycle.
2. Bend both arms and flex your biceps hard. Hold for 7 seconds, then relax for 20 seconds. Repeat. Absorb
that feeling of relaxation. How do your muscles feel when theyre relaxed?
3. Tense your triceps (the muscles on the back of your arms, opposite your biceps) by straightening your arms
and pushing them down hard by your sides. Release and notice the feeling of relaxation. Repeat.

1. Raise your eyebrows high and feel the tightness in your forehead. Release after 7 seconds and let the feeling
of relaxation take hold for 20 seconds. Repeat.
2. Press all your features together, tightening all the muscles in your face as you concentrate on the tip of your
nose. Release, relax, and repeat the cycle.
3. Press your eyelids together and smile as widely as you can. After 7 seconds, relax for 20 seconds and repeat.

4. Tighten your jaw muscles and press your tongue against the roof of your mouth. Hold, then release. Repeat.
Open your mouth as wide as you can, making your lips into an O. After 7 seconds, release and let your jaw
relax. How does your face feel? Repeat.
5. Let your head fall back as far as it will go. Hold, then relax. Repeat. Tilt your head to the side, toward your
shoulder. Hold the position, then relax and repeat. Next, tilt your head to the other side. Again, hold, then
relax and repeat. Return your head to a neutral position and feel the absence of tension. Let your lower jaw
drop slightly. Let your head fall forward toward your chest. Lift your head back up to a neutral position and
feel the lack of tension for 20 seconds. Repeat.

1. Hunch your shoulders up around your ears. After 7 seconds, let them relax back to their normal position.
Repeat. Stretch your shoulders back, pinching your shoulder blades together. Relax and repeat.
2. Lift your arms out in front of you until theyre parallel with the floor. Without bending your arms or dropping them down, cross them until you feel a strong stretch in your back. After 7 seconds have passed, let
your arms fall down to your sides and feel the deep relaxation for 20 seconds. Repeat.
3. Breathe deeply. While holding your breath, tighten the muscles of your abdomen and hold for 7 seconds.
Exhale. Repeat.
4. Arch your back gently. Hold, then relax and let your back go flat again. Repeat.

1. Clench your buttocks and tighten your thigh muscles. You can increase the tension by straightening your
legs and imagining energy going out through your heels. Hold for 7 seconds. Relax for 20 seconds, then
2. Press your legs together firmly to engage your inner thigh muscles. Hold, relax, and repeat the sequence.
3. Contract your leg muscles by pointing your toes. Hold, relax, and repeat.
4. Now contract your leg muscles again by flexing your toes up toward your shins. Hold, relax, and repeat the

Visualization Skills
If you have difficulty creating a vivid, peaceful scene in your mind, try adding some of these elements to your
next practice session.
Focus on your senses. How would it feel if you were actually in this place? If your scene is outdoors, think
about the elements. Is the air dry and warm, or misty and cool? What time of day is it? Is the sun low or high
in the sky? How deep are the shadows that you see? Concentrate hard until you can imagine textures under
your fingertips: the grain of wood, silky-smooth fabric, a rough stone, powdery sand.
If there are areas of the environment that you want to fill in, enter the scene and put all your focus
on that area. Let the more obvious parts of the scene fade away until the gap begins to fill. Once
something begins to appear, take extra care to establish the tiny details that will help you hold this
part of the scene in your imagination.
Play with one detail at a time. Mentally trace the outlines of that mountain until every crag is
embedded in your mind. Zero in on colorsis that wildflower fuchsia, magenta, or hot pink? Get as
specific as you can.
Think about where you are within the scene. Are you looking out from your own eyes, or are you
viewing yourself from afar? If you are seeing yourself from afar, shift your perspective so that youre
looking out at the scene from your own point of view. This will place you inside the scene instead
of outside it, allowing you to experience it in greater detail.

Examples of Peaceful Scenes

The beach. You begin by walking along a winding path that rises gradually as you go. At the crest of the path,

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

air is still a bit cool, and you pull your sleeping bag around you and settle in to watch your favorite part of the
day. Wind-carved spires rise in the distance. The sand around you seems to contain every color imaginable,

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

Worry Risk Assessment
Risk Assessment Process
You can use the following process to make accurate risk assessments by estimating accurate probabilities and
making reasonable outcome predictions. Find a notebook or use your computer to write down your work as
you go through the following steps.
1. Record one of your worries in the form of a feared event. Write down the worst possible version of your
worry you can think of. For example, if you worry about your teenager going out at night, imagine the
worst: a head-on collision of drunk teens and a big truck, everybody dead on impact or dying in the emergency room after suffering horribly.
2. Then, write the automatic thoughts that typically come up: Shell die Ill die Blood and pain Things
will never be the same Awful Cant stand it Jot down whatever comes to mind, even if it is just an
image or a fleeting word.
3. Next, rate your anxiety when considering this worst-case scenario. Use 0 for no anxiety and 100 for the
worst fear you have ever experienced. Then rate the probability of this worst-case scenario coming to
passfrom 0 percent for no likelihood at all to 100 percent for absolute inevitability.
4. Assuming that the worst did happen, predict the consequences you most fear. Then spend some time figuring out what you would tell yourself and what you would do in order to cope with the catastrophe. When
you have a clear picture of possible coping strategies, make a revised prediction of the consequences. After
these predictions, rerate your anxiety and see if it has diminished.
5. List the evidence against the very worst outcome happening. Figure the odds as realistically as you can.
Then list all the alternative outcomes you can think of. Finally, re-rate your anxiety and the probability of
the event. You should find that both your anxiety and probability ratings have declined as the result of your
making a full and objective risk assessment.
Go through this process each time youre confronted by a significant worry, or whenever you return to a
worry more than once. Its important to do this exercise consistently. Each risk assessment helps you change
old habits of catastrophic thinking. When youve completed a risk assessment, keep your work. You may wish
to refer to it again when confronting a similar worry.

Worry Time
More to Think about during Worry Time
Another kind of inaccurate thinking to watch out for is magical thinking, a pattern in which you believe that
your worrying somehow works to protect you or people you care about from bad things that might happen. By
worrying, you imagine yourself to be a kind of sentry, waiting and watching for the first sign of misfortune.
This kind of thinking might look like prudence and due diligence on the face of it, but looks can be deceiving.
How often do you engage in this kind of thinking? While our thoughts exert great influence over how we feel,
they dont have much effect at all on the world around us, as most people whove tried to bend spoons with
their minds know. Can you catch this kind of thinking next time it pops up?

Relief from Panic
The Fight-or-Flight Reaction
Heres how your fight-or-f light mechanism works: It starts with an event inside or outside your body. An external event might be a stressor or challenge at work or at school, an interpersonal conflict, or the reoccurrence
of a previously panic-inducing situation. An internal event could be any of the physical symptoms that you
associate with panic.
Next, the event triggers worry. Your worry thoughts might be about the situation (a crowded classroom and
what it would be like to lose control there) or your physical sensations (Uh-oh, this dizziness means another
panic is coming!).
As worry thoughts flash through your mind, priming your system for potential danger, your body starts to
prepare for disaster. This part happens very quicklyso quickly that you might not even notice it because the
worry thoughts flit through your mind so quickly. But your body feels it, and this step lights the match for the
panic cycle to begin.
And now the fight-or-f light response kicks in. You know this one: Your body is prepared for the worst kind
of danger. Your heart speeds up and pumps blood to your large muscles, getting you ready to run or fight. Your
legs may feel weak and wobbly as blood gathers there to help you run and flee the threat. You start to breathe
more quickly to get enough oxygen for your next movebut this may make you feel pain or tightness in your
chest. This common side effect of increased respiration is actually no threat at all, but for obvious reasons it
plays a key role in exacerbating panic for those who experience it.
What else happens when youre in fight-or-f light mode? The blood supply to your brain decreases, producing feelings of dizziness, confusion, and unreality. The blood flow to skin, fingers, and toes is reduced, to
protect you by reducing bleeding if you are injured. This makes your extremities cold while, simultaneously,
you may feel flushed.
Youll find yourself sweating (a protective mechanism that makes it harder for a predator to keep a grip on
you). As your energy is diverted for supposedly more important functions, your body slows its digestion, which
may result in cramping, nausea, and other intestinal symptoms. These harmless but often dramatic symptoms
lead you to the next step in the panic sequence: you start to have catastrophic thoughts about whats happening in your body. You might worry that youll suffocate, have a heart attack, or pass out in the middle of the
What happens next? These overwhelming thoughts cause your body to release adrenaline, cranking up
your distressing fight-or-flight symptoms even more dramatically. You feel even worse physically, and your
catastrophic thinking escalates as well. Yes, this is the part where you start to think youre going to die, right
on the spot. Though the panic cycle can keep building through this process, it doesnt have to: you can learn
new ways to interpret and work through stress symptoms. See section 10, on breath control training, and section 11, on interoceptive exposure, in the book and in this Practice and Examples file.

Sample Coping Thoughts

Here are some coping thoughts that work well for specific physical symptoms of panic or anxiety.
Light-headedness: Im only light-headed because of hyperventilation or the release of stress hormones that cause my

blood vessels to constrict temporarily. As soon as I get through the fight-or-f light reaction it will pass, and it cant hurt
me while it lasts.
Feeling faint: It might feel like Im going to faint, but thats unlikely. Fainting is caused by low blood pressure, and

anxiety tends to make blood pressure higher.

Racing heart: Even if my heart were to beat this fast for weeks on end, it wouldnt cause any damage. A short period

of rapid heartbeat caused by stress cant hurt me at all.

Dizziness: This is just a temporary effect of hyperventilation. When I relax, it will go away.
Weak legs: This means my body is giving me strength to run or fight by sending lots of blood to my leg muscles. It

feels strange, but it means Im stronger than usual, not weaker. I feel shaky, but thats because Im not using all this
extra strength to run or fight.
Feeling depersonalized or not yourself: This one seems scary, but its just another symptom of the hyperventilation

and constricted blood vessels that are part of my normal stress response. It cant hurt me, and it will go away when I
Shortness of breath: When I get anxious, my diaphragm gets tight, which means its harder for me to take a deep

breath. But Im in no danger of running out of air. My body knows exactly how to keep getting air, no matter how
anxious I get. Ill feel better as soon as I relax my diaphragm with deep, calm, slow breaths.
Fear of losing control: Ive felt like this before, but Ive never gone crazy or acted out, and its not going to happen

this time.
Feeling hot or cold: My bodys temperature regulation feels messed up because of my stress response. This is a nor-

mal part of the fight-or-f light reaction, and it cant hurt me at all.

Breath Control Training
Further Help with Breath Control Training
If you have difficulty counting during breath control exercises, you can make a recording to help you learn the
proper pacing. To make a twelve-breaths-per-minute tape:
1. Say the word in for two seconds.
2. Say the word out for two seconds.
3. Pause one second.
4. Continue repeating in for two seconds and out for two seconds, followed by a one-second pause.
The recording should last about five minutes. To make an eight-breaths-per-minute recording, do everything the same except say in and out for three seconds each.

Interoceptive Exposure
Interoceptive Assessment Chart


Shaking head from side to side

30 seconds

Repeatedly lowering your head between your

legs and then lifting it (keep repeating)

30 seconds

Running in place

60 seconds

Running in place wearing a heavy jacket

60 seconds

Holding your breath

30 seconds (or as
long as you can)

Tensing major musclesparticularly in your


60 seconds (or as
long as you can)

Spinning while you sit in a swivel chair

60 seconds

Very rapid breathing

Up to 60 seconds

Breathing through a narrow straw

120 seconds

Staring at yourself in a mirror

90 seconds


Similarity to Panic

Introceptive Hierarchy/Anxiety Intensity Chart


Trial 1

Trial 2

Trial 3

Trial 4

Trial 5

Trial 6

Trial 7

Trial 8


Desensitization in Natural Settings

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

More Tips for Desensitization

If you have difficulty desensitizing and lowering your anxiety during exposure, it may be because you have
catastrophic thoughts that havent been addressed. As you begin an exposure exercise, monitor your thoughts
about the bodily sensations that come up. What are you telling yourself? What terrible thing do you fear
might happen? What is the worst possible outcome?


Fears and Phobias

Contingency Planning

Its wise to plan for outside problems that may come up in your exposure work. Imagine that youre attempting
exposure in a public place where many different elements are outside your control. You might have to adjust
your approach if things dont go according to plan. For example, what do you do if youre attempting exposure
practice in a restaurant, but you have to wait a long time to give your order and service seems extremely slow?
You might plan that youll continue your exposure work at a short-order coffee shop, or order just a single

More Tips for Exposure Practice

You may want to try using acceptance during exposure. As hard as you may try to control your thoughts, your
breathing, and your reaction to your physical symptoms, you simply cant control everything, especially once
that adrenaline rush gets going. When that hormonal burst occurs, youre going to feel it, and you might wish
to use an acceptance-based coping thought to help you accept the physical feelings rather than fighting them.
Try statements such as these:
I can float past this anxiety.
I can notice these sensations without fighting them.
I accept what is happening in my body. It will pass.


Steps to Problem Solving

Problem Checklist

After each situation listed, check the box that best describes how much of a problem it is for you. If you have
trouble determining whether a situation is a significant problem for you, imagine yourself in that situation.
Include lots of sights and sounds and actions to make it seem real. In that situation, do you feel angry,
depressed, anxious, or confused? These are red flag emotions. When you experience anger, depression, anxiety, or confusion, you are probably in a situation that is a problem for yousomething about the way you are
responding to the situation isnt working for you.
No problem: either minimal interference with daily life or not applicable to you
Minor problem: some interference with daily life
Moderate problem: significant interference with daily life
Major problem: regular, severe interference with daily life and a major negative impact on your

Difficulty sleeping
Weight problems
Feeling physically tired and run-down
Stomach trouble
Chronic physical problems
Difficulty getting up in the morning
Poor diet and nutrition














Difficulty making ends meet

Increasing amounts of debt
Unexpected expenses
Too little money for hobbies and recreation
No steady source of income
Too many financial dependents

Living Situation
Bad neighborhood
Insufficient money for basic necessities
Too far from work or school
Too small
Unpleasant conditions
Things in need of repair
Poor relationship with landlord










Monotonous and boring work

Poor relations with boss or supervisor
Being rushed and under stress
Wanting a different job or career
Needing more education or experience
Fear of losing job
Not getting along with coworkers
Unpleasant conditions
Needing more freedom at work

Having a particular bad habit
Religious problems
Problems with authority
Competing goals or demands
Obsession with distant or unobtainable goals
Lack of motivation
Feeling very depressed at times
Feeling nervous at certain times
Feeling blocked from attaining goals
Feeling angry a lot










Not having enough fun

Ineptitude at sports or games
Too little leisure time
Wanting more chance to enjoy art or
Little chance to enjoy nature
Wanting to travel
Needing a vacation
Inability to think of anything fun to do

Social Relationships
Timidity or shyness
Not having many friends
Too little romantic contact
Feeling lonely
Not getting along well with certain people
A failed or failing love affair
Feeling left out
Lack of love and affection
Vulnerability to criticism






Feeling rejected by family

Discord at home with mate
Not getting along with one or more of the children
Feeling trapped in painful family situation
Insecurityfear of losing mate
Inability to be open and honest with family
Desire for sexual contact with someone other than

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

Evaluating Consequences Chart

When working through step 4 of the problem-solving process, you may find it helpful to use the following form
to evaluate the consequences of the three strategies representing your best ideas. On the form, list the negative
and positive consequences you can think of for each strategy. How would putting that strategy into action
affect what you feel, need, or want? How would it affect the people in your life? How would it change their
reaction to you? How would it affect your life right now, next month, or next year? Take some time to get both
positive and negative consequences for each possible strategy.
When you have the major consequences listed, go over each one and ask yourself how likely it is to come
about. If the consequence is very unlikely, cross it outyoure telling your self horror stories or being falsely
optimistic. Then score the remaining consequences as follows:
If the consequence is predominantly personal, give it 2 points.

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

If the consequence is predominantly long-range, give it 2 points.
If the consequence is predominantly short-range, give it 1 point.
Note that consequences can be both personal and long-range at the same time (total score of 4), have a
long-range effect on others (total score of 3), and so on.
Add up the scores for each strategy to see whether the positive consequences outweigh the negative. Then
select the strategy whose positive consequences most greatly outweigh the negative consequences.

Evaluating Consequences
Positive Consequences


Negative Consequences




Positive Consequences


Negative Consequences




Positive Consequences


Negative Consequences




Positive Consequences


Negative Consequences




Be Mindful
More Everyday Mindfulness
As a further mindfulness practice, you can do pretty much any daily activity as an exercise in mindfulness:
Doing the dishes or any other household chore
Eating an apple (or any other food)
Drinking a beverage, such as tea
Looking at something beautiful
Bathing or showering
Listening to a friend
Washing your hands
Listening to music

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


Label and Let Go

Putting Watching, Labeling, and Letting Go Together

When defusing from your thoughts, its helpful to establish a sequence of responses to use with each cognition.
The simplest way to do this is to choose one labeling exercise and combine it with either a letting-go visualization or the physical dropping experience.
Mark, who ruminates about scary future possibilities, chose to respond to these thoughts with a labeling
exercise (Im having a thought that) and a letting-go exercise using the image of leaves on a stream. Each time
one of his what-if thoughts showed up, Mark carefully described it using the labeling exercise, and then imagined the thought as a leaf, dropping in a stream and drifting away. After a time, Mark realized that the leaves
on a stream image was hard to call up when he was in social situations. So he replaced it with a covert spreading of his fingers that symbolized letting go. Mark found that when he used the labeling and letting-go process
for each negative thought, these old cognitions felt less believable and upsetting.


Use Distancing Techniques

More Distancing Techniques

Negative label repetition: Edward Titchener (1916) discovered that if you keep repeating a word fifty or more

times, it begins to lose its meaning. It becomes just a sound rather than a concept. Take, for example, the word
milk. You can imagine the color and smell and the cool liquid flowing down your throat. But consider what
happens if you say the word milk out loud over and over again. What if you keep saying it as fast as you can
while still pronouncing it clearly? Go ahead and do it right now for at least sixty seconds.
What happens to the meaning of the word? Do those same sense impressions still hold, or does the word
feel strangely vacuous or conceptually empty? Is it more a sound than a word?
The fact that repetition changes and diminishes meaning is very useful for defusion. You can repeat negative self-judgments or feared future outcomes until they lose their sting and ability to disturb you. Try it right
now. Choose a negative label you often apply to yourself. Repeat it fifty times and notice what happens to this
Physicalizing thoughts: A classic way to make thoughts less important and disturbing (dating back to Fritz

Perls Gestalt Therapy) is to physicalize them. Sticky thoughts that keep bothering you can be assigned a color.
You can also ask yourself what shape the thought has, what texture, and how big it is. Its easier to distance
from a thought when you imagine that it is green, as big as a basketball, the texture of cheesecake, and the
shape of a starfish.
Card carrying: Some thoughts keep showing up, like unwelcome relatives for another visit. One way to distance

from these thoughts is to carry an index card, and write them down whenever they come into your mind.
Then, when those thoughts reoccur, you can remind yourself, I have it on the card.
Wearing signs: Sometimes its helpful to openly acknowledge the most painful thoughts your mind can create.

Write the thought down on a sticky note or name tag and wear it for a few hours on your shirt. You might do
this in the privacy of your home, or with a few friends. Youll find that it doesnt take long for the power and
sting of the thought to diminish once youve begun to wear it. Many people find this especially helpful for
judgmental thoughts, such as, Im stupid or Im a bad parent or Im lonely and empty. Acknowledging a thought
seems to have the magical effect of making it seem further away and less important.

Walker is a twenty-four-year-old draftsman who struggled for years with anxious and self-denigrating thoughts.
He had judgment thoughts about his competence at work and his ability to socialize and make interesting
conversation. Walker also had fear thoughts about being rejected, judged by others, and losing his job, his
apartment, and his independence. Walker wanted to return to school to pursue a degree in mechanical engineering. However, thoughts about failure and potential financial disaster with school loans were keeping him
from moving forward.
Walker chose a simple defusion process to observe and let go of difficult thoughts. As each cognition
showed up, he said to himself, Now my minds having a (judgment or fear) thought. Then he turned
his hand in a dropping motion and sometimes imagined the thought falling through the floor and out of sight.
As Walker became more skilled at labeling and letting go of thoughts, he noticed a shift in how he related
to his mind. Instead of feeling that each judgment or fear thought was terribly important, he began to regard
them as mere thoughts and part of his endless mental chatter.
Despite these positive changes, Walker still experienced some of his fear thoughts as sticky and powerful.
Chief among these was the thought that he would fail if he returned to school. Walker first tried Titcheners
repetition and the card carrying strategy to distance himself from these thoughts. Finally, he committed himself to use the distancing drill to give himself some breathing room with these cognitions. Each time one of
the fear thoughts about school came to mind, Walker asked how old it was. The answer was that these
thoughts had begun about the time he first entered collegemore than eleven years ago. The function of the
thoughts was always the same: to protect himself from failure (and anxiety about failure) by avoiding difficult
When Walker turned to the workability question, he recognized that these fear thoughts had never been
helpful. During his first years in college they drove him to avoid the hard engineering courses, and ultimately
to drop out. He also remembered that the thoughts, instead of protecting him from anxiety, had made his
college years a nervous nightmare. And now every time he thought about going back to school his heart raced
and he felt a surge of anxiety. Instead of protecting him from anxiety and failure, his thoughts were filling him
with fear and guaranteeing failure.
Finally, Walker asked himself the most important question. Would he be willing to have these fear thoughts
and still fill out the school applications? He decided to fill out the applications anyway, regardless of how much
failure and disaster his mind predicted.


Work on Anxiety-Making Behavior Patterns

Monitoring Avoidance and Checking


Old Behavior

New Behavior

How Did My Anxiety

Level Change?


Identify Trigger Thoughts

Keeping an Emotional Record

To help you recognize your emotions, its often helpful to say how youre feeling out loud. This method of labeling might sound silly at first, but the act of saying how you feel out loud will highlight your emotions for you
and help you pay extra attention to what youre experiencing. Describing your emotions aloud, especially your
overwhelming emotions, can also help deflate your distressing feelings. So the more you can talk about an
emotion, the less urge you might have to do something about it. You do not have to scream how you feel; it
might be enough to say your emotion quietly to yourself. Just find what works best for you. Say to yourself
Right now I feel And remember to pay attention to your pleasant and joyful emotions too. The more youre
able to recognize them and say them out loud, the more fully youll be able to enjoy those feelings.
Then, in order to further reinforce the experience, record your emotions in your Emotional Record.
Recording your feelings throughout the week will help you recognize, label, and describe your emotions.
Photocopy the blank form and keep a copy with you in order to record your emotions shortly after you recognize them. Do this exercise for at least two weeks. Weve provided an example to help you see how to fill out
the form.

Example: Emotional Record

When Did It Happen
and Where Were

How Did You Feel?

Did You Say How You
What Did You Do
(Right now, I feel )
Felt Out Loud?
After You Recognized
How You Felt?

Thursday night, at home

I feel angry.


I went to the kitchen and

had a glass of wine.

Thursday night, at home

I feel sad.


I tried to go to sleep, but I

kept thinking about how
sad I was.

Friday morning, on the


I feel agitated.


I tried to calm down by

distracting myself and
reading the newspaper.

Friday morning, at work

I feel pissed off.


I went outside and had a


Friday afternoon, at work

I feel jealous.


I continued to ignore my
friend whos dating a
woman I like.

Friday night, at home

I feel lonely.


I decided to go to the
movies by myself and
have a good time.

Saturday afternoon, at
the park

I feel happy.


I stayed at the park with

my friends.

Saturday night, at Bens


I feel cheerful.


I didnt say much to

anyone because I didnt
want to mess up my

Emotional Record
When Did It Happen
and Where Were

How Did You Feel?

Did You Say How You
What Did You Do
(Right now, I feel )
Felt Out Loud?
After You Recognized
How You Felt?


Make Room for Positive Feelings

Following is a list of over one hundred pleasurable activities you can try. Check off items you think youd
enjoy, then commit to trying them
Talk to a friend on the telephone.

Sleep or take a nap.

Go out and visit a friend.

Invite a friend to come to your home.

Eat chocolate (its good for you!) or eat something

else you really like.

Text message your friends.

Eat your favorite ice cream.

Organize a party.

Cook your favorite dish or meal.


Cook a recipe that youve never tried before.

Lift weights.

Take a cooking class.

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


Go out for something to eat.

Stretch your muscles.

Borrow a friends dog and take it to the park.

Go for a long walk in a park or someplace else

thats peaceful.

Give your pet a bath.

Go outside and watch the clouds.

Go jogging.
Ride your bike.
Go for a swim.
Go hiking.

Go outside and play with your pet.

Go outside and watch the birds and other

Watch a funny movie (start collecting funny movies
to watch when youre feeling overwhelmed with
Go to the movie theater and watch whatevers

Do something exciting, like surfing, rock climbing,

skiing, skydiving, motorcycle riding, or kayaking, or
go learn how to do one of these things.

Watch television.

Go to your local park and join a game being

played or watch a game.

Go to a sporting event, like a baseball or football


Go play something you can do by yourself if no

one else is around, like basketball, bowling,
handball, miniature golf, billiards, or hitting a tennis
ball against the wall.

Play a game with a friend.

Get a massage; this can also help soothe your

Get out of your house, even if you just sit outside.
Go for a drive in your car or go for a ride on public
Plan a trip to a place youve never been before.

Listen to the radio.

Play solitaire.
Play video games.
Go online to chat.
Visit your favorite websites.
Visit crazy websites and start keeping a list of
Create your own website.
Start a blog.

Join an Internet dating service.

Paint your nails.

Sell something you dont want on the Internet.

Change your hair color.

Buy something on the Internet.

Take a bubble bath or shower.

Do a puzzle with a lot of pieces.

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

Go shopping.

Sign up for a class that excites you at a local

college or online.

Go get a haircut.
Go to a spa.
Go to a library.
Go to a bookstore and read.
Go to your favorite caf for coffee or tea.

Read your favorite book, magazine, paper, or

Read a trashy celebrity magazine.
Write a letter to a friend or family member.

Visit a museum or local art gallery.

Write a poem, story, movie, or play about your life

or someone elses life.

Go to the mall or the park and watch other

people; try to imagine what theyre thinking.

Write in your journal or diary about what

happened to you today.

Pray or meditate.

Write a loving letter to yourself when youre feeling

good and keep it with you to read when youre
feeling upset.

Go to your church, synagogue, temple, mosque,

or other place of worship.
Join a group at your place of worship.
Write a letter to God.
Call a family member you havent spoken to in a
long time.
Learn a new language.
Sing or learn how to sing.
Play a musical instrument or learn how to play
Write a song.
Listen to some upbeat, happy music (start
collecting happy songs for times when youre
feeling overwhelmed).
Turn on some loud music and dance.
Memorize lines from your favorite movie, play, or
Make a movie or video with your camcorder.
Take photographs.
Join a public-speaking group and write a speech.

Make a list of ten things youre good at or that you

like about yourself when youre feeling good and
keep it with you to read when youre feeling upset.
Draw a picture.
Paint a picture with a brush or your fingers.
Have sex with someone you care about.
Make a list of the people you admire and want to
be likeit can be anyone real or fictional
throughout history. Describe what you admire
about these people.
Write a story about the craziest, funniest, or
sexiest thing that has ever happened to you.
Make a list of ten things you would like to do
before you die.
Make a list of ten celebrities you would like to be
friends with and describe why.
Make a list of ten celebrities you would like to have
sex with and describe why.

Sing in a local choir.

Write a letter to someone who has made your life

better and tell them why. (You dont have to send
the letter if you dont want to.)

Join a club.

Create your own list of pleasurable activities.

Plant a garden.

Other ideas:

Work outside.

Knit, crochet, or sewor learn how to.

Participate in a local theater group.

Make a scrapbook with pictures.


Use Distraction and Self-Soothing

Meditation Practice for Loving-kindness toward Yourself and Others

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

Take a comfortable position. Bring your focus mindfully to your breath or body for a few breaths. Open and soften
as much as feels safe to you as you allow yourself to connect with your natural inner feelings of kindness and compassion for others.
Now shift your attention to yourself. It could be a sense of your whole self or some part that needs care and attention, such as a physical injury or the site of an illness or a feeling of emotional pain.
Imagine speaking gently and quietly to yourself, as a mother speaks to her frightened or injured child. Use a phrase
like May I be safe and protected or May I be happy or May I be healthy and well or May I live with ease or
make up one of your own. Let the phrase you pick be something anyone would want (safety, ease, joy, and so on). Pick
one that works for you. It can be a single phrase. Then put all your heart into it each time you speak to yourself. Let
kindness and compassion come through you.
Practice by repeating your phrase to yourself silently as if singing a lullaby to a baby. Practice for as long as you
like. It may help to practice for just a few minutes at a time at first and later build up to a longer practice.
When you like, you can shift your attention and focus to a friend or someone you know who is troubled. You can
also focus on groups of people, such as all my friends or all my brothers and sisters.
When you wish, you can experiment with difficult people in your life. Try sending them kindness and your
wish that they might be happy, and watch your inner response. In doing loving-kindness for a difficult person,
you are not allowing them to abuse or hurt you but are making an attempt to see that they, too, are human
beings who seek happiness. This can change your relationship to the situation and release you from resentment you may be holding.
Please note that in doing loving-kindness meditation, you are likely to experience many different feelings!
Some may even be disturbing, such as sadness, grief, or anger. If this happens, you have not made a mistake.
It is common for deeply held feelings to be released as one practices loving-kindness. This release is actually a
kind of healing in itself. Just pay attention to all of your feelings, honoring each one, and continue your


Insomnia and Solutions

More Tips for a Good Nights Sleep

If youre having trouble sleeping, try the following.

Try a hot shower or bath before bedtime.
Develop a sleep ritual before bedtime. This is an activity you do nightly before turning in.
Purchase a quality mattress. Try varying the firmness of your mattress. Invest in a new one or insert a board

underneath one that sags or is too soft. If a mattress is too hard, place an egg-crate foam pad between the
mattress surface and the mattress cover.
Have separate beds if your partner snores, kicks, tosses, or turns. Discuss this with your partner and decide

on a mutually acceptable distance.

Have physically and emotionally satisfying sex. This often aids sleep.
See a psychotherapist if necessary. Anxiety and depressive disorders commonly produce insomnia. Talking

to a competent psychotherapist can help. Getting more emotional support and expressing your feelings to
someone you trust often helps too.


Target Aerobic Heart Rate

The table below indicates aerobic pulse ranges for various ages:

Heart Rate











Daily Record of Exercise



Type of Exercise:


Pulse Rate: Satisfaction Level:

Common Excuses for Not Exercising

You probably have a variety of excuses for why you avoid exercise. Here are some common ones, along with
ideas on how to address them:
Im too busy. Its true that when you feel stressed and anxious, it seems like you dont have an extra minute

in the day. However, if you stick with an exercise program for just a few weeks, youll find that its mainly a
matter of priorities. And, better yet, the stress relief and anxiety reduction will make you calmer and more
productive all day, not just when youre working out.
I dont have the energy. Its one of the great miracles of exercise: moving your body even when you feel tired

will give you more energy. It takes time to build the habit, but once you do, youll find that energy devoted to
exercise will pay you back many times over. If you find youre especially tired late in the day, exercise in the
morning or at lunchtime.
Its just too complicated. As described earlier in this section, starting an exercise program is as simple as

putting on a comfortable pair of shoes and walking out the door.

Joining a gym is too expensive, plus, who has the extra time to go to and from the gym? Its pretty simple

to solve this onethere are many exercises you can do at home. You can ride a stationary bike, use an
elliptical trainer or treadmill, jump rope, lift dumbbells, work with a medicine ball or stability ball, or do
workout videos. In even a small amount of space, you can get a vigorous workout without spending much
money and without spending any time going to and from the gym. At home, you have the freedom to watch
TV or listen to any music you want (as loud as you want).
Ugh, its so boring. Wed venture a guess here that you havent tried every form of exercise in the world. Get

out there and try something newtheres something that works for everyone. If having an exercise partner
would help, turn exercise into a social event. If you have kids, play. Watch what kids do and try that: mock
battles with toy swords, running like mad after a Frisbee, skateboarding, or swinging on the monkey bars.
Im too old. This one is just not trueplenty of people take up exercise late in life and make it a habit. Unless

your doctor says not to because of a medical problem, age is not a barrier. If you think you would be putting
yourself in danger by taking up an exercise program, by all means discuss this with your doctor.
What if exercise causes a panic attack? If you have panic attacks, its natural to feel concerned. Walking

and other milder forms of aerobic exercise are unlikely to cause symptoms that might lead to panic. You can
test out more vigorous exercise in very short bursts to get comfortable with the sensations that you might
associate with paniccall it exercise exposure therapy. The end result of regular exercise is likely to be a
reduction in your susceptibility to panic attacks, not an increase.