The Anxiety and Depression Workbook

Supplemental Guide for Clinicians

Michael A. Tompkins

Anxiety
The
and Depression
Workbook
Supplemental Guide
for Clinicians

Michael A. Tompkins, PhD, ABPP

Why a single treatment for anxiety and depression? During the last few years, researchers have developed new treat-
ments that target the core factors believed to maintain symptoms of excessive anxiety and depression (Moses and
Barlow 2006; Allen, McHugh, and Barlow 2008; Taylor and Clark 2009; Norton and Paulus 2016). These new treatments
are called transdiagnostic treatments because they are effective whether you have a diagnosis of an anxiety or a depressive
disorder, or both (Farchione et al. 2012; Ellard et al. 2010). There are several advantages to a single treatment for anxiety
and depressive disorders:

• Many clients with an anxiety disorder also have a depressive disorder. For example, the co-occurrence
of anxiety disorders and major depressive disorder is as high as 60 percent (Kaufman and Charney 2000). A
single treatment that works for both anxiety and depressive disorders simplifies recovery. Presenting a
limited set of skills that are effective whether your clients are anxious or depressed increases the likelihood
that you’ll be able to reach and help more clients who suffer with anxiety and depressive disorders.

• Many clients have anxiety and depressive symptoms that don’t quite meet full criteria for a partic-
ular anxiety or depressive disorder. A single treatment that targets central factors thought responsible for
excessive anxiety and depression might improve the lives of many more clients. This is because clients who
don’t have an emotional disorder still benefit from learning skills to manage the excessive emotional
responses they experience from time to time.

• Many clients with a depressive disorder experience periods of intense anxiety, and many clients
with an anxiety disorder experience intense periods of depression. Research has shown clients with
emotional disorders experience both anxious and depressed episodes regardless of their primary diagnosis
(Regier et al. 1998). A single treatment that teaches common skills can help clients manage periodic episodes
of anxiety or depression regardless of the primary emotional disorder they have.

As an experienced clinician, you know that most clients who seek help with their anxiety or depression often suffer with
both. That’s where The Anxiety and Depression Workbook comes in. The skills in this workbook—such as mindfulness, flexible
thinking, and self-compassion—are typical cognitive behavioral therapy (CBT) skills, and CBT is the gold standard for the treat-
ment of anxiety and depression. More than fifty years of research tells us that the skills in this workbook can help your
clients recover from excessive anxiety and depression. What’s more, the exercises in this workbook are simple and
straightforward enough that you can be sure clients can learn them, as long as they’re willing to practice them until
they’re mastered; and while the skills come from CBT, you don’t have to be a CBT therapist to teach them. Ultimately,
whether clients are anxious or depressed, or suffer with an anxiety or a depressive disorder or both, this workbook can
help them. One workbook, one program to follow, and one set of skills for clients to learn and practice to increase the
flexibility of their emotional systems and thus their psychological health.

Psychological Flexibility Means Psychological Health

We now know that a flexible emotional system is perhaps the single most important feature of psychological health.
That’s because psychological health depends on an emotional system that responds to life’s challenges with an appropri-
ate level of emotion and quickly returns to a normal level of emotion as the challenge resolves. People with an inflexible
emotional system, on the other hand, don’t bounce back from these challenges. They’re stuck in their distressing

© Michael Tompkins / New Harbinger Publications 2

negative emotions days, or weeks, or months and because their stuck, they soon have trouble functioning at work, at
home, and in life.

Fortunately, the flexibility of our emotional systems isn’t fixed—it’s plastic. With the right skills, clients can enhance the
plasticity or flexibility of their emotional systems and free themselves from excessive and persistent anxiety and
depression.

The skills in this workbook target the factors that experts believe maintain an inflexible emotional system. The first
target is the tendency for anxious and depressed clients to repeatedly focus on certain aspects of a situation over other aspects. For example,
anxious clients tend to focus on threat rather than on safety. Depressed clients tend to focus on the negative rather than
on the positive aspects of themselves or of situations. The second target is the tendency for anxious or depressed clients repeatedly
to interpret or predict events in a particular way. For example, anxious clients tend to predict that negative outcomes are likely
to occur. Depressed clients tend to predict that they’ll fail at anything they try. The final target, and perhaps the most
important one, is the tendency of anxious or depressed clients to avoid the negative feelings that arise due to their ten-
dency to focus on or interpret events in inflexible ways. Although this may seem counterintuitive to people who struggle
with excessive anxiety or depression, we now know that avoiding negative emotional experiences is the primary factor
that maintains and intensifies them over time. Therefore, the overarching goal of the skills in this workbook is to help
clients face their anxious and depressed feelings rather than avoid them. Clients who approach rather than avoid their
anxious and depressed feelings learn, over time, that they can tolerate these feelings. And once they learn this counter-
intuitive lesson, their lives open again.

The Organization of the Program

The program outlined in The Anxiety and Depression Workbook is organized into two parts. Part I includes four chapters
that describe the role of emotional inflexibility in the persistence of excessive anxiety and depression.

In Chapter 1, “What Is Emotional Flexibility?” clients learn the parts of their anxious and depressed emotional responses,
and how these natural and normal emotions can develop over time into anxiety or depressive disorders. In Chapter 2,
“Anxiety and Depression,” clients learn features of emotions and emotional disorders and the role that an inflexible
emotional system can play in both normal and non-normal emotional responses to life events. This chapter also describes
the features of anxiety and depressive disorders, and introduces characters with these disorders that appear throughout
the workbook.

In Chapter 3, “Record the ABCs of Emotion,” clients learn the ABCs of emotion: the antecedents (the event or situation
that triggers the emotion), the basics (the thoughts and body sensations that characterize the emotion, what the emotion
steers them to pay attention to, and the actions they take in response), and the consequences. It’s essential that your clients
understand the parts of their anxious and depressed emotions because the workbook skills that follow target these parts.

Once clients understand the parts of their emotional responses, they then learn to record them. Recording your emo-
tions, rather than simply reacting to them, is the first step in building a more flexible emotional system. It’s also the way
that clients learn to identify the particular antecedents or triggers of their emotional responses and what happens after
these responses are triggered (the consequences). It’s particularly important that clients understand the consequences
that follow their emotional responses because these consequences are likely the reasons they want to learn skills to
manage their emotional reactions to events.

© Michael Tompkins / New Harbinger Publications 3

In Chapter 4, “Build Motivation and Set Goals,” clients set goals for the workbook program and learn skills to increase
their willingness to move forward with their recovery. Although clients can recover from their excessive anxiety and
depression, it takes considerable motivation and hard work, in part because moving forward means facing and accepting
emotions that are uncomfortable. You’ll likely repeatedly revisit the skills in this chapter, particularly as you encourage
your clients to face their uncomfortable feelings.

Part II includes six chapters that present the skills clients learn and practice to increase their emotional flexibility and
thereby lessen their anxiety and depression, and to maintain this flexibility over time.

In Chapter 5, “Build Flexible Attention,” clients learn skills to shift their attention and watch their emotional responses
in a different way. Observing emotional responses rather than directing attention away from them is a powerful skill in
itself. In this chapter, clients learn a number of skills to anchor themselves to the present moment. These observing
skills provide clients with a bit of distance on their emotional responses, which can help them tolerate those responses
better.

In Chapter 6, “Build Flexible Thinking,” clients learn about the particular thinking habits that maintain their anxiety
and depression—particularly the way they interpret events that intensifies and perpetuates their anxious and depressed
feelings. Through the many thinking skills in this chapter clients learn to become more flexible thinkers, and this flex-
ibility increases their willingness to approach rather than avoid their anxious and depressed feelings.

In Chapter 7, “Build Flexible Action,” clients learn the role of action habits, including mental action habits, in the main-
tenance of excessive anxiety and depression. Rumination, for instance, is a mental action habit. All emotions include
rumination, and emotional disorders, such as anxiety and depressive disorders, include a great deal of rumination. So,
in this chapter, clients learn skills to decrease rumination as well as to decrease their tendency to escape or avoid their
emotional responses.

In Chapter 8, “Build Emotion Tolerance,” clients learn the benefits of stepping toward rather than away from the situ-
ations, events, and physical sensations that trigger uncomfortable anxious and depressed feelings. Clients also learn a
systematic approach to overcome the avoidance that is a core feature of any emotional disorder.

In Chapter 9, “Build Gratitude and Compassion,” clients learn skills to increase happiness, self-acceptance, and self-com-
passion. These skills come from the field of positive psychology, and they’re focused on building a life worth living.
These skills will complement the ones clients have learned to manage anxious and depressed feelings. Many of them
also inoculate clients against the inevitable bumps in life.

In Chapter 10, “Keep Going,” clients learn to maintain their newfound emotional flexibility over time. In this chapter,
clients develop a plan to resist falling back into their old habits or patterns of unhelpful thinking, attention, and action.

Each of the skills in this workbook is important, and so is the overarching goal of all the skills: to assist clients to culti-
vate a radically open attitude toward their anxious and depressed feelings. The attitude is radical because it is counter-
intuitive for clients who have lived years avoiding rather than approaching their negative feelings. Herein lies the
paradox: step toward anxious and depressed feelings in order to free yourself from them. It is a life-altering lesson.

© Michael Tompkins / New Harbinger Publications 4

How to Use this Workbook in Therapy
Workbooks are no substitute for thoughtful and creative clinicians. And creative and flexible application of the exercises
in The Anxiety and Depression Workbook is the key to effective counseling or psychotherapy. I encourage you to select exer-
cises that target a client’s particular difficulties, based on your understanding of each client’s unique strengths and
weakness. For example, although I have strived to make the exercises as simple and easy to use as possible, you may wish
to further simplify the exercise when working with an overly concrete client, or to shorten an exercise when working
with an inattentive client. Furthermore, clients who are highly anxious or depressed may have trouble remembering or
learning the skills you teach them in session. With these clients, you may wish to ask them to read along as you describe
the skill or to refer to the workbook later when you ask them to practice a skill as therapeutic homework.

Again, the skills in The Anxiety and Depression Workbook are based on CBT. You likely know many of them and already
include them in the counseling or psychotherapy you provide. At the same time, it’s not necessary that you identify as a
cognitive behavioral psychotherapist in order to use the exercises in this workbook or the resources in this supplement
with your clients. Whatever their particular therapeutic style or theoretical orientation, clinicians can easily integrate
these workbook skills into the psychotherapy they provide.

I encourage you to ask clients to complete the Depression, Anxiety, and Stress Test (included in this resource) in the
beginning, middle, and end of their work with the workbook. Or, if you use other measures of anxiety and depression
in your practice, feel free to use those instead. Regardless of the measure you use, clients who practice the workbook
skills and observe a decrease in their anxious and depressed feelings are more likely to continue practicing the skills and
to continue psychotherapy with you. The old adage “Nothing succeeds like success” underscores the value to clients of
knowing that they’re progressing toward their goal of feeling less anxious or depressed—particularly early in therapy,
when clients are more likely to drop out, or during the emotion exposures in Chapter 8, which are often the most chal-
lenging for anxious and depressed clients.

There are a number of ways to use the workbook in an ongoing psychotherapy. You can teach one or two exercises, or
parts of exercises, in the session and focus the entire session on the exercises themselves. Alternatively, you can ask
clients to read the material and complete an exercise as an out-of-session therapeutic homework assignment.

Guidelines for Assigning Therapeutic Homework

Therapeutic homework assignments—even if you only ask clients to read an exercise and give you a “book report” at
the next appointment—are essential for clients to master any therapeutic skill. To increase the likelihood that clients
complete these therapeutic homework assignments and learn what you wish them to learn, I suggest you follow these
simple guidelines.

Provide a rationale for the therapeutic homework linked to client’s treatment goals. It’s essential that clients
understand how a particular exercise will help them feel less anxious and depressed. For example, when you encourage
clients to record their emotional responses with the ABCs of Emotion log, you might say something like, “I can teach
you the best skills in the world, but they’re useless to you if you don’t know when to use them. That’s why recording your
emotional responses is such an important first step. In order to use the thinking tools I’ll teach you later, for example,
it’s important that you know what you’re thinking. If you don’t know what you’re thinking than you won’t know what to

© Michael Tompkins / New Harbinger Publications 5

do to change it.” If the client sought psychotherapy for other goals, you may wish to connect the therapeutic homework
assignment to those goals too. For example, if the client sought psychotherapy following a recent relationship breakup,
you’ll want to explain how the proposed exercise (for example, deep slow breathing) will help the client manage the
emotional aftermath of the breakup itself.

Ask clients to rate their confidence about completing a therapeutic homework assignment. Clients who are
confident that they can complete a therapeutic homework assignment are more likely to do it. A client’s confidence can
vary depending on the day or the therapeutic homework assignment, and there can be any number of reasons for low
confidence. However, asking clients to rate their confidence is the first step in designing a therapeutic homework assign-
ment that a client is likely to try. So, when you’re giving a homework assignment, ask clients to rate how confident they
are about their ability to complete it, from 0% to 100%, and adjust the exercise until they are 90% confident (or greater)
that they can complete the homework assignment as agreed upon.

Discuss with the client obstacles to completing a therapeutic homework assignment. There may be real or imag-
ined obstacles to completing a therapeutic homework assignment. For example, a depressed client might think, “What’s
the point of trying. I’ll only screw it up.” An anxious client might feel self-conscious about, for instance, recording their
anxious episodes in public with the ABCs of Emotion log. Explore possible obstacles to completing the homework
assignment and brainstorm with clients possible solutions or workarounds to the obstacles. If you’re reworking a thera-
peutic homework assignment, be sure to ask clients to rerate their confidence that they can complete the homework
assignment.

Set up the therapeutic homework assignment as a “no-lose” proposition. Explain to clients that they’ll learn some-
thing helpful no matter how well the homework assignment turns out. This approach is particularly helpful for anxious
or depressed clients who may hesitate trying an assignment for fear they will fail at it. You might say, “Whether the
homework turns out well or not, we’ll learn something that helps you with the next one. Even if you decide not to try
the homework, we’ll learn something that helps you to try it next time.”

Send quick messages of support or offer brief coaching appointments. We all benefit from a little encouragement,
particularly when we’re practicing new skills for the first time. A quick text or email message that says something like
“I know you can do it,” particularly around the time you’ve asked clients to start the therapeutic homework, increases
the likelihood that clients will try it. Alternatively, you can offer clients five- to ten-minute coaching sessions to get them
started with the homework assignment, particularly if they’re not confident they can do it. During the coaching sessions,
stay focused on the therapeutic assignment rather than discussing the day or some difficult situation that arose. If you
must focus on a difficult situation a client brings up, ask clients first to retrieve their workbook and find a skill within
the workbook that might help them with the situation at hand. In this way, you encourage clients to solve problems and
resolve situations on their own with the skills that they’ve learned, and you get them to have the workbook handy so you
can move into discussing the homework assignment afterward. This approach builds the client’s confidence that they
can do a therapeutic homework task, or implement any skill they’ve learned, on their own without your assistance. After
all, building a client’s skill set and building their confidence that the skills can help them achieve their therapeutic goals
is why most clients seek cognitive behavior therapy.

© Michael Tompkins / New Harbinger Publications 6

Practice the skill in session before assigning therapeutic homework. There are many good reasons to ask clients
to practice a skill before assigning it as a therapeutic homework task. First, after you explain an exercise to clients, they
may believe that they know how to do it, but they actually don’t know quite yet. They then either complete the exercise
at home incorrectly, or they don’t complete it at all because they realized later that they didn’t quite understand the ther-
apeutic homework task you developed with them. When clients practice an exercise in session with you, you can observe
and offer corrective feedback until you and they are confident that they’re doing the task correctly. For example, I teach
clients in session to record using the ABC of Emotions log. We take several recent episodes of anxious or depressed
feelings and complete the ABCs of Emotions log together. Sometimes clients confuse a feeling (anxiety or depression)
with a thought. A client might write in the feeling column, “I feel like a loser.” However, this is actually a thought, and
this thought likely causes the client to feel depressed. So, I make sure the client understands that distinction. Once I’m
confident clients know how to complete the log correctly, I then ask them to record their emotions as they arise between
this session and next, as therapeutic homework.

It’s also true that some skills, such as slow deep breathing, can make clients anxious, particularly if breathing sensations
evoke anxious thoughts like, “I’m suffocating.” Practicing the breathing skill in session with you first provides an
opportunity for you to observe the response of clients, and work with them to complete the task as therapeutic home-
work. Last, clients are more likely to try a skill as a therapeutic assignment if they’re confident they know how to do it.
The belief, “I know how to do this,” lessens the anxiety they may feel about trying the exercise on their own without
your support.

Ask client to imagine practicing the skill in session. To increase the willingness of clients to try a skill out of
session, ask them to imagine practicing the skill first. This is called cognitive rehearsal and this simple technique increases
the likelihood clients will complete a skill as therapeutic homework because it builds confidence that they can practice
the skill when they’re feeling anxious or depressed. For example, if you’ve taught a client to say no to a coworker’s unrea-
sonable requests, ask the client to imagine saying no when they’re feeling anxious. You might ask the client to imagine
the coworker asking her to do his photocopying and feeling anxious while she imagines saying no to the coworker. Ask
clients to imagine practicing repeatedly the skill in session with you, and ask them to rate their confidence (0 to 100%)
that they can and will do this after each practice. As the client benefits from cognitive rehearsal, the client’s confidence
rating will increase. Try for at least a 90% confidence level.

Set up the therapeutic homework as a learning experiment. The objective of any workbook exercise, whether com-
pleted in session or out of session, is that clients learn something that will help them manage their anxiety and depres-
sion. Setting up therapeutic homework as experiments can pique clients’ curiosity and increase their willingness to try
it. First, explore with clients their predictions regarding how helpful the exercise might be. For example, if you’re teach-
ing slow deep breathing to a client, ask the client to rate how strongly they believe (0 to 100) that the breathing exercise
will lower their anxiety or stress. Then, ask the client to close their eyes and imagine an anxiety-evoking situation (e.g.,
waiting to present to co-workers) in which they might use the breathing skill. Ask the client to rate the level of anxiety
(0 to 10) they’re feeling as they imagine the anxiety-evoking situation. Next, ask them to practice slow deep breathing
for a few minutes. Then ask clients to rerate their level of anxiety. Most clients will rate a lower level of anxiety. In this
way, you’ve demonstrated to the client the rationale for the skill (i.e., decrease anticipatory performance anxiety). Because
they’ve experienced the skill working, they’re more likely to try the breathing exercise as therapeutic homework.

© Michael Tompkins / New Harbinger Publications 7

Always review therapeutic homework. If you don’t review therapeutic homework assignments, clients may begin to
believe that therapeutic homework isn’t important. Set aside time in every psychotherapy session to review the home-
work assignment. Ask clients whether the homework was helpful or not, and if not, what change they might make to the
homework that would make it more helpful. Ask clients what they learned from the homework assignment and whether
what they observed either confirmed or disconfirmed their prediction. Always praise the client for trying the therapeutic
homework, and strive to develop a therapeutic homework assignment as part of every psychotherapy session.

Downloadable Worksheets
I encourage you to ask clients to purchase a copy of the workbook and to bring it to each psychotherapy session. Ask
them to enter into the workbook all their notes from completing the exercises and about what they’ve learned in session
with you and out of session. In this way, all that they’ve learned is in one place so that they can easily refer to an exercise
later to refresh their memory. In addition to the workbook, you may wish to download blank worksheets and logs to
accompany certain exercises in the workbook that you would like clients to practice repeatedly. We’ve made a sampling
of these worksheets available in this supplement, along with details about how you can use them in therapy, even if you
choose not to use the workbook. Still other worksheets can be downloaded freely when you purchase The Anxiety and
Depression Workbook. These worksheets and logs are a great way to help clients organize the exercises and to remember
to practice.
1. Depression, Anxiety, and Stress Self-Test: Use this self-test to monitor therapeutic progress. Clients typically com-
plete the self-test at three points: at the beginning, middle, and end of the workbook (or treatment).
2. Basics of Emotion Worksheet: Use this worksheet in session to teach clients the cognitive model. The elements of
the model (thoughts, actions, bodily sensations) are the targets for the workbook’s interventions. Use the work-
sheet when assigning the task as therapeutic homework.
3. ABCs of Emotion Worksheet: Use this self-recording worksheet in session to enhance the client’s self-awareness, to
introduce clients to the cognitive model of emotion, and to provide you with data to plan treatment. You can
also use the worksheet when assigning the task as therapeutic homework.
4. Identify My Thinking Traps Worksheet: Use this worksheet in session to teach clients to identify the typical thinking
errors that influence excessive anxiety and depression. Clients who can identify thinking errors as they arise are
better able to disconnect from their emotional responses. Use the worksheet when assigning the task as thera-
peutic homework.
5. Identify My Hot Thought Worksheet: Use this worksheet in session to identify the most emotion-evoking (hot)
thought. Identifying the hot thought enables clients to target that thought during emotion exposures.
6. Catch It, Check It, Change It Worksheet: Use this worksheet in session to teach clients the three steps of cognitive
restructuring: identifying the automatic thought, evaluating the automatic thought, and modifying the auto-
matic thought. Use the worksheet when assigning the task as therapeutic homework.
7. Values Clarification Worksheet: Use this worksheet in session as part of a values clarification exercise. Clarifying
values is the first step in developing values-driven self-talk to enhance the motivation of clients. Use the work-
sheet when assigning the task as therapeutic homework.

© Michael Tompkins / New Harbinger Publications 8

 8. My Values-Driven Action Plan Worksheet: Use this worksheet in session to assist clients to develop value-driven
self-talk they’ll use to enhance their motivation to approach their anxious or depressed feelings. Use the work-
sheet when assigning the task as therapeutic homework.
9. Assess My Physical Sensations Worksheet: Use this worksheet in session to assess the physical sensations that become
targets for emotion exposure. Assist clients to identify the physical sensations that evoke the greatest discomfort
and are the most similar to the physical sensations that are part of a client’s emotional responses.
10. Track My Physical Sensations Response Log: Use this log in session to assist clients to track their progress during
emotion exposures that involve physical sensations. Use the log when assigning the task as therapeutic
homework.
11. Emotion Exposure Planning Worksheet: Use this worksheet in session to plan emotion exposures. The worksheet
identifies the practice situation and what clients will do instead of emotion-driven actions.
12. Emotion Exposure Practice Log: Use this log in session to assist clients to plan and learn from emotion exposures.
It’s essential that clients learn they can tolerate their emotional responses in order to recover from anxiety and
depressive disorders. Use the log when assigning the task as therapeutic homework.
13. Identify Alternative Actions Worksheet: Use this worksheet in session to assist clients to identify their emotion-driven
behaviors and to identify alternatives to those behaviors. Clients will use the alternative behaviors during
emotion exposures.
14. Practice Alternative Action Log: Use this log to identify alternatives to emotion-driven behaviors and to teach
clients the benefits of resisting emotion-driven behaviors. Resisting emotion-driven behaviors is essential if
clients are to benefit fully from emotion exposures. Use the worksheet when assigning the task as therapeutic
homework.
15. Predictions Worksheet: Use this worksheet in session to assist clients to learn that they have a tendency to over-es-
timate the likelihood of negative outcomes. Use the worksheet when assigning the task as therapeutic
homework.
16. Coped in the Past Worksheet: Use this worksheet in session to modify the tendency of clients to underestimate their
ability to cope by identifying ways clients coped with difficult situations in the past. Use the worksheet when
assigning the task as therapeutic homework.
17. Jump Back from the Worst Plan: Use this worksheet in session to teach clients to de-catastrophize events. The jump
back from the worst plan orients clients to coping rather than avoiding by increasing their confidence that they
can cope with difficult situations. Use the worksheet when assigning the task as therapeutic homework.
18. Meet My Self-Compassionate Mind Worksheet: Use this worksheet in session to introduce clients to the three parts of
self-compassion. Use the worksheet when assigning the task as therapeutic homework.
19. North Star Map: Use this map in session to introduce the task of values clarification. Encourage clients periodi-
cally to re-visit the North Star map to stay on course relative to their core values. Use the worksheet when
assigning the task as therapeutic homework.
20. Problem Solving Worksheet: Use this worksheet in session to teach clients the steps to effective problem solving. Use
the worksheet when assigning the task as therapeutic homework.

© Michael Tompkins / New Harbinger Publications 9

 21. View from the Balcony Worksheet: Use this worksheet in session as part of this exercise to teach clients to shift per-
spectives on events in order to shift their emotional responses. Use the worksheet when assigning the task as
therapeutic homework.
22. Why-to-How Thinking Worksheet: Use this worksheet in session to teach clients the anti-rumination technique of
changing big-picture “why” thinking to small-picture, concrete “how” thinking. Use the worksheet when
assigning the task as therapeutic homework.
23. My Practice Plan to Keep Going Log: Use this worksheet in session to develop a relapse prevention plan with clients.
The worksheet summarizes all the workbook skills clients are have learned. Use the worksheet when assigning
the task as therapeutic homework.

© Michael Tompkins / New Harbinger Publications 10

 Depression, Anxiety, and Stress Test

Date:         

Instructions: Read each statement and rate how much the statement applied to you during the past week. These results are for
educational purposes only. If you are concerned in any way about your health, please consult with a qualified professional.

Rating Scale

0:  Did not apply to me at all

1:  Applied to me to some degree or for some of the time

2:  Applied to me to a considerable degree or for a good part of the time

3:  Applied to me very much or most of the time

1. I found myself getting upset by quite trivial things.

2. I was aware of dryness of my mouth.

3. I couldn’t seem to experience any positive feelings at all.

4. I experienced breathing difficulty (breathlessness or excessively rapid breathing) in the absence of

physical exertion.

5. I just couldn’t seem to get going.

6. I tended to overreact to situations.

7. I had a feeling of shakiness (for example, feeling weak in the knees).

8. I found it difficult to relax.

9. I found myself in situations that made me so anxious that I was most relieved when they ended.

10. I felt that I had nothing to look forward to.

11. I found myself getting upset rather easily.

12. I felt that I was using a lot of nervous energy.

13. I felt sad and depressed.

© Michael Tompkins / New Harbinger Publications 11

 14. I found myself getting impatient when I was delayed in any way (for example, in lines or at traffic lights).

15. I had a feeling of faintness.

16. I felt that I had lost interest in just about everything.

17. I felt I wasn’t worth much as a person.

18. I felt that I was rather touchy.

19. I perspired noticeably (for example, sweaty hands) in the absence of high temperatures or physical
exertion.

20. I felt scared without any good reason.

21. I felt that life wasn’t worthwhile.

22. I found it hard to wind down.

23. I had difficulty in swallowing.

24. I couldn’t seem to get any enjoyment out of the things I did.

25. I was aware of the action of my heart in the absence of physical exertion (for example, sensing my heart
rate increase, noticing my heart missing a beat).

26. I felt down-hearted and blue.

27. I was very irritable.

28. I felt I was close to panic.

29. I found it hard to calm down after something upset me.

30. I feared that I would be “thrown” by some trivial but unfamiliar task.

31. I was unable to become enthusiastic about anything.

32. I found it difficult to tolerate interruptions to what I was doing.

33. I was in a state of nervous tension.

© Michael Tompkins / New Harbinger Publications 12

 34. I felt I was pretty worthless.

35. I was intolerant of anything that kept me from getting on with what I was doing.

36. I felt terrified.

37. I could see nothing in the future to be hopeful about.

38. I felt that life was meaningless.

39. I found myself getting agitated.

40. I was worried about situations in which I might panic and make a fool of myself.

41. I experienced trembling (for example, in my hands).

42. I found it difficult to work up the initiative to do things.

© Michael Tompkins / New Harbinger Publications 13

 Instructions: Enter the rating you gave each question (Q). Add the two ratings in each row, then enter this value in the
unshaded box. For example, if Q1 has a rating of 1 and Q22 has a rating of 2, add 1 and 2, then place the value 3 in the
unshaded box for “Stress Score.” Last, add the scores in each column to give you the total Depression, Anxiety, and Stress
scores.

Q Rating Q Rating Depression Score Anxiety Score Stress Score

1. 22.

2. 23.

3. 24.

4. 25.

5. 26.

6. 27.

7. 28.

8. 29.

9. 30.

10. 31.

11. 32.

12. 33.

13. 34.

14. 35.

15. 36.

16. 37.

17. 38.

18. 39.

© Michael Tompkins / New Harbinger Publications 14

 19. 40.

20. 41.

21. 42.

Total D Score: Total A Score: Total S Score:

Normal Mild Moderate Severe Very Severe

Depression 0 to 9 10 to 13 14 to 20 21 to 27 28 +

Anxiety 0 to 7 8 to 9 10 to 14 15 to 19 20 +

Stress 0 to 14 15 to 18 19 to 25 26 to 33 34 +

© Michael Tompkins / New Harbinger Publications 15

 Basics of Emotion Worksheet

Thou ghts

Event

Atte ntion

P h ys i c a l S e n s a ti on s P h ys i c a l A c ti on s

Me n ta l Action s

© Michael Tompkins / New Harbinger Publications 16

 ABCs of Emotion

Date:

Antecedent Basics of Emotion Consequences

Thoughts Attention Physical Sensations Actions

© Michael Tompkins / New Harbinger Publications 17

 Identify My Thinking Traps Worksheet

Date/Time Situation Hot Automatic Thought Feeling Thinking Trap

… Jumping to conclusions

… Doom and gloom

… Thinking the worst

… Jumping to conclusions

… Doom and gloom

… Thinking the worst

… Jumping to conclusions

… Doom and gloom

… Thinking the worst

© Michael Tompkins / New Harbinger Publications 18

 Identify My Hot Thought Worksheet

Automatic thought: 

• If this were true, what would this mean about me (or other people)?

• What would happen if this were true?

• What would happen next?

• Why does this matter to me?

Underlying thought: 

• If this were true, what would this mean about me (or other people)?

• What would happen if this were true?

• What would happen next?

• Why does this matter to me?

Underlying thought: 

• If this were true, what would this mean about me (or other people)?

• What would happen if this were true?

• What would happen next?

• Why does this matter to me?

Underlying thought: 

• If this were true, what would this mean about me (or other people)?

• What would happen if this were true?

• What would happen next?

• Why does this matter to me?

Underlying thought: 

© Michael Tompkins / New Harbinger Publications 19

 Catch It, Check It, Change It Worksheet

Instructions: You can learn to catch, check, and change your thoughts that make you feel anxious, angry, sad, or guilty. In the
“Catch it” row, write the thought that is troubling you. Then, in the “Check it” row, write the thinking trap for the thought you
caught. Now, go through the questions in the “Change it” section and see if you can reason your way through the thought and
feel better.

Triggering
Situation

Catch it What words, phrases, or images went through my mind just before
or while I was feeling anxious or depressed? What is my worst fear?

What do these thoughts mean about me, my life, or my future?

Emotions Intensity of emotion (0–100)

Strength of belief (0–100%)

Check it Identify the thinking traps. … Jumping to conclusions

… Doom and gloom

… Thinking the worst

Change it Am I 100 percent certain this event or consequence will happen?

Could there be any other explanations?

What’s the evidence that this belief is true?

Is the situation really so important?

What would I tell a friend who was in this situation?

Is there a more helpful way to think about this?

Is there another view that better fits the evidence?

Emotions Intensity of emotion (0–100)

Strength of belief (0–100%)

© Michael Tompkins / New Harbinger Publications 20

 Values Clarification Worksheet

Domain Value Very Somewhat Not At All

Important Important Important

Community life and citizenship

Education and learning

Family

Social life and friendship

Health and self-care

Intimate relationship

Parenting

Recreation and leisure

Spirituality and faith

Work and career

© Michael Tompkins / New Harbinger Publications 21

 My Values-Driven Action Plan

1. Select the most important value domain: 

2. Write one or two value statements: 

3. Write a series of specific committed actions:

Committed action 1: 

Committed action 2: 

Committed action 3: 

Committed action 4: 

In the service of the value: 

I choose to feel: 

So that I can: 

© Michael Tompkins / New Harbinger Publications 22

 In these steps:

1. 

2. 

3. 

4. 

© Michael Tompkins / New Harbinger Publications 23

 Assess My Physical Sensations Worksheet

Exercise Physical Sensation Sensation Sensation Discomfort

Intensity Similarity Intensity
(0–100) (0–100%) (0–100)

Shake my head from side to

side for 30 seconds.

Repeatedly (for 30 seconds)

lower my head between my legs
and then lift it quickly.

Run in place for 60 seconds

(check with my doctor first).

Run in place for 60 seconds

while wearing a heavy jacket.

© Michael Tompkins / New Harbinger Publications 24

 Exercise Physical Sensation Sensation Sensation Discomfort
Intensity Similarity Intensity
(0–100) (0–100%) (0–100)

Hold my breath for 60 seconds

or as long as I can.

While seated in a swivel chair

(not while standing), spin for
60 seconds.

Tense major muscles, abdomen,

fists, forearms, and shoulders
for 60 seconds.

Breathe very rapidly for up to

60 seconds.

Breathe through a thin straw

for 120 seconds.

© Michael Tompkins / New Harbinger Publications 25

 Exercise Physical Sensation Sensation Sensation Discomfort
Intensity Similarity Intensity
(0–100) (0–100%) (0–100)

Stare at myself in a mirror for

90 seconds.

Hunch my head down while

frowning and tightening my jaw
for 90 seconds.

Walk with a 10-pound weight

held to my abdomen for 120
seconds.

© Michael Tompkins / New Harbinger Publications 26

 Track My Physical Sensations Response Log

Instructions: Every day practice the assigned physical sensation exposure task. Use one of these forms for each physical sensation. Next to the date of
each practice, rate (0–100) the maximum intensity of the sensation and the maximum discomfort you feel about the sensation. Write these numbers
in each of the four quadrants of the boxes. Enter the first practice in the top box and enter subsequent practices in the boxes clockwise.

Physical Sensation: 

Absent Mild Moderate Much Maximum

0 25 50 75 100

Date Intensity Discomfort Date Intensity Discomfort

© Michael Tompkins / New Harbinger Publications 27

 Date Intensity Discomfort Date Intensity Discomfort

© Michael Tompkins / New Harbinger Publications 28

 Emotion Exposure Planning Worksheet

0 25 50 75 100

No discomfort Some discomfort Moderate discomfort Strong discomfort Extreme discomfort

Rank Practice Situation Emotion-Driven Actions Alternative Actions

© Michael Tompkins / New Harbinger Publications 29

 Emotion Exposure Practice Log

Instructions: Describe the emotion exposure task from your emotion exposure practice ladder.
Also describe the alternative actions you’ll use during the task. Describe what you learned in the prior emotion exposure
practice that was helpful. Before you begin the emotion exposure, describe what you’re thinking (for example, predictions,
interpretations, assumptions), the physical sensations you’re feeling, and any actions or urges to control your feelings. After
you complete the emotion exposure, describe the length of time (in minutes) that you engaged in the practice, how
uncomfortable (0 to 10) you felt during and at the conclusion of the practice, and your attempts, if any, to control or dampen
your feelings. Last, describe what you learned that was helpful. Did your feared outcome occur? Were you able to cope with
the feelings, and how did you do this? Were your predictions, interpretations, or assumptions correct or incorrect?

Emotion exposure task:

Prior Learning to Remember for This Practice

Before Emotion Exposure Practice

Rate your anticipatory discomfort

(0–10):

What are you thinking?

What physical sensations are you

experiencing?

What are you doing or having urges

to do?

© Michael Tompkins / New Harbinger Publications 30

 After Emotion Exposure Practice

Length of practice (minutes):

Maximum discomfort during practice

(0–10):

Discomfort at end of practice

(0–10):

Attempts to avoid or control

emotions:

What did you learn?

© Michael Tompkins / New Harbinger Publications 31

 Identify Alternative Actions Worksheet

Type of Action Emotion-Driven Action Alternative Action

Avoidance

Situational

Subtle Behavioral

Cognitive

Protective Signals

Emotion-Driven

Behavioral

Mental

© Michael Tompkins / New Harbinger Publications 32

 Practice Alternative Action Log

Situation Feeling Emotion-Driven Alternative Action What happened?

Avoidance or Action

Yes Yes Yes Yes Yes Yes

Yes Yes Yes Yes Yes Yes

Yes Yes Yes Yes Yes Yes

© Michael Tompkins / New Harbinger Publications 33

 Predictions Worksheet

What negative thing will happen and Strength of What really happened? Check False
when? Your Belief Predictions (√)
(0–100%)

© Michael Tompkins / New Harbinger Publications 34

 Coped in the Past Worksheet

1. Difficult Situation in the Past

Ways I Coped with this Situation

2. Difficult Situation in the Past

Ways I Coped with this Situation

© Michael Tompkins / New Harbinger Publications 35

3. Difficult Situation in the Past

Ways I Coped with this Situation

4. Difficult Situation in the Past

Ways I Coped with this Situation


5. Difficult Situation in the Past

Ways I Coped with this Situation


 Jump Back from the Worst Plan Worksheet

Describe the worst-case prediction. Ability to

Cope Before
(0–100%)

What are my strengths and resources

that will help me cope?

What can I do to help me cope?

What can I say to myself to help me

cope?

With whom can I speak or seek

support to help me cope?

Other ways to cope? Ability to

Cope After
(0–100%)
 Meet My Self-Compassionate Mind Worksheet

Situation Critical Self-Talk Feelings Compassionate Self-Talk

Self-Kindness Common Humanity Mindfulness

© Michael Tompkins / New Harbinger Publications 39

 North Star Map
Place an X in each value domain column relative to how close your actions and activities are to the North Star
for that value. If your actions are 100 percent on course and consistent with the value, you’ll place the X in the
block for the value domain closest to the North Star. The farther away the X is relative to the North Star, the
farther your actions are off course from the value.

North Star
 Problem Solving Worksheet

Step 1: Define Problem

When defining the problem, try to be as clear and complete as possible. If you’re having trouble separating the problem
from your feelings about the problem, imagine how an impartial friend would define the problem.

Steps 2 and 3: Brainstorm Solutions and Examine Strengths and Weaknesses

Write at least three possible solutions to the problem. An inflexible emotional system tends to get stuck on the same
solution. There are usually several solutions to a problem, and the first or usual solution often isn’t the best. Next, discard
any solution that is impractical or may create more problems for you. Then, write the strengths and weakness of each of
the remaining solutions. To help identify strengths and weaknesses, consider whether the solution is short term or long
term, whether you’ll likely follow through with the solution, and how the solution will affect other people.

Solution 1: Rank

Strengths Weaknesses

Solution 2: Rank

Strengths Weaknesses

Solution 3: Rank

Strengths Weaknesses

Steps 4 and 5: Rank Effectiveness of Solution then Plan and Try Solution
Rank the solutions 1 to 3, whereby 1 is the first solution to try. Once you select the solution to try first, then plan when,
where, and how you’ll implement the solution. You can schedule some solutions (for example, 4:00 p.m. Friday), or
implement them when something happens (for example, when I feel frustrated, or when Jeff calls me). Next, describe how
you’ll do it. List the specific steps you’ll take to implement the solution.

When and Where

Steps

Step 6: Review How Solution Worked and Decide Next Steps

Last, after you implement the solution, review what worked and what didn’t. Even if your problem was a one-time
situation, you can learn something that will help solve the problem more quickly if it arises again. Take a moment to reflect
on your problem and how you handled it. If the solution didn’t work, think through what you might do differently next time,
or try the next solution.
 View from the Balcony Worksheet

Describe the event or situation.

Describe my negative view Strength of belief

(anxious or depressed (0–100%)
interpretation) from the balcony.
Before

Strength of belief
(0–100%)

After

Other views from the balcony. Likelihood this view

is true
(0–100%)
 Why-to-How Thinking Worksheet

Why Thinking

Situation:

What and How Thinking

What is my goal or desired outcome?

How? What are the specific steps I’ll take to achieve my goal?

Step 1:

Step 2:

Step 3:

Step 4:

When will I do it or start to do it?

Who will help me achieve my goal?

How did the “how” thinking work?

 My Practice Plan to Keep Going Log

Instructions: Each time you practice one of the workbook skills listed below, check the box. Some skills you’ll be able to
practice every day, so circle “Today” for those skills. Other skills you’ll likely practice several times per week (but not every
day), so circle “This Week” for those skills.

Chapter 5: Build Flexible Attention

Breath as an Anchor  Today/This Week

Mindfulness of Your Emotions  Today/This Week

Anchor to Daily Activities  Today/This Week

Anchor to “And”  Today/This Week

Anchor to One Thing at a Time  Today/This Week

Chapter 6: Build Flexible Thinking

Take the Long Way Around a Thought  Today/This Week

Catch It, Check It, Change It  Today/This Week

Test the Accuracy of Your Predictions  Today/This Week

Calculate Your Validity Quotient  Today/This Week

View from the Balcony  Today/This Week

Examine How You Coped in the Past  Today/This Week

Create a Plan to Jump Back from the Worst  Today/This Week

Unhook from the Meaning of the Thought  Today/This Week

Chapter 7: Build Flexible Action

Understand Emotion Avoidance  Today/This Week

Practice Alternative Actions  Today/This Week

© Michael Tompkins / New Harbinger Publications 45

 Practice Effective Problem Solving  Today/This Week

Postpone Emotion-Driven Mental Actions  Today/This Week

Postpone Emotion-Driven Mental Actions in Steps  Today/This Week

Change Why to How  Today/This Week

Chapter 8: Build Emotion Tolerance

Practice Physical Sensation Exposure  Today/This Week

Practice External Situation Emotion Exposure  Today/This Week

Practice Internal Situation Emotion Exposure  Today/This Week

Chapter 9: Build Gratitude and Self-Compassion

Keep a Gratitude Journal  Today/This Week

Write Thank-You Notes  Today/This Week

Meditate on Gratitude  Today/This Week

Write a Compassionate Letter to Yourself  Today/This Week

Hand on Heart  Today/This Week

Meditate on Loving-Kindness  Today/This Week

Keep a Self-Compassion Journal  Today/This Week

Take a Self-Compassion Break  Today/This Week

© Michael Tompkins / New Harbinger Publications 46

References
Allen, L. B., R. K. McHugh, and D. H. Barlow. 2008. “Emotional Disorders: A Unified Protocol.” In Clinical Handbook
of Psychological Disorders: A Step-by-Step Treatment Manual, 4th ed., edited by D. H. Barlow. New York: Guilford Press.

Ellard, K. K., C. P. Fairholme, C. L. Boisseau, T. J. Farchione, and D. H. Barlow. 2010. “Unified Protocol for the
Transdiagnostic Treatment of Emotional Disorders: Protocol Development and Initial Outcome Data.” Cognitive and
Behavioral Practice 17 (1): 88–101.

Farchione, T. J., C. P. Fairholme, K. K. Ellard, C. L. Boisseau, J. Thompson-Hollands, J. R. Carl, M. W. Gallagher, and

D. H. Barlow. 2012. “The Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders: A Randomized
Controlled Trial.” Behavior Therapy 3: 666–678.

Kaufman, J., and D. Charney. 2000. “Comorbidity of Mood and Anxiety Disorders.” Depression and Anxiety 12 (Supplement
1): 69–76.

Moses, E. B., and D. H. Barlow. 2006. “A New Unified Treatment Approach for Emotional Disorders Based on Emotion
Science.” Current Directions in Psychological Science 15 (3): 146–150.

Norton, P. J., and D. J. Paulus. 2016. “Toward a Unified Treatment for Emotional Disorders: Update on the Science and
Practice.” Behavior Therapy 47 (6): 854–868.

Regier, D. A., D. S. Rae, W. E. Narrow, C. T. Kaelber, and A. F. Schatzberg. 1998. “Prevalence of Anxiety Disorders and
Their Comorbidity with Mood and Addictive Disorders.” British Journal of Psychiatry 173 (Supplemental 34): 24–28.

Taylor, S., and D. A. Clark. 2009. “Transdiagnostic Cognitive-Behavioral Treatments for Mood and Anxiety Disorders:
Introduction to the Special Issue.” Journal of Cognitive Psychotherapy: An International Quarterly 23: 3–5.

© Michael Tompkins / New Harbinger Publications 47

 About the Author

Michael A. Tompkins, PhD, ABPP, is a board-certified psychologist in behavioral and cognitive psychology. He is
codirector of the San Francisco Bay Area Center for Cognitive Therapy; and assistant clinical professor of psychology
at the University of California, Berkeley. Tompkins is author or coauthor of twelve books, including five books pub-
lished by New Harbinger. Tompkins has presented more than 600 workshops, lectures, and keynote addresses on cog-
nitive behavioral therapy (CBT) and related topics nationally and internationally. He is an adjunct faculty member of the
Beck Institute for Cognitive Behavior Therapy.

© Michael Tompkins / New Harbinger Publications 48

This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is distributed with the understanding that the pub-
lisher is not engaged in rendering psychological, financial, legal, or other professional services. The medical information in this book is provided as an educational resource
only, and is not intended to be used or relied upon for any diagnostic or treatment purposes. The interventions in this book should not be used as a substitute for conventional
medical therapy.

© 2021 Michael Tompkins / New Harbinger Publications. First published May 2021

For more information please contact

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