THRP 1

Helping Health Anxiety
Module 1
Understanding Health Anxiety
Introduction 2
What is Health? 2
What Is Health Anxiety? 3
When is Health Anxiety a Problem? 4
Negative Impacts of Health Anxiety 5
What Can You Expect from this Information Package? 7
Module Summary 8
The information provided in the document is for information purposes only. Please refer to
the full disclaimer and copyright statements available at www.cci.health.gov.au regarding the
information on this website before making use of such information.
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C Interventions Module 1: Understanding Health Anxiety Page 1
• Psychotherapy • Research • Training
Introduction
From time to time, we will all worry about things like relationships, work, finances, and, of course, our
health. Everyone, at some point or another, will notice sensations or changes in their bodies, will wonder
whether they could have a serious medical problem, and will take steps to relieve their health worries and
concerns. However, there is a difference between general concern about health, which we all have from
time to time, and more problematic health anxiety.
Are you a person who finds that you worry a great deal about your health? Have you noticed that your
effort to find answers for your symptoms is impacting on you in a negative way? If so, you may want to
keep reading these “Helping Health Anxiety” Modules.
The aim of this current module is to provide you with some general information about health anxiety, to
discover whether health anxiety is a problem for you, and to discuss the negative impacts of health anxiety.
What Is Health?
Before we talk about health anxiety, it is important that we first consider what “health” is and to recognise
that health means different things to different people.
Many people will consider health to mean the absence of disease, injury or disability. However, the meaning
of health changes from person to person, and across cultures and continents. For example, an extremely fit
athlete might consider themself to be unhealthy if they suffer an injury that prevents them from training.
However, a person with a diagnosed condition, such as diabetes or asthma, could consider themself as
healthy if they are managing their condition well.
Most definitions of health therefore extend beyond the concept of a mere absence of disease, injury or
disability, to include a person’s state of physical, mental and social functioning. Most importantly, rather
than thinking about health in black and white terms (i.e., we either have or don’t have health in these areas),
most definitions of health consider these three areas of functioning to be on a continuum ranging from very
poor to excellent.
Before we go any further, take a few moments to describe your overall health
Now notice how you described your health. What did you focus on? What
aspects of health stood out as being the most important to you? Did you
consider you physical, mental and social functioning and wellbeing?
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What Is Health Anxiety?

Anxiety comes about at times when we think something bad might or will happen.
This is actually a survival instinct and can be particularly helpful for us in real life-
threatening situations. For example, if you are confronted by a dangerous animal it
is helpful for your brain to recognise the threat and to tell your body to run, hide,
or get ready to fight. Your body will therefore go through a range of physiological
changes known as the “fight or flight” response, which helps to prepare our
bodies and protect us from danger.
There are times however when we can experience an anxiety response due simply to a perceived threat.
Have you been concerned that others might dislike a speech you are about to give and noticed your heart
beating faster? Have you ever walked through a dark alley at night and felt tense while worrying that
something bad might happen? In both of these situations something bad may or may not happen, but what is
important, is that if you believe there is some danger you will usually feel some level of anxiety.
Health anxiety therefore refers to the experience of thinking that there may be a threat to your health,
which consequently triggers your anxiety response.
While we may think and worry about any number of health related issues, some of the more common
health related fears include having or developing cancer, Alzheimer’s Disease, multiple sclerosis, muscular
dystrophy, a mental illness such as schizophrenia, a thyroid disorder, or that you may have a heart attack.
Not everyone thinks about specific problems though. Your fears could be more general, in that you simply
think that something is “not quite right”.
In what ways do you worry about your health? What would you consider to be the greatest threats to
your overall health? Do you worry about particular physical symptoms? Is there a particular health
problem, illness or disease that you are concerned (or even convinced) that you may have now or will
develop in the future?
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In some cases, the fear we have may even be about the health of a loved one. For example, a parent who
has noticed their child is tired frequently may become worried that their child has leukaemia, or a person
who has noticed that their partner has been coughing frequently may begin to worry that they have lung
cancer. While these modules are directed at worries you may have about your own health, most of the
exercises could also be also used if you are anxious about the health of a loved one.
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When is Health Anxiety a Problem?
To a certain extent, milder forms of health anxiety can affect us all from time to time. Who hasn’t been
concerned when we are waiting for some test results to come back, or had some worrisome thoughts
about a new lump or bump that we have noticed? So, at what point does mild health anxiety become a
problem? While having concerns about your health and seeking advice and appropriate health checks are
something that all human beings experience, as with anything, too much of something can be bad for you.
Health concerns can become a problem when they:

• are excessive,
• are out of proportion to the realistic likelihood of having an actual and serious medical problem
• are persistent despite negative test results and/or reassurance from your health practitioner,
• lead to unhelpful behaviours such as excessive checking, reassurance seeking (e.g., from doctors,
family or friends), or avoidance (e.g., of check-ups, doctors, health related information), and
• cause you significant distress, or impair your ability to go about your day-to-day life.
This is when normal health concerns become health anxiety. From this point forward, when we talk about
health anxiety, we will be referring to problematic levels of health anxiety.
Let’s find out if health anxiety is an issue for you. Here are a few statements for
you to consider:
Never Occasionally Often Very

Often
I worry about my health
I worry that I may have or will develop a serious medical problem
I worry that bodily sensations/changes are a sign of a serious medical
problem
I find it difficult to control or let go of my health worries
I mentally scan my body and/or mind for signs that something is
wrong
I focus my attention on my bodily sensations or symptoms
I have difficulty concentrating on things other than my bodily
sensations or symptoms
I physically check my body for symptoms and changes
I frequently visit health professionals (e.g., GPs, specialists) to discuss
my health concerns and symptoms or to have tests performed
I avoid health professionals (e.g., GPs, specialists) as I am too worried
about my health and/or test results
I have continued to worry about my health despite my doctor’s
reassurance or despite negative tests
I search for information about my symptoms (e.g., on the internet, in
books, in pamphlets from health clinics)
I discuss my symptoms with family and/or friends
I avoid people, places or activities that trigger off health worries
I avoid people, places or activities that trigger off particular physical
sensations
If you have answered most of the above questions with Often or Very Often, then health anxiety might be
something you want to work on. Even if you have only answered Often or Very Often for a few of the
above statements, you may still want to stay with us as you might learn some skills that could be useful in
the future.
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BUT I HAVE REAL SYMPTOMS?!?!

It is important to recognise that health anxiety can exist in people who are “healthy”, in people who are
experiencing real yet unexplained medical symptoms, and in people who have an existing and diagnosed
medical condition. This means that the physical symptoms you experience that are at the centre of your
health anxiety are not “all in your head”.
Whether or not you have real symptoms or an actual medical condition is not the
main issue when it comes to health anxiety. The issue is how you are responding to
and coping with your symptoms or condition. If you respond to health issues or
symptoms with excessive and persistent worrying, checking, reassurance seeking or
avoidance, then health anxiety may still be a problem.
Negative Impacts of Health Anxiety

Health anxiety can impact on us in numerous negative ways. Below are the most common areas affected by
health anxiety.
Relationships with family / friends. Time spent worrying about your health or seeking help from
professionals may impact on your ability to socialise or attend to important family matters. Family and
friends may join you in your worrying, leading to everyone feeling more distressed. On the other hand,
they may become frustrated with you if you continue to worry despite negative test results or ongoing
reassurance. In some cases, you may feel let down by or even angry towards your family or friends for not
understanding what you are going through, or for not helping in your efforts to find out what is wrong.
Work or study. Many people with health anxiety find it difficult to stop worrying about and checking for
signs of illness. All this worrying can impact on your ability to concentrate and focus on the task at hand.
Work or study time may also be taken up by medical appointments or internet searching leading to you
falling behind in your work or study tasks.
Life enjoyment and satisfaction. Focussing on potential health problems can lead you to have a skewed
negative outlook and may even lead to depressed mood. In some cases, you may become so focussed on
your health concerns and seeking certainty about your health that you will stop doing things that you used
to enjoy or that gave you a sense of achievement (e.g., exercise, socialising). This withdrawal leads to
further depressed mood as you limit your opportunities for fun and success.
Relationships with health professionals. Repeated trips to the doctor without clear results can leave
both you and your health provider feeling dissatisfied. You may even begin to feel frustrated or angry
towards your health provider or towards the health system entirely! In some cases, you may have even had
the experience of feeling like your health provider does not believe you or thinks you are a
“hypochondriac”. In some cases, your doctor may have even said this too you!
Obviously, this is neither helpful for you or your health professional. We want our health providers to be
on board with responding to our health needs. In turn, most health providers want to help us work out
why we are feeling the way we do, and to help us reduce, eliminate or manage our health worries and
problems.
Finances. Multiple or repeated medical tests or procedures, time spent away from
work, and even travel costs to attend medical appointments can soon start to add up.
For some people, the worry, checking and reassurance seeking behaviours associated
with health anxiety can become so overwhelming or time-consuming that you are no
longer able to work.
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Unpleasant anxiety symptoms. As already discussed, each time you worry about your health you set
off your fight/flight response. People experiencing health anxiety may therefore
feel restless, physically tense, or unable to relax. They may also experience sleep
disturbance, nausea, heart palpitations, chest pain or pressure, sweating, dizziness
or light-headedness, tingling sensations, and feelings of detachment from part of or
all of their body. Given you may already be worrying about your health, having
more physiological symptoms can sometimes then gives you even more sensations
to worry about!
If you are experiencing health anxiety, take a moment to write down how health anxiety is
affecting you.
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What You Can Expect From This Information Package

Whether you are experiencing excessive health worries alone, or in combination with unexplained or
diagnosed health symptoms or conditions, this information package can help you begin to reduce your
excessive worry and any unhelpful behaviours you may be engaging in.
We have begun with a discussion about what health anxiety is and what impact it can have on one’s life. In
the next two modules, we will explore and discuss how health anxiety develops and what keeps it going.
The modules after these will focus on what you can do to overcome health anxiety.
The following are the modules that make up this information package:
Module 1: Understanding Health Anxiety

Module 2: How Health Anxiety Develops
Module 3: What Keeps Health Anxiety Going?
Module 4: Reducing Your Focus on Health Symptoms and Worries
Module 5: Re-evaluating Unhelpful Health Related Thinking
Module 6: Reducing Checking and Reassurance Seeking
Module 7: Challenging Avoidance and Safety Behaviours
Module 8: Adjusting Health Rules and Assumptions
Module 9: Healthy Living and Self Management Planning
When using self-help materials, some people might skip sections or complete things in a different order.
The modules in this information package have been designed to be completed in the order they appear.
We recommend that you work through the modules in sequence, finishing each module before moving on
to the next one in the series. We believe that by doing this, you will maximise the benefits you might
receive from working through this information package.
We believe that this information package will be beneficial for anyone who would like to address any
difficulties they might have with health anxiety. We encourage you to take this journey through all our
modules, and hope that you will come away with a balanced view of your health and continue to engage in
appropriate health seeking behaviours. You might find that it gets a little tough at times, but we encourage
you to stay with it and keep on working through these modules until you reach the end. See you at the
next module!
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Module Summary
• To worry about your health is a normal human experience.
• Health anxiety refers to the excessive concern that there may be a threat to your health which
triggers your anxiety (fight/flight) response.
• Health anxiety is problematic when it is excessive, out of proportion to the realistic chances of
having a serious problem, persists despite negative tests and reassurance from health professionals,
leads to excessive unhelpful behaviours such as body-checking and medical test-seeking, and causes
you significant distress or impacts on your functioning.
• Health anxiety can exist in people who are “healthy”, in people who are experiencing real yet
unexplained medical symptoms, and in people who have an existing and diagnosed medical
condition. In health anxiety the issue is not whether your physical symptoms are real, but whether
you are responding to and coping with your symptoms in a helpful or unhelpful way.
• Health anxiety can impact on your relationships with family and friends, and even with health
professionals. It can also impact on your capacity to maintain work or study commitments, and
affect your mood and finances.
• When you worry about your health, you trigger off your fight/flight response. This gives you more
physiological symptoms which you may then also start to worry about.
Coming up next …
In the next module, we will explore
and learn more about how health
anxiety develops.
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About The Modules

CONTRIBUTORS
Dr Rebecca Anderson (MPsych1; PhD2) Paula Nathan (MPsych1)
Centre for Clinical Interventions Centre for Clinical Interventions
Dr Lisa Saulsman (MPsych1; PhD2)

Centre for Clinical Interventions
1 2
Masters of Psychology (Clinical Psychology) Doctor of Philosophy (Clinical Psychology)
BACKGROUND
The concepts and strategies in these modules have been developed from evidence based psychological
practice, primarily Cognitive-Behaviour Therapy (CBT). CBT for health anxiety is based on the approach
that health anxiety is a result of problematic cognitions (thoughts) and behaviours.
REFERENCES
These are some of the professional references used to create the modules in this information package.
Abramowitz, J., Taylor, S., & McKay, D. (2010). Hypochondriasis and severe health anxiety. In McKay, D.,
Abramowitz, J., S., & Taylor, S. (Eds.). Cognitive -behavior therapy: Turning failure into success (pp. 327-346).
Washington, DC: American Psychological Association.
Asmundson, G., & Taylor, S. (2005). It’s not all in your head: How worrying about your health could be making
you sick – and what you can do about it. New York: The Guilford Press.
Furer, P., & Walker, J. (2006). Health anxiety treatment manual. University of Manitoba: Manitoba.
Furer, P., Walker, J., & Stein, M. (2007). Treating health anxiety and fear of death. New York: Springer.
Papageorgiou, C., & Wells., A. (1998). Effects of attention training on hypochondriasis: A brief case series.
Psychological Medicine, 28, 193-200.
Salkovskis, P., Warwick, H., & Deale., A. (2003). Cognitive-behavioural treatment for severe and persistent
health anxiety (Hypochondriasis). Brief Treatment and Crisis Intervention, 3, 353-367.
Willson, R., & Veale, D. (2009). Overcoming health anxiety: A self-help guide using cognitive behavioural
techniques. London: Robinson.
“HELPING HEALTH ANXIETY”

This module forms part of:
Anderson, R., Saulsman, L., & Nathan, P. (2011). Helping Health Anxiety. Perth, Western Australia: Centre
for Clinical Interventions.
ISBN: 0 9757995 6 8 Created: August 2011
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Module 2
How Health Anxiety Develops
Introduction 2
Negative Health Experiences 2
Heightened Health Vulnerability 3
Protecting Ourselves: Unhelpful Health Rules & Assumptions 3
Protecting Ourselves: Increased Health Sensitivity 5
Model of Health Anxiety: How Health Anxiety Develops 6
Worksheet: How Health Anxiety Develops 7
The Good News 7
Module Summary 8
About the Modules 9
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Introduction
So far we have looked at the difference between normal, everyday worries about health and more
excessive and problematic levels of health anxiety. We have also considered some of the negative impacts
health anxiety can have on our day-to-day functioning, relationships, and our life satisfaction and enjoyment.
However, something that many people who experience this problem will ask is, “why do I have health
anxiety?”
The exact cause of health anxiety is not known. While there is some evidence that health anxiety, like all
anxiety disorders, may in part be an inherited or biologically based problem, it is generally accepted that
several other important factors can increase the likelihood of you developing this problem. In this module,
we will explore how some of these factors may contribute to the onset and development of health anxiety.
Negative Health Experiences

As discussed in Module 1, health anxiety refers to the excessive concern that there may be a threat to your
health which then triggers off your anxiety (fight/flight) response. So where does this excessive concern
come from? People who experience health anxiety often report the following prior experiences:
Having family members or others around you experience a serious illness

Especially during our childhood and adolescence, our experiences can influence how
we view ourselves, how we view others, and how we view the future. If we witness
someone experiencing pain and suffering it may lead to us feeling vulnerable and
concerned that this could happen to us too. If we have witnessed someone with a
progressive illness, we may feel quite helpless. We may even develop a sense that
“illness” means “nothing can be done”. In circumstances where the illness experienced by a family member
has a degree of heritability, we may start to focus on the likelihood that we too will develop the illness as
opposed to the chance that we won’t.
Death of a family member or someone known to you

While death is an eventual certainty for all of us, on a day-to-day basis most of us can tolerate the
uncertainty of not knowing when and how it will happen. However, if we are put in a situation where we
are made to think about what our own death will be like and the impact our death will have on others,
most people will feel somewhat uncomfortable. The death of someone close or known to us, whilst often
distressing in itself, can increase our awareness of our own mortality and lead us to contemplate these
issues. If we have witnessed someone suffer a prolonged disease prior to death, we may associate illness
with intense suffering and certain death. If the death was sudden, and especially if it was of someone
previously perceived to be “healthy”, it can lead to an increase in our sense of vulnerability and
helplessness.
Having experienced a medical problem yourself

Experiencing a medical problem can lead us to being more “tuned in” to our bodily sensations and changes,
and alert us to our chances of further medical issues or even death. When explaining a diagnosis, doctors
will often review the possible risks and complications of the diagnosis with a patient, alerting us to
previously unknown information. Furthermore, for people who have overcome a
medical condition (e.g., cancer, or a heart attack), having experienced the problem
once may increase the likelihood of the problem reoccurring. Focussing on the
potential risks, complications, and chance of recurrence can increase our sense
that there will be ongoing threats to our health, and make us feel more anxious.
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Having a family member with health anxiety
We tend to learn a lot about the world from those around us. So, if we have grown up observing or
listening to others worry about health or frequently checking for signs of illness or injury, we are more
likely to use these same coping strategies when we are confronted with health issues or sensations.
Negative information from the media or internet

The internet and media today allow us immediate access to a range of interesting health related stories and
information. However, in an effort to “sell” their stories, media outlets must ensure that their shows or
stories grab the attention of the public. Health stories in the media or on the internet can therefore focus
on rare diseases, incurable health problems, and fatal conditions. Furthermore, they may report on the
experiences of patients who were misdiagnosed, sometimes despite repeated efforts to
seek medical help. While these cases do occur, the emphasis sometimes portrayed in
the media on these unlikely conditions and events can lead us to question our medical
care, to view benign bodily sensations and changes with greater suspicion, and to
consider previously ignored and highly unlikely health problems as common.
Take a moment to write down what experiences you have had that may have increased your
concerns about your health.
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Heightened Health Vulnerability

It makes sense that these past negative health experiences may increase your overall sense of vulnerability
regarding your own health. If you have been exposed to negative health experiences in your life, you may
develop the belief that your health is vulnerable, and view illness as not only common but perhaps painful
or deadly. With this sense of vulnerability hanging over you, it is only natural that you would focus your
attention on bodily sensations or health problems which other people may simply ignore. The remainder of
this module will focus on how you may try to decrease these feelings of vulnerability and protect your
health by developing health rules and assumptions and by going on “high alert” for signs of illness.
Protecting Ourselves: Unhelpful Health Rules and Assumptions

Rules and assumptions can exist in all areas of our lives and are generally designed to help us function well
and keep us in good health. For the most part, having rules and assumptions can provide us with helpful
guidelines for living, so long as they are realistic and somewhat flexible. For example, I might have the rule
that “I should brush my teeth twice daily to prevent decay” or the assumption that “If I don’t exercise
regularly, then I will put on weight”. These rules and assumptions seem helpful in that they appear fairly
accurate (i.e., it is generally accepted that a lack of exercise will lead to weight gain), and they are also
flexible (i.e., while it is good to aim for twice daily teeth brushing, it is unlikely to be problematic if you
forget to brush occasionally). However, we can also have more unhelpful rules and assumptions by which
we try to lead our lives. A rule or assumption tends to be unhelpful when it is inaccurate and/or inflexible
in some way.
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At the heart of health anxiety lays certain unhelpful rules and assumptions, often comprised of inaccurate
or inflexible “shoulds”, “musts” or “if… then” statements. Remember, that it is often due to your past
experiences that you develop these rules or assumptions. For example, imagine that you
have grown up with a very anxious parent, who would respond to any minor health
complaint with one or more trips to the doctor and lots of time spent worrying, even if
the doctor had said nothing was wrong. These experiences may lead you to develop
some guidelines (i.e., rules and assumptions) about your health. You may develop a rule
that “I must find out what is causing this sensation”. You may also begin to assume that
“If I don’t report these symptoms, I could miss an important one”.
Keep in mind that your rules and assumptions have developed as a way of attempting to protect you, it is
only when they become inaccurate and/or inflexible that they become a problem. Below are some common
unhelpful rules and assumptions linked to health anxiety.
Health rules may include:

“I must take all symptoms and bodily changes seriously”
“I must be symptom free to be healthy”
“I must report all new bodily sensations to a health professional”
“I must have a diagnosis so I can move forward”
“My doctor must be certain”
“My doctor should be able to explain each of my bodily sensations and changes”
Health assumptions may include:

“All discomfort and bodily changes are problematic”
“If my doctor orders a test, then there must be something wrong”
“If my doctor doesn’t know exactly what the problem is, then it must be really serious”
“If I don’t get a clean bill of health from the doctor, then I must be ill”
“If I don’t keep checking / having tests, I could miss something really important”
“If I don’t persist, my Doctor may miss something important”
“If I’m not vigilant, an underlying problem could be getting worse”
“Once you are sick, there are no second chances”
“If I miss an important health symptom, it could kill me”
Health rules and assumptions can also be combined as follows:

“If my doctor can’t tell me exactly what it is, it must be serious and needs further investigating”
“I must keep measuring the size of this lump, otherwise I won’t know if it is getting worse”
“Doctors miss things, so I should see several different doctors until I get a clear diagnosis”
Take a moment to consider the sorts of rules or assumptions you may hold about your
health. Take a few minutes to write these down. Also, take a moment to think about how this
may be linked back to your past health-related experiences.
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Protecting Ourselves: Increased Health Sensitivity

A very useful part of your fight/flight response is that it makes you focus your
attention on possible threats and ways to escape these threats. For example, if you are
walking through the bush looking at wildflowers and you come across a snake, your
attention is likely to be drawn to the snake. You may find it hard to look at anything
other than the snake, unless it is to look around for the safest path away or perhaps a
stick to protect yourself with. At that moment, you are probably not focussed on the
sound of the breeze blowing through the trees, the colour of the sky and clouds, whether your feet are
feeling comfortable in your shoes, or the motion of birds as they dart between the trees above. Your
attention has been drawn to focus on the threat before you in an effort to protect you from harm. You
may also find that for the rest of your walk that day, you scan the ground more frequently and are in a
generally higher state of alert. You may even jump at the sound of leaves rustling or the sight of slight
movement out of the corner of your eye.
Most people, most of the time, will not pay much attention to minor discomfort, changes in their bodily
functions (e.g., heart rate, saliva production), bodily noises, minor lumps and bumps that come and go, and
increases or decreases in their energy levels. For the most part, we accept that our bodies are like noisy
old cars – sometimes they run well, sometimes they run a little rough, but for the most part they just keep
on running so long as we add fuel and get the occasional tune-up.
However, just as a snake might seem threatening to some of us and hence we become sensitive to its
presence in order to protect ourselves; people with health anxiety believe their health is under threat, and
become sensitive to their health in order to protect themselves.
In the case of health anxiety, you can become more sensitive or “tuned in” to signs or symptoms of illness.
People with health anxiety will tend to pay closer attention to sensations or changes in their bodies,
noticing things that others would simply not pay any attention to.
Unfortunately, focussing on a symptom can sometimes amplify the intensity of the

symptom. Going back to our snake example, the more you focus on the snake the more
aware you will become of the size, colour and shape of the snake. Similarly, the more
you focus on your symptoms, the more aware you will become of the peculiarities of
that symptom, and the more likely you will be to worry about and further focus on the
symptom.
Take a moment to think about the signs or symptoms you tend to look for or worry about
and record them below. Do you have a particular symptom and sensation you focus in on, or
several things that you worry about and pay attention to? How much time do you spend each
day focussing on that symptom or sensation?
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Model of Health Anxiety: How Health Anxiety Develops
A useful way of pulling together the information covered so far is to place it in a diagram so that you can
see how it all fits together. We call this diagram a “model”. Throughout this workbook we will often refer
back to this model to remind ourselves as to how health anxiety may have developed. We will also add
more information in the next module where we will examine what happens to keep health anxiety going.
Negative Health Experiences  Heightened Health Vulnerability

Past experiences like: Develop an overall sense that my own
• Illness of someone I know health is vulnerable
• Death of someone I know
• Own previous medical problem
• Family with health anxiety
• Negative information in media
Attempt to protect health via:
Unhelpful Health Rules & Increased Health Sensitivity

Assumptions
Inaccurate/inflexible beliefs about Highly “tuned in” to my health signs
what I should do and expect in order and symptoms
to be healthy (“shoulds”, “musts”,
“If…thens”)
Increased susceptibility to health anxiety.

But…remains dormant until triggered…
As you can see, this model identifies that our past experiences can increase our sense of vulnerability and
general concerns about our health. In an effort to protect ourselves from harm, we will develop health
rules and assumptions plus become more tuned in to our bodily changes and sensations.
Many people experience the kinds of life events we have discussed, and a proportion of us will have
particular rules and assumptions about our health and be tuned in to bodily sensations and changes. We
therefore may be at an increased susceptibility for health anxiety but it can lay dormant until one or more
events trigger off or “activate” the health anxiety.
In the next module, we will discuss the kind of things that may trigger off an episode of health anxiety. We
will also discuss a number of things that keep health anxiety going once it has been activated.
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Worksheet: How Health Anxiety Develops
Let’s take a moment to consider how your health experiences, your health rules and assumptions, and your
awareness of your bodily sensations may have combined to increase the likelihood of you developing health
anxiety. You can go back to the last few pages and copy your answers from each section in to the model
below.
Negative Health Experiences  Heightened Health Vulnerability

Write down any health experiences that may Develop an overall sense that my own health
have increased your concerns about your health is vulnerable
Attempt to protect health via:
My Health Rules & Assumptions Increased Health Sensitivity

What “should” or “must” rules, or Which symptoms or sensations do you
“If…then” assumptions do you hold focus your attention on? What bodily
about your health? changes are you most tuned in to?
Increased susceptibility to health anxiety.

But…remains dormant until triggered…
The Good News…

Given that your susceptibility to health anxiety is likely to have come from a combination of biological
factors coupled with some negative health experiences from the past, it may at first seem a little
discouraging because our biological make-up and our past experiences are something that we can’t change.
But the good news is that it doesn’t necessarily matter how your susceptibility to health anxiety came
about, when it comes to taking steps forward to change it. It is really important to read on, because as you
will see in the next module, there are things we do in the ‘here and now’ that keep our health anxiety alive
and well. And it is these things that we can tackle and change in order to overcome our health anxiety.
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Module Summary
• Our earlier experiences can leave us feeling somewhat vulnerable and lead us to develop increased
concerns about our health. Such experiences can include:
• Having family members or others around you experience a serious illness
• Death of a family member or someone known to you
• Having a family member with health anxiety
• Having experienced a medical illness yourself
• Negative information from the media or internet
• Some people who have these experiences will go on to develop unhelpful health rules and assumptions,
and become increasingly sensitive to bodily sensations and changes. We do this in an effort to protect
ourselves from threats to our health and to reduce our overall sense of vulnerability.
• Health rules and assumptions are generally designed to help us function and keep us in good health. It is
only when they become inaccurate and/or inflexible that they become unhelpful.
• People with health anxiety tend to pay closer attention to sensations or changes in their bodies,
noticing things that others would simply not pay any attention to.
• Focussing on our bodily sensations and changes can sometimes amplify the intensity of the symptoms,
in turn making it more likely that we will worry about and further focus on the symptom.
• While we may be susceptible to developing health anxiety due to our past experiences, rules and
assumptions, and sensitivity to symptoms or changes, health anxiety can lay dormant until one or more
events trigger off or “activate” the health anxiety.
Coming up next …
In the next module, we will look at
what triggers off health anxiety, and
what then keeps it going.
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About The Modules

CONTRIBUTORS

1 2
BACKGROUND
REFERENCES

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Module 3
What Keeps Health Anxiety Going?
Introduction 2
How Health Anxiety is Triggered 2
How Health Anxiety is Maintained 3
Unhelpful Health Related Thinking 3
Increase in Anxiety Symptoms 3
Focussing on Symptoms 4
Checking & Reassurance Behaviours 5
Avoidance & Safety Behaviours 6
Putting it All Together 7
Model of Health Anxiety Maintenance 7
Worksheet: How My Health Anxiety is Maintained 10
The Good News 11
Module Summary 12
About the Modules 13
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C Interventions Module 3: What Keeps Health Anxiety Going? Page 1
Introduction
In Module 2, we explored how our past experiences may lead us to feel more vulnerable, increasing our
concern about our health and making us more sensitive to bodily symptoms and changes. We also
identified the concept of “dormant” health anxiety – where unless we are confronted by something that
“activates” or triggers off our health anxiety, it may not bother us for periods of our life. In this module, we
will discuss potential triggers to health anxiety, and explore how health anxiety is then maintained in the
longer-term.
How Health Anxiety is Triggered

If you ask any friend or family member whether they have ever worried about their health, most people will
probably admit to having some health-related concerns from time to time. Interestingly, the same things
that would make any other person worry about their health could trigger off an episode of health anxiety.
It is usually when these triggers are combined with a set of inflexible and inaccurate health rules or
assumptions that health anxiety is triggered. These triggers can be something internal within us or external
in our environment.
Internal triggers
Remember in the last module we talked about our bodies as being like old cars. Over
time they will develop some strange noises and start to run a bit rougher.
All-in-all, it is normal to feel some symptoms and sensations in your body. This can include stomach
discomfort, tingling or numbness in parts of your body, ringing in your ears, sensitivity to heat or cold in
your teeth, increases or decreases in your heart rate, changes in your saliva production, and variations in
your energy levels. Sometimes new or unfamiliar symptoms may begin for you, such as the onset of
headaches or development of a rash. Many women whilst pregnant will also report a range of new and
sometimes bizarre sensations in their bodies. You may even have unusual sensations, such as developing a
strange taste in your mouth or a muscular twitch under one of your eyes.
External triggers
Besides things happening within your body, a number of external things can draw your attention towards
possible health problems and therefore trigger off episodes of health anxiety. For example:
• Health scares in the news
• Upcoming medical appointments
• Being in contact with people who are unwell
• Hearing about someone who has been diagnosed with an illness
• Receiving inconclusive results on a medical test
• Being told you do have a health condition
• Being away from known health-care systems (e.g., travelling overseas)
Take a moment to write down any triggers you have experienced in relation to health
anxiety.
Internal triggers External triggers
____________________________ ____________________________
____________________________ ____________________________
____________________________ ____________________________
____________________________ ____________________________
____________________________ ____________________________
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How Health Anxiety is Maintained
Unhelpful Health Related Thinking
If your unhelpful health rules or assumptions are activated by the types of triggers just mentioned, they are
likely to negatively affect the way you think about sensations or variations in your body, and how you
interpret health information from medical professionals or other sources. In general, people with health
anxiety tend to overestimate the likelihood that they have a serious health problem and underestimate
their ability to cope with such a problem. They also tend to discount other factors which suggest that
things will not be as bad as they have predicted (e.g., overlook their doctor’s reassurance that a serious
illness is unlikely, focus on the most negative potential outcomes rather than the chances of cure or good
management). As such, all health-related experiences are viewed as a ‘catastrophe’ or ‘worst-case’ scenario.
Catastrophic interpretation of bodily sensations

If you hold an unhelpful health assumption such as “All discomfort and bodily changes are a sign of serious
illness”, and are then faced with the trigger of experiencing pain in your joints, you may come up with
catastrophic interpretations of what the pain means. You might say things like: “This could be arthritis”, “I
probably have bone cancer”, “This problem will be the end of me”, or “This could be something incurable”.
Catastrophic interpretation of health related information

You may also misinterpret health information as indicating that you are at higher risk
than you really are. For example, imagine that your doctor tells you that your blood
test showed a low white blood cell count but that it is “…probably just due to a
common cold”. If you hold the unhelpful health assumption “If my doctor doesn’t
know exactly what the problem is, then it must be really serious” you are more likely
to come up with thoughts such as “Maybe it is actually leukaemia”, or “My doctor
hasn’t tested for really serious problems like HIV or Lupus, so there is a chance that
is what I actually have”.
Take a moment to write down some of the unhelpful thoughts you have experienced in
regard to your health. What kinds of things are you saying to yourself about your health or
about any health information you have received?
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Increase in Anxiety Symptoms

As you can probably imagine, if you start having catastrophic thoughts about your bodily sensations, you are
likely to be firing up your fight/flight response in reaction to this perceived threat to your health. Your
fight/flight response is designed to protect you by helping you survive a battle (“fight”) or to run away to
save yourself (“flight”) and can include the following changes:
 muscular tension, tiredness or exhaustion
 skipping, racing or pounding heart
 changes in breathing rate / breathlessness, chest pain or pressure
 dizziness, light-headedness, blurred vision, confusion, feelings of unreality and hot flushes
 numbness and tingling in your fingers and toes
 an increase in sweating
 widening of the pupils, blurred vision, spots before the eyes, a sense that the light is too bright
 a dry mouth, nausea or an upset stomach
You may notice one, some or all of these symptoms in varying degrees of intensity.
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These physical alarm responses are important when facing real danger, but they can also occur when there
is only a perceived danger. If you say things to yourself like: “This could be something incurable”, “I may
have cancer”, or “My doctor may have missed something important”, it is likely that these perceived dangers
will set off your fight/flight anxiety symptoms.
Unfortunately, people who have a tendency to notice and worry about health signs and
symptoms can then also start to worry about some of these fight/flight anxiety
symptoms – jumping to the conclusion that they are another sign that something really
is wrong!
This can lead to a vicious cycle where real symptoms trigger catastrophic thoughts
about health problems, which in turn trigger anxiety symptoms. These anxiety
symptoms can then lead to more catastrophic thoughts about health problems, which
trigger more anxiety symptoms… and so on. Although driven by your catastrophic thinking, you experience
real physical symptoms.
Focussing on Symptoms
In Module 2, we discussed how a useful part of our fight/flight response is to focus on the thing by which
we feel threatened, and also, on ways of possible escape. We also talked about how hard it can be to draw
our attention away from that threatening thing. We used the example of coming across a snake in the bush
from which we find it hard to look away.
Unfortunately, focussing your attention on something can sometimes amplify the intensity with which you
experience that thing. Going back to our snake example, if you were to focus your attention on the snake
you will become more aware of the size, colour and shape of the snake. You may also notice the sound of
the snake as it moves across the ground. Overall, focussing more intensely helps you to evaluate and
monitor the threat before you.
Similarly, the more you focus on your symptoms, the more aware you will become of the peculiarities of
that symptom. Unfortunately, focussing on a symptom can also amplify the intensity of that symptom and, in
turn, create more concern about the symptom and increase your desire to focus on the symptom.
Try this exercise. Focus in on your stomach…notice all the tiny sensations you
can feel…it might be tightness or gurgling or fluttering or something
else…really hone in on any symptoms or sensations you notice in your
stomach. Stay with this for 1 minute. Now ask yourself whether you had
noticed any of these sensations before you purposely focused on your
stomach? Also as the time spent focusing on your stomach dragged on, did the
sensations get more or less noticeable? Usually people find they notice a
whole bunch of sensations they had not previously been aware of, and that
these sensations seem to grow over the minute, as they pay more and more
attention to them.
Take a moment to write down any symptoms, sensations or areas of your body that you tend
to focus on regularly. When you are paying attention, what do you notice most about that
symptom, sensation or body area? Is it the intensity? The level of pain or discomfort?
Whether it is staying the same or changing?
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
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Checking and Reassurance Seeking Behaviours
To check on or ask for reassurance about things we are worried about is a normal human behaviour. Most
people have thought to themselves “I’m not sure I locked the door properly”, then walked back and
checked or even asked a companion “Did I lock the door when we left?” Usually, this will lead to us feeling
less anxious, and allow us to continue on with our everyday lives.
In terms of our health, we are actually encouraged to check our bodies and seek reassurance. For example,
we are often encouraged to monitor moles for any signs of change, and women are frequently encouraged
to check their breast regularly. We are then encouraged to contact a medical professional if we are
concerned about our health, or notice any changes in our general wellbeing. Just like the previous example
of checking whether we’d locked the door, checking or obtaining reassurance about our
health status will usually lead us to feel less anxious, and allow us to continue on with our
everyday lives.
However, people who experience health anxiety tend to continue worrying about their
health, continue to feel anxious, and therefore continue to engage in checking and
reassurance seeking to try to reduce their concerns and unpleasant feelings.
People with health anxiety have reported engaging in frequent and repeated:
• Checking in the mirror for signs of asymmetry, areas of discolouration, or new moles or lumps
• Poking, palpating or pinching of the skin, breasts, stomach or other areas of the body
• Examination of bodily excretions (e.g., saliva, urine, faeces) for signs of blood or infection
• Measuring parts of their body (e.g., using tape measure or callipers)
• Monitoring of bodily processes (e.g., taking pulse, checking blood pressure)
• Weighing of their body or bodily excretions
• Asking family members, friends, and health care providers about their symptoms
• Researching their symptoms on the internet or in medical texts
• Posting of their symptoms on internet sites to obtain others opinions about their symptoms
• Requesting of medical tests or evaluations, and second opinions
In some cases, the efforts to check for an illness can bring about new and painful symptoms themselves. For
example, when performing a breast self-examination, Sally noticed a bumpy area that she had not noticed
before. Over the next two weeks, she continued to worry and began to push on and even squeeze the area
to see if any of the lumps were getting any bigger. She also informed her boyfriend and mother about her
concerns, getting them to also feel the lumpy area and asking them for their advice. Each day, the area
became more and more tender and painful to touch, thus increasing her concern that something was
seriously wrong.
Take a moment to write down any checking or reassurance seeking behaviours you have
engaged in. What were you looking for? What did you find? Were there any negative
consequences of the checking or reassurance behaviours?
____________________________________________________________
____________________________________________________________
____________________________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
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Avoidance and Safety Behaviours
Whilst checking and reassurance seeking are designed to decrease feelings of anxiety that are already
present, avoidance and safety behaviours are strategies used to try to prevent us from experiencing anxiety.
People who experience health anxiety will generally try to avoid the internal and external triggers we
identified earlier in this module. To avoid internal triggers, you may avoid engaging in things that lead to
changes in your physiological state. This could include: exercising, walking up stairs, drinking coffee, having
sex, eating spicy foods, and drinking fizzy drinks.
To avoid external triggers, you may avoid a large range of potential people, places or situations which
remind you of health issues. To name a few, this can include avoiding:
• medical professionals or check-ups • eating foods close to the used by date
• doctor’s surgeries • visiting a friend who has a non-infectious disease
• watching the news or reading the newspaper • using public restrooms
• walking past funeral homes • watching medical dramas on TV
• writing a will • visiting a relative who has recently been sick
• phoning for test results • not reading information provided by a Doctor
Avoidance means that in the short term, there are fewer reminders of health
related issues and therefore less chance of feeling worried and concerned.
However, in the longer term avoidance can keep your fears going, or even make
them worse.
The term “safety behaviours” refers to a more subtle form of avoidance. To use
safety behaviours means that you may not outrightly avoid something, but will only
approach that feared place, person or activity if certain back-up plans are in place.
For example, someone who fears contracting meningococcal disease may still go
out in public and even attend medical appointments , but only if they are carrying hand sanitiser and
antibiotics in their bag. Similarly, someone who is fearful of having a heart attack may continue going about
their daily business, but only if they are around others and are carrying a mobile phone at all times in case
an ambulance needs to be called.
Engaging in safety behaviours only temporarily reduces your health worries and concerns. The next time
you are confronted with a similar situation, you will feel the need to use them again and never learn that
you can survive without them.
Take a moment to write down the things you might be avoiding because of your health fears.
This could include certain people, places, activities, objects, or even foods. Also, are there any
behaviours you engage in to increase your sense of safety in these situations?
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Note: Although they could seem like opposite behaviours, you may engage in
checking and avoidance at the same time. For example, you could be engaging in
daily breast self-examinations, yet avoid telling others about your concerns or
going to the doctor to have them check you over. Alternatively, you may engage in
only checking or avoidance, or a little of each of these. The combination of
checking and avoidance behaviours will vary from person to person.
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Putting It All Together:
Model of How Health Anxiety is Maintained
It is quite normal to experience both internal and external triggers. So how do these triggers lead to health
anxiety? Remember from Module 2, if you have already experienced a number of negative health
experiences, you may be more sensitive or “tuned in” than others to noticing these internal and external
triggers. This in turn increases your chance of “setting off” health anxiety.
Generally speaking, when confronted with an internal or external trigger, your health rules and assumptions
become activated. By “activated” we mean that they move from being dormant to being switched on like a
light switch. Once activated, your health rules and assumptions can start to affect how you think, feel, and
behave in response to those triggers.
If you hold flexible and realistic rules and assumptions about your health, these internal or external triggers
probably won’t worry you too much. For example, let’s say you notice pain in your joints, plus you hold the
rule “If this pain gets worse or is still there in another week, then I will get the Doctor to check it out”.
Such a rule is:
• flexible, in that it allows you to experience what may be normal bodily sensations,
without excessive worry, checking, or medical opinion seeking, and is
• realistic, in that it doesn’t discount the possibility that there may be a problem
that could need medical attention.
However, imagine that you notice pain in your joints, plus hold the unhelpful health
assumption “All discomfort and bodily changes are a sign of serious illness”. How might
you then respond to that pain in your joint? What might you start to think about that pain? How would you
be feeling each time you thought about that joint pain? How would you rate your chance of a good
outcome should you even visit the doctor?
All-in-all, when you experience a combination of unhelpful health rules or assumptions plus internal or
external triggers that draw your attention to health related issues, you are at increased risk for
experiencing health anxiety. You are more likely to interpret bodily sensations or changes as a sign of
serious illness, to misinterpret health related information, and to set off more physiological sensations each
time you worry.
You may then engage in unhelpful efforts to control your anxiety or reduce your risk of
disease. You may focus on your symptoms in an effort to monitor and evaluate any
potential health threats. You may check or seek reassurance to increase your sense of
certainty over your health status. You may also engage in avoidance or safety behaviours
to stop your health anxiety from being triggered in the first place.
In the short term, these behaviours may provide a temporary sense of relief or control over your health
concerns. However in the long term there can be negative consequences. For example, focusing on your
symptoms can enhance the intensity of those symptoms. Checking behaviours may lead to tenderness or
inflammation. Seeking and then being given medical tests may reinforce your belief that something is wrong.
Researching your symptoms can alert you to catastrophic yet unlikely explanations for your symptoms. All
of these behaviours create more worry and therefore keep your health anxiety going.
Also, avoiding or using safety behaviours can limit your ability to learn anything new about your health. For
example,
• If you don’t go to the doctor for a check-up, you don’t find out whether you do or do not have a
health problem. You may therefore continue to worry about your health.
• If you avoid people or places that you believe may make you sick, you never get to find out if this
really does occur. So in the longer term you feel that you must continue to avoid it.
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The following case illustrates how this can develop in to a vicious cycle of anxiety.
Sarah was a 30yo woman who continued to visit her doctor complaining of a sore throat. Sarah
had read a magazine article about a person who had developed throat cancer despite never
being a smoker. Sarah had worried ever since that she may develop or even already have this
problem, and had begun to notice some unusual sensations in her throat region (i.e., tightness, a
dry throat). On multiple occasions her doctor informed her that her throat “looked inflamed” but
that there were no current signs of actual cancer. Her doctor told her not to worry about the
soreness but rather to come back and see him if the symptoms got worse.
Unhappy with her doctor’s response, Sarah began engaging in daily forced coughing behaviours to
try to “bring up” as much phlegm as possible so that she could check it for signs of blood or
infection. She would sometimes use her toothbrush to push on the back of her tongue so that she
could check for areas of tenderness, and also engaged in regular palpating of her neck, checking
it for lumps and areas of tenderness. Sarah had difficulty concentrating and performing her job as
she continuously focussed on the unpleasant sensations and spent time researching her symptoms
and potential treatments on the internet. Sarah began to switch off the television whenever
medical dramas or documentaries came on the television, stating that she didn’t need to be
reminded of what the future may hold.
On the following page we have collated this information into a model, so that it is easier to see how Sarah’s
health anxiety is being triggered and then maintained.
As you can see, Sarah is caught in a vicious cycle of worrying about her health, setting off more
physiological symptoms (including anxiety itself), and engaging in efforts to control her worry and
symptoms which in the long term can keep the problem going. On the following page, there is a worksheet
for you to collate your own example.
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How Sarah’s Health Anxiety is Maintained
Triggers
- Reading magazine article about a person with throat cancer
- Noticing unusual sensations in throat region
Activates unhelpful health rules / assumptions

- I must be symptom free to be healthy
- If I miss an important symptom, it could kill me
Unhelpful health related thoughts

- This is cancer, I just know it
- My doctor said the area is inflamed and to
keep monitoring, so something serious is happening
Anxiety symptoms
Increased muscular tension, racing heart, dry mouth and throat
Focussing on Checking & Avoidance &

Symptoms Reassurance Seeking Safety Behaviours
- Pays close attention to - Checking tongue, phlegm, - Avoids medical
sensations in throat throat region dramas or
- Notice all minor - Seeking reassurance from documentaries
changes/sensations doctor and internet
Short term consequences

• Sense of relief or control over symptoms
Long term consequences

• Focus on symptoms may enhance the intensity of symptoms
• Checking (i.e., using toothbrush, coughing up phlegm, pressing on neck) may
lead to further inflammation and tenderness
• Doctor and internet cannot provide complete reassurance
• Avoidance limits opportunities to change perceived threat of medical dramas
or documentaries.
• Worrying continues and may increase. Anxiety symptoms increase. Increased
desire to focus on symptoms, check and seek reassurance, and to avoid or use
safety behaviours.
• Vicious cycle keeps going
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How My Health Anxiety is Maintained
Triggers
My internal or external triggers…

My health rules & assumptions (can be copied from last module)…

What do I tell myself about my bodily sensations and changes?
What do I say to myself about information my doctor gives me or that I hear from other sources?
Anxiety symptoms
Physiological sensations I experience…

symptoms Reassurance Seeking Safety Behaviours
What am I focussing on? e.g., body checking, reassurance seeking People, places, things I avoid…or things
from Drs or the internet I feel I must do to confront these…

e.g., sense of relief or control over symptoms

e.g., thoughts, rules and assumptions remain unchallenged, anxiety continues
increased desire to focus on symptoms, check and seek reassurance, and to avoid or use safety behaviours
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More Good News…

At first, it may look overwhelming to see how your efforts to try to control or reduce your worrying and
symptoms can actually lead to them increasing. However, being able to understand what is keeping health
anxiety going on a day-to-day basis lets you see where you can start to make some changes to break this
vicious cycle.
The remainder of these modules will cover a range of cognitive and behavioural strategies aimed at
gradually breaking down the unhelpful thoughts, behaviours, and rules & assumptions that can keep this
cycle going.
Looking at the model, you may wonder why we don’t start at challenging the unhelpful rules and
assumptions first. The reason we leave these until later is that they can be somewhat harder to shift than
your unhelpful thoughts and behaviours (after all, these rules and assumptions may have been there for
quite some time). We therefore come back to these towards the end of the modules once you have
started to “wear down” the old maintaining cycle. We encourage you to commit to working through the
modules, in order, and completing all of the exercises and worksheets, as this will bring you the most
benefit.
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Module Summary
• Health anxiety can be triggered by a range of internal or external triggers
• It is quite normal to experience these internal and external triggers. However, when they are paired
with unhelpful health rules or assumptions, they can lead to:
- negative health related thinking
- increased anxiety symptoms
- a narrowing of attention on to the feared symptoms
- checking and reassurance seeking behaviours, and
- avoidance and safety behaviours
• In the short term, these behaviours may provide a sense of relief or control over symptoms
• In the long term, these behaviours may lead to:
- increased focussing on symptoms
- more worry and concern about symptoms
- more anxiety symptoms
- tenderness or pain in the area being checked
- an increased desire to check and seek opinions
- increased use of avoidance and safety behaviours
• Understanding what keeps our health anxiety going is the first step towards breaking this vicious cycle.
Coming up next …
In the next module, you will learn
how to start decreasing your focus on
your health symptoms and worries.
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About The Modules

CONTRIBUTORS

1 2
BACKGROUND
REFERENCES

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Module 4
Reducing Your Focus on
Health Symptoms and Worries
Introduction 2
Focussing on Symptoms and Worries 2
Overcoming Barriers to Attention Training 3
Attention Training 4
Mundane Task Focussing 4
Meditation Training 6
Postponing Your Health Worries 8
When to Seek Medical Attention 10
Module Summary 11
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C Interventions Module 4: Reducing Your Focus on Health Symptoms and Worries Page 1
Introduction
In Modules 2 and 3, we discussed how focussing on our symptoms can have the negative consequence of
increasing the intensity of the symptoms. This, in turn, can create more worry about the symptoms, which
brings on more anxiety sensations, increasing our desire to focus on our symptoms even more! This
Module will explore ways that you can start to decrease the amount of time spent focussed on health
symptoms and worries, and thus start to break this vicious cycle.
Focussing on Symptoms and Worries

People who experience health anxiety will often find themselves scanning their bodies for signs of ill health
and then worrying about bodily sensations. To a certain extent, it is normal to be aware of bodily
sensations and changes, and to pay some attention to potential health problems. However, if you are
spending too much time focussing on your symptoms or you find it difficult to stop thinking about these
symptoms, you may need to start working on retraining your attention.
Before we start to work on this, let’s stop to think about what you tend to focus on when you are feeling
anxious about your health. Take a moment to list those particular sensations or areas of your body that
you tend to become increasingly aware of when you are worrying about your health. You may also wish to
highlight or circle these on the diagram. If you are not bothered by particular sensations or body areas, but
instead spend most of your time just worrying about illness or death in general, you can still list below the
health concerns that preoccupy your attention.
Unfortunately, as we’ve mentioned, focussing on our symptoms can amplify the

intensity of the symptoms, and thus bring on more worry and anxiety symptoms. Also,
when we are focussed on our symptoms, it can take our attention away from everyday
activities and even from important tasks. For example, have you ever found it hard to
focus on a household chore, a work project, or even just reading these modules
because your attention kept wandering back to a particular area of your body, back to
health worries, or back to a particular bodily sensation?
Learning to retrain your attention is therefore an important step in overcoming your health anxiety. It will
not only reduce the amount you focus on your sensations, but also free up your attention to focus on
other activities and experiences.
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Overcoming Barriers to Attention Training

Before you start to work on retraining your attention, it can be important to examine whether you hold
any positive beliefs about the benefits of continuing to focus on your health symptoms or worries.
Examples of such positive beliefs include:
“Focusing on my symptoms helps me evaluate how dangerous they really are”
“Focusing on my body means I will catch any problems before it is too late”
“Not focusing on symptoms is tempting fate”
“Worrying about my health gets me prepared for anything”
“Worrying helps me solve my health problems”
“If I keep worrying, I will prevent illness and disease”
It makes sense that if you hold such positive beliefs about focusing your attention on your health symptoms
and worries that you will continue to do so. After all, you are telling yourself it is helpful and even
protective!
If you hold any positive beliefs about focusing on your symptoms and worries, even to a small degree, we
recommend that you first dissect and challenge those beliefs. Once you have evaluated whether your
focussing on symptoms or worries is really helpful, you will then be in a better position to decide if you
would like to change that behaviour. Below are a range of questions you can ask yourself to evaluate your
positive beliefs about focusing on your symptoms and worries.
Positive belief to be evaluated: ___________________________________________________

How much do you believe this now (0% = not at all, 100% = completely): _________%
What is the goal of focusing your attention in this way?

Does focusing your attention in this way truly reach your goal? How exactly does it help and protect you? If you were diagnosed
with a health problem tomorrow, how has focusing on symptoms and worries truly prepared you?
Are there any negative consequences to focusing your attention in this way?
Does it increase the intensity of the sensation? Are you setting off more fight/flight anxiety symptoms by worrying so much?
Is it possible that by focusing on one symptom or worry you are missing another? How can you decide which symptom or worry
to focus on?
If a child was focusing on their symptoms and worries as much as you, would you encourage them to do it
more? If not, why not?
What conclusions can you make from this?
Re-rate the strength of your positive belief (0% = not at all, 100% = completely): _________%
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Attention Training
So, how do we let go of focussing on and worrying about our symptoms, and get our attention back to the
here and now? Well, think of your attention like a muscle… if you don’t exercise it regularly, it will become
weak and won’t work as well. We need to strengthen it by giving it regular exercise!!
There are two ways you can give your attention a regular workout. One of these involves practicing
sustaining your attention while engaged in everyday tasks, and the other involves a more formal meditation
practice.
It is important to remember while engaging in these workouts that it is completely normal for our minds to
wander off to other things. This is what minds do. They drift off to memories, concerns, sensations, images,
planning, and daydreams, to name a few. When you notice that your mind has wandered
during these activities, be careful not to criticise yourself for this. After all, it is completely
normal. Instead, think about each and every “wander” as another opportunity to practice
your skills of bringing your attention back to the here and now. Think of it this way, the
skill you are learning is not to have perfectly sustained attention, but instead to catch your
attention as it wanders and bring it back. As such, it really doesn’t matter how many times
your attention wanders, as that is part of the training.
Mundane task focussing

You may have noticed that when you are doing everyday household jobs like the dishes or the ironing, your
mind is not really on the task at hand. These are often times that our mind starts to wander. Therefore,
these types of tasks are great opportunities to practice strengthening our attention muscle.
With mundane task focussing, the goal is to gradually practice sustaining your attention on a mundane
activity for longer and longer periods of time – thus giving your attention a good workout.
Take a moment to think about some everyday household activities that you engage in where your mind
might wander frequently (e.g., doing the dishes, ironing, gardening, taking a shower, vacuuming, eating a
meal). Write these below so that you can refer back to them when planning your attention workout.
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Pick one of these tasks for your first attention workout, and record the task and when and where you will
do it on the My Attention Workout Worksheet, Now, start the task without intentionally trying to work
your attention. You may wish to gauge your ‘pre-workout’ attention levels by rating the percentage of your
attention that is currently focussed on your self (including on your own thoughts, and bothersome
symptoms and sensations) versus the percentage currently focussed on the task at hand.
Now, whilst continuing the task, you can officially start your attention workout. Each time you notice your
mind has wandered off the task, anchor your attention back to the task by focussing on the following:
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• Touch: What does the activity feel like? What is the texture like (e.g., rough, smooth)? Where on
your body do you have contact with it? Are there areas of your body with more or less contact
with the task?
• Sight: What do you notice about the task? What catches your eye? How does the task appear?
What about the light… the shadows… the contours… the colours?
• Hearing: What sounds do you notice? What kinds of noises are associated with the task?
• Smell: What smells do you notice? Do they change during the task? How many smells are there?
• Taste: What flavours do you notice? Do they change during the task? What is the quality of the
flavours?
You don’t actually have to write down the answers to these questions. Simply use them to help anchor
your attention back to the task at hand. Once you have completed the mundane task focussing activity, you
may wish to re-rate how much of your attention was self versus task focussed, and think about what you
have learned from completing the activity.
My Attention Workout
Mundane task for my attention workout: ___________________________________________

Where and when will I do my workout: ___________________________________________
Before starting the attention workout, where do I notice my attention is focussed?

• Self-focussed attention (including thoughts, bothersome symptoms/sensations): ______%
• Task-focussed attention (the task I was actually engaged with): ______%
100 %
During the attention workout, anchor my attention back to the task at hand by focussing on:
• Touch: What does the activity feel like? What is the texture like (e.g., rough, smooth)? Where on
my body do I have contact with the task? Are there areas of my body with more or less contact
with the task?
• Sight: What do I notice about the task? What catches my eye? How does the task appear? What
about the light… the shadows… the contours… the colours?
• Hearing: What sounds do I notice? What kinds of noises are associated with the task?
• Smell: What smells do I notice? Do they change during the task? How many smells are there?
• Taste: What flavours do I notice? Do they change during the task? What is the quality of the
flavours?
Remember that it is normal for my mind to wander off. Rather than beating myself up over this, use each
time my mind wanders as an opportunity to workout my attention muscle again.
Having completed the attention workout, where did I notice my attention was focussed during the
workout?
• Self-focussed attention (including thoughts, bothersome symptoms/sensations): ______%
• Task-focussed attention (the task I was actually engaged with): ______%
100 %
What did you learn from this? What conclusions can you make from this?
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Meditation training
Using a meditation exercise is another way that you can obtain regular practice at being present focussed,
dealing with a wandering mind, and disengaging from distressing thoughts and sensations.
Mindfulness is one type of meditation that can assist you to skilfully disengage from such thoughts and
sensations. This approach involves practicing how to notice when your attention has wandered off, and
then skilfully redirecting your attention back to the present, to the here and now.
It is not an attempt to control your thoughts or sensations or to make them go away. It is actually about
allowing these thoughts and sensations to be present in your mind and body, but choosing to shift your
attention back on to your breathing.
Mindfulness can be combined with a “letting go” activity, where you choose to
notice but then let go of distressing thoughts, emotions or physical sensations.
It is important to remember that this is not a quick fix, it is not easy, and
requires regular practice. By practicing daily you may eventually become
better at letting go of your distressing thoughts and sensations in a more
informal way as they pop up throughout the day.
Meditation Steps
1) To begin the practice, sit down in a chair and adopt a relaxed and alert posture, then ask yourself, what
am I experiencing right now? What thoughts are around, what feelings are around, and what body
sensations? Allow yourself to just acknowledge, observe and describe these experiences to yourself,
without judgment and without trying to change them or make them go away. Spend 30 seconds to 1
minute just doing this.
2) Now bring your focus of awareness to your breath, focusing on the sensations of your breath as it moves
back and forth in your belly. Binding your awareness to the back and forth movements of the sensations
in your belly from moment to moment, and letting all thoughts go. Maybe say to yourself ‘relax’ or ‘let
go’ on each outward breath. If your mind wanders away to other thoughts, feelings and sensations –
again do not try to change them or make them go away. Simply acknowledge their presence, allowing
them to be there, then letting go with your attention and focusing back on your breath. Spend about 1
or 2 minutes doing this.
3) Now expand your awareness to sensing your whole body breathing, being aware of sensations throughout
your body. If there are any strong feelings around, maybe saying to yourself “whatever it is, it is OK, just
let me feel it.” Allowing yourself to breathe with these feelings, and if your mind wanders to
bothersome thoughts or sensations, just acknowledge and let go of these - focusing back on sensing
your whole body breathing. Continue doing this for about another 1 or 2 minutes.
As you start to get more familiar with this skill you can try increasing the time of steps 2 & 3. We would
recommend that you keep increasing this until you are able to practice twice per day for ten minutes or
more, and then try to keep practicing daily at this level.
Remember, your attention is like a muscle, if you stop the regular exercise your muscle won’t work quite
so well. You can use the Attention Training Diary to keep track of your progress.
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Attention Training Diary
You can use this sheet to both plan your attention training and to record your progress along the way.
The last column asks you to jot down any comments about the experience – What did you notice? Where
did your mind wander off to? Were you able to notice this? Were you able to interrupt this? How did it
compare to other times you have practiced?
Date & Time Attention Task Duration Comments

e.g.,
Monday Meditation 3 mins This was quite hard as my mind kept wanting to jump ahead
28th, 8:00am to thinking about work.
Monday 28th, Mundane task 10 mins I noticed lots of things I didn’t usually notice, but I was still
5:30pm focussing (while thinking a lot about my health. It was probably a little
doing the dishes) easier than the meditation as I had something to focus on.
We recommend that you practice at least daily mundane task focussing workouts and twice daily
meditation. If you find it difficult to fit the regular meditation exercises in, you could instead increase the
number of mundane task focussing workouts you do per day. Remember, mundane task focussing isn’t
asking you to do anything extra, only to use those activities you are already doing in a particular way.
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Postponing Your Health Worries
Even though you have started to exercise your attention muscle to help overcome your tendency to over-
focus on physical symptoms, you may notice that your attention keeps wandering back to worries about
specific symptoms or sensations, or more general worries about your health. While it is completely normal
for health worries to pop in to our minds, the more we focus on these worries the more anxiety
symptoms we trigger in our bodies. This in turn gives us even more to worry about!
Many people with health anxiety will therefore try to stop their worrying by trying to distract themselves
or telling themselves not to think about their health. Unfortunately, trying not to think about something can
have the opposite effect by making us think about it even more! For example, try not to think of a pink
elephant for the next 60 seconds and see how well you do.
So, if focussing on our worries creates more worries and symptoms, and trying not to focus on our worries
actually increases the amount we worry, what should we do?!? Fortunately, there is third option we can use
called Worry Postponement.
Postponing your health worries means that it is alright for an initial worrisome thought to pop in to your
mind (e.g., “what if this chest pain is a heart attack”), and even to start focussing on those symptoms you
are worried about. However, as soon as you notice this, you make a decision not to ‘chase’ the worries or
symptoms any further at that particular time.
Not chasing the worrisome thought any further means that you don’t try to evaluate the
symptoms or sensations any further, anticipate the worst or run scenarios and solutions
related to the symptom through your head over and over again (e.g., “This could be cancer, I
think the pain is getting worse? What will happen to me and my family if it is? I should see my
doctor” etc). Instead, you postpone worrying about your health until a later time, using your
attention skills to bring your attention back to the here and now, and back to the task at hand.
How to postpone
1. Set a worry period
- Nominate a set time, place and length of time to do all your worrying and focussing on symptoms
- Try and keep your worry period the same everyday (e.g., 6pm, dining room, 20mins). We
recommend no more than 30 mins per day
- Try not to set your worry period before bed.
2. Postpone
- When you notice yourself worrying or focussing on particular symptoms throughout the day, list
your concerns on the Postponing Health Worries Worksheet, or even on a piece of paper or a
notepad if the worksheet is not available to you. Note the worries down briefly (in a couple of
words only e.g., “Noticed pain in my side, thought it could be appendicitis”)
- Decide to think about it later and save your thoughts for your worry period
- Use your attention skills to bring your attention back to the present and reassure yourself that you
will deal with the worries and sensations during your worry period.
3. When you get to your worry period

- Only think about the things you’ve listed if you feel you must
- You don’t have to worry about them if they no longer bother you, or if they no longer seem
relevant to you
- If you do need to worry, only worry for the set amount of time specified
- If you run out of time during your worry period to cover all the things on your list, remind yourself
that these items will be covered the following day during your next worry period.
We recommend that you practice this strategy over the next week by completing the Postponing Health
Worries Worksheet. We then suggest that you then continue to use postponement as a strategy for as long
as you continue to worry about your health.
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Postponing Health Worries Worksheet
Set Your Worry Period
Start Time: End Time: Place:
Briefly record your health worries

Then use your attention strategies to bring your attention back to the present. Remind yourself that you
will come back to these worries and sensations during your worry period.
Day Worries (in a few words only)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
After practicing this for a week, take a moment to review how you went with the
postponement strategy
What happened to the worries you postponed? Did you still need to worry about them later?
If you were able to postpone, what happened to the symptoms you were worrying about?
If you had trouble postponing - Did you actually write down your worries (recommended) or just try to
remember them (not recommended)? Do you need to work more on your attention training exercises?
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When To Seek Medical Attention
Throughout this module we have been discussing ways to decrease our focus on and worry about bodily
symptoms and sensations. However, we obviously don’t want you to ignore symptoms that may indicate
the real need for medical attention. So how do we know when to postpone our worries and when to act
on them?
While there are no simple answers to this question, Patricia Furer and colleagues, experts in health anxiety
from the University of Manitoba, recommend the following guidelines:
• Use those self-care remedies you are already familiar with for managing symptoms of cold and flu,
headaches, or backaches (e.g., rest, medication, heat/cold packs)
• For many symptoms, such as pain or colds, try the “wait two weeks” approach. Many symptoms
will disappear without medical assistance over this period of time. You can think of this as a
prolonged postponement exercise, where rather than waiting until your worry period that night,
you are putting off thinking about it for another two weeks. Obviously this will take quite a bit of
practice with using the attention strategies!
• If symptoms persist beyond two weeks, then see your doctor
• Seek prompt medical attention if you have a high fever, intense pain, and signs of a worsening
infection
We must also acknowledge that for people with particular diagnoses or who are
taking particular medications, there may be other specific indicators that immediate
medical intervention is needed. If you do have a diagnosis or are taking a medication,
we would recommend that you speak with your doctor about developing your own
guidelines for when to postpone your worries versus when to act on them
immediately.
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Module Summary
• People who experience health anxiety will often find themselves scanning their bodies for signs of ill
health and then worrying about bodily sensations
• Focussing on your symptoms can amplify the intensity of the symptoms, and thus bring on more worry
and anxiety symptoms
• Learning to retrain your attention, so that you can decrease the amount of time you spend focussed on
your symptoms and worries is therefore an important step in overcoming your health anxiety
• There are two ways you can retrain your attention. Mundane task focussing involves practicing
sustaining your attention while engaged in everyday household tasks. Meditation involves a more formal
daily practice of focussing your attention back onto your breathing each time your mind drifts off to
different thoughts or sensations.
• Once you have started to strengthen your attention muscle, you can combine this with a
postponement exercise to decrease the amount of time you spend worrying about and focussing on
your health.
• While we have provided some guidelines, it is important to work with your doctor to develop your
own set of guidelines as to when you should postpone your worries about symptoms, versus when you
should seek medical assistance.
Coming up next …
In the next module, we will explore
ways to address your unhelpful health
related thoughts during your worry
period.
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About The Modules

CONTRIBUTORS

1 2
BACKGROUND
REFERENCES

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Module 5
Re-evaluating Unhelpful Health
Related Thinking
Introduction 2
The Mind-Body Connection 2
How to Address Unhelpful Health Related Thoughts 4
Thought Diary - Example 6
Thought Diary - Worksheet 7
Summary of My Thought Diaries 8
An Important Word on Factual Evidence 9
Module Summary 11
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C Interventions Module 5: Re-evaluating Unhelpful Health Related Thinking Page 1
Introduction
In Module 3, we talked about how our health anxiety can remain dormant for some time, but when
triggered is likely to negatively affect the way we think about our bodily symptoms or sensations, and
health-related information. In Module 4, we practiced disengaging our attention from these distressing
symptoms or worries by first building up our attention muscle and then learning to put off or “postpone”
our worries until a later time. In this Module, we will examine what you can do with these negative and
often unhelpful thoughts once you get to your elected “worry period”. We will examine these thoughts in
more detail, and discuss ways of evaluating and overcoming them.
The Mind-Body Connection

What you think, and the thoughts that go through your mind, are very important in determining how you
feel. Stop for a moment and think: when you are feeling good, what sorts of thoughts roam around in your
head? Conversely, when you are feeling bad, what sorts of thoughts are you having?
It makes sense to most people when we say that:

It is not the situation you are in that determines how you feel,
but the thoughts, meanings, and interpretations you bring to that situation.
Here is an example of what we mean. Imagine you are in bed at night and hear a loud noise. Below are
three different ways of thinking about this same situation and the different emotions, physical sensations,
and behaviours that could result from thinking in these different ways.
Example event: In bed at night, hear a loud noise

Emotions Physical Behaviour
Thought 1
I bet that was my naughty little Amused Smiling, quite Laugh, call for cat
cat. I wonder what kind of relaxed
mischief he has just got up to
Thought 2
Oh no, someone must be trying to Anxious Heart racing, Concentrate on further
break in!! tense, sweating noises, grab phone and
begin to dial for police
Thought 3
Hmm. The neighbours must be Neutral Quite relaxed Go back to sleep
putting their bins out.
Because we are usually not aware of these thoughts, we may not realise just how much they are affecting
us. Can you now see how what we think can be so important in determining how we feel emotionally and
physically, and can influence what we do?
Overall, having our thoughts influence our emotional and physical state is usually a fairly
helpful process. After all, if someone really is breaking in to our house – having your
anxiety response kick in, including having your heart beat faster and starting to sweat
means you are physically more prepared to deal with that threatening situation.
However, people with health anxiety often perceive that there is a greater threat to their
health than there actually is. This doesn’t mean that you are imagining the symptoms –
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those symptoms are real! But if you interpret or think about the symptoms in a catastrophic way, this will
often bring about intense negative feelings and sensations in your body.
People with health anxiety tend to:

• Overestimate the likelihood that they have or will develop a serious health problem
• Overestimate how bad things will be
• Ignore or discount other possible (and often less catastrophic) explanations for their symptoms or
their doctors response, and
• Underestimate their ability to treat, cope with or manage a health problem
Here are some examples of common thoughts experienced by people with health anxiety:
I’ve been so tired and run-down - I could have leukaemia

My mother had cancer so there’s a pretty good chance I’ll get it too
My heart is racing - I am going to have a heart attack
I could get a serious illness and die
I’m sure I have diabetes as I’ve been to the bathroom four times today
My side is aching - this could be ovarian or stomach cancer
I’ve been having weird thoughts - I could be schizophrenic and not know it
This operation could kill me
I’ve never seen this mole before - it could be a melanoma
I’ve had diarrhoea for three days - this could be colon cancer
I have a headache - this could be a brain tumour or an aneurism
My knees hurt - I must have arthritis
I keep forgetting things - this could be the start of dementia
I’ve been feeling really weak lately - this could be a sign of multiple sclerosis
As each of these health related thoughts are about a potential threat to one’s health and well-being, it will
likely trigger our anxiety response. This is the mind-body connection in action! Unfortunately, this can then
become a vicious cycle of worrying about our health, triggering more anxiety sensations, noticing these
sensations as well and then worrying even more.
Health
anxiety
Even more worry
More anxiety sensations

More worry
About original issue + new anxiety sensations
Anxiety sensations
Worry about health
Trigger
(e.g., notice a sensation or symptom, waiting for test results)
Fortunately, something can be done about this vicious cycle. This Module will explore how we can begin to
break this cycle by identifying and challenging those worrisome thoughts you are having about your health.
Note: While we have touched on the idea of behaviours that come about from these thoughts, we will come back to
these in Modules 6 and 7
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How to Address Unhelpful Health Related Thoughts
One way to help address unhelpful health related thoughts is to challenge them head on. Remember that
our thoughts are just that, thoughts. Sometimes our thoughts will be accurate, sometimes they will only be
partially correct, and sometimes they will not represent the reality of the situation at all. The only way we
can work out how accurate our thoughts really are is to question, dissect and evaluate them.
A helpful way to think about this is to imagine that you are a detective - collecting evidence for and against
a case, considering other possible causes and explanations, and trying to work out the most accurate and
likely explanation. Evaluating these thoughts isn’t something you should try to do in your head as this can
get messy and confusing. The best way is to write it down and we suggest using a Thought Diary to help
you through this process. Thought Diaries are designed to guide you through the evaluation process step
by step, on paper, making things clearer and more helpful for you.
On the next few pages are instructions and an example of how to complete a Thought Diary. Following
that is a blank Thought Diary for you to practise on.
The Thought Diary will first ask you to Identify Your Unhelpful Health Related Thoughts. To help
you do that, first ask yourself:
• What triggered off this episode of health anxiety?
Then:
• What am I worrying about?
• What am I predicting?
• What conclusions am I jumping to?
After you have written these down, underline the most bothersome of these thoughts and rate the
strength of your belief between 0 and 100%.
You’ll then need to ask yourself – when I am thinking like this, what do I feel?
• What emotion(s) am I feeling? (e.g., worry, fear, sadness, concern, anxiety)
• Rate the intensity of your emotion(s) between 0 and 100%
• What physical sensations(s) do I notice? (e.g., heart racing, muscular tension, fatigue)
Once you have completed the first section, you are ready to begin to Challenge Your Unhelpful
Health Related Thoughts. Here are the questions asked in your Thought Diary to challenge these
types of thoughts:
• What is the factual evidence for this thought?
• What is the factual evidence against this thought?
Note: Be sure to include only good quality evidence – see pages 9-10 for a summary
• How does it affect me when I expect the worst?
• What could I do to cope if ‘the worst’ did happen?
• Are there any other possible explanations for my symptoms, or for my doctor’s
response?
• What is the most likely explanation?
• What can I do to cope with this symptom or situation right now?
The ultimate aim of doing this Thought Diary is for you to Develop more Realistic Health Related
Thoughts. Once you have explored the answers to the above ‘challenging’ questions in your Thought
Diary, ask yourself:
• What would be a more realistic thought about this symptom or situation?
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The final step is then to:
• Re-rate how much you now believe your original thought,
• Re-rate the intensity of the emotions that you were originally feeling,
• Rate whether there has been any change in your physical sensations.
If you experience only a few unhelpful health related thoughts per day, and they are not taking up a
significant amount of your time or interfering with your daily activities, we recommend that you start to
practice using a Thought Diary whenever you notice you are feeling anxious or worried about your health.
However, if you experience numerous unhelpful health related thoughts throughout the day, and the
amount of time spent thinking about your health is interfering with your daily activities, we recommend
that you combine the worry postponement exercise from Module 4 with using these Thought Diaries. This
means that whenever you catch yourself worrying about your health, you postpone any further thoughts
about your health until a later specified time and place. When you get to this specific time and place, then
you can spend time completing the Thought Diary to evaluate your thoughts.
If you work through the entire Thought Diary for challenging your unhelpful health related thoughts, it is
likely that you will experience a decrease in the strength of your belief and therefore a decrease in the
intensity of your emotions and physiological sensations. While it will take some effort and practice, we
recommend that you continue to use the thought diaries until it becomes second nature to stop and
question your thoughts.
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Thought Diary – Example
Identify Unhelpful Health Related Thoughts
What triggered off this episode of anxiety?
Received a negative test result for an iron deficiency after feeling tired and run-down for several weeks.
Doctor said to just monitor my symptoms and come back if it gets worse.
What am I worrying about? What am I predicting? What conclusions am I jumping to?
If it is not an iron deficiency, it must be something much worse
My doctor hasn’t tested for more serious problems
This tiredness could mean something serious, like leukaemia
Underline the most bothersome thought and then rate how much I believe it (0-100%)? 80%
When I am thinking like this, what do I feel?
Emotions (Rate the intensity 0-100%): Physical sensations:
Worried (90%) Heart rate increases, chest feels heavy
Challenge Unhelpful Health Related Thoughts

What is the factual evidence for this thought? What is the evidence against this thought?
- I have been feeling tired - My doctor said tiredness and fatigue are very
- I have looked on the internet and tiredness and common and may be related to stress
fatigue are symptoms of leukaemia - I don’t have the other symptoms of leukaemia
- The test results showed it is not an iron deficiency (swollen lymph nodes, frequent infections,
- My doctor didn’t specifically test for leukaemia bruising easily, unexplained weight loss, or pain
in my joints and bones)
How does it affect me when I think about the worst?

Makes me feel anxious and a bit angry at my doctor for not doing some more tests
Find it hard not to focus on the tiredness
What could I do to cope if ‘the worst’ did happen?

I would have to start treatment. This would probably involve chemotherapy and a bone marrow
transplant if a match could be found for me. I would have to think about the possibility of death. The
entire experience would probably be quite difficult but I would have the support of family and friends.
Are there any other possible explanations for my symptoms, or for my doctor’s response?
Have I recently changed my routine, diet, medications, or activity levels? Do I need to improve these? Have I been experiencing increased stress
lately, or have I experienced a minor medical ailment – such as a cold, that could account for what I am feeling?
I have been quite busy and stressed at work lately. I probably haven’t been looking after myself or sleeping
as well as usual. My doctor probably sees a lot of people who are feeling this way, who don’t have
leukaemia, so isn’t too concerned about it.
What is the most likely explanation?

I am just run down and need to look after myself a bit better
What can I do to cope with this symptom or situation right now?

I will make sure I buy some fresh fruit and vegetables to eat, rather than just getting by on coffee. I will
also take some time out for myself to relax by having a bubble-bath, will go to bed a little earlier, and will
ask for some help to manage a big project at work.
Develop Realistic Health Related Thoughts

What’s a more realistic thought about this symptom or situation?
This is probably just a sign that I am stressed and run down. I don’t have any other symptoms so my
doctor probably isn’t very worried about this tiredness.
How much do I believe my original thought now (0-100%) 40%

How intense are my emotions now (0-100%) 30%
How intense are my physical sensations now (Circle) More intense Same Less intense
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Thought Diary
Identify Unhelpful Health Related Thoughts
What triggered off this episode of anxiety?
What am I worrying about? What am I predicting? What conclusions am I jumping to?
Underline the most bothersome thought and then rate how much I believe it (0-100%)?
When I am thinking like this, what do I feel?
Emotions (Rate the intensity 0-100%): Physical sensations:
Challenge Unhelpful Health Related Thoughts

What is the factual evidence for this thought? What is the evidence against this thought?
How does it affect me when I think about the worst?
What could I do to cope if ‘the worst’ did happen?
Are there any other possible explanations for my symptoms, or for my doctor’s response?
Have I recently changed my routine, diet, medications, or activity levels? Do I need to improve these? Have I been experiencing increased stress
lately, or have I experienced a minor medical ailment – such as a cold, that could account for what I am feeling?
What is the most likely explanation?
What can I do to cope with this symptom or situation right now?
Develop Realistic Health Related Thoughts

What’s a more realistic thought about this symptom or situation?
How much do I believe my original thought now (0-100%)

How intense are my emotions now (0-100%)
How intense are my physical sensations now (Circle/Check box) More intense Same Less intense
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Summary of My Thought Diaries
Once you have completed several thought diaries, you can complete this worksheet as a quick reference
guide to remind you of your new realistic health related thoughts. That way, if the same or a similar
unhelpful and distressing thought pops up, you can simply review this worksheet rather than trawl back
through all of your completed thought diaries. However, if you feel like when you read something from the
“New Realistic Health Related Thought” column that you don’t actually believe it, you may need to go back
and complete another thought diary on that issue.
Original Unhelpful Health Related Thought New Realistic Health Related Thought
e.g., This could be something serious, like This is probably just a sign that I am stressed and
leukaemia run down. I don’t have any other symptoms so my
doctor probably isn’t very worried about this
tiredness.
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An Important Word on “Factual Evidence”
With the wealth of information readily available to us via the media and internet search engines, it is
important for us to remain smart consumers of the information we receive. When completing these
thought diaries we are asked to consider “factual evidence” both for and against our thoughts. But how
can we tell whether the information we have is “factual” or not?
Unfortunately, not all health information available in magazines, newspapers and on the internet goes
through a quality control process. Some websites, for example, may look quite convincing on the surface,
but not actually represent the best practice and most up to date health-related information. This can be
both confusing and dangerous for us.
It can be confusing when we receive mixed messages about whether or not we need to
make changes to important things such as our diets, medications, or other lifestyle choices. It
can also be confusing when we receive mixed messages about the importance of particular
symptoms, their relevance to serious health problems, and the need to continue to seek help
from health professionals. It can be potentially dangerous when we do make decisions
about our health or changes based on information that is not reliable or factual.
While we will talk a lot more in the next module about seeking information from various sources, by
changing the way we search for and evaluate health information, we can start to reduce any confusion and
risks and begin to take a more helpful and critical stance.
Information seeking
Quite often we can turn the very thing we are thinking about into the phrase we type into an internet
search engine. For example, if we are concerned about the impacts of worrying on our potential for a
heart attack, we may type “worry and heart attacks” and hit Search.
This type of searching can be problematic as it can lead to biased results. That is, you will most likely
• filter in web pages that do talk about there being links between worry and heart attacks, and
• filter out any that do not talk about or debunk such links.
This unhelpful searching can therefore reinforce your worrisome belief that there is a link!!
There are two steps you can take to change the way you gather and filter information from the internet.
Step 1: Practice using more helpful and less biased search phrases to find out what you want to know.
For example,
Instead of: You could try:

“Worry and heart attacks” “What causes heart attacks?” or “Leading causes of heart attacks”
Less helpful More helpful
More biased filtering Less biased filtering
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Step 2: Look for ways of filtering in alternative view points. You can do this by typing in mismatching
statements. For example, you could try: “Is coffee bad for you?” and “Is coffee good for you?”
These strategies can lead to you coming up with some very different health information!
If you are someone who has or is thinking about using the internet to search for health information, take a
moment to think about some alternative ways you could search for that information:
Instead of: I could (also) try:
Evaluating health information

Even with good search strategies we will often come across unhelpful or even conflicting information (e.g.,
one magazine article stating that coffee is good for you whilst another states that coffee is bad for you).
Unfortunately, in this day and age, anyone with access to the internet can send
information around the world and claim it to be factual. Some website or magazine
articles can also appear to contain useful information from reputable sources. So how do
we know what is good information and what is not so good?
Ten questions to ask...

 Is this written by a qualified and registered health professional (e.g., GP, Psychologist)?
 Does the author represent an established and reputable health organisation (e.g., government
body, university, major hospital)?
 Is the author free of commercial interests (i.e., they are not trying to sell you a product or
sensationalise a story to sell a magazine)?
 Does the article include multiple pieces of evidence to back up it’s claims (i.e., discusses the
results of several research studies conducted by reputable organisations rather than anecdotal
stories or one-off studies)?
 Is enough information provided for you to check the background research for yourself?
 Was the background research based on people similar to yourself (e.g., similar age, height/weight,
gender, diagnosis, comorbid problems etc)?
 Was the background research based on many people?
 Are statistics clearly explained?
 Is this information consistent with health information you have read from other reputable
sources, (e.g., other government bodies, universities, major hospitals)?
 Is a review date provided so that you can tell the information is up-to-date?
The more ticks you have above, the better your health information is likely to be. However, it is
important to remember that information from the internet and media is one resource only, and
should never alone be used to diagnose a medical or psychological condition, or to make
important changes to your medication, diet, or other lifestyle choices. Your GP or local
health clinic can assist you in understanding the specific risks and benefits of such changes
based on your full personal medical and/or psychological history.
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Module Summary
• Our thoughts influence our emotional state and the presence of some physical sensations in our bodies.
This is known as the mind-body connection.
• People with health anxiety tend to:
- Overestimate the likelihood that they have or will develop a serious health problem
- Overestimate how bad things will be
- Ignore or discount other possible (and often less catastrophic) explanations for their symptoms or
their doctors response, and
- Underestimate their ability to treat, cope with or manage a health problem
• When we think there is a threat to our health, we can trigger off our anxiety response. This gives us
more physical sensations, which we may then also worry about. This can lead to a vicious cycle of
health anxiety.
• One way to overcome this vicious cycle of health anxiety is to challenge our unhelpful health related
thoughts head-on using a Thought Diary. This involves identifying what you are predicting or worried
about, challenging your predictions or expectations, and developing more realistic health related
thoughts.
• If we are using evidence from the internet or media to weigh-up the likelihood of our health-related
thoughts being true, we need to ensure that we access information from established, reputable, and
unbiased health organisations.
Coming up next …
In the next module, we will start
exploring ways to reduce excessive
checking and reassurance-seeking
behaviours.
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About The Modules

CONTRIBUTORS

1 2
BACKGROUND
REFERENCES

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Module 6
Reducing Checking
and Reassurance Seeking
Introduction 2
Why Do We Check and Seek Reassurance? 2
Common Checking and Reassurance Seeking Behaviours 3
Helpful vs. Unhelpful Checking and Reassurance Seeking 4
How to Reduce Unhelpful Checking and Reassurance Seeking 5
Reducing Checking & Reassurance Seeking – Example 1 9
Reducing Checking & Reassurance Seeking – Example 2 10
Reducing Checking & Reassurance Seeking – Worksheet 11
Module Summary 12
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C Interventions Module 6: Reducing Checking and Reassurance Seeking Page 1
Introduction
In Module 3, we identified that people with health anxiety will often engage in excessive checking and
reassurance seeking behaviours. Generally this is done in an effort to ease health anxieties, but instead
these behaviours can actually fuel the problem. In this Module, we will revisit the different ways people
check and seek reassurance for their health, explore the difference between helpful and unhelpful checking
and reassurance seeking, and explore strategies to reduce or eliminate these behaviours.
Why Do We Check and Seek Reassurance?

Most of us will engage in checking and reassurance seeking behaviours with regards to our health. We do
this to reduce our worrying, increase our sense of control and certainty about our health, and to reassure
ourselves that our health is not at risk. These behaviours often give us some short term relief.
Unfortunately, we can never really be sure that we are completely healthy. The very nature of medical tests
is to rule in or rule out a particular diagnosis. Doctors do not have a “test for everything” that could
possibly go wrong with our bodies. We can therefore sometimes fall into a vicious Reassurance Cycle where
our worrying about our health leads us to check and/or seek reassuring information about our health. In
the short term this gives us a sense of control or relief, but in the long term we cannot rule out all possible
health problems, and so the cycle starts again.
Worry about Check and /or

health seek reassuring
information
Long term: cannot

rule out all health Short term: relief,
problems with sense of control
100% certainty
As already suggested, it is impossible for anyone to have a 100% guarantee that they are of perfect health.
Yet, this uncertainty is something that all human beings must learn to tolerate. Unfortunately, the act of
excessive checking and reassurance seeking ultimately stops us from building up this tolerance and
accepting that our health is uncertain. Instead we spend a lot of our time preoccupied with trying to rid
ourselves of this uncertainty (via checking and reassurance), instead of sitting with the uncertainty and
building our tolerance.
One way to break this Reassurance Cycle is to reduce our checking and reassurance behaviours to a more
helpful level, and to practice tolerating and accepting some of the uncertainty and anxiety that goes along
with not checking or seeking reassuring information.
Throughout this module we will explore the different types of checking and reassurance
seeking commonly reported by people with health anxiety. We will also discuss the
difference between helpful and unhelpful levels of checking and reassurance seeking and
ways that you can start to reduce these behaviours.
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Common Checking and Reassurance Seeking Behaviours
In Module 3, we introduced a range of commonly reported checking and reassurance seeking behaviours.
To recap, take a moment to look over the list below and see whether any of the behaviours listed are
things you are doing frequently and repeatedly. You may also be aware of other behaviours not listed here,
so there is additional room to list these below.
Checking in the mirror for signs of asymmetry, areas of discolouration, or new moles or lumps
Poking, palpating or pinching of the skin, breasts, stomach or other areas of the body
Examination of bodily excretions (e.g., saliva, urine, faeces) for signs of blood or infection
Measuring parts of your body (e.g., using tape measure or callipers)
Monitoring of bodily processes (e.g., taking pulse, checking blood pressure)
Weighing of your body or bodily excretions
Asking family members, friends, and health care providers about your symptoms
Researching your symptoms on the internet or in medical texts
Posting of your symptoms on internet sites to obtain others opinions about your symptoms
Requesting of medical tests or evaluations, and second opinions
Other checking or reassurance seeking behaviours:
__________________________________________________
__________________________________________________
__________________________________________________
Take a moment to think about how often you are doing these behaviours and record this below. If you are
not certain, you may wish to engage in a mini-survey to work out the amount and frequency of your
behaviours. For example, you could:
• Ask family or friends to note down each time you ask them about a health issue over a set period
• Place a notepad and pencil next to your mirror and keep a tally of each time you check yourself
• Review your diary to see how many medical appointments you have had in the past month
• Record how much time you spend on the internet researching your symptoms
Behaviour Amount / Frequency

e.g., Checking the moles on my back in the mirror Twice daily
e.g., Researching symptoms on the internet About three hours each weekend
_____________________________________________ ___________________________
_____________________________________________ ___________________________
_____________________________________________ ___________________________
_____________________________________________ ___________________________
If you engage in several of these behaviours, you may wish to select one or two to work on whilst
completing this module. Some people prefer to start with reducing those behaviours which are having the
most impact on their everyday lives. Others prefer to start on those behaviours that they feel might be
easiest to work on first, gradually building their confidence to tackle some of the harder changes later.
Which one or two checking or reassurance seeking behaviours will you work on first? Record them below:
1. _________________________________________________
2. _________________________________________________
Once you have worked on these for a while, you can then come back and address any
remaining behaviours.
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Helpful vs. Unhelpful Checking and Reassurance Seeking
It is generally considered helpful to be aware of changes in our bodies, to check our bodies for signs of ill
health, and to ask for medical opinions and advice. Ultimately, engaging in these behaviours is designed to
protect us from ill health and to ensure our longevity.
So, when do these behaviours become problematic? What is considered too much? Well, it
may vary from one behaviour to the next, but in general we have to think about health
seeking behaviours as being on a continuum. If our behaviours fall at either of the two
extremes of the continuum, we may not be engaging in “healthy” levels of checking and
reassurance seeking.
For example, let’s think about the health behaviour of regular breast self-examinations. Someone who
never conducts breast self-examinations might put themselves at risk by not being aware of changes to
their breast tissue. However, someone who checks daily may be checking too regularly to actually notice
any changes, and could develop discomfort or soreness due to the continued prodding and poking.
Never check or seek Very frequently & repeatedly

information/results or ask check or seek information/
others about symptoms results or ask others about
Helpful checking and reassurance seeking symptoms
The goal of this module is therefore not to move you from one extreme to the other, by asking you to
eliminate all checking and reassurance seeking behaviours. The goal is to be able to develop more helpful
levels of these behaviours and to decrease the negative consequences often associated with high levels of
checking and reassurance seeking.
Excessive levels of checking and reassurance seeking may have multiple negative consequences for you aside
from fuelling your health anxiety. The following are just a few examples:
• Frequent physical prodding and poking can increase feelings of pain or tenderness.
• Medical appointments and tests may have significant financial costs attached.
• Significant time may be spent engaging in checking and reassurance seeking rather than engaging in
activities that can give you a sense of enjoyment or achievement (e.g., work, socialising).
• Your relationships with friends, family and health care providers may also be tested, as your
continuous striving for reassurance combined with a lack of clear answers can leave both you and
others feeling frustrated.
Take a moment to write down any negative impacts of your checking or reassurance
seeking behaviours. What do you notice? Are these behaviours something that you
would consider changing?
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
Note: In the next module, we will address avoidance behaviours that can occur at the other end of this continuum
(e.g., for people who never check or seek information/results or ask others about symptoms).
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How to Reduce Unhelpful Checking and Reassurance Seeking
One way to reduce our levels of checking and reassurance seeking is to evaluate just how helpful the
current behaviour is, and to consider and test out alternative health behaviours. We suggest you use the
following 3 Step process and worksheet on page 10 to help you address these behaviours. The worksheet
is designed to guide you through the evaluation and planning process step by step, allowing you to see
more clearly how helpful your current behaviours are, and to evaluate and plan alternate behaviours.
Step 1- Evaluate how helpful your current health behaviour is

To do this, you will need to:
• Identify the health behaviour you are going to work on (e.g., checking my breasts daily for lumps)
Then, you will need to ask yourself:

• What is the goal of my behaviour?
• Are there any advantages to doing this behaviour as frequently as I currently am?
• Are there any disadvantages to doing this behaviour as frequently as I currently am?
• Does this behaviour really achieve my goal?
• At this point, how much sense does it make to keep going with this health behaviour?
• How much sense does it make to do it as frequently as I do?
• Do the advantages of this behaviour outweigh the disadvantages?
Completing these questions should give you some ideas about how helpful your current behaviour is and
whether it is therefore something you want to keep doing or change. But remember, changing your
behaviour doesn’t necessarily mean getting rid of it! Sometimes it might make sense simply to reduce the
amount or frequency.
The next question is therefore an important one.

• Do I need to decrease, postpone or eliminate this behaviour? Why?
Decrease or postpone your behaviour

To postpone your behaviour means to put it off until a clearly defined but later time. To decrease or
postpone your behaviour makes sense when your behaviour is something that is consistent with advice
given by medical practitioners, but you are doing it:
• excessively,
• too frequently, or
• in the absence of any significant symptoms.
For example, medical practitioners often encourage us to be aware of any changes in the colour, shape and
size of our moles. However, consider the following case:
… after hearing news that an old friend had died from skin cancer, Jim grew concerned
that he too would miss a change in his moles and develop cancer. He therefore began
each day by measuring the size and shape of each of his moles – spending up to an
hour each day making detailed sketches and notes regarding the dimensions of each
mole on his body. He was often late for work as a result.
Respected organisation, The Cancer Council® of Australia, recommend visually checking your body
approximately once every three months for signs of skin cancer, and notes that this should take
approximately 15 minutes1. As you can see, Jim’s behaviour represents a significant departure from this
health information, so he might consider gradually decreasing or postponing his checking until it reaches the
recommended levels.
1 Please note that this information was correct at the time of publication but may since have changed. We recommend using the “Evaluating
Health Information Checklist” in Module 5 (page 10) to evaluate any new health information you are considering using as a guideline.
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Eliminate your behaviour
To eliminate your behaviour makes sense when your behaviour is at odds with the
advice of medical practitioners. For example, most medical practitioners would
discourage the use of internet chat rooms as a means of obtaining health
information, due to the limited quality control in this form of communication.
Similarly, in most circumstances, medical practitioners would discourage you from
engaging in any self-examination that results in significant pain or discomfort.
Remember, if you are not sure whether you have a good understanding of recommended levels of checking
or reassurance seeking behaviours, you can use the “Evaluating Health Information Checklist” from Module
5 to evaluate any information you are considering using as a guideline. Or, even better, ask your medical
practitioner for appropriate guidelines regarding self-examinations and check-ups.
Step 2 - Generate and evaluate a new behavioural goal

Based on your decision to decrease, postpone or eliminate your behaviour, you will need to:
• generate a new behavioural goal, and
• identify what specifically you will do to work towards this goal
In some circumstances, the new goal and specific behaviours attached can be easily identified and attempted
straight off. For example, imagine that you had been researching “causes of muscular twitching” on the
internet to find out whether your symptoms were normal or a sign of serious illness. An
alternative goal might be “to postpone any further researching on the internet”, as this would
give you time to see whether the symptoms progress or go away of their own accord. The
specific behaviour attached to this goal might then be “I will wait a week and see whether my
symptoms get worse before taking things any further”.
However, sometimes reducing or eliminating particular behaviours may be something 80

that you need to do more gradually. For example, if Jim were to immediately set a goal of 75
“visually checking my moles, only once every three months for fifteen minutes as per the 65
Cancer Council’s recommendations”, there is a chance that this would be too difficult to do 50
35
straight away. Instead he could break his goal down into smaller steps, gradually working towards the
recommended level of checking.
To make gradual reductions in a particular behaviour we recommend that you use a Stepladder to help you
1) identify your overall goal, and 2) identify the gradual steps needed to work towards your overall goal.
Each step on the stepladder can be given a “Distress” rating between 0 and 100, where 0 = this step is not
distressing at all, and 100 = this step is highly distressing. Your stepladder might have fewer or more “in
between” steps than the example given below, but the idea is to gradually build up to your overall goal in an
achievable manner. Here is Jim’s example:
JIM’S STEPLADDER
GOAL: visually checking my moles, only once every three months for fifteen minutes as DISTRESS (0-100)
per the Cancer Council’s recommendations 85
STEP DISTRESS
1 Visually check moles (no drawing or notes), every day for 30 minutes only 25
2 Visually check moles (no drawing or notes), every 2nd day, for 20 minutes only 35
3 Visually check moles (no drawing or notes), every 4th day, for 20 minutes only 45
4 Visually check moles (no drawing or notes), once per week, for 20 minutes only 55
5 Visually check moles (no drawing or notes), once per fortnight, for 15 minutes only 65
6 Visually check moles (no drawing or notes), once per month, for 15 minutes only 70
7 Visually check moles (no drawing or notes), once every 2nd month, for 15 minutes 75
only
8 Visually check moles (no drawing or notes), once every 3rd month, for fifteen 5
minutes
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If you need to break your overall goal down in to more manageable steps, you can use this Stepladder
below to do so:
MY STEPLADDER
GOAL: DISTRESS (0-100)
STEP DISTRESS
1
Once you have identified your new behavioural goal and what you will specifically do
to work towards this goal, you will need to ask yourself:
• What is the goal of this new behaviour?
• Are there any advantages to doing this behaviour as frequently as I have planned?
• Are there any disadvantages to doing this new behaviour as frequently as I have
planned?
• At this point, how much sense does it make to try out this alternative health
behaviour?
By now, you should have a fairly good idea about whether you have developed a helpful new behaviour and
hopefully the scales are tipped towards you wanting to have a go at this new behaviour. However, that
does not necessarily mean that it will be easy to do it!
We have to expect that we will feel some distress whilst doing these things. After all, if they were easy –
you would probably be doing them already! You will therefore need to consider:
• How will I manage any anxiety and worry? What will I say to myself? What will I do?
While there are numerous things you could consider here, particularly drawing from the work you have
already done in Module 4 “Reducing Your Focus on Health Symptoms and Worries”, here is a short cut of
some ideas that other people have reported as being helpful:
- Reminding yourself “this anxiety will pass, it can’t go on forever”
- Reminding yourself that your body is like an old car and will sometimes run a little rough. Not
every creak and sound needs an engine overhaul.
- Remembering that if you check or seek reassurance, it may relieve some worry in the short term,
but in the long term it can keep it going (i.e., the Reassurance Cycle)
- Viewing this as good practice in learning to tolerate and accept that your health
(just like anyone’s) can’t have a 100% guarantee
- Using relaxation exercises to manage tension
- Using your attention exercises from Module 4 to bring your attention back to
the present, rather than continuing to focus on health symptoms and worries
- Planning something fun or enjoyable as a reward for taking a difficult step.
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Step 3 – Test it out!!!

If you have worked through steps 1 and 2, it is likely that you will be ready to engage in your new
behaviour. Now it is time to DO IT!! Then…
If you were able to do what you had planned, ask yourself:

• What did you find out about yourself?
• What did you find out about your original and new behaviours?
If you were not able to do what you had planned, do not be concerned. It may be that you set too hard a
task to achieve immediately, or that your motivation decreased a little (or a lot!) once you were
confronted with the anxiety and distress that often goes with breaking the Reassurance Cycle.
Therefore, if you had trouble completing any step, we recommend that you:
1) Go back to Steps 1 and 2 and re-evaluate the advantages and disadvantages of your original and
new behaviours? On balance, does it make sense to go ahead with the new behaviour? Try to focus
on the disadvantages of the old behaviour and advantages of the new behaviour.
OR
2) Break your new behavioural goal from Step 2 down in to more manageable steps using the
Stepladder.
Also, don’t forget that it is normal to feel some distress while trying out these new behaviours and that
changing your behaviour is a bit like riding a bike – it takes encouragement and often lots of repetition
before it becomes less worrisome and starts to feel more natural.
On the next two pages are examples of how to complete the Reducing Checking & Reassurance Seeking
Worksheet. The first example explores the behaviour of a woman who is checking her breasts on a daily
basis for signs of breast cancer. The second example explores the behaviour of a man who is researching
his symptom on the internet. After you have read through these examples, there is a blank worksheet for
you to try out on your own checking or reassurance seeking behaviour.
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Reducing Checking & Reassurance Seeking – Example 1
Step 1: Evaluate how helpful your current health behaviour is
Behaviour: Checking my breasts daily for lumps
Advantages of this behaviour Disadvantages of this behaviour
What is the goal of my behaviour? Are there any advantages to doing Are there any disadvantages to doing this behaviour as frequently as I
this behaviour as frequently as I currently am? currently am? Does this behaviour really achieve my goal?
I won’t miss a lump if it is there Checking daily keeps my mind focussed on the
If there is a problem - I will probably catch it possibility of developing breast cancer – which isn’t
early nice to be thinking about
It isn’t 100% foolproof. I could still miss something
Checking every day has made it hard to work out if
there is anything new or changing.
It has sometimes made my breasts sore which makes
me worry even more that there is something wrong
At this point, how much sense does it make to keep going with this health behaviour? How much sense does it
make to do it as frequently as I do? Do the advantages of this behaviour outweigh the disadvantages?
Checking my breasts is OK. My doctor has even said to be aware of any changes that occur. But doing it
every day is making me sore and probably making it hard to notice any real problems.
Do I need to decrease, postpone or eliminate this behaviour? Why?

I need to decrease the amount of checking I do, as my doctor has said it is unnecessary to check as
frequently as I do and the more frequent checking is making me sore.
Step 2: Generate and evaluate a new behavioural goal

New behavioural goal: Checking my breasts monthly
What specifically will I do? Will I do it straight away or gradually?
I will check my breasts only once per month. I think I can start this straight away, so will give it a try.

What is the goal of this new behaviour? Are there any advantages to Are there any disadvantages to doing this new behaviour as frequently as
doing this behaviour as frequently as I have planned? I have planned?
I will still pick up on changes There will still be times I am worrying about breast
My breasts won’t be as sore – this might help me to cancer. Telling myself I can’t check until later will
notice when there is real soreness there, rather probably leave me feeling uncomfortable for a while
than soreness I’ve brought on by my checking afterwards.
I won’t spend so much time thinking about breast
cancer
If I needed to check more, my doctor would have
encouraged my for what I was doing before
At this point, how much sense does it make to try out this new health behaviour?
I can see there are plenty of reasons to try it out and my doctor will be pleased if I can reduce my
checking
How will I manage any anxiety and worry? What will I say to myself? What will I do?
I will remind myself that I am still checking and am unlikely to miss anything if I keep up these monthly
checks. I will use my meditation exercises to try to manage any worries that keep popping up.
Step 3: Test it out!!!

Was I able to do what I had planned?
“Yes”
What did I find out about myself? What did I find out about my original and new behaviours?
I found it hard not to check everyday because it had become quite a habit. The first two weeks were really
hard and I quickly checked a couple of extra times. It was nice to not be sore from the constant poking
and prodding. I feel like I am now in a better position to notice any real changes.
“No”
I may need to:
1. Go back to Steps 1 and 2 to re-evaluate the advantages and disadvantages of my original and new behaviours.
OR
2. Break my new goal from Step 2 down in to more manageable steps using the Stepladder
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Reducing Checking & Reassurance Seeking – Example 2
Behaviour: Researching any new symptoms on the internet
I can find out whether my symptoms are normal I have sometime spent ages researching a symptom
I can access information my doctor may not even that ended up being harmless and just went away
know about When I search for one symptom I sometimes get
I can get instant information rather than information on some seriously scary health
waiting for an appointment with my doctor problems. This just leaves me feeling even more
worried about what could be wrong
Even if I find a match with my symptoms, this
usually can’t be confirmed until my doctor does
some tests.
While I can quickly access a lot of information about my health symptoms on the internet, I can never
really be sure that I am on the right track. I may end up worrying about normal symptoms.

It is probably not helping me at all to find out if there is actually something wrong. It is just making me
more worried. I should probably eliminate this behaviour.

New behavioural goal: To not use the internet to research my symptoms
I will stop using the internet to research explanations for my symptoms.

I won’t keep myself feeling worried about unlikely I’m not going to know what to do with myself. I
and frightening diseases and illnesses. have spent a lot of time doing this research in the
I won’t waste time researching symptoms that may past. I will have to think of some other way to fill my
be normal. time.
I can see that my internet research only makes me more worried about my health.
I will stick a reminder note on my computer that researching my symptoms only makes me feel worse. I
will remind myself that the desire to check will pass with time – I just have to ride it out. I will get out of
the house and go for a walk to remove the temptation to search.

“Yes”
By not researching my symptoms on the internet I am actually less focussed on my health in general. It
was initially fairly hard to not check as my computer was never far away. I had to keep reminding
myself that the urge to check would pass. I think it will be worthwhile to keep this change going.
“No”
I may need to:
OR
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Reducing Checking & Reassurance Seeking Worksheet
Behaviour:

New behavioural goal:


“Yes”
“No”
I may need to:
OR
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Module Summary
• Most of us will engage in checking and reassurance seeking behaviours with regards to our health. We
do this to reduce our worrying, to increase our sense of control and certainty about our health, and to
reassure ourselves that our health is not at risk.
• In the short term, checking and reassurance seeking may provide a sense of relief or control. However,
in the long term, we can never be certain that we are 100% healthy, so our worry and need to check
and seek reassurance continues in a vicious Reassurance Cycle.
• The more we check and seek reassurance, the less opportunity we have to practice tolerating and
accepting that our health (just like anyone’s) can never have a 100% guarantee.
• Checking and reassurance seeking behaviours fall on a continuum, where too much or too little can be
unhelpful and even unhealthy.
• Excessive levels of checking and reassurance seeking can have a range of negative consequences,
including: increased pain or tenderness; financial costs; a reduction in time spent in enjoyment or
achievement related tasks (e.g., socialising, work); and relationship difficulties.
• One way to overcome excessive levels of checking and reassurance seeking is to evaluate and test out
new health behaviours that involve reducing, postponing or eliminating the current checking and
reassurance seeking.
• It is normal to feel some distress while trying out new health behaviours and decreasing your checking
and reassurance seeking. If you are finding things tough, use a Stepladder to break down your new goal
behaviour in to smaller and more manageable steps.
Coming up next …
In the next module, we will start
exploring ways to reduce avoidance
behaviours.
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About The Modules

CONTRIBUTORS

1 2
BACKGROUND
REFERENCES

Centrelinical
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Module 7
Challenging Avoidance
and Safety Behaviours
Introduction 2
What are Avoidance and Safety Behaviours? 2
Graded Exposure 2
My Avoidance & Safety Behaviours 3
Planning Your Goals 5
Building Your Stepladder 6
Exposure Stepladder - Example 7
Exposure Stepladder - Worksheet 9
Taking a Step 10
Climbing Your Stepladder 10
Module Summary 13
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C Interventions Module 7: Reducing Avoidance and Safety Behaviours Page 1
Introduction
In Module 6, we identified how health related behaviours exist on a continuum, where too much or too
little of a behaviour may be unhelpful for us. While Module 6 explored behaviours we might be doing too
much, this Module will explore behaviours that we may be avoiding or putting off due to feelings of anxiety.
In Module 3, we introduced the notion of avoidance and safety behaviours. In this Module, we will revisit
the common types of avoidance and safety behaviours, and introduce a way to gradually start to challenge
and overcome these behaviours.
What are Avoidance and Safety Behaviours?

When we feel anxious or expect to feel anxious, we often act in one of two ways to try to
control our anxiety. One way is to engage in avoidance, where we stay away from those
situations or activities that we associate with feared illnesses or that remind us of our
mortality. This could include avoiding:
• people (e.g., medical staff, ill friends or relatives),
• places (e.g., hospitals, public restrooms, funeral homes), or
• activities (e.g., attending medical appointments, thinking about death, writing a will)
Also, because people with health anxiety tend to worry more that usual about physical symptoms in their
bodies, we may also avoid activities that bring about changes in our physiological state (e.g., exercise, having
sex, eating spicy foods, drinking caffeinated drinks).
Alternatively, we may engage in safety behaviours, where we may not outright avoid a situation or
activity, but we will only do so if certain precautions are in place. For example, someone who is fearful of
contracting an illness may only visit a friend with a non-infectious disease if they are taking a preventative
course of antibiotics and plan minimise touching objects within the friend’s house . Safety behaviours are
often thought of as a more subtle form of avoidance because you are not fully testing out your fears or
engaging with the situation.
Avoiding situations or activities, or using safety behaviours to cope with them, may reduce the anxiety we
feel in the short term, but is likely to have some less helpful long term effects. In the long term, our health
worries and concerns will continue, because we haven’t given ourselves the opportunity to face our fears
and see how things really play out. We will also feel the need to continue to use avoidance and/or safety
behaviours, as we haven’t learnt whether we can survive without them. Over time, using avoidance and
safety behaviours can deplete our sense of self confidence. These behaviours may also stop us from doing
things we would like to do and lead to a very restricted an unsatisfying life.
Ultimately, you will need to face and confront your fears if you want to overcome health anxiety.
Overcoming the fears that drive avoidance and safety behaviours can seem daunting at first. Some people
might encourage you to tackle your biggest fear first – to “jump in the deep end” and get it over and done
with. If, however, you try to tackle your biggest fear straight away, it can end up being too overwhelming
and may even leave you more anxious than when you started. Many people therefore prefer to take it
“step-by-step, like climbing up a stepladder. We call this stepladder approach “graded exposure”.
Graded Exposure
Graded exposure consists of structured and repeated exposure to anxiety-provoking situations or
activities. These are presented in levels of difficulties, starting with the situation or activity that provokes
the least amount of anxiety, and then moving towards more challenging ones. There are a number of
benefits to engaging in exposure.
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Exposure gives you the chance to continue to challenge your fears. People with health anxiety
often overestimate the likelihood that they have or will develop a serious health problem, and
underestimate their ability to cope with such health problems. Exposure gives you the opportunity to
confront your fears regarding potential illness, and by doing so develop more realistic appraisals of the true
likelihood of a serious illness and your true coping abilities.
Exposure gives you the chance to get used to anxiety sensations. While in the short term it can
feel uncomfortable to experience anxiety sensations, in the long term you will feel more in control of your
anxiety. By continuously bringing on your anxiety sensations you will also become more tolerant and less
bothered by them.
Exposure gives you the chance to use your skills. By repeatedly confronting feared situations and
activities, you will gradually become more used to them. Feeling comfortable in these situations is not
instantaneous though. First of all you need to stay in the situation long enough so that your body adjusts
your anxiety downward. Then you can use the strategies you have learnt so far to help you cope
with anxious thoughts and feelings (e.g., using thought diaries to challenge unhelpful health
related thoughts).
Exposure gives you the chance to improve your confidence. If you plan these steps
carefully, you will build up your confidence and this will allow you to take further steps
forward. With increased confidence, you are more likely to face your other 'fears'.
My Avoidance & Safety Behaviours

The first step towards graded exposure is to identify the situations and activities you tend to avoid, or any
safety behaviours you may be engaging in. You can list these on the next page.
You can look back to Module 3, where you may have already listed some of your avoidance and safety
behaviours. If you have been working through your thought diaries, you’ve probably mentioned a few
situations that you’ve felt anxious about and avoided, or where you have employed safety behaviours to
cope, so it might be worthwhile looking at those for ideas.
To help you along, we have provided some examples of situations and activities that often cause distress for
people with health anxiety. If you see any that seem familiar to you, you can rephrase them on your “My
Avoidance & Safety Behaviours” list, so that they are more relevant to you.
Make sure that you think about any possible safety behaviours, as these may often be quite subtle (e.g.,
carrying medications “just in case”, carrying a mobile phone so that you can call for help). Also, make sure
you include those activities that might bring on feared physical sensations, such as exercising or eating spicy
foods, if this is relevant for you.
You will also need to consider whether you are avoiding thinking about illness or death. It
is quite common that people experiencing health anxiety will try to avoid thinking about
those things that they are most fearful of, especially thoughts of death and dying. This is
called thought suppression. Unfortunately, trying not to think about something can have
the opposite effect by making us think about it even more!
Can you remember back in Module 4, we asked you to try to not think of a pink
elephant for 60 seconds? Can you remember how well you did? If not, you may wish to try this again now
to see how well you do. Generally, most people find that the more they try not to think about something,
the more our mind tends to think about it. If this type of avoidance is familiar to you, record the things you
avoid thinking about on your list too.
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Commonly avoided people, places and activities:
• medical professionals • reading information provided by a doctor
• doctors’ surgeries • exercising
• using public restrooms • walking up stairs
• walking past funeral homes • drinking coffee
• writing a will • having sex
• phoning for test results • eating spicy foods
• eating foods close to the used by date • drinking fizzy drinks
• medical check-ups or follow-ups • visiting a friend who has a non-infectious disease
• watching the news or reading the newspaper • reading the obituaries
• visiting a relative who has recently been sick • going out in public without hand-sanitiser
• leaving the house without medications or a • taking a medication prescribed by your doctor
mobile phone “just in case something happens” • telling your doctor about concerning symptoms
• thinking about your funeral • thinking about how others will cope with your
• watching medical dramas on TV death
Take a moment to record your own examples below:
My Avoidance & Safety Behaviours
Now that you have identified a number of situations that you fear and avoid, how do you build a stepladder
to where you want to get to? First of all, let’s take a look at where it is that you do want to get to by
planning your goals. After that you can start thinking about the steps you'll need to take to reach those goals
by building your exposure stepladder.
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Planning Your Goals
Let’s think about how you can turn those situations that you fear and avoid into specific
goals that you would like to achieve.
To start with, you might want to just choose one or two behaviours to work on, rather than trying to do it
all at once. When you’re planning goals for exposure you should focus on those behaviours that you want
to change, rather than planning goals that are not very important to you. By setting a goal that is important
to you, you will be more likely to put in the effort, and to put up with some of the discomfort that is
natural when doing exposure exercises.
It is also important to think about setting specific goals. Think about what your behaviour looks like now,
and what it would look like if you met your goal. For example, if your current behaviour is “avoiding
doctors’ surgeries” then your goal might be “attending an appointment at my doctor’s surgery”. If your
current behaviour is “avoiding exercise” then your goal might be “engaging in exercise so that I can feel my
heart beating and am out of breath”.
Gradually allowing yourself to have thoughts about illness and even death may also be an important part to
your recovery. While it may seem strange, if your current behaviour is “avoiding thinking about my death”
then your goal might be “to write a will” or “to plan my funeral”. Or, if your behaviour is “to not let myself
think about having Multiple Sclerosis”, then your goal may be “to read a book about
Multiple Sclerosis” or “to write a story about being diagnosed with Multiple Sclerosis”.
Working on goals such as these allows you to gradually confront your feared thoughts,
and to reduce the unhelpful thought suppression that often accompanies such thoughts.
My goals
With these ideas in mind, record one or two goals below that you would like to work on. Also, take a
moment to think about and record why it is important to work on this goal. You may need to review this
later if you find your motivation is waning or you are uncertain about continuing on with your stepladder.
Specific Goal #1: ______________________________________________________

Why is it important for me to work on this goal?
____________________________________________________________
____________________________________________________________
____________________________________________________________
Specific Goal #2: ______________________________________________________
Why is it important for me to work on this goal?
____________________________________________________________
____________________________________________________________
____________________________________________________________
If you would like to work on more goals, it is usually best to come back and work through these steps again
rather than trying to do too much at once and feeling overwhelmed.
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Building Your Stepladders
You can now start building a stepladder of situations and activities that you can begin to climb as you work
towards your goal. Remember that by taking a step-by-step approach you can get through the smaller
challenges, which will in turn help you feel more confident.
Many people who have engaged in exposure exercises have found that breaking their overall goal down into
small, specific steps helps them feel more comfortable by knowing what's coming up. It also means that
you'll be able to make sure the steps are small enough to take, but big enough that you believe you're
heading in the right direction.
Try to think of a set of situations and activities you can engage in, starting with the least anxiety provoking
then building up in intensity until you reach your main goal. Just like in the last module, each step on the
stepladder can be given a “Distress” rating between 0 and 100, where 0 = this step is not distressing at all,
and 100 = this step is highly distressing. Your stepladder might have fewer or more “in between” steps than
the example provided. In general, a very difficult goal may need lots of small achievable steps so that you
don’t feel overwhelmed and discouraged while working up the stepladder.
You can break your overall goal into smaller steps by changing WHO is there, WHAT you
do, WHEN you do it, WHERE you do it, and HOW long you do it for. Sometimes your
goals will be opportunity-specific, that is, there might not always be a steady stream of
medical follow-ups where you can practise your steps. So you need to think of situations
that can act as steps that will still help you to climb the ladder to your goal.
The following case illustrates how you can set a goal and build a stepladder to work
towards it. You can then use the Exposure Stepladder Worksheet to complete the steps for
your own goal.
Phil avoids places associated with people who are unwell. He avoids medical facilities because he is fearful of
catching something from the other people who are there for appointments or procedures. He is especially reluctant
to attend his doctor’s surgery on weekends when the clinic is at its busiest, even though he works full time and finds
it difficult to attend during the week. He also sometimes avoids the medicinal aisle at his local supermarket. He
worries that people who are unwell have been there before him and possibly touched and “contaminated” items on
the shelves. He no longer feels that he can go to larger shopping centres as he feels the risk of contamination is
higher at these. Phil is aware that he is well overdue for a check-up and is becoming frustrated with himself each
time he has to shop.
Phil identified a goal of “attending an appointment at my doctor’s surgery”. He recognised that this was
important because he was well overdue for an annual check-up and putting it off was adding to the amount
he worried about his health. In developing his Exposure Stepladder, Phil was able to identify that any steps
that involved directly attending his doctors surgery would be quite challenging (Distress = 80). He
therefore developed some steps around visiting the medicinal aisle at various supermarkets, visiting a
pharmacy, and attending a walk-in clinic so that he could gradually build up his confidence to engage in the
harder step of visiting his own doctor’s surgery for an appointment. Phil also identified that he would need
to gradually reduce his safety behaviour of not touching things in these situations, so that he could truly
confront his fear that he would contract an illness. Here is Phil’s stepladder:
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Exposure Stepladder – Example
GOAL: Attending an appointment at my doctor’s surgery
STEP DISTRESS (0-100)

1 Attend local supermarket, stand in medicinal aisle for five minutes, not 25
touching anything
2 Attend local supermarket, stand in medicinal aisle for ten minutes, 35

touching a range of items (e.g., picking up different boxes of tissues,
reading the information on a packet of cough lozenges)
3 Attend larger supermarket store, stand in medicinal aisle for ten 40

minutes, not touching anything
4 Attend larger supermarket store, stand in medicinal aisle for ten 50

minutes, touching a range of items
5 Attend local pharmacy, on a weeknight, stay for ten minutes, touching 55

a range of items
6 Attend local pharmacy, on a weekend, stay for ten minutes, touching a 65

range of items
7 Attend local after hours walk-in clinic, sit in waiting room for 15 70
minutes, not touching anything
8 Attend local after hours walk-in clinic, sit in waiting room for 75
15minutes, touch items in waiting room (e.g., read magazines)
9 Attend my doctor’s surgery without appointment booked, sit in waiting 80

room for 15 minutes, touch items in waiting room (e.g., read
magazines)
10 Attend my doctor’s surgery with appointment booked, touch items in 90

waiting room (e.g., read magazines)
Exposure to feared thoughts

Your exposure stepladder can also include exposure to feared thoughts about illness and death. The
following activities could be built in to your stepladder to help gradually start to confront, rather than
avoid, feared thoughts about illness and death.
• Reading the obituaries to trigger thoughts about how loved ones feel when someone passes away
• Writing the word “death” repeatedly on a piece of paper to trigger thoughts of death
• Preparing a will to confront the reality of death
• Visiting a funeral home or cemetery to confront the processes involved with death and dying
• Planning your own funeral. Discussing this plan with others.
• Reading a story written by someone else who has been diagnosed with a terminal illness
• Watching a movie or reading a book where the central character has the same condition you are fearful
of
• Writing your own obituary to confront the reality of death. Writing it as though you died this week, at
your current age.
It can also be helpful to confront your greatest fears head on by writing out a Worry Story. Your story
could be about being diagnosed with a terminal illness, about your own death, or about how others would
cope if you were to die. If you are going to try this, be sure to write stories about diagnosis and your own
death in the first person, and as though it is happening here and now. Focus on how you are feeling and
what you are thinking about or doing. Here is an example:
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I am at the doctor’s surgery and he calls me in. He is normally quite happy to see me but this
time he looks grim and serious. I already know that something is wrong but try to convince myself
that this can’t be happening to me. I sit down in the chair and he starts to say that he has
received my test results back. As he is saying the words I am nodding and saying “ok” but inside
my heart is beating so fast and I am feeling so sick that it is hard to focus on what he is saying.
He hands me a brochure on motor neuron disease and is talking about a referral to a specialist.
I’m not really listening because my head is full of the words “two to five years”. For the first time
in my life, I truly know that I am going to die. I’m thinking about how bad it will get and whether
I’ll go quickly or suffer in pain. I then think about my kids. All I can focus on is that they are going
to see me deteriorate and that is all they will remember of me because they are too young. I feel
so stuck and helpless, knowing there is no cure.
How did you feel reading through the story above? Most people will find this at least a little upsetting to
read, even if you are not worried about motor neuron disease, or don’t have children. How many times
per day do you think you would need to read this story over the next week so that it no longer affects you
the way it did today?
Remember that with any exposure exercises, once is often not enough. You will need to repeat your
exposure exercises multiple times to truly confront these feared thoughts and to see a reduction in the
anxiety and distress associated with these thoughts. You may need to read your Worry Story several times
per day, over one or two weeks, before you see a noticeable change in how upsetting it is to you.
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Exposure Stepladder Worksheet
GOAL:
STEP DISTRESS (0-100)
Remember, your stepladder might have more or fewer steps depending on how difficult your overall goal
is. You can include more ‘in-between’ steps if you think the jump between one step and the next is too big.
You can break your goal into smaller steps by changing:
• WHO is there • WHERE you do it
• WHAT you do • HOW long you do it for
• WHEN you do it
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Taking a Step
So, you’ve selected a goal that you want to work on first. Where do you go from here? First, let’s have a
look at how to take a step on the stepladder. Then we will explore how to climb up your stepladder.
Plan your first step

It can be helpful to set a specific date, time and place that you will begin your first step. That way, you are
making a firm commitment to yourself to begin the process of change. Usually, you would start at the step
on your stepladder that had the lowest ‘Distress’ rating. If your goal only has a few steps, it is still often
useful to gradually work up to this goal, even though it might seem like a “waste of time”. These steps give
you extra situations for your body to get used to things that are uncomfortable for you. They also give you
extra opportunities to gather evidence about any unhelpful health related thoughts you might be
experiencing.
Expect some anxiety

When you enter the situation – at any step - remember that you’ll probably experience some anxiety or
discomfort. That’s why it’s important to start small, and work your way up. This gives you the chance to
adapt to that level of anxiety, so that you aren’t overwhelmed by higher levels of distress.
After all, the only way to get used to those feelings is by experiencing them.
Remember your realistic health related thoughts

If you haven’t completed a thought diary to challenge any unhelpful health related thinking,
you may want to complete one prior to taking your first step. If you have completed one,
remind yourself of your realistic health related thoughts if you notice any of the unhelpful
thoughts coming up.
Stay in the situation

Some anxiety is expected, and it might be tempting to leave if you feel uncomfortable, but try to stay in the
situation until the anxiety goes down. In this way you can see that, as frightening as the feelings are, they
are not dangerous, and they do subside. If you leave just as the level of anxiety experienced reaches its
highest point, it will be more difficult to accomplish the same step the next time. On each attempt, you
should try to face as much fear as you can stand and just try to “ride out” the anxiety – like surfing a wave.
Drop those safety behaviours

Some steps on your stepladder might involve recognising and dropping safety behaviours. Regardless of the
situation or activity, try to be honest with yourself about whether you are fully participating, or only doing
so if there are some precautions in place. Full participation means being fully aware of what is happening
within and around you. This also means not taking alcohol or drugs to try and “mentally escape” from the
exposure exercise. Remember, if it seems too hard to drop a safety behaviour immediately, you could use
your stepladder to gradually decrease it.
Climbing the Stepladder

OK, so now that you have some tips on how to get through one step, how do you keep moving onwards
and upwards? Here are some guidelines for how you can continue to climb each step to reach your goal.
Take one step at a time

Climbing a stepladder is not about taking one giant leap, it’s about taking one small step at a time. You
begin with the least difficult step and gradually work your way up the step ladder. As you climb higher up
the ladder, your ‘Distress’ rating becomes higher, but you also get used to the anxiety at each of those
steps. Your primary aim at each step is to complete that step and that step alone.
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Over and over again

Do a step frequently and repeatedly, and do them in close succession to make sure you are comfortable
with the situation before you move onto the next step. This might take 3 or 4 times. If you only enter a
situation once, you might be relieved it is over, convince yourself that it was luck that you got through it,
and think that if you did it again it wouldn’t go so well. If you can, it is best to repeat the step
as soon as possible so that you can get used to the situation more quickly and become more
comfortable, and so you are truly convinced that the step is no longer a problem for you.
Acknowledge the steps you’ve made

When you are comfortable with a particular step, admit to your successes and acknowledge
the steps that you’ve made so far. You can even build in some rewards to acknowledge your
progress along the way.
Deal with step-backs

We all have our up and down days, and sometimes you might think might you’ve taken a ‘step-back’
because an exposure exercise didn’t go as well as you hoped. Each time we do an exposure exercise is
likely to be different. That’s why it’s important to do a step over and over until you are comfortable with
that step. If you are having some trouble with a particular step, you may want to create a “bridging” or in-
between step. This would involve planning another step that is slightly less distressing and has a slightly
lower ‘Distress’ rating. Alternatively, you could try going back to the previous step and use it as an
opportunity to refresh your skills before attempting to move up again. Don’t forget to set a specific date,
time and place as to when you will take the next step.
Use the Exposure Diary

On the next page is an Exposure diary for you to record details about the exposure exercises that you
make. This is useful because it helps you to acknowledge the steps that you’ve made, it reminds you of
things that helped you to get through this, and it helps you identify what you can do if the step didn’t go as
well as you hoped.
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Exposure Diary
You can use this sheet to record your progress on your stepladders. You can describe what you planned
to do, and your ‘Distress’ ratings for how nervous you both expected to be and how nervous you actually
were. The last column asks you to jot down any comments about the experience – were you able to do
what you planned? What helped you to do this? If you experienced a great deal of difficulty, you can note
down why you think this might have been the case, and how you might prepare yourself for next time.
Planned exposure exercise Expected Actual Did you do it? What helped you complete the step?
Distress Distress OR
0-100 0-100 Describe what made it difficult to complete the step and
how you can prepare for next time?
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Module Summary
• Avoiding situations or activities, or using safety behaviours to cope with them, may reduce the anxiety
you feel in the short term, but in the long term can keep your health anxiety going.
• Confronting feared situations and activities, and thoughts about illness and death, is known as exposure.
Exposure gives you the chance to:
• get used to previously feared situations/activities
• get used to anxiety sensations
• continue to challenge your fears
• use your skills
• improve your confidence
• Grading your exposure allows you to break your planned exposure exercises down in to more
manageable steps. These can be recorded on a Stepladder so that you know what steps you need to
take to reach your overall goal.
• When taking a step, it is important to remember to:
• Plan your steps – be specific about what you will do and when
• Expect some anxiety
• Remember your realistic health related thoughts from your thought diaries
• Try to stay in the situation or activity until your anxiety goes down
• Drop any safety behaviours you are aware of
• When climbing your stepladder:
• Take it one step at a time
• Do the step frequently and repeatedly – make sure you are comfortable with that step
before trying to move up to the next one
• Acknowledge the steps you’ve made
• Expect to have some step-backs. Recognise that everyone has their up and down days. If
you had difficulty completing a step, get yourself back on track by either adding an in-
between step, or going back to the previous step and refreshing your skills before trying to
move up again.
Coming up next …
In the next module, we will learn to
adjust any unhelpful health rules or
assumptions we may hold, and to
create more realistic and flexible ones.
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About The Modules

CONTRIBUTORS

1 2
BACKGROUND
REFERENCES

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Module 8
Adjusting Health
Rules and Assumptions
Introduction 2
Helpful vs Unhelpful Rules & Assumptions 2
Identifying My Unhelpful Health Rules & Assumptions 2
Adjusting Health Rules & Assumptions 4
Worksheet (Example) 6
Worksheet 7
Following Through 8
Module Summary 9
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C Interventions Module 8: Adjusting Health Rules and Assumptions Page 1
Introduction
You have now learned strategies to decrease the amount of time spent worrying about and focussing on
health symptoms, to directly challenge unhelpful health related thoughts, and to decrease unhelpful health
related behaviours. We hope that you are finding these strategies helpful in improving how you think and
feel about your health, and how you behave in relation to your health on a day-to-day basis. Now that you
have some experience in working with strategies to manage your health anxiety, it is also important to
tackle some of the more difficult underlying reasons that you started to worry about your health in the first
place. In this module, we will discuss adjusting the underlying health rules and assumptions that gave rise to
your health anxiety.
Helpful vs Unhelpful Rules & Assumptions

As we mentioned in Module 2, we all have rules and assumptions by which we live our lives. Although we
aren’t specifically taught “the rules”, we learn them through our early experiences and from observing
other people who influence us in our earlier years. You may not even be aware that you developed these
rules or assumptions, but they consistently influence your thoughts and behaviour anyway.
As we’ve mentioned earlier, some rules and assumptions are helpful and some are not. We all need
guidelines for living to help us make sense of the world and to cope with our everyday lives. So having
rules, in itself, is not a bad thing.
Helpful rules and assumptions are realistic and somewhat flexible. An example of a healthy rule is, “drivers
should stop at red lights”. This is a helpful rule because there is evidence to suggest that not stopping at a
red light may result in a car accident. So keeping this rule can help ensure our survival!
Helpful rules are also flexible and adaptable, and this helps us to adapt our behaviour to different situations.
For example, having the rule that “it is good to try to eat healthy food” is helpful because there is evidence
to support the fact that you will have fewer health problems if you eat healthy foods. But there is also
flexibility in this rule so that it takes into account occasions when it may be preferable to eat foods that are
less healthy without feeling guilty (e.g., birthdays or Christmas).
Unhelpful rules are those that are inflexible and unreasonable. For example, holding
the belief “my doctor should be able to explain each of my bodily sensations and
changes” is unreasonable in the sense that it is unlikely that your doctor will be able to
maintain this standard every time you see them. It is not possible or reasonable to
expect your doctor to know exactly what is happening within your body at all times.
Therefore, this type of unhelpful rule will only keep you worried about your health,
and dissatisfied or perhaps even frustrated with your doctor.
Identifying My Unhelpful Health Rules & Assumptions

Let’s now take some time to identify what unhelpful rules and assumptions you might have developed
regarding your health. You might already have an idea of these from the work you have completed in
Module 2. If you are unsure, there are several ways that you can start to identify these rules or
assumptions.
Take a moment to record some responses to the following questions:

• How have people around me responded to health concerns in the past? What might I have learned
from them?
• What standards do I expect myself to meet regarding my health?
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• What standards do I expect my doctor or other health professionals to meet?
• What symptoms do I allow myself to experience without worrying?
• What symptoms or sensations do I never allow myself to experience?
• What negative predictions do I repeatedly make about my health? (Note: you may want to review
your thought diaries from Module 5 for any repeated themes)
Health rules and assumptions can be in the form of statements such as:
“I must / should / have to always…” e.g., “I must take all symptoms and bodily changes
seriously”, “I must be symptom free to be healthy”
“My doctor must / should / has to always…” e.g., “My doctor must be certain”, “My doctor should be
able to explain each of my bodily sensations and changes”
“I must / should never…” e.g., “I should never ignore a symptom”
“My doctor must / should never” e.g., “My doctor should never discount a symptom until all
possible tests have been conducted”
“If…, then…” e.g., “If my doctor doesn’t know exactly what the problem
is, then it must be really serious”, “If I don’t persist, then
my doctor could miss something important”
Now that you have read this section on identifying your health rules and assumptions, have you been able
to identify any that are operating in your life? What are some of those health rules and assumptions? Take a
few moments to write them down.
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Adjusting Health Rules and Assumptions
By now, you might have been able to identify those health rules and assumptions that have been guiding
your everyday health-related thoughts, feelings and behaviours. Just as in the previous modules, you can
work at challenging your health rules and assumptions by asking yourself specific questions, and using one
of our worksheets to guide you through this step-by-step. If you have worked through the previous
modules, you will probably find that changing these rules and assumptions will be a little easier. After all,
you will have already tackled those health-related thoughts, feelings and behaviours that have been fuelling
your health rules and assumptions day-to-day.
The goal of completing the Adjusting My Health Rules & Assumptions Worksheet is not to get rid of your
health rules or assumptions, but rather to adjust them into more realistic and flexible health guidelines.
Before completing the worksheet, read through the following steps:
1. Identify the health rule or assumption you would like to adjust

You may have a number of rules or assumptions that you would like to work on. There is no right or
wrong place to start with this. Some people like to tackle the one that is impacting on them the most.
Others like to start on the rule or assumption they think will be easiest to challenge, so that they can
build up some confidence. Either of these strategies is fine.
2. Ask yourself “Where might this rule / assumption have come from? Why is it still
here?”
The purpose of the first question is to think about why you developed this rule or assumption. As
mentioned before, these rules and assumptions have often developed as a way to protect ourselves and
to make ourselves feel less vulnerable. It is therefore quite possible that the rules or assumptions made
sense at the time you developed them. The purpose of the second question is to examine why you are
still holding on to these rules or assumptions. Ask yourself, “What advantages are there to living by this
rule or assumption? What benefits do I obtain? What do these rules or assumptions protect me from
now?”
3. Ask yourself “What impact does this rule / assumption have on my life?”
Take a moment to record how holding this rule or assumption has affected your
thinking, feelings, and behaviours. How has it impacted on your relationships with others,
including with health professionals? How has it impacted on your ability to do things that
you value, and that give you a sense of enjoyment or satisfaction?
4. Ask yourself “In what ways is this rule / assumption unreasonable, unrealistic or
unhelpful?”
• Is your rule actually achievable? (E.g., if you believe “I must be symptom free to be healthy” –
can you actually ever be symptom free?)
• Can you or your doctor really live up to this standard? Is it possible that your doctor is holding
a different set of rules or assumptions to yourself? (E.g., if you believe “my doctor should be
able to explain each of my bodily sensations and changes” – does the doctor know your
rules/assumptions? Does your doctor hold the same rules or assumptions? If not, what rules or
assumptions might they be operating under? Can doctors always explain everything?)
• Do the disadvantages of this rule / assumption outweigh the advantages? If there are more
advantages than disadvantages, then maybe you don’t need to challenge this rule / assumption. If
however you decide that the rule / assumption is unhelpful, then let’s move on to the next step
5. Now, think carefully about what might be a more balanced and flexible rule or
assumption.
Consider using less extreme terms than “musts” and “shoulds”, such as “sometimes”, “I’d prefer it
if…”, “I would like…”, “It would be nice if…”. For example, instead of the unhelpful rule “I should
never ignore a symptom”, consider the alterative “I will sometimes need to pay attention to symptoms,
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such as pain, fever and signs of infection. However most symptoms will improve over time and it is
pretty normal to experience various sensations, including aches and pains.”
You may also consider changing the ending of any “If… then…” statements to a less worrisome
conclusion. For example, instead of the unhelpful assumption “If my doctor doesn’t know exactly what
the problem is, then it must be really serious”, consider the alternative “If my doctor doesn’t know
exactly what the problem is, then maybe it is nothing to worry about”.
Balanced rules and assumptions might end up being more lengthy in their wording than your old rules
and assumptions. This is because they are more sophisticated – you are making it realistic, flexible and
adaptable. If you find it difficult to think of an alternative rule or assumption that is more balanced,
don’t worry. Continue with the strategies your have learned in the previous Modules to address your
day-to-day health related thoughts, feelings and behaviours. By doing this, more balanced rules and
assumptions may become apparent to you over time.
6. Finally, ask yourself “What can I do to put this rule / assumption into practice on a
daily basis?”
Why do you think it might be important to do this? Remember that your old rule or assumption may
have been in operation for some time, and has guided how you behave in relation to your health. So it
is important that you not only have a new rule, but new behaviours to accompany this rule so that the
new rule can be “house-broken” and become part of your new way of operating.
On the next page is an example of how an Adjusting My Health Rules & Assumptions Worksheet can be
completed. On the page after that, there is a blank worksheet. After you have a chance to look at the
example, try working through a worksheet yourself to adjust one of your unhelpful health rules or
assumptions.
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Adjusting My Health Rules & Assumptions

(Example)
Rule or assumption I would like to adjust
I must be symptom free to be healthy

Where might this rule / assumption have come from? Why is it still here?
My family have always worried about their health.

My mother took us to the doctor for antibiotics even if we had just the slightest cold.
If we told her about any aches or pains, she would get really concerned and worried.
I guess that even now I am still worried that if I drop this standard, I am exposing myself to
illness
What impact does this rule / assumption have on my life?
I’m always thinking and worrying about sensations in my body

I feel the need to go to the doctor every time I notice something weird or new in my body
I don’t like to feel tired, so I don’t do much. I miss out on lots of fun things my friends do.
I find it hard to concentrate at work, especially if there is something going on in my body
In what ways is this rule / assumption unreasonable, unrealistic or unhelpful?
When I say to myself, “I must be symptom free to be healthy” I am setting a pretty

unachievable standard.
It is impossible to be symptom free and it is normal to feel some aches and pains from time to
time.
Even some “healthy” people will have aches and pains occasionally.
What is an alternative rule / assumption that is more balanced and flexible?
I would prefer not to feel any discomfort or strange sensations in my body, but it is unlikely
that I will always be symptom free.
It is probably more helpful if I think about trying to maintain a healthy lifestyle than
worrying about all the different symptoms and sensations in my body.
What can I do to put this rule / assumption into practice on a daily basis?
I will start doing more things with my friends and letting myself feel tired occasionally
I will ensure I buy fresh fruit and vegetables each week to improve my diet
I will use my attention strategies and postponement to keep getting on with life, even if I feel
some strange sensations in my body
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Adjusting My Health Rules & Assumptions
Rule or assumption I would like to adjust
Where might this rule / assumption have come from? Why is it still here?
What impact does this rule / assumption have on my life?
In what ways is this rule / assumption unreasonable, unrealistic or unhelpful?
What is an alternative rule / assumption that is more balanced and flexible?
What can I do to put this rule / assumption into practice on a daily basis?
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Following Through
Now that you have worked through the worksheet, be sure to keep a copy of this new rule or assumption
somewhere easily accessible. After all, those old health rules are likely to pop up from time to time, as they
can take a while to wear out. Until your new rule or assumption becomes ‘worn in’, you may need to keep
reminding yourself of it.
Importantly, keep putting your new rule into practice by carrying out those daily actions you have planned.
Although it might seem difficult to you now, it will get easier as you keep doing them, and eventually it will
become the new way of living your life.
Remember that the goal is not to rid yourself of helpful health rules (e.g., “if I have worsening pain, I should
see a doctor”), but rather to adjust those unrealistic, unhelpful and outdated rules.
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Module Summary
• We all have rules and assumptions by which we live our lives. Although we may not be aware of them
they consistently influence our thoughts and behaviours.
• Helpful rules are those that are realistic and somewhat flexible. They are designed to help us function
and to keep us safe.
• Unhelpful rules are those that are inflexible and unreasonable.
• Although we may develop health rules and assumptions to try to protect ourselves, if they are inflexible
or unreasonable they can keep our health anxiety going.
• To adjust any health rules or assumptions you have identified, you can:
• Consider where the rules or assumptions came from and why they might still be here
• Identify the current impacts of the rule or assumption
• Consider the ways that the rule or assumption might be unreasonable, unrealistic or unhelpful
• Develop a new balanced and flexible rule or assumption
• Think of new ways of behaving that would put the new rule or assumption into practice
Coming up next …
In the next module, we will develop a
healthy living self-management plan for
you to keep everything going that you
have learnt throughout these
modules.
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About The Modules

CONTRIBUTORS

1 2
BACKGROUND
REFERENCES

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Module 9
Healthy Living &
Self-Management Planning
Introduction 2
The Health Anxiety Model Revisited 2
A New Way of Operating 3
Preventing Set-backs 5
Self Management Plan 6
Healthy Living 7
Module Summary 9
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C Interventions Module 9: Healthy Living and Self-Management Planning Page 1
Introduction
Congratulations on making it to the end of this information package! In this final module, you will find a
summary of all of the important concepts and strategies introduced to you in the previous modules. You
will also find a self-management plan designed to help you stay on track in the future.
The Health Anxiety Model Revisited

Remember the model of how health anxiety is maintained from Module 3? It showed how certain internal
or external triggers can activate your health rules or assumptions. Once activated, these rules and
assumptions can negatively affect the way you think about your health and interpret health related
information. The more you think in this negative manner, the more anxious you feel, and the stronger your
desire is to focus on your symptoms, check and seek reassurance, and avoid things that remind you of your
health related concerns. Engaging in these behaviours may provide some short term sense of relief or
control. However, in the long term, the vicious cycle remains unchallenged and continues each time you
are confronted with a trigger. Below is a simplified model to refresh your memory.
Internal or External Triggers
Anxiety symptoms

symptoms Reassurance Seeking Safety Behaviours

Sense of relief or control over symptoms

Focusing on symptoms can increase intensity of symptoms
Checking behaviours may bring on or intensify symptoms
Avoidance limits opportunities to learn new things and challenge fears
Unhelpful health related thoughts, rules and assumptions continue unchallenged
Anxiety continues
Increased desire to focus on symptoms, check and seek reassurance, and to avoid
or use safety behaviours
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A New Way of Operating

The old health anxiety model represents a vicious cycle, where the things that you think and do actually
increase the amount you worry about your health, and the frequency and intensity of physical sensations
you experience. The good thing about a cycle is that you can reverse it from a negative cycle to a more
positive cycle. It is like a wheel moving in one direction that has some momentum behind it. By making
some changes and putting some force against the old motion, you can usually get it to spin in the opposite
direction. Initially, trying to change the direction of the wheel can be a real effort and may not be smooth at
first. However, with some persistence it starts to get easier and the wheel eventually gathers its own
momentum in the new direction.
We hope that by now you have been able to start loosening up the old health anxiety cycle. So let’s take a
moment to review the key strategies introduced throughout these modules, and see how they might fit
together in a new model (see page 4).
Notice in the new model, that internal or external triggers can still activate your old unhelpful health rules
and assumptions. This is because those unhelpful rules and assumptions have generally been around for a
long time, so you can’t expect them to disappear overnight. The key thing is that instead of allowing these
unhelpful rules and assumptions to then guide your thoughts, feelings and behaviours, you choose to do
things differently. Over time these old rules and assumptions may then fade out and not be so easily
activated.
So, when your old health rules and assumption are activated you instead:
• Adjust your health rules and assumptions by challenging them, devising new helpful health
rules and assumptions, and putting them into practice;
• Let go of your focus on health symptoms and worries by practicing your attention exercises
(mundane task focussing, meditation), and using your postponement strategy to delay any further
focussing on these to a later time and place;
• Re-evaluate any unhelpful health related thoughts by using a thought diary during your
“worry period” to address any thoughts that keep popping back up;
• Reduce any unhelpful checking or reassurance seeking behaviours by evaluating how
helpful the old behaviour really is, generating a new more helpful behaviour, and then testing it out;
• Reduce any avoidance or safety behaviours by gradually confronting
feared thoughts, people, places and activities.
Doing each of these things, although sometimes hard in the short term, can lead to a
range of long term benefits. The key thing is to keep going, because the more of the
above strategies you use, the more likely you are to reverse that old cycle of health
anxiety.
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My New Way of Operating
Internal or External Triggers
INSTEAD INSTEAD
Adjust unhelpful health rules / assumptions
Ask myself:
Where did it come from? Why is it still here?
What impact does it have on my life?
How is it unreasonable, unrealistic or unhelpful?
What is an alternative rule / assumption?
How can I put this into practice?
Let go of my focus on health symptoms Re-evaluate unhelpful health related thoughts

and worries If I am still worrying when I get to my worry
Practice my attention exercises period, use a thought diary to directly challenge
(i.e., mundane task focussing and meditation) the worry and develop more realistic predictions
Use postponement to delay any further focussing

on these until a specific later time and place
Reduce Checking & Reassurance Seeking Reduce Avoidance & Safety Behaviours
Ask myself: Gradually start to confront feared thoughts,
How helpful is my checking/reassurance seeking? people, places and activities
What are the advantages / disadvantages?
Should I decrease, postpone or eliminate this? Be aware of and try to gradually decrease any
What specifically will I do instead? Why? safety behaviours I am using
Test out this new behaviour

• Initial increase in anxiety, discomfort and uncertainty

• Less worry and concern about symptoms and general well-being
• Less chance of bringing on physical symptoms of anxiety
• Less chance of creating new symptoms due to checking behaviours
• More opportunities and confidence to be able to respond appropriately to health
problems that arise
• Less time spent checking, reassurance seeking, or avoiding
• Improved relationships with friends, family, and health professionals
• More time for other important or enjoyable activities
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Preventing Set-backs
Now that you have made it to the end of this information package, the most important thing is to keep
going! It is important to recognise though, that even if you are trying your hardest to put all of the
strategies in place, you can expect some set-backs to happen along the way. Change is never a straight-
forward process.
Think about the idea of trying to learn a new sport. It will take some time for the skills to feel more natural
and to learn all the new rules. You will need to persist and practice to make it easier on yourself. At times,
you may come up against some tough competition, but that doesn’t mean that you should give up! It just
means that you might need some more practice.
Try not to focus too much on any set-backs that you experience. Instead, focus your
attention on what you will do next to get back on track, such as practicing the strategies
summarised by the “My New Way of Operating” model. You can even use any set-backs
you experience as a way of learning something new about yourself, to help avoid similar
problems in the future.
It may be helpful to create a personalised self-management plan to recognise the signs of a set-back and to
put things in place as soon as possible. This way you can prevent a small set-back from turning into a large
one.
On the next page is a self-management plan worksheet for you to identify:

• Early warning signs of a set-back. These are clues you can keep watch for that indicate you
might be starting to worry about your health again.
• Potential problem situations. These are the things that could potentially trigger off another
episode of health anxiety in the future.
By being aware of these early signs and potential triggers, you will be in a better position to “spot” the
onset of health anxiety, and then take early action to prevent it from becoming worse.
There is also room for you to record helpful:

• Strategies or techniques. These are the things you have learnt that are helpful for reducing your
health anxiety.
• Coping statements or phrases. These could include your new health rules or assumptions,
ideas you have developed from your thought diaries, or any other things you have found helpful to
remind yourself of from these modules.
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Self-Management Plan
What are the early warning signs that tell me I might be heading for a set-back and need to do
something about it myself? (e.g. particular thoughts, behaviours such as checking or avoidance, things
others say to me, anxiety symptoms)
What situations are potential problems for me? (e.g. times of increased stress, medical check-
ups, receiving a diagnosis)
What strategies/techniques have I learned that I could apply when I notice some early warning signs?
What are some of the coping statements or helpful phrases that I can use to help myself cope
when I am feeling anxious or worried, or have had a set back?
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Healthy Living
You might recall that right back at the start of Module 1, we discussed the idea that ‘health’ does not just
refer to the absence of disease, injury or illness. Rather, ‘health’ often refers to a person’s state of physical,
mental and social functioning. The final step to overcoming health anxiety is therefore to think about how
you might improve those areas. After all, if you are taking real steps to improve your overall health, it gives
you less to worry about!
On the next page, you will see that there is room to write in your ideas about a variety of ways you might
improve your overall health. We recommend that rather than setting an overall goal, that you are specific
with what you will actually do. For example, you might look at the “diet” box and think that you would like
to eat more healthily. To get this started you could write “I will buy fresh fruit and vegetables with my
shopping”.
Below are some questions that might help you identify whether you need to do something to improve each
area on the Healthy Living Worksheet. We have also provided an example of how to set a specific goal for
that area.
• Social activities and support: Do you need to catch up with old friends? Do you need to initiate
some new friendships? “I will call Jane this week to catch up for coffee”
• Stress management: Is there too much stress in your life at the moment? How could you reduce it?
“I will join a Tuesday yoga class and leave work on time to get there”
• Diet: Are you eating a nutritional and balanced diet? Are there any problem areas with your diet?
“I will cut back to one coffee per day this week”
• Exercise: How often do you exercise? Do you need to do more or less exercise?
“I will walk the dog two mornings per week instead of letting my partner do it”
• Pleasant or fun activities: Do you have enough fun in your life? Are there things you used to enjoy
that you have cut back on or stopped doing? Do you put ‘fun’ last on the priority list?
“I am going to buy and start a jigsaw this Thursday”
• Sleep: Are you getting enough rest? Do you find it hard to get to sleep or stay asleep? Do you put
off going to sleep because you are doing other things? Do you have good sleep habits?
“I will take the TV out of the bedroom because I keep staying up later than I ought to”
• Personal goals: Is there anything you would like to achieve that you need to start working on?
What are your short, medium and long term goals? What is on your ‘to do’ list? Of all the things on
your ‘to do’ list, which would you most like to achieve? What clear step could you take towards
this goal?
“I will visit my relatives more often, starting with a visit to my Aunt this Saturday”
• Other: Is there anything else that you could do that would improve your overall health? Do you
need to reduce you alcohol intake? Are you due for a check up with your dentist or doctor? If you
have been recommended a medication or other treatment programme, are you maintaining it? If
not, how will you maintain it?
“I will call my dentist to book a check up”
You may find that you have identified quite a few changes that you would like to make.
You may want to get a diary so that you can schedule in each of these activities and keep
track of how you are going with meeting your new goals.
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Social Activities & Support Stress Management
Diet Exercise
Healthy
Pleasant or Fun Activities Sleep
Living
Personal Goals Other
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Module Summary
• To reverse the vicious cycle of health anxiety you need to:
• Adjust your health rules and assumptions
• Let go of your focus on worrisome symptoms
• Re-evaluate any unhelpful health related thoughts
• Reduce any unhelpful checking or reassurance seeking behaviours
• Reduce any avoidance or safety behaviours
• Changing your health related rules, thoughts and behaviours takes time and lots of practice
• Expect set-backs, but rather than focussing on them use your self-management plan to recognise them
early, prevent them from getting worse, and get back on track.
• Engage in behaviours that promote your overall health, such as accessing social support, managing your
stress levels, having a healthy and balanced diet, exercising regularly, having fun, getting enough sleep,
setting and achieving personal goals, limiting your alcohol intake, attending regular check-ups, and
managing any health issues you have.
To finish up …
Congratulations! You have made it to
the end of the modules. We hope you
have found them to be beneficial and
that you will maintain the gains you
have made. Do keep using the
strategies and review the modules
from time to time. Good luck!
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About The Modules

CONTRIBUTORS

1 2
BACKGROUND
REFERENCES

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Stepping Out of
Social Anxiety
Stepping Out of Social Anxiety
Module 1
Understanding Social Anxiety
Introduction 2
What is Social Anxiety? 2
What Causes Social Anxiety? 3
What Keeps Social Anxiety Going? 3
Model of Social Anxiety – Example 8
My Model of Social Anxiety 9
Module Summary 10
This information provided in this document is for information purposes only. Please refer to the
full disclaimer and copyright statements available at www.cci.health.wa.gov.au regarding the
Stepping Out of
Social Anxiety
Introduction
Do you worry a great deal about how you come across to others and what people will think about you?
Do you find certain everyday social situations so anxiety-provoking that they are distressing for you? Do
these concerns lead you to avoid social situations to a degree that interferes with the life you want to be
living? If so, you may find it helpful to work through this workbook, either on your own or with the
support of a clinician. The modules cover a set of strategies that research has shown to be effective in
reducing social anxiety. The aim of this module is to provide you with information about social anxiety
disorder and what keeps it going.
What Is Social Anxiety?

Social anxiety is anxiety that occurs in response to social situations. The anxiety may occur before, during,
or after the social situations, and quite often at all three times. A certain amount of social anxiety is
completely normal, with around 90% of people acknowledging that they feel shy at certain points in their
lives. Most people feel anxious about some social situations, such as public speaking and job interviews.
They worry about whether the speech or interview will go well, or what other people will think. Most
people will also feel relieved when it is over. For some people, however, the anxiety may be so distressing
that they avoid the situation at all costs.
‘Social anxiety disorder’ or ‘social phobia’ refers to an intense, longstanding, and debilitating
fear of social situations. Often people with social anxiety disorder will avoid social situations
if they can. They believe that they will be evaluated negatively or criticised by other people,
and may fear that they will be embarrassed or humiliated in some way. They find that their
social anxiety is getting in the way of the life that they want to be living.
People with social anxiety will differ from each other with respect to the range and severity of their
problems. We will use the term ‘social anxiety disorder’ in these modules to reflect a level of social
anxiety that interferes with people’s lives in an important way. They may fear most social situations or one
or two specific situations. The types of social situations found to be anxiety-provoking will also vary from
person to person. Some common types of situations that people with social anxiety may find anxiety-
provoking include:
• One-on-one conversations • Dating • Phone calls

• Interacting in groups • Public speaking • Initiating social catch-ups
• Going to parties or social • Being watched while • Using public toilets
gatherings writing, eating or drinking • Sitting facing other people
• Initiating/maintaining • Walking down the street on a bus or train
conversations in view of others • Being assertive with
• Meeting new people • Shopping others
If you find any of the above situations anxiety-provoking because of concerns about how you will come
across or what people will think about you, and this anxiety is interfering with your life, you may find it
helpful to keep reading these Stepping Out of Social Anxiety modules.
Module 1: Understanding Social Anxiety Page 2

Stepping Out of
Social Anxiety
What Causes Social Anxiety?

There is no single or simple answer to the question of what causes social anxiety disorder. Contributing
factors are many and they can vary for different individuals. However, there are some important factors
that can increase someone’s chance of developing social anxiety disorder. These factors can be divided
into biological and psychological causes.
Biological factors such as a family history of anxiety disorders or depression increase your chances of
having an anxiety disorder. The more of your family members that suffer with anxiety or depression, and
the closer they are to you genetically, the more likely you are to develop an anxiety disorder. We are also
born with our own temperaments, which may be inherited to some degree. Many people with social
anxiety disorder report that they were shy or inhibited as very young children. While most children will
grow out of early shyness, if they are shyer and more timid than their peers this also increases their
chances of developing social anxiety disorder later in life.
Having a biological vulnerability does not necessarily mean that someone will develop an anxiety disorder.
It also may depend on the person’s lifestyle, the types of life stressors they have encountered, and their
early learning. Many people with social anxiety disorder report experiencing bullying or abuse during their
childhood or adolescence. Others report having one or two particularly distressing social experiences that
have stuck in their minds, whilst others report experiencing regular criticism early in life. Others report
that their families did not socialise much during their childhood, so they did not have the opportunity to
develop confidence in their ability to develop relationships with others.
For any given person, it may not be possible to have a complete explanation of exactly how and why they
developed social anxiety disorder. Most of the time it probably takes a combination of biological,
temperamental, and social factors. The good news is that regardless of what originally caused your social
anxiety disorder, there are well-researched and effective ways to overcome your social anxiety.
What Keeps Social Anxiety Going?

To overcome your social anxiety it is helpful to understand what is keeping it going in the present.
Social anxiety occurs when we perceive a ‘social threat’ in a particular situation. Our perception of
social threat is how strongly we believe that a ‘social catastrophe’ will occur. This perception is
divided into two parts: probability and cost. The probability refers to how likely our fears are to
happen. If we believe our fears are highly likely to come true then our fear response (also
known as ‘fight or flight’) is more likely to be triggered. The cost refers to how bad we believe
it will be if our fears do come true. If you believe that it is very likely that you will appear nervous
and make a mistake when delivering a presentation (high probability), and if this does happen then
you will be criticised or humiliated by others (high cost), then you are likely to feel very anxious about the
presentation.
Once the perception of social threat is triggered (i.e., perceived social danger is high) you will experience a
strong fear response. This usually results in physical symptoms such as:
• Trembling or shaking • Sweating

• Blushing • Hyperventilation
• Pounding heart • Difficulty concentrating
• ‘Going blank’ • Urge to escape
• Nausea
These symptoms are part of the fight or flight response, the body’s protective mechanism. If we are under
real threat (e.g., approached by a robber) our body must ready itself for fighting or fleeing from the threat.
Module 1: Understanding Social Anxiety Page 3

Stepping Out of
Social Anxiety
As a result, we get a surge of adrenaline and our breathing rate increases (to get more oxygen to the
body), we sweat (to cool the body), our muscles tense (to prepare for fighting or fleeing), our heart rate
increases (to pump more blood around the body), our attention narrows and focuses on the threat (so that
we aren’t distracted from dealing with the threat), and so on. As you can see, all these changes are
designed to help us deal with the threat.
But in most social situations we can’t simply fight or run away at top speed, so we aren’t able to use all the
extra resources in our body (e.g., adrenaline, oxygen). As a consequence, we subjectively experience these
bodily changes as intense anxiety.
So we feel socially anxious when we perceive a social threat. People with social anxiety disorder have a
bias to their thinking whereby they overestimate social threat and therefore have their fight or flight
response easily triggered in social situations. We will now describe six factors that can each play a role in
maintaining the overestimation of social threat.
Negative Thoughts
Most people, when they are upset, have upsetting thoughts going through their minds. These thoughts can
have powerful impacts on our emotions. These thoughts may be about the past, present, or future.
Common social anxiety thoughts may include:
• I will say something stupid and others will laugh

• Other people are talking about me behind my back
• I am trembling, shaking, and looking as bright red as a beetroot
• I won’t know what to say
• People think I am very odd
Negative thoughts about social situations are one of the reasons people feel socially anxious. Sometimes
these negative thoughts are in the form of words, and sometimes they are in the form of images. Images
may involve multiple senses. We may see a visual image of the social situation playing out. We may recall
people’s voices (auditory memories) or see snapshots (visual memories) from past social situations, or we
might imagine these aspects of future social situations. They may be vague or fuzzy, or they might be as
clear as if you were watching a movie.
Take a moment to write down some of the negative thoughts and images you have that make
you feel anxious about social situations. What are some of the negative predictions you have
about what others will think or how you will come across?
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Avoidance
In order to stop feeling anxious, most people with social anxiety try to avoid or escape from social
situations to prevent their negative thoughts from coming true. Avoidance makes sense in the short term,
because it may provide some relief from the anxiety. However, the relief is only temporary because the
underlying perception of social threat is never directly tested, challenged, and modified. As a consequence,
the social fear remains. In fact, avoidance usually results in increasing anxiety in more and more situations
as people come to believe that they cannot cope with social situations. Avoidance also causes a practical
problems and interference in people’s lives.
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Stepping Out of
Social Anxiety
Take a moment to write down any social situations you avoid because of your fear of being
judged negatively by others.
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Safety Behaviours
Sometimes it is not possible to completely avoid social situations. In these cases, socially anxious people
often use subtle avoidance behaviours called ‘safety’ behaviours to help them feel more comfortable. Safety
behaviours are the things you do within social situations to try and prevent your fears from coming true.
For example, a person might go to a work meeting but not say anything at the meeting. They haven’t
avoided the situation altogether, but at the same time they have avoided testing their fears (e.g., that if they
say something they will be criticised). Common safety behaviours include:
• Using alcohol or drugs

• Not making eye contact
• Not contributing to discussions/meetings
• Wearing inconspicuous clothes
• Asking a lot of questions so you don’t need to disclose personal information
• Making excuses to leave early
• Covering up your anxiety symptoms in some way (e.g., using makeup to cover blushing)
• Perfectionistic behaviours such as over-preparation for presentations/meetings
• Carrying anti-anxiety medications to take ‘when or if needed’
• Only talking to specific ‘safe’ people
We might feel like these ‘tricks of the trade’ are helping to reduce our anxiety and prevent social
catastrophes, but in fact they just stop us from learning that our fears are less likely to happen than we
think (probability) and less catastrophic when they do happen (cost). If a social situation goes well it
doesn’t seem to make a difference to our social anxiety, because we attribute the success to our safety
behaviour, rather than learning that the situation itself is safe and we can cope socially. Safety behaviours
can actually make things worse because they can cause us to become more self-focused and appear less
engaged in the social situation.
What are some of the safety behaviours you use in social situations?
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Self- and Environment-Focused Attention
People with social anxiety focus their attention in ways that increase their anxiety in social situations. In
particular, socially anxious people focus most of their attention on themselves, including their physical
symptoms of anxiety and their negative thoughts (self-focused attention). They may also look around their
environment for any evidence that they are in fact being negatively evaluated (environment-focused
attention, e.g., people laughing in another part of the room, anyone looking in their direction). When most
of our attention is directed towards ourselves and/or looking for threats in our environment, very little
attention is left over to focus on the ‘task at hand’ (task-focused attention). The effects of this are to
increase self-consciousness and anxiety, and it interferes with social performance because you are not
focusing on what you are trying to do (e.g., maintain a conversation).
When you are in a social situation and are feeling socially anxious, where is your attention
focused?
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How You Think You Appear To Others
Close your eyes and see if you can create an image in your mind of how you think you appear
to other people when you are feeling socially anxious. Most people with social anxiety
think that they are performing very badly and that their anxiety is blatantly obvious to other
people. For example, we may believe we are blushing bright red, shaking, trembling,
looking away, sweating, or stumbling over our words. However, many people who feel
anxious in social situations have inaccurate views about how they appear to others. It is
possible that although you may feel anxious, others cannot see this. In fact, most people
with social anxiety come across far better than they think they do. Inaccurate and overly
negative beliefs about your social performance and how anxious you appear to others can
therefore mislead you and increase your perception of social threat.
How do you think you appear to others when you are feeling socially anxious? Are there any
physical symptoms of your anxiety that you believe are obvious to others?
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Core Beliefs
Many people with social anxiety disorder recall early life events that were associated with significant social
anxiety. There may be one or two situations, or many early experiences, that you identify as substantially
contributing to your social anxiety. These early experiences may be associated with important meanings
about ourselves, others, and the world in general. We call these ‘core beliefs’. For example, if I was bullied
I may have formed beliefs such as “I am unlikeable” or “I am inferior”. I might also have come to believe
that “others are hostile or critical”. As a consequence, when I think about entering a social situation now, I
think my ‘inferiority’ is obvious and I expect to be criticised by others. Core beliefs are not necessarily
conscious thoughts, but are more like ‘unwritten’ rules through which people interpret what is happening
around them. They can act like ‘filters’ that guide our thoughts and expectations in the here-and-now.
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Stepping Out of
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All six of these factors – negative thoughts, avoidance, safety behaviours, how you think you appear to
others, self- and environment-focused attention, and core beliefs – work together to maintain your fear of
negative evaluation and cause you to feel anxious and uncomfortable in social situations. On the following
page we have summarised this information into a model which shows how all six factors contribute to
social anxiety disorder. The shaded areas of the model explain the link between the triggers, perception of
social danger (probability and cost), and the fear response. The unshaded parts are the six factors that
contribute to the perception of social threat. We have listed some specific examples for each part of the
model. On the page after that there is a worksheet for you to complete by filling in each part of the model
with your own examples.
The good news is that the components of this model can also work for us, because making a change in any
one of the parts will flow through to the others. The modules to follow will provide you with some
practical ways to make changes to each of these maintaining factors of your social anxiety.
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Model of Social Anxiety – Example
Triggers
e.g., Parties, meetings, tutorials, walking
down the street, public toilets, eating in
front of others
Negative Thoughts Avoidance

e.g., I’ll make a fool of myself, e.g., Parties, lunch room,
be laughed at and criticised making phone calls
Core Beliefs Safety Behaviours

e.g., Memories of being bullied
mean I’m unlikeable, inferior
Perception of Social Threat e.g., Use alcohol, don’t speak,
don’t disclose personal
information, no eye contact
Probability Cost
How likely is it that What are the
my fears will come consequences of my
true? fears coming true?
How I Think I Self- and

Appear to Others Environment-
e.g., Look like a ‘beetroot’, Focused Attention
shaking, voice quivering
e.g., Vigilant to anxiety
symptoms, looking for ‘threat’
Fear Response
e.g., Blush, shake, heart racing, trembling,
sweating, urge to flee
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My Model of Social Anxiety
Triggers
Negative Thoughts Avoidance
Core Beliefs Safety Behaviours

Perception of Social Threat
Probability Cost
How likely is it that What are the
my fears will come consequences of my
true? fears coming true?
How I Think I Self- and

Appear to Others Environment-
Focused Attention
Fear Response
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Module Summary
• Social anxiety is anxiety that occurs in response to social situations. A certain amount of social
anxiety is completely normal, with around 90% of people acknowledging that they feel shy at
certain points in their lives.
• People with ‘social anxiety disorder’ or ‘social phobia’ fear being judged negatively by others and
often avoid social situations, to the point that their social anxiety gets in the way of the life that
they want to be living.
• Social anxiety occurs when we perceive a ‘social threat’ in a particular social situation. This is
usually a fear of being judged negatively by others or not coming across well to others (e.g., coming
across as awkward or uninteresting).
• Our perception of social threat is divided into two parts: probability and cost. The probability
refers to how likely our fears are to happen. The cost refers to how bad we believe it will be if our
fears do come true.
• People with social anxiety disorder feel more socially anxious than others because they tend to
overestimate the social threat in some social situations. Overcoming social anxiety disorder is
therefore a matter of reducing this tendency to overestimate social threat.
• Six factors maintain the overestimation of social threat. These are negative thoughts, avoidance,
safety behaviours, self- and environment-focused attention, how you think you appear to others,
and negative core beliefs.
• The modules to follow will provide you with some practical ways to make changes to each of these
six maintaining factors of your social anxiety.
Coming Up…
In the next module we will look at how
your thinking patterns contribute to social
anxiety, and will introduce strategies to
address unhelpful thinking patterns.
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Social Anxiety
About the Modules

CONTRIBUTORS
Samantha Bank (MPsych1) Melissa Burgess (MPsych1)
Clinical Psychologist Clinical Psychologist
Dr Adelln Sng (MPsych1; PhD2) Dr Mark Summers (MPsych1; PhD2)

Senior Clinical Psychologist Senior Clinical Psychologist
Dr Bruce Campbell (MPsych1; DPsych3) Dr Peter McEvoy (MPsych1; PhD2)

Consultant Clinical Psychologist Senior Clinical Psychologist
Professor, School of Psychology, Curtin University
1Masters of Psychology (Clinical Psychology) 2Doctor of Philosophy 3Doctor of Psychology (Clinical)
Some of the materials in the modules of this information package were taken from:
McEvoy, P. & Saulsman, L. (2017). Imagery-Based Cognitive Behaviour Group Therapy for Social Anxiety Disorder (IB-CBGT).
Perth, Western Australia: Centre for Clinical Interventions.
BACKGROUND
The concepts and strategies in the modules have been developed from evidence based psychological practice,
primarily Cognitive Behaviour Therapy (CBT). Examples of this are reported in:
McEvoy, P. M., Hyett, M. P., Bank, S. R., Erceg-Hurn, D. M., Johnson, A. R., Kyron, M. J., Saulsman, L. M., Moulds, M. L.,
Grisham, J. R., Holmes, E. A., Moscovitch, D. A., Lipp, O. V. Campbell, B. N. C., & Rapee, R. M. (in press).
Imagery-enhanced versus verbally-based group cognitive behavior therapy for social anxiety disorder: a
randomized clinical trial. Psychological Medicine. http://dx.doi.org/10.1017/S0033291720003001
Rapee, R. M., Gaston, J. E., & Abbott, M. J. (2009). Testing the efficacy of theoretically derived improvements in the
treatment of social phobia. Journal of Consulting and Clinical Psychology, 77, 317–327.
REFERENCES
McEvoy, P. M., Saulsman, L. M., & Rapee, R. M. (2018). Imagery-enhanced CBT for social anxiety disorder. Guilford Press.
Hackmann, A., Bennett-Levy, J., & Holmes, E. A. (Eds., 2011). Oxford Guide to Imagery in Cognitive Therapy. Oxford:
Oxford University Press.
Kemp, N., Thompson, A., Gaston, J., & Rapee, R. (2003). Cognitive behavioural therapy-enhanced for social anxiety
disorder: group treatment program. Centre for Emotional Health, Macquarie University.
Saulsman, L. M., Ji, J. L., & McEvoy, P. M. (2019). The essential role of mental imagery in cognitive behaviour
therapy: what is old is new again. Invited review for Australian Psychologist, 54, 237-244. doi:
10.1111/ap.12406.
“STEPPING OUT OF SOCIAL ANXIETY”

Bank, S., Burgess, M., Sng, A., Summers, M., Campbell, B., & McEvoy, P. (2020). Stepping Out of Social Anxiety. Perth,
Western Australia: Centre for Clinical Interventions.
ISBN: 978 0 9757995 1 2 Created: October, 2020
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Social Anxiety
Module 2
Overcoming Negative Thinking
Introduction 2
The Thought-Feeling Connection 2
Challenging Your Negative Thoughts 3
Thought Challenging Record Example 5
Thought Challenging Record 6
Module Summary 7
About the Modules 8
Stepping Out of
Social Anxiety
Introduction
In Module 1, we talked about six factors that keep social anxiety going by increasing our sense of threat in
social situations. This module will focus on what you can do about the first of these factors: the negative
thoughts you may be having about social situations. In this module you will learn how to identify and
challenge your negative thoughts. This can help you to recognise when you are overestimating the level of
threat in a social situation, and to think about the situation in a more realistic way.
The Thought-Feeling Connection

Our thoughts play a very important role in determining how we feel emotionally. There is a range of
different thoughts we could have about any given situation. This means that in a given situation there is a
range of feelings we could have, depending on how we think about the situation.
Here is an example. Imagine that it is your birthday and your parents have invited you over to their
house for dinner. As you arrive, you notice that it is all dark and there are no lights on. You knock
on the door and ring the doorbell but no one comes to answer the door. You turn the doorknob
and find that the door is unlocked. You step in and find that the house is in total darkness.
Suddenly, you hear a chorus of voices shouting, “Surprise!” The lights come on and you see a
group of your friends and relatives singing “Happy Birthday” to you. Below are two different ways
of thinking about this situation, and some different emotions that one might feel as a result of
thinking in these different ways.
Example event: Surprise birthday party

Thoughts Emotions
Thought 1
Oh NO! I can’t believe my parents would do Anxious, embarrassed
this to me! Everyone’s staring at me, and I’m
not even dressed up. I just want to get out of
here.
Thought 2
Wow! What a really nice surprise! People must Happy
think I’m pretty important to throw me this
party!
Another important thing to note about our thoughts is that they are not always true. Sometimes our
thoughts about a situation will be accurate, sometimes they will be partially accurate, and sometimes they
will not be true at all. Therefore, there will be times when our feelings are based on an inaccurate view of
a situation. This happens for everyone some of the time. It is also a big part of why people with social
anxiety feel anxious in social situations.
People with social anxiety have thoughts about social situations that overestimate social threat in two ways:
• Overestimating probability, i.e., overestimating the likelihood of your social fears coming true.
• Overestimating cost, i.e., overestimating how bad it would be if your social fears did come true.
Overestimating probability and cost increases our social anxiety: the higher the threat we perceive, the
more anxious we will feel.
Module 2: Overcoming Negative Thinking Page 2

Stepping Out of
Social Anxiety
Next we will discuss how to recognise when you are overestimating the threat in a social situation, and to
view the situation in a more accurate and realistic way. This can help to reduce your anxiety about the
situation.
Challenging Your Negative Thoughts

In order to address the thoughts that are making you anxious, the first step is to identify what those
thoughts are. Most people have thoughts in their minds before, during, and after anxiety-provoking social
situations. You may be very aware of such thoughts or you may not. Because these thoughts are often
anxiety-provoking, you may even try to avoid thinking about them. However, once we are aware of them
we can challenge them and overcome our fears, so it is important that we start paying attention to them so
we can then do something about them. Take the metaphor of boxing with a blindfold on – it is pretty hard
to do when you can’t see your opponent. If you take off the blindfold your opponent may look scary, but
you are in a much better position to plan a strategy for how to overcome them.
Practice using the Thought Challenging Record to challenge your anxious thoughts about social situations.
This involves eight steps:
1. Trigger situation: What is the social situation you are feeling anxious about? Briefly describe what is
happening and who is there.
2. Negative thoughts: Describe the negative thoughts going through your mind. This will often be in the
form of negative predictions about what you fear happening in the situation (e.g., predictions about how
you will come across to others or what others will think about you). Here it can be very helpful to use
mental imagery, by actually closing your eyes and imagining what you see happening in the social situation
you are anxious about. A major benefit of doing this is that it can help you to be much more specific about
your fears.
Many of the negative thoughts people have when they are socially anxious refer to something bad
happening in general or to some general negative label. For example, we might think “I will look like an
idiot” or “They will think I am an idiot”. The problem is that when we make such a general statement, it is
unclear exactly what we mean. Specifically, what does looking like an “idiot” actually mean? Our fears
remain quite vague, which makes it difficult to find ways to challenge them and test them out. On the
other hand, if I were to bring to mind a mental image of what I feared happening, it might include details like
“I see myself shaking, stuttering, turning bright red, having nothing to say” (which is more specific than
“looking like an idiot”) or “I see others laughing at me, criticising me, turning away, and avoiding
speaking to me” (which is more specific than “They will think I am an idiot”). The more specific
and detailed you can be when describing your negative thoughts, the better position you will be in
to challenge them effectively.
3. Anxiety Level: Rate the intensity of your anxiety from 0 (no anxiety) to 10 (extreme anxiety).
4. Contrary Evidence: Look for evidence that suggests your original thought may not be 100%
true, and consider alternative ways of viewing the situation.
It is easy to fall into the trap of only recognising or remembering experiences that confirm our
fears, while ignoring contrary experiences. The best way to counteract this bias or ‘filter’ is to think about
evidence that does not support your negative thoughts. The types of questions you can ask yourself are:

Stepping Out of
Social Anxiety
• Have I had any experiences that show that this thought is not completely true all of the
time?
• Are there any small things that contradict my thoughts that I might be ignoring?
• Have I been in this type of situation before? What happened? Is there anything different
between this situation and previous ones? What have I learned from prior experiences
that could help me now?
• Is my thought based on facts, or am I ‘mind reading’? What evidence do I really have?
• Am I jumping to any conclusions that are not completely justified by the evidence?
• If someone who loves me knew I was having this thought, what would they say to me?
What evidence would they point out that would suggest that my thoughts were not 100% true?
• What is the worst thing that could happen and could I cope with this? Would life go on? What
could I do that would help?
• Are there other ways of looking at this situation?
• What are all the possible explanations in this situation? Are there any alternatives to mine?
• What’s the best that could happen?
• What’s the worst that could happen? What’s so bad about that?
• Even if it is true, is it helpful to think this way? What would be a more helpful way to think?
• If the roles were reversed, how might I judge the situation/other person?
5. Realistic Probability and Consequences: Given the contrary evidence and alternative perspectives,
what is most likely? What are the most likely consequences?
6. Helpful Image: Describe as a picture the most likely outcome in the situation. If the situation plays
out in the way that is most likely, what will that look like?
7. Visualise the Helpful Image: Now spend a few moments visualising this helpful (most likely) image of
the situation.
8. Re-rate Anxiety Level: Re-rate the strength of your anxiety after you have visualised the helpful
image.
On the next two pages you will find an example of a completed Thought Challenging Record, followed by a
blank one for you to use. Challenging our negative thinking is something we can get better at with practice.
Also, there will probably be a range of negative thoughts in different social situations that contribute to
your social anxiety, and which could all potentially benefit from some thought challenging. For these
reasons, lots of practice and repetition is important, particularly while you are still mastering the skill. As a
guide, completing three to four Thought Challenging Records per week is recommended. If you have any
upcoming social situations that you are feeling anxious about, this would be a good place to start. There
may be other types of social situations that would make you anxious, but which you do not currently
engage in due to your social anxiety. If this is the case, these types of situations would also be good
examples to work on with a Thought Challenging Record. Challenging your negative predictions about
could help you to become more willing to enter these situations in the future as you progress through
these modules.

Stepping Out of
Social Anxiety
Thought Challenging Record – Example

1. Trigger 2. Negative 3. Anxiety 4. Contrary Evidence 5. Realistic Probability and 6. Helpful Image 8. Re-rate
Situation Thoughts Level Consequences Anxiety
What evidence do I have that does How likely is it that my negative Describe as a picture the most
What is What thoughts are How anxious not support these thoughts? predictions will actually occur? realistic outcome and/or a more Re-rate
happening? going through my do I feel Alternative ways to view the If something bad happened, then so helpful image anxiety level
Where am mind? (0-10)? situation? what? Would it really be that bad? (0-10)
7. Visualise the helpful image as if it were actually occurring now

I? Would I cope?
I’m about Everyone will stare 8/10 People don’t always look up It is likely (50%) that some people A couple of people glance as I 5/10
to go into at me as I walk in. whenever I enter a room. will look at me, but not everyone. It walk in the room and then go
the lunch is unlikely they will actually stare (i.e., back to their conversation.
room at They will all interact I am often quiet and don’t say look longer than 3 seconds)
work. with each other, but anything unless someone asks me a I sit at the table and a couple of
I won’t say anything. question, but not always. It is very likely (90%) that I will be people say hi. I listen to the
quiet and not say anything unless I’m conversation.
They will Sometimes people do make small spoken to.
deliberately ignore talk with me. One person asks me a question.
me. It is possible (30%) that someone will I focus on eating my lunch and
It would be pretty rude to just try to speak with me. making the effort to talk, and ask
stare at someone who had just them a question back.
walked in. If some people do look at me I will
feel uncomfortable, but then they will My colleagues are mostly friendly
If they don’t include me it might be probably just go back to what they and are just interested in
because they are caught up in the are doing. whatever conversation is going
conversation they are already on.
having. If no one speaks to me then I will just
read my magazine. The times I am silent are OK by
everyone.
My colleagues are unlikely to ignore
me in a rude or critical way.
Module 2: Overcoming Negative Thinking

Page 5
Stepping Out of
Social Anxiety
Thought Challenging Record
1. Trigger 2. Negative 3. Anxiety 4. Contrary Evidence 5. Realistic Probability and 6. Helpful Image 8. Re-rate
Situation Thoughts Level Consequences Anxiety
What evidence do I have that does How likely is it that my negative Describe as a picture the most
What is What thoughts are How anxious not support these thoughts? predictions will actually occur? realistic outcome and/or a more Re-rate
happening? going through my do I feel Alternative ways to view the If something bad happened, then so helpful image anxiety level
Where am mind? (0-10)? situation? what? Would it really be that bad? (0-10)
7. Visualise the helpful image as if it were actually occurring now

I? Would I cope?
Module 2: Overcoming Negative Thinking

Page 6
Stepping Out of
Social Anxiety
Module Summary
• Our thoughts play a key role in determining how we feel emotionally.
• No one’s thoughts are 100% accurate, 100% of the time. This means that everyone sometimes has
feelings that are based on an inaccurate view of a situation.
• People with social anxiety often have thoughts about social situations that are inaccurate in two ways:
overestimating the probability of their social fears coming true, and overestimating the cost (how bad it
would be if their social fears did come true). This is a major reason why people with social anxiety feel
anxious in social situations.
• One way to change your negative thoughts about social situations is to challenge them using a Thought
Challenging Record. This involves identifying what you are thinking, challenging your negative thoughts,
and developing more realistic thoughts about the situation.
Coming Up…
In the next module we will discuss how
avoiding situations you are anxious about
keeps your anxiety going. We will
introduce a strategy to help you start
testing your fears through approaching the
situations you are anxious about.

Stepping Out of
Social Anxiety
About the Modules

CONTRIBUTORS


BACKGROUND
McEvoy, P. M., Hyett, M. P., Bank, S. R., Erceg-Hurn, D. M., Johnson, A. R., Kyron, M. J., Saulsman, L. M., Moulds, M.
L., Grisham, J. R., Holmes, E. A., Moscovitch, D. A., Lipp, O. V. Campbell, B. N. C., & Rapee, R. M. (in press).
treatment of social phobia. Journal of Consulting and Clinical Psychology, 77, 317– 327.
REFERENCES
10.1111/ap.12406.


Stepping Out of
Social Anxiety

Module 3
Overcoming Avoidance
Introduction 2
What is Avoidance? 2
Why is Avoidance a Problem? 2
The Vicious Cycle of Anxiety and Avoidance 3
Behavioural Experiments 4
Behavioural Experiment - Example 5
Testing Probability and Cost 6
Behavioural Experiment – Testing Cost Example 7
Conducting Behavioural Experiments 8
My Behavioural Experiment 9
Extra Tips for Behavioural Experiments 10
Module Summary 11
The information provided in this document is for information purposes only. Please refer to the full
disclaimer and copyright statement available at www.cci.health.wa.gov.au regarding the information on this
website before making use of such information.
Stepping Out of
Social Anxiety
Introduction
So far in the modules you have learned about what social anxiety is, what keeps it going, and how to
challenge your negative thinking about social situations. In this module we will focus on avoidance and how
it keeps us stuck in our anxiety. We will learn why it is important to approach the situations that make us
anxious rather than avoiding them. This might sound hard, but we will also look at how we can break things
down to do this step by step.
What is avoidance?
Avoidance behaviours are things we do to escape upsetting feelings. As outlined in Module 2, our thoughts
about social situations influence how we feel and what we do. If we think that a social situation will not go
well, we will probably feel anxious about it. If you feel anxious, or anticipate feeling anxious, it makes sense
that you will do things to reduce your anxiety. Sometimes, people will try to reduce their anxiety by
avoiding the feared situation altogether. This usually results in instant relief and reduction of anxiety, as we
no longer have to face the feared situation.
Some typical situations that people with social anxiety avoid include:
• unfamiliar people
• large groups of people
• attending appointments
• phone calls
• answering emails
• public places
• certain kinds of people (e.g. those our own age, older people, people in a position of
authority, people we are attracted to)
Why is avoidance a problem?

Although in the short-term avoidance may help us to feel safer and less anxious, in the longer-term
avoidance keeps us anxious for a number of reasons.
1. We never get to test our negative thoughts. When we avoid a social situation we are assuming that our
negative thoughts are accurate. However, avoidance never gives us an opportunity to directly test our
fears. If we did, we might discover that our thoughts are actually inaccurate. We might learn that our fears
rarely occur and instead that things often turn out better than expected. We might also find that even if
social experiences don’t go to plan sometimes, then we can cope with this as well. So avoidance prevents
us from getting an accurate impression of the true probability and cost of our fears coming true.
2. We never get opportunities for positive experiences. As long as we avoid social situations, we have no
chance of having positive social experiences that would motivate us to engage more socially over time.
3. Loss of self-esteem. Because people with social anxiety aren’t doing what they would really like to do
(e.g. have more satisfying relationships) they tend to be very self-critical and can have low self-esteem. They
may ruminate about aspects of life that are passing them by, which leaves them more vulnerable to further
anxiety and depressed mood. In fact, people with social anxiety can often use their avoidance as just
another reason to criticise themselves.
4. Avoidance and anxiety can spread. As we avoid situations and lose confidence in an area of our lives (e.g.,
relationships with peers), our anxiety can start to spread out to more and more areas of our life (e.g.,
relationships with people at work, family relationships).
Module 3: Overcoming Avoidance Page 2

Stepping Out of
Social Anxiety
The vicious cycle of anxiety and avoidance

The vicious cycle of anxiety is illustrated below:
Anxiety
Negative expectations Avoidance

are strengthened
Long term Short term

Never test negative expectations Relief
Miss out on positive experiences
More self-criticism
Start feeling anxious in more situations
It is crucial that the cycle of avoidance and increasing anxiety is broken. To start breaking this vicious cycle,
it is important to start approaching the situations that make us feel anxious. In the short-term this might
increase our anxiety, but it gives us the opportunity to test our fears and build confidence in our own
coping skills, which helps to reduce our anxiety over time. This is shown in the cycle of progress below.
Anxiety
reduces
Start by
More realistic approaching
expectations
situations
Long term
Short term
Opportunity to test negative expectations
Feel more
Opportunity for positive experiences
anxious
Less self-criticism
Build confidence in own ability to cope

Stepping Out of
Social Anxiety
Behavioural Experiments
Just like a scientist who uses an experiment to test a prediction, behavioural experiments are designed to
test our negative predictions about social situations. Behavioural experiments provide a structured way of
systematically and directly testing our fears.
Sometimes, just ‘taking the plunge’ and rushing in to situations that make us anxious might not help us test
our fears properly. We might spend the whole time we are in the social situation focused on just getting
through it, or selectively focusing on negative details, and might not notice the information we need to test
our fears. Approaching feared situations in a structured way by using behavioural experiments can help us
make sure we focus on the information we need to test our fears.
Conducting a behavioural experiment involves taking a step back from our negative thoughts. Rather
than assume our negative thoughts are definitely accurate, we will treat them as ‘just a prediction’ and
test them out. The goal of behavioural experiments is to find out what really happens in social
situations, so that we can learn to think in realistic ways. There are a number of steps to conducting a
behavioural experiment that enable us to learn as much as possible from social experiences:
1. Negative thoughts: Identify a social situation that triggers anxiety for you and write down what you
think will happen in the social situation.
Tip: Using imagery can help you identify your predictions about a social situation.
Try closing your eyes and imagining yourself in that situation, as vividly as you can, as if you were
experiencing it right now. What are you seeing happen? What are you doing? What are other
people doing? How are they responding to you?
2. Rate your anxiety (?/10): Rate the intensity of your anxiety about this situation (0 = no anxiety, 10 =
extreme anxiety)
3. Plan an experiment: Plan your experiment. What could you do to find out how accurate these
thoughts are? How could you find or create a situation that would enable you to test the accuracy of
these thoughts?
4. Evidence to observe: What evidence would you need to look for to check the accuracy of your
thoughts? An important note is that this evidence must be clear, observable, and objective evidence.
One way of thinking about evidence is to consider whether the evidence would hold up in a court of
law, or would the judge disregard it because it was too subjective or just an opinion instead of a fact.
5. Conduct the experiment: Do the experiment
6. Results: Note the results of your experiment. What evidence did you observe?
7. Develop conclusions: What does the evidence tell you about your initial negative thoughts?
Our brains are prone to falling back into old thinking habits. If we learn something from the
experiment that is different to what we expect, it is helpful to reinforce this new learning. This can
make it easier to bring to mind new and helpful information when you need it in the future. Some ways
to reinforce new information include:
• Visualising any helpful conclusions you have come to.
• Repeating helpful conclusions in your mind.
• Jotting down any helpful conclusions on a post-it note or in your phone.
• Re-reading your behavioural experiment records.
On the next page you will find an example of how to record a behavioural experiment.

Stepping Out of
Social Anxiety
Behavioural experiment example - Charlotte
Charlotte is anxious when buying her groceries. She tends to avoid it and to shop online whenever possible. She worries that when she speaks to the
cashier her mind will go blank or she will say something stupid. She also worries that the people in line behind her will make negative judgements about her
purchases, and that they will think she is lazy for buying microwave meals. Her anxiety about doing grocery shopping is 8/10. Charlotte completed the
following experiment to test her fears.
Negative Thoughts Anxiety Experiment Evidence to Results Conclusion

Describe your prediction. /10 Specifically, what could you Observe What happened? What clear What conclusion follows from your results?
Specifically, what do you think How anxious do do to test these thoughts? Specifically, what do you need evidence did you collect? How can you keep this new information in mind?
will happen? you feel? to look for to confirm or Stick to unambiguous facts. How can you find more opportunities to test
What negative images do you disconfirm your thoughts? your predictions?
have about the situation?
The cashier will ask me a 8/10 Buy groceries at the Can I respond to the The cashier asked about My predictions were not accurate this
basic question and I won’t shops, including some cashier without freezing? my day. I was able to time.
be able to answer. I will microwave meals. Are there any objective answer without freezing.
freeze up at first, and signs the cashier thinks I I couldn’t see any sign I was able to talk without freezing,
then blurt out something Talk to the cashier. am weird (e.g. making a that she thought I was even though I was anxious.
stupid. The cashier will comment about me weird.
think I am weird. being weird)? People did not seem to be overly
No one behind me focused on me.
People lined up behind Do people behind me seemed to pay much
me will judge me for what pay attention to what I attention to my I was expecting the worst and it didn’t
I buy. They will think I am buy? Do they say purchases. They seemed happen.
lazy for buying microwave anything to me or make to be focused on what
meals. comments to each other they were doing. Nobody I am going to put a reminder note on
about me being lazy? said anything about me my grocery bag, so I remember this
being lazy. next time I go shopping.
I’m going to try this experiment out

again the next time I go shopping.

Stepping Out of
Social Anxiety
Testing probability and cost
As described in Module 2, when people with social anxiety anticipate what is going to happen in a social
situation, they tend to overestimate threat in two ways. Firstly, they tend to overestimate the probability or
likelihood of their social fears coming true. Secondly, they tend to overestimate the ‘cost’ or how bad it
would be if their social fears did come true.
Behavioural experiments can be designed to test the probability or the cost of a social fear coming true. In
the example above, Charlotte tested the probability of her social fears, as she was testing how likely it was
that she would freeze or say something stupid when speaking to the cashier. She found that this was less
likely than she initially expected. However, even if we learn that our social fears are very unlikely to come
true, if we still think the cost would be bad then we may still feel anxious. If we think there is even a 1%
chance of a social catastrophe, we will still feel anxious.
It is therefore very important to test the cost of our social fears. People
with social anxiety often have a very narrow range of what they think
other people will accept and what they can cope with. They feel like they
are ‘walking a tightrope’ of what is socially acceptable, and if they put a
foot wrong it will be a disaster. This puts them under a lot of stress and
pressure when they are socialising. It is important to test whether the
costs of making mistakes or doing something socially unusual are as bad as
we expect.
By testing the cost of our fears we may learn that there is more leeway than we expect in social situations
– we may find out that we can put a foot wrong at times, and that nothing bad will happen. Learning this
can really ease the pressure and stress in social situations. On the next page you will find an example of a
behavioural experiment Charlotte designed to test the cost of her social fears coming true.

Stepping Out of
Social Anxiety
Behavioural experiment – testing cost example - Charlotte
Charlotte is anxious when buying her groceries. She worries that when she speaks to the cashier her mind will go blank or she will say something stupid.
Last time she went shopping, she tested this fear by speaking to the cashier. She learned that the conversation went okay, and that she did not freeze or say
anything stupid. This made her feel a bit less anxious, and her anxiety about doing grocery shopping is now 7/10. However, she is still worried that if she did
freeze or say something stupid, the cashier would think she was weird and would laugh at her. She is still nervous this could happen one day, even if it is less
likely than she first expected. Charlotte completed the following experiment to test her fears.
Negative Thoughts Anxiety Experiment Evidence to Results Conclusion

Describe your prediction. /10 Specifically, what could you Observe What happened? What clear What conclusion follows from your results?
Specifically, what do you think How anxious do do to test these thoughts? Specifically, what do you need evidence did you collect? How can you keep this new information in mind?
will happen? you feel? to look for to confirm or Stick to unambiguous facts. How can you find more opportunities to test
What negative images do you disconfirm your thoughts? your predictions?
If I freeze up or say 7/10 Talk to the cashier Are there any objective The cashier asked about my The cashier didn’t seem to care when I
something stupid the when I am buying signs the cashier thinks day. I froze on purpose for a froze.
cashier will think I am groceries. Deliberately I am weird (e.g. making few seconds. She didn’t seem
weird. She will laugh at freeze and then say a comment about me to react to that and just When I said something that was
me, and will make fun something stupid on being weird)? waited for me to say wrong, she laughed but acted friendly
of me to the other purpose to see how something. instead of mean. She kept the
customers. she reacts. Does the cashier laugh conversation going and didn’t seem
at me in a negative I said “I am having a good focused on me saying something
way? (I will know she is weekend so far” even though stupid. She didn’t make fun of me.
laughing at me if it it is Wednesday. The cashier
happens directly after I laughed a little bit, but she Maybe it is not such a big deal to
speak, whilst she is was smiling at me. She said make a mistake or say something
looking at me. I will “I’m thinking about the stupid.
know it is negative weekend too! It can’t come
based on her tone and soon enough”. Then she just People act more nicely than I expect
facial expression). kept talking about other them to.
things.
Does the cashier make I am going to replay this in my mind a
fun of me to the other When I had finished paying, few times to help me remember what
customers (e.g., do I the cashier just moved on happened.
hear them talking about and asked the next person
me negatively)? how their day was. She
didn’t make any comments
about me.

Stepping Out of
Social Anxiety
Conducting experiments
Now it is time to put things into action and start to conduct behavioural experiments. Choose a social
situation that you would be willing to approach, even though you feel anxious about it. You might
choose to start with an experiment that only generates mild anxiety, and work your way up to
more challenging behavioural experiments – see module 4 for more details on this. Use the blank
behavioural experiment record on the next page to plan a behavioural experiment that will help you
test your fears.
Fill in the first four columns on the Behavioural Experiment Record to plan your behavioural
experiment, and then conduct the experiment to gather your results. After you finish conducting the
experiment, complete the final two columns on the Behavioural Experiment Record worksheet to record
what you observed and what you learned from the experiment.
It is important to keep conducting behavioural experiments regularly. Research shows that regularly
conducting behavioural experiments is more effective than doing them ‘now and then’. Doing several
behavioural experiments every week is the most helpful approach. This might mean repeating the same
experiment several times, or it might mean taking a new step by approaching a more challenging situation.
Keep using the Behavioural Experiment record on page 9 to plan behavioural experiments and record what
you learn.

Stepping Out of
Social Anxiety
Behavioural experiment record
Negative Thoughts Anxiety Experiment Evidence to Observe Results Conclusion
Describe your prediction. How anxious do Specifically, what could you do Specifically, what do you need to What happened? What clear What conclusion follows from your results?
What goes through your mind? you feel (0-10)? to test your predictions? look for to confirm or evidence did you collect? How can you keep this new information in
What do you see happening? disconfirm your predictions? Stick to unambiguous facts. mind?
What negative images do you have How can you find more opportunities to test
about the situation? your predictions?
Fill in these columns BEFORE the experiment Fill in these columns AFTER the experiment

Stepping Out of
Social Anxiety
Extra tips for behavioural experiments
Remember, anxiety can influence what we pay attention to, how we interpret things, and how we
remember things. When we are anxious we tend to pay the most attention to negative aspects of a
situation. This can involve negative aspects of our own experience (e.g.
noticing how uncomfortable we feel), or threatening aspects of the
situation (e.g. searching people’s faces for any signs of boredom). When we
are anxious, we also tend to interpret ambiguous things in a negative way
(e.g., if someone yawns we might take that as proof we are boring, but
there are many other reasons someone might yawn). This means we might
not pay attention to neutral and positive aspects of a situation, and we
might misinterpret things in an overly negative way. As we can only
remember the information we paid attention to in the first place, these
unhelpful automatic tendencies can leave us with a negative memory of a
situation, although this might not be an accurate reflection of what really
happened.
In order to get the most accurate information you can, it is important to…
1. Plan what you need to pay attention to during the experiment to test your fears. This helps you
know what evidence you need to pay attention to in order to test your thoughts, rather than just
automatically focusing on the negative aspects of the situation. For example, imagine you are trying
to test the fear “when I walk down the street, everyone will stare at me”. If you walked down the
street with your eyes looking down at the ground then you are not going to gather any
information about whether other people were staring or not. In order to find out whether other
people are staring or not, you would need to pay attention to looking at other people as you
walked down the street.
2. Write down the evidence you collect, and make sure it is objective, factual evidence (rather than
opinions or assumptions). This can help make sure you are not being overly negative in the way
you interpret things. For example, if you have a prediction “other people will laugh at me”, whenever
you hear laughter you might quickly assume that people are laughing at you. However, there are
many other explanations for why people might be laughing (e.g. they may be laughing at something
someone else said, or something they are reading). You would need to collect more evidence to
know whether the laughter was about you or about something else (e.g. observe whether they are
looking at you or looking elsewhere while laughing).
3. Write down the conclusions of the experiment. This helps you remember things as they really
happened, rather than your anxiety leaving you with a memory focused on the negative aspects of
a situation.

Stepping Out of
Social Anxiety
Module Summary
• Avoidance keeps social anxiety going, because it stops you from testing your fears and erodes your
confidence in your coping
• To break the vicious cycle of avoidance and anxiety it is important to approach the situations that
make you feel anxious. This might increase anxiety in the short-term, but in the longer-term will
help you overcome social anxiety.
• Behavioural experiments can be used to test your fears in a structured way. When you conduct
behavioural experiments, there are several points that are helpful to remember.
 Writing down the experiment is important, as it helps to counteract biases in our attention and
memory.
 It is important to conduct behavioural experiments regularly – research shows consistent

practice will have the best impact.
 It is important to test both the probability and the cost (or consequences) of our fears.
Learning that our fears are less likely to come true than we expected will help reduce our
anxiety. However, if we continue to believe that there would be very severe consequences of
our fears coming true, some anxiety will remain. You can use behavioural experiments to test
the probability or the cost of your social fears.
Coming Up…
In the next module we will introduce
‘stepladders’ as a tool to help you plan a
step by step way to approach situations you
are anxious about. Taking things step-by-
step can make it easier to get started, and
can help you build confidence as you go.

Stepping Out of
Social Anxiety
About the Modules

CONTRIBUTORS


BACKGROUND
REFERENCES
Hackmann, A., Bennett-Levy, J., & Holmes, E. A. (Eds., 2011). Oxford Guide to Imagery in Cognitive Therapy.
Oxford:Oxford University Press.
10.1111/ap.12406.


Stepping Out of
Social Anxiety
Module 4
Behavioural Experiment Stepladders
Introduction 2
Taking it One Step at a Time 2
Behavioural Experiment Stepladder 2-3
Behavioural Experiment Stepladder – Example 1 4
Behavioural Experiment Stepladder – Example 2 5
My Behavioural Experiment Stepladder 6
Completing a Step on Your Stepladder 7
Working Through Your Stepladder 7-8
Module Summary 9
Stepping Out of
Social Anxiety
Introduction
In Module 3, we looked at how avoidance keeps anxiety going, and introduced behavioural experiments as
a way to break out of the vicious cycle of anxiety and avoidance and test our social fears. In this module,
we will introduce a way to order your behavioural experiments in a step-by-step way, so testing your fears
feels more manageable.
Taking it one step at a time

Conducting behavioural experiments to test your fears involves going outside of your comfort
zone. Some people find it helps to do this one step at a time, rather than trying to do the hardest
possible thing first. Sometimes, if you try to tackle your biggest fear straight away, it can end up
being too overwhelming, or it may even leave you more anxious than when you started, or it
may be so confronting that you continue to avoid.
Breaking things down and beginning with slightly easier experiments can help in finding a
manageable way to get started, and then you can build from there. You can start with
experiments that generate mild anxiety, progress to those that generate moderate anxiety, and
then work your way up to those that generate high anxiety. One advantage of ordering things this way is
that you can test your fears and build your coping skills and confidence as you go – by the time you get to
the hardest steps, they may not be as anxiety-provoking as they once were.
Behavioural experiment stepladders

A behavioural experiment stepladder is a tool to plan behavioural experiments in increasing order of
difficulty. The following steps will help you develop your behavioural experiment stepladder:
1. Identify an area for change. What would you like to be different? In what area of your life are you
having difficulties that you would most like to change?
Most people with social anxiety find that there is more than one area of their life they would like to change.
Write down any ideas you have about areas of your life you would like to change on the lines below. Once
you have written down your ideas, choose one area you would like to start with. You could choose the
area that is most important to you, or the area it would be easiest to make changes in. Working on one
goal at a time can help keep you focused, and can give you a greater sense of progress than if you work on
lots of different goals as once.
Areas I would like to change:

e.g. Talking to colleagues at work; Being more independent (e.g. going to shops and appointments
alone); meeting new people; joining a hobby group; going out on dates______________________________
The area I will start with first:
e.g. Talking to colleagues at work _____________________________________________________________________
2. Identify your fears. Now that you have identified an area for change, the next step is to identify your
social fears relating to this area of your life. What are you worried may happen? What negative
thoughts or images do you have relating to this situation? What do you predict will happen in these
situations?
Module 4: Behavioural Experiment Stepladders Page 2

Stepping Out of
Social Anxiety
Write down your answers on the lines below.
e.g. At work I am worried that I will say the wrong thing. People will think I am stupid and
they will be frustrated by me___________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
3. Design behavioural experiments to test your fears. Now that you have identified the fears that you
have about this situation, it is time to plan a range of experiments that will help you test your
predictions (aim for up to 10 different experiments). What situations will you need to approach to test
your negative predictions?
e.g. To find out how my colleagues will respond to me, I will need to talk more at work. I could
say something as I walk past someone in the corridor, I could speak to people in the lunch
room, or I could speak up at a work meeting.
Try to plan a range of behavioural experiments. You might like to initially plan some experiments that are
less challenging, and build towards doing more difficult experiments over time.
There are a number of factors you can tweak to make a behavioural experiment more or less difficult.
These could include:
o Who is there?
o How many people are there?
o How familiar/unfamiliar are the people?
o How familiar/unfamiliar is the place?
o What am I doing?
o When am I doing it?
o Where am I doing it?
As you consider these questions, you may be able to change aspects of the situation to make a task more
or less challenging. For instance, you might feel more anxious if there are more people around. So speaking
to someone one-on-one might feature around the bottom of your stepladder and speaking within a group
situation might feature closer to the top. On the next two pages you will find examples of behavioural
experiment stepladders.

Stepping Out of
Social Anxiety
Behavioural experiment stepladder - example 1
Area for change: Share my ideas more at work
Negative predictions about these situations:

I will say the wrong thing. My colleagues will think I am stupid. They will roll their eyes and laugh
about me with each other. They won’t want to work with me and will get frustrated if they have
to.
ANXIETY
GOAL: To give a presentation at work (?/10)
Give a presentation at the team meeting 10
9
Give a practice presentation to a few colleagues
Give a practice presentation to my family/friends 8
Attend a team meeting and say at least two things

7
Attend a team meeting and say at least one thing

6
Eat in the lunch room and make small talk with my colleagues 5
4
Reply to a group email and make my own suggestion
3
Reply to a group email and agree with what someone else wrote

Stepping Out of
Social Anxiety
Behavioural experiment stepladder - example 2
Area for change: Expanding my social network

Others will think I am weird. They won’t want to interact with me. When I try to talk to them
they will make an excuse to leave. They will avoid me in future.
ANXIETY
GOAL: Join the board games group at my local games shop (?/10)
10
Invite someone from the board games group to go for coffee
Attend the board games group and participate 9
Contact the board games group organiser and sign up to go 7/8
Invite my neighbour over for coffee 6
Say hello to other people at the dog park and ask them a
5
question
4
Say hello to my neighbour and ask at least one question
3
Say hello to my neighbour when we are both out the front

Stepping Out of
Social Anxiety
Create your own behavioural experiment stepladder
Now that you have seen some examples, it is time to develop your own behavioural experiment
stepladder. Use the worksheet on this page to plan your stepladder. There is no right or wrong
number of steps – so feel free to add more steps, or use less steps than the spaces on the
worksheet allow. It is important to be aware that there is no right or wrong order in which to do
your behavioural experiments – if you are willing to start with behavioural experiments that
generate high anxiety right away then this is helpful too. The main thing is to find a step you are
willing to start with.
My behavioural experiment stepladder

Area for change:
GOAL: ANXIETY
_______________________________ (?/10)
TIP: When thinking about the steps, consider what would make it harder or easier for you to complete
the experiment. Who is there? What you are doing? How long are you doing it for? When will you do it?
Where will you do it? By manipulating these variables you can create harder or easier steps.

Stepping Out of
Social Anxiety
Completing a Step on your stepladder

Now that you have prepared a behavioural experiment stepladder, you can make an appointment with
yourself to take the first step. By setting a date, time, and place you are making a firm commitment to
yourself to begin. When you are in the situation that you have planned, there are a few points to
remember.
1. Expect some anxiety

When you enter the situation – at any step - remember that you’ll probably experience some anxiety or
discomfort. That’s why the stepladder helps you to start small and work your way up. This gives you the
chance to adapt to that level of anxiety, so that you aren’t overwhelmed by higher levels of distress. After
all, the only way to get used to those feelings is by experiencing them.
2. Use your skills

You can use the thought challenging strategy from Module 2 to deal with any unhelpful thoughts that come
up. Challenging your unhelpful thinking can help manage your anxiety to enable you to take the steps on
your stepladder.
3. Stay in the situation

Some anxiety is expected, and it might be tempting to leave if you feel uncomfortable, but it is very
important to stay in the situation until you have had a chance to follow through with your planned
experiment. Otherwise, you will not be able to collect the information you need in order to test out your
negative predictions. Staying in the situation can also give you the opportunity to learn that as frightening as
the feelings are, they are not dangerous and they do subside. You might also learn that you are better able
to cope with feeling anxious than you thought you were.
Working through your stepladder

OK, so now that you have some tips on how to get through one step, how do you keep moving onwards
and upwards? Here are some guidelines for how you can continue to work through each step to reach
your goal.
1. One step at a time

Working through your behavioural experiment stepladder is about taking one small
step at a time. You begin with a more manageable step and gradually work your
way up to more challenging steps.
2. Over and over again

It can be helpful to repeat experiments in close succession to consolidate your learnings before you move
onto the next step. If you only enter a situation once, you might convince yourself that it was luck.
Repeating experiments helps to build up the evidence for when you are disputing any unhelpful thoughts,
and will help you feel more convinced by the evidence you are gathering.
3. Use your skills

That’s right – use your skills again! Work through any unhelpful thoughts about the situation after you have
completed each step, or repeated a step. Remind yourself of what you have learned from each experiment
to help reinforce new information and break old unhelpful thinking patterns.

Stepping Out of
Social Anxiety
4. Acknowledge the progress you are making

When you have completed a particular step, make sure to give yourself credit
for your success. This can be hard work, and it helps to remind yourself of the
progress you are making rather than just focusing on the eventual goal at the
top of your stepladder. Acknowledging your progress can be encouraging and
motivating.
5. Setbacks
We all have our good and bad days, and sometimes behavioural experiments might not go as well as you
hoped. If a situation hasn’t gone as well as you hoped or you’ve taken a step backwards, there are a number
of things you can do.
• Use your thought challenging record as a way of challenging unhelpful thoughts that arise about the
situation.
• Set a time and date to try the step again (remember – over and over).
• If you have tried it a few times and you still find it distressing, you may find it useful to create an ‘in-
between’ step, by planning another step that is slightly less distressing and has a slightly lower anxiety
rating. You might think of this as a ‘bridging step’ in the same way that some people might take a
‘bridging course’ to get them ready for the next step. You might also want to consider whether there
are some additional negative predictions causing the distress that still haven’t been tested. Do these
predictions require a different behavioural experiment? Is so, set one up and go for it!
• You may find it helpful to go back and repeat the previous step. Sometimes, if it has been a while since
you’ve completed a behavioural experiment, you may find it helpful to repeat it to build your
confidence in what you have learned. This can help you feel ready for the next step. You might think of
these as ‘refreshers’ in the same way that people take ‘refresher courses’ before they go on to the next
step.

Stepping Out of
Social Anxiety
Module Summary
• Sometimes approaching feared situations can be overwhelming. To assist with this, you can use
behavioural experiment stepladders to confront your fears in a step-by-step way.
• You can make each step easier or harder by adjusting the ‘Who’, ‘What’, ‘When’, ‘Where’ and
‘How’ components of each step.
• Once you develop your behavioural experiment stepladder, make an appointment with yourself to
take the first step. Making a written commitment about the day, time and place to do something
increases the likelihood of following through.
• Repetition is important. Repeating the same behavioural experiment multiple times can help
reinforce new learnings, and to build confidence before taking the next step. Repeating experiments
in close succession is more effective than if we leave a long time between each behavioural
experiment.
• Setbacks are normal. If something doesn’t go to plan, you can use your skills to manage it and get
back on track.
Coming Up…
In the next module we will discuss safety
behaviours, which are subtle avoidance
behaviours that can keep social anxiety
going. We will show how you can apply
behavioural experiments to start dropping
safety behaviours.

Stepping Out of
Social Anxiety
About the Modules

CONTRIBUTORS


BACKGROUND
L., Grisham, J. R., Holmes, E. A., Moscovitch, D. A., Lipp, O. V. Campbell, B. N. C., & Rapee, R. M. (in
press). Imagery-enhanced versus verbally-based group cognitive behavior therapy for social anxiety disorder:
a randomized clinical trial. Psychological Medicine. http://dx.doi.org/10.1017/S0033291720003001
treatment of social phobia. Journal of Consulting and Clinical Psychology, 77, 317– 327.
REFERENCES
10.1111/ap.12406.


Stepping Out of
Social Anxiety
Module 5
Safety Behaviours
Introduction 2
What are Safety Behaviours? 2
The Problem with Safety Behaviours 2-3
Identifying Safety Behaviours 3-5
Dropping Safety Behaviours 5
Behavioural Experiment Example 6
Plan Your Behavioural Experiment 7
Module Summary 8
About the Modules 9
Stepping Out of
Social Anxiety
Introduction
At this point in the modules you have learned about how to challenge your negative predictions, and
how to use behavioural experiments to test your fears. In this module we will focus on safety
behaviours, which are subtle avoidance behaviours. We will look at how safety behaviours keep us
stuck in our anxiety, and why it is important to drop them.
What are safety behaviours?

It is very difficult to completely avoid all social situations. However, when people with social anxiety
can’t avoid social situations they often rely on more subtle forms of avoidance called safety
behaviours. Safety behaviours are used in an attempt to prevent feared predictions from coming
true and to feel more comfortable in social situations.
Safety behaviours may be very different for different people. It is not what you do, but why you
are doing it that determines whether something is considered a safety behaviour.
Here is an example: Sarah and Jane are doing the same thing, but for different reasons…
Sarah Jane
What is the behaviour? Listening to music on the bus. Listening to music on the bus.
What is the function of the It is a fun way to pass the time. Wearing headphones means
behaviour? people won’t try to talk to me.
What would happen If it wasn’t possible to listen to If I couldn’t wear headphones
without the behaviour? music on the bus, it might be a on the bus I would feel really
bit boring, but it would not be a anxious. I’m worried someone
big deal. I could still catch the would try to talk to me – I
bus. won’t know what to say and
they will think I am weird. I
wouldn’t want to catch the bus
without my headphones.
As you can see, although the behaviour is the same, the function of the behaviour is different. If a
behaviour is intended to prevent our fears from coming true, then it is a safety behaviour. In this
case, Jane is listening to music on the bus as a safety behaviour because she is trying to reduce the
chance of her social fears coming true.
The problem with safety behaviours

While safety behaviours may help you to feel safer in the short-term, unfortunately they serve to
maintain social anxiety in the longer term because...
1. Safety behaviours stop us from directly testing our fears. Although we haven’t avoided the
situation completely, by using our safety behaviours we are not directly testing our fears. For
instance, if you attend a university tutorial but don’t contribute then you never get to test your
prediction of “saying something stupid and other people laughing or looking confused at my answers”.
When the next tutorial comes along the same prediction will come to mind and again you will
Module 5: Safety Behaviours Page 2

Stepping Out of
Social Anxiety
be gripped by fear. If you directly tested your fear by making a contribution to the tutorial you
would have an opportunity to discover that your negative prediction was perhaps inaccurate.
After you test the prediction numerous times and find that it does not come true then the
negative prediction can be seen for what it is – just a thought or image that does not reflect
reality. It will have less emotional impact and it will no longer need to dictate what you do.
2. Safety behaviours can become ‘self-fulfilling prophecies’. Safety behaviours can actually cause the
outcomes we are trying to prevent by using them. For instance, imagine if you stay quiet at work
meetings because you are worried about saying something wrong and your boss being annoyed.
Your boss might actually get more frustrated with you for not contributing to meetings than
they would have if you did contribute from time to time.
3. If our fears don’t come true we mistakenly ‘thank’ the safety behaviour. If we use our safety
behaviours and our fears don’t come true, we might believe that the safety behaviours have
‘prevented’ our fears. As a result we can become very dependent upon our safety behaviours
and start to feel even more anxious if they can’t be used. The truth may be that our fears might
not have come true even without the safety behaviour, but we never discover this as long as we
continue relying on them.
4. Safety behaviours increase our self-focused attention. Safety behaviours often

involve people scrutinising themselves (what they are doing, how they are doing it,
monitoring their thoughts), which can be very distracting. Self-focused attention
hijacks attention from the ‘task at hand’ (e.g., the conversation), which can make it
even more difficult to keep up with conversations and contribute.
So, as you can see, we may think safety behaviours help us feel more comfortable, but they keep our
social anxiety going in the longer-term. If anxiety remains high after repeatedly confronting a social
situation, chances are you are using safety behaviours that are preventing you from directly testing
your fears.
Identifying safety behaviours

To overcome social anxiety we need to stop using our safety behaviours. The first step in this
process is to recognise your safety behaviours – this can be hard to do, as they are often subtle and
might have been used for so long that they are quite habitual. You might also use different safety
behaviours in different situations. Here are some examples of common safety behaviours:
Behaviour The outcome I’m trying to prevent
Staying quiet in social If I talk I might say something stupid and I would feel
situations humiliated
Wearing headphones on public If someone tried to speak to me I wouldn't know what to

transport say and they would think I am an idiot

Stepping Out of
Social Anxiety
No/limited eye contact If I looked up I would see negative reactions from others,
or they might try to talk to me, and I wouldn’t be able to
cope
Alcohol/Drugs If I didn’t use alcohol or drugs my anxiety would

overwhelm me and I wouldn’t be able to interact with
people
Rehearse/plan what I’m about to say If I don’t plan what I will say I will stumble over my words
or say something stupid
Wear inconspicuous clothes If I don’t dress plainly then I will draw negative attention to
myself
Keep the focus of conversation on If I shared anything personal people would think I was
other people boring or stupid
Carrying anxiety medication If I don’t have my medication available I will feel

completely overwhelmed and would not be able to cope
This list might give you some ideas of behaviours to look out for. You might also use other safety
behaviours that are not on this list. Safety behaviours might be about trying to minimise anxiety,
trying to make anxiety less obvious to others, trying to avoid attention, or trying to
come across better to others. To start to tune in to some of your safety behaviours,
think about the following:
When you can’t avoid a situation, what do you do to make yourself feel less
anxious?___________________________________________________________________
________________________________________________________________________
When you feel anxious in a social situation, what do you do to avoid

attention?_________________________________________________________________
__________________________________________________________________________
When you feel anxious in a social situation, what do you do to come across better to
others?____________________________________________________________________
__________________________________________________________________________
Are there situations that you have approached lots of times, but that you are still
anxious about? What do you do in this situation to reduce your
anxiety?___________________________________________________________________
__________________________________________________________________________
You might find that some of the examples from the previous page are relevant to you, or that the
answers to the questions above have highlighted some of your safety behaviours. You might need to
keep adding to this list over time as you become more aware of your safety behaviours.

Stepping Out of
Social Anxiety
Dropping safety behaviours
Once you are aware of your safety behaviours, the next step is to drop
them. This can be hard at first, as you may have come to depend on
your safety behaviours to manage your anxiety. You might feel a bit
more anxious in the short-term when you start to drop your safety
behaviours, but in the longer term dropping your safety behaviours
will lead to reduced anxiety.
Because safety behaviours get in the way of testing social fears the
most efficient approach is to stop using any safety behaviours you are aware of
right away. If you are not prepared to do that, then you could also choose to
drop your safety behaviours in a more gradual way (starting with those that are
easiest to drop, and working towards those that are harder to drop). On the next page you will find
an example of a behavioural experiment about letting go of safety behaviours.

Stepping Out of
Social Anxiety
Behavioural experiment example - Troy
Troy feels anxious talking about himself, as he is worried other people won’t be interested in what he has to say. In social situations, he uses the safety
behaviour of keeping the focus of conversation on other people. His anxiety about saying something personal is 8/10. Troy completed the following
experiment to test his fears.

Describe your prediction. /10 Specifically, what could you do Specifically, what do you need to What happened? What clear What conclusion follows from your results?
Specifically, what do you think will How anxious to test these thoughts? look for to confirm or evidence did you collect? How can you keep this new information in mind?
happen? do you feel? disconfirm your thoughts? Stick to unambiguous facts. How can you find more opportunities to test your
What negative images do you predictions?
If I talk about anything 8/10 When I go out with Do my friends seem My friends were talking It turned out better than I expected.
personal then people my friends I will join bored and uninterested about holidays they My friends seemed interested in what
won’t be interested. the conversation and in what I have to say? have taken, and I talked I had to say.
They will think I am share something about about the trip I took
boring and will want to myself. Some signs they are last year. I can challenge myself.
get out of the bored by me would be I was able to cope with the anxiety I
conversation as quickly Safety Behaviours them directly saying A few people asked felt about sharing something personal.
as possible. to drop something negative some questions about
I will need to drop the about how boring I am; my trip. They seemed I should keep testing my fears.
safety behaviour of them ignoring my interested and the
always keeping the contribution; them conversation kept I’ve added a note to my phone to
focus on others. immediately changing going. There was no remind myself that this situation went
the subject, or sign that my friends better than expected.
I will also drop the immediately leaving the thought I was boring.
safety behaviour of conversation after I I can keep testing my fears by
avoiding eye contact. I speak. One friend said they speaking about something personal at
will need to look at would like to see lunch with my family tomorrow.
people to know how photos of my trip.
they are reacting.

Stepping Out of
Social Anxiety
Plan your behavioural experiment
Plan an experiment where you will drop one or more of your safety behaviours. What are you worried will happen if you don’t use your safety behaviour?
Note this down in the negative thoughts column, and plan how you will test these fears and what evidence you will need to observe during your
experiment. Then, conduct the experiment and write down your results and conclusions. You may need to conduct several behavioural experiments to
learn what happens when you drop your safety behaviours.

Describe your prediction. /10 Specifically, what could you do Specifically, what do you need to What happened? What clear What conclusion follows from your results?
Specifically, what do you think will How anxious to test these thoughts? look for to confirm or disconfirm evidence did you collect? What did you learn by dropping your safety
happen? do you feel? your thoughts? Stick to unambiguous facts. behaviours?
What negative images do you have How can you keep this new information in mind?
about the situation? How can you find more opportunities to test your
predictions?
Safety Behaviours
to drop

Stepping Out of
Social Anxiety
Module Summary
• Safety behaviours are a subtle form of avoidance. They may help you feel more comfortable
in the short term, but keep your anxiety going in the longer term.
• Safety behaviours may be different for everyone – there is no definitive list of safety
behaviours! To discover your safety behaviours, pay attention to what you do to try to
reduce your anxiety in social situations. Ask yourself: how anxious would I feel if I could not
do this? If you would feel anxious without the behaviour, it is probably a safety behaviour.
• Safety behaviours may have become habitual over time, so you might need to make a
conscious effort to notice your safety behaviours. You may discover new safety behaviours
over time, as you become more aware of them.
• Once you become aware of your safety behaviours, it is important to drop them. This might
increase your anxiety temporarily, but will help you overcome your anxiety in the longer
term.
• It is preferable to drop your safety behaviours immediately, as this will allow you to learn
more from your behavioural experiments. You can use your behavioural experiment
hierarchy from Module 4 to plan a step you are willing to try without safety behaviours. If
you are not willing to drop all of your safety behaviours immediately, you can use your
behavioural experiment hierarchy to help you gradually phase them out over time.
Coming Up…
In the next module we will discuss the role
of attention in maintaining social anxiety.
We will introduce strategies to retrain your
attention in a more helpful way.

Stepping Out of
Social Anxiety
About the Modules
CONTRIBUTORS


McEvoy, P. & Saulsman, L. (2017). Imagery-Based Cognitive Behaviour Group Therapy for Social Anxiety Disorder (IB-
CBGT). Perth, Western Australia: Centre for Clinical Interventions.
BACKGROUND
McEvoy, P. M., Hyett, M. P., Bank, S. R., Erceg-Hurn, D. M., Johnson, A. R., Kyron, M. J., Saulsman, L. M.,
Moulds, M. L., Grisham, J. R., Holmes, E. A., Moscovitch, D. A., Lipp, O. V. Campbell, B. N. C., &
Rapee, R. M. (in press). Imagery-enhanced versus verbally-based group cognitive behavior therapy for
social anxiety disorder: a randomized clinical trial. Psychological Medicine.
http://dx.doi.org/10.1017/S0033291720003001
Rapee, R. M., Gaston, J. E., & Abbott, M. J. (2009). Testing the efficacy of theoretically derived improvements in
the treatment of social phobia. Journal of Consulting and Clinical Psychology, 77, 317–327.
REFERENCES
McEvoy, P. M., Saulsman, L. M., & Rapee, R. M. (2018). Imagery-enhanced CBT for social anxiety disorder. Guilford
Press.
Hackmann, A., Bennett-Levy, J., & Holmes, E. A. (Eds., 2011). Oxford Guide to Imagery in Cognitive Therapy.
Oxford:Oxford University Press.
Kemp, N., Thompson, A., Gaston, J., & Rapee, R. (2003). Cognitive behavioural therapy-enhanced for social
anxiety disorder: group treatment program. Centre for Emotional Health, Macquarie University.
10.1111/ap.12406.

Bank, S., Burgess, M., Sng, A., Summers, M., Campbell, B., & McEvoy, P. (2020). Stepping Out of Social Anxiety.

Stepping Out of
Social Anxiety
Module 6
The Role of Attention
Introduction 2
Self- and Environment-Focused Attention 2
How Do Self- and Environment-Focused Attention 2-3
Maintain Social Anxiety?
Task-Focused Attention 3
Attention Training 3-5
Attention Training Record 6
Attention Focusing 7
Module Summary 8
About the Modules 9
Stepping Out of
Social Anxiety
Introduction
Human beings are hardwired to detect and attend to threat in our environment to ensure our
survival. For people who are socially anxious, living in a social world means that threat can appear
almost everywhere! When we perceive a social situation to be threatening, it makes sense that we
focus all of our attention on responding to the threat. It is important to detect threat in an
environment with real threat; however problems can arise when our attention is unnecessarily
focused on perceived rather than real threats. As you have learned so far, when you experience social
anxiety, you will often overestimate the likelihood of something going wrong when socialising. As a
result, your attention regularly locks onto any potential social threat when you are trying to
socialise, which can keep your anxiety going. In this module, we aim to help you recognise where
your attention is focused in social situations and practice refocusing onto more helpful places.
Before you start learning how to refocus your attention, you first need to become aware of where
your attention wanders more generally when you are in social situations. To do this, we will
introduce you to two areas that attention can be focused.
Self-focused attention
Most people with social anxiety notice that most of their attention is self-
focused. For example, you may focus on physical sensations of anxiety
(e.g., racing heart, sweaty palms), negative thoughts or images about your
performance (e.g., “this person isn’t interested in anything I have to say”, an image of yourself trying
to speak but messing up your words and going bright red), or what you are going to say or do next
(e.g., rehearsing conversation topics).
Environment-focused attention
People with social anxiety might also scrutinise their environment for any social threat. For example,
you might look around for people who are laughing at or criticising you. Ambiguous social feedback
such as a frown, yawn, glance at a watch or pauses in conversation could lure your attention. This
feedback is then often interpreted as evidence to confirm predictions that you are being judged
negatively by others.
Where do you notice your attention is focused in social situations? Write down what
you have noticed in the space provided below.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
How Do Self- and Environment-Focused Attention

Maintain Social Anxiety?
Many people who experience social anxiety say that they focus their attention on themselves in an
attempt to improve their social performance, or on the environment to protect themselves from
anything bad happening. The problem with self- and environment-focused attention is that it keeps
you focused on threat when you are trying to socialise. As a result, your ability to engage in (and
enjoy!) social conversations can suffer.
Module 6: The role of attention Page 2

Stepping Out of
Social Anxiety
Self- and environment-focused attention maintain social anxiety by:
1. Distracting you from the task at hand: When you are self- and environment-focused you are
less able to pay attention to what is being said in conversations and less able to come up
with your own contributions. You may miss cues that it is your turn to speak, not pick up
on potential leads for further questions/comments you could make in
the conversation, and be more likely to draw mental blanks when it is
your turn to speak. This can have a negative impact on the quality of
your conversations.
2. Increasing your perception of social threat: If you are always looking

out for threat in the environment, then it can increase your sense that
something bad will happen.
3. Missing non-threatening feedback: When you are so preoccupied with social threat, you may
miss positive and neutral feedback from others. This is because your attention is limited.
You simply can’t take in all of the information around you. Our brains can only encode and
remember what we pay attention to. If you are only ever attending to threatening
information, then your memory of the social experience can become negatively biased. For
example, you may only remember how awful it felt or the negative evidence you collected
to the exclusion of any positive feedback!
4. Misinterpreting ambiguous feedback: If you are looking for social threat, you may be more
likely to interpret neutral feedback from others as negative. For example, if you start a
conversation looking for signs that you are boring then you are more likely to interpret
someone yawning (ambiguous behaviour) as proof that you are boring versus thinking that
perhaps the person is just tired.
You may also notice that your attention gets stuck focusing on past social situations that you think
went badly, or future social situations that you expect to go badly. This often leads to more self-
focused attention, which in turn increases anxiety.
Our aim is to help you become aware of when you are being too self- and environment-focused, and
as best you can, redirect your attention back to the task at hand. But what exactly is the task at hand
when we are trying to socialise?
Task-Focused Attention
In social situations, task-focused attention usually involves paying attention to the conversation. This
could be one-on-one or in a group environment. It involves absorbing oneself in the moment,
concentrating on the topic of the conversation, listening to what the other person is saying, noticing
common interests, making links to your own experience, and following your natural curiosity about
what the other person is saying.
So how do we stay task-focused?
Attention Training
Remaining task-focused in social situations can be very hard to do, especially when we are feeling
anxious! As such, it can be helpful to practice training our attention daily with non-social activities. It
may be useful to think of your attention a bit like a muscle. We need to practice strengthening the

Stepping Out of
Social Anxiety
attention ‘muscle’ by ‘training it in the gym’ using different exercises, so that when the time comes
you are ready to use it in the ‘big race’ (i.e., to be task-focused in social situations).
Attention training is a strategy aimed at improving your awareness of where your attention is
focused and your ability to refocus it where you want. It involves paying attention to the present
moment by ‘coming to your senses’. By this we mean noticing what you can see, hear, smell, taste,
and touch in the moment. We can practice training our attention at any time of the day, regardless
of what we are doing. For example, we can pay attention to:
• The breath
• Sensations while walking
• Taste/smells of food/drink
• Sensations of water on body while swimming
• Sensations of water on body during a shower
• Feel of the water and plates while washing dishes
• Sensations of the chair on your body as you sit
• Sensations of the bristles and smell and taste of the toothpaste whilst brushing your teeth
The goal of attention training is not to be 100% task-focused on the present moment – that is
impossible! Instead, the goal is to catch when your attention wanders and shift it back to the task at
hand. It doesn’t matter how many times your attention wanders – this is what minds do. It is the
noticing and redirecting back to the task that is most important. Each time you notice your attention
wandering, it may be helpful to anchor your attention back to the task by focusing on the following:
• Touch: what does the activity feel like? What is the texture like (e.g., rough, smooth)?
Where on your body do you have contact with it? Are there areas of your body with more
or less contact with the task?
• Sight: what do you notice about the task? What catches your eye? How does the task
appear? What about the light… the shadows… the contours… the colours?
• Hearing: what sounds do you notice? What kinds of noises are

associated with the task?
• Smell: what smells do you notice? Do they change during the

task? How many smells are there?
• Taste: what flavours do you notice? Do they change during the

task? What is the quality of the flavours?
When you notice that your mind has wandered during attention training, be careful not to criticise
yourself for this. After all, it is completely normal. Instead, think of every ‘wander’ as another
opportunity to practice the skill of bringing your attention back to the task at hand.
Take a moment now to think about everyday routine tasks that you do (e.g., dishes,
hanging out laundry, eating, driving, showering) and that you could use as an
opportunity to practice attention training. Write your ideas down in the space provided
below.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Stepping Out of
Social Anxiety
We recommend that you practice attention training at least once daily, and preferably several times
per day. These exercises can be brief (as little as two minutes). The good thing about attention
training is that you don’t have to add anything extra into your day. It’s just about changing how you
pay attention to the things you are already doing. You may find it helpful to monitor a sample of
these exercises and make notes of what you notice on the ‘Attention Training Record’ provided on
the next page.
Over time, attention training will help you:

 Become aware of your focus of attention more generally
 Make deliberate choices about where you want to deploy your attention
 Focus on the task at hand in the present moment, which leaves less attentional resources to
focus on other, less helpful or relevant things
A quick point on safety behaviours…

When practicing attention training, it is important that you do not use your training activity as a
safety behaviour to minimise anxiety in social situations (refer back to module 5 if you need a
refresher on safety behaviours). For example, we don’t want you to be focusing on your breath or
the taste/smell of food when socialising, even if it makes you feel less anxious in the short-term. This
will take your attention away from the task at hand. In social situations, the task at hand is typically
the conversation or interaction you are having with your peer/s. It is important you focus as much of
your attention on the conversation as possible, even if it is more anxiety provoking to start with.

Stepping Out of
Social Anxiety
Attention Training Record

Date/Time Attentional Task Duration Concentration Comments
(e.g., breath, walking, eating, brushing Level What did you notice? When your attention
teeth, dishes) (0-10) was task-focused, how much attention was
left over to focus on other things?
How frequently did your mind wander? How
easy/difficult was it to redirect your attention
back onto the task at hand?
Do you notice anything changing with
practice?

Stepping Out of
Social Anxiety
Attention Focusing
Once you have practiced training your attention using everyday activities, you are well equipped to
apply this skill to social situations. We call this attention focusing – you’ve done the training in the
gym and now it’s time to focus your strengthened muscle in the big race!
When socialising, once you become aware that your attention is self- or environment-focused, it is
important to direct your attention back onto the task at hand. Remember, in social situations the
task typically involves getting absorbed in the conversation, focusing on the other person when they
are speaking, and then switching to your own message when you are speaking. Again, it’s all about
noticing when your attention wanders and bringing it back to the present task. This is not easy to do
when you are feeling anxious and it requires regular practice!
We recommend that you practice attention focusing in future social interactions. Devote as much of
your attention on to the conversation as possible. You may find it helpful to try to recall the details
of a conversation, as this is a good marker of task-focused attention. We also encourage you to
reflect on the impact of your practice over time on your anxiety within social interactions and the
quality of your social performance.

Stepping Out of
Social Anxiety
Module Summary
• When you experience social anxiety, it is common to direct your attention to yourself or
your environment in an attempt to detect potential social threat.
• Self- and environment-focused attention can maintain social anxiety by distracting you from
the task at hand, increasing your perception of social threat, and leading you to miss non-
threatening feedback or misinterpret neutral feedback.
• Attention training is a skill aimed at increasing your awareness of your attention and
improving your ability to redirect it to the task at hand. You can practice attention training
with all sorts of routine daily tasks. Remember that the goal of attention training is not to
maintain 100% focus on the task, but to notice when your mind has wandered, and to gently
redirect it back to the task, no matter how many times this happens.
• Practicing focusing your attention on the conversation when socialising can help to reduce
your anxiety, improve the quality of your social performance, and make your social
interactions more enjoyable.
Coming Up…
In the next module we will look at how
misperceptions about how you appear
to other people can worsen your social
anxiety. We will introduce strategies to
help you get a more accurate idea about
how you come across to others.

Stepping Out of
Social Anxiety
About the Modules

CONTRIBUTORS


BACKGROUND
http://dx.doi.org/10.1017/S0033291720003001
Rapee, R. M., Gaston, J. E., & Abbott, M. J. (2009). Testing the efficacy of theoretically derived
improvements in the treatment of social phobia. Journal of Consulting and Clinical Psychology, 77, 317–
327.
REFERENCES
McEvoy, P. M., Saulsman, L. M., & Rapee, R. M. (2018). Imagery-enhanced CBT for social anxiety disorder.
Guilford Press.
Hackmann, A., Bennett-Levy, J., & Holmes, E. A. (Eds., 2011). Oxford Guide to Imagery in Cognitive
Therapy. Oxford: Oxford University Press.
Kemp, N., Thompson, A., Gaston, J., & Rapee, R. (2003). Cognitive behavioural therapy-enhanced for
social anxiety disorder: group treatment program. Centre for Emotional Health, Macquarie
University.
10.1111/ap.12406.


Stepping Out of
Social Anxiety
Module 7
How I Think I Appear to Others
Introduction 2
Thinking About How I Appear to Others 2-3
Testing Out How I Appear to Others 3-6
Behavioural Experiment Record 7
Module Summary 8
About the Modules 9
Stepping Out of
Social Anxiety
Introduction
Our modules so far have focused on challenging and experimenting with predictions about how
others will react to you in social situations. Hopefully, by regularly conducting behavioural
experiments, you are beginning to update your initial negative thoughts about the likelihood (and
cost!) of your social fears coming true. We are now going to look at thoughts about how you appear
to others when you are feeling anxious, as it is common for people with social anxiety to think their
anxiety symptoms are very obvious to others.
Thinking About How I Appear to Others

Let’s imagine you’re about to give a presentation in front of a group of your
peers and you’re feeling anxious. You notice that your palms and forehead feel
sweaty, your cheeks are warm, and your hands are beginning to shake. You
imagine stumbling over your words, and that everyone is going to notice these
anxiety symptoms and think you’re weird. So you decide to stay home and
avoid the presentation altogether…
This is one example of negative imagery related to how you appear to others. It is common for
people with social anxiety to hold negative thoughts and images about how they come across to
others. These thoughts and images are typically guided by people’s physical feelings of anxiety rather
than objective feedback about how they actually appear (e.g., “because I feel anxious I must also look
anxious”). On the one hand this makes sense - if you’re noticing physical signs of anxiety then surely
others will notice too?! Interestingly however, research shows that people with social anxiety
commonly overestimate the observability of their anxiety and underestimate their social
performance relative to others.
What thoughts or images come to mind about how you appear to others when you feel
anxious? What personal physical signs of anxiety do you think are obvious to others
(e.g., blushing, sweating, stuttering, shaking, mind blanks, “umms or ahhs”)? How do
you imagine you are performing? Write your answers in the space provided below.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Holding negative thoughts about how you appear to others can maintain your social anxiety by:
1. Increasing your perception of social threat: If you believe that your anxiety symptoms are
highly obvious to others and will be associated with very negative consequences (e.g., will
lead to negative judgment from others), then it makes sense that you would see social
situations as more threatening.
2. Promoting self-focused attention: If you’re worried about anxiety symptoms being obvious
to others, then your attention is more likely to be self-focused in an effort to detect any
early warning signs of anxiety. As outlined in module 6, self-focused attention can distract
you away from the social task at hand, interfere with your social performance, and increase
your awareness of even small changes in your anxiety (and therefore heighten your
expectation that it is obvious to others).
3. Increasing your urge to escape and avoid: You’ll remember from previous modules that
avoidance prevents you from testing the accuracy of your negative predictions. If you avoid
Module 7: Negative Self-Imagery Page 2

Stepping Out of
Social Anxiety
social situations because you think you will appear anxious, you will never get to find out
how you actually come across to others, or how much it actually matters if people do notice
symptoms of your anxiety.
The figure below represents the relationship between negative thoughts/images about how you
appear and social anxiety.
Testing Out How I Appear to Others

Since research shows people with social anxiety tend to perform better than they imagine in social
situations, we want to encourage you to be curious about the accuracy of your own negative
thoughts about how you come across when anxious. It is possible that your anxiety is not as obvious
to other people as it is to you.
Consider what it would be like to find out that in fact, many of the anxiety symptoms
you imagined were obvious are actually very mild (or unnoticeable) from other people’s
perspective. What impact would that have on your expectations of negative
judgement? What would this free you up to do differently when socialising or
performing? Write your answers in the space provided below.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
You can find out how you appear to others when you feel anxious by conducting a behavioural
experiment. It is important that the information you collect from your experiment is unambiguous,
objective, constructive and believable to you. We believe that experiments involving video feedback
are the best way to achieve these aims. Obtaining video feedback is the best way to find out once

Stepping Out of
Social Anxiety
and for all, in a way that is convincing to you, how you actually come across when you’re feeling
anxious.
Video feedback experiments involve recording yourself when you are feeling anxious.
They aim to directly compare your initial negative thoughts and images to how you
actually appear on video. It is essential that you are feeling anxious when recorded so
that you have an opportunity to observe how obvious these symptoms really are. You
may benefit from asking a trusted partner, friend or family member for support in
videotaping you (either subtly or in an observable way – the choice is yours!).
You may need to get creative in the way you set up your behavioural experiment. Most importantly,
the experiment should be designed to test your specific fears regarding the observability of your
anxiety. Ideas may include:
• Recording yourself completing a speech in front of the mirror
• Completing a 2-minute recorded impromptu speech in front of a select group
• Recording a 1:1 interaction with a trusted peer / friend / acquaintance / stranger
• Recording a speech or social interaction with your mental health practitioner
• Recording a group interaction
• Making use of the recording function in virtual resources (e.g., Zoom, Skype, FaceTime)
If you’re finding the recording aspect too challenging, you can always ask a trusted friend or family
member for feedback, although this feedback may be less believable to you.
You may wish to alter the type of task, audience, number of people, length of time recorded, or
where the task is completed. Most importantly, the experiment should be set up to be at least 5/10
anxiety provoking. If you’re not feeling anxious then you are unlikely to learn any helpful information
regarding how you appear when you’re in an anxious state.
Testing the Cost of How I Appear to Others

If you are concerned about receiving negative feedback from others in response to showing signs of
anxiety, then you may benefit from designing experiments aimed at testing the cost of these
symptoms. Ideas include recording other’s reactions to you when you are:
• Shaking – by holding a full glass of water and intentionally shaking to the point you spill some
of it
• Sweating – by intentionally splashing your face/armpits with water beforehand
• Blushing – by intentionally applying excess pink/red makeup to your cheeks beforehand
These experiments can be very challenging, but they can also be very powerful in
updating the way you think you come across to others in social situations. Moving
forward with a more accurate view of yourself can lead to more genuine choices about
what you would like to do in life, without unfair and inaccurate perceptions dictating
these choices for you.
We have provided an example Behavioural Experiment Record aimed at obtaining video

feedback on the next page. Remember, the more specific you can be in describing your
negative predictions and evidence to observe, the more informative the behavioural
experiment will be.

Stepping Out of
Social Anxiety
Behavioural experiment example

Describe your prediction. /10 Specifically, what could you Specifically, what do you need What happened? What clear What conclusion follows from your results?
Specifically, what do you think How anxious do you do to test these thoughts? to look for to confirm or evidence did you collect? How can you keep this new information in mind?
will happen? feel? disconfirm your thoughts? Stick to unambiguous facts. How can you find more opportunities to test your
My anxiety is really 9/10 Record myself Blushing will be 9/10 My cheeks were a little Maybe my anxiety symptoms aren’t as
obvious to other people. I presenting a 2-minute observable flushed, but I had to look obvious as I initially thought
go bright red, stutter, impromptu speech in really closely to notice –
shake and can’t get my front of my immediate Stuttering will be 10/10 2/10 observable The things I could see could be due to
words out. family (mum, dad, observable the fact that I didn’t prepare for the
brother and sister) I did not stutter – 0/10 speech rather than being obviously
My hands will shake and observable anxious
this will be 9/10
observable My hands were a bit I asked Mum to look over the video and
fidgety but I did not she mostly agreed with my ratings,
I will say “umm” and notice them shake – although she said she couldn’t see the
“ahh” at least 20 times 0/10 observable blushing at all
I will have mind blanks I said “umm” and “ahh” This info helps me to feel more
(at least 5 that extend but only 5 times confident when socialising with others
for approx. 10 seconds)
My mind went blank I will write myself a note in my phone
once but only lasted a and come back to it when I’m worried
couple of seconds before about my anxiety being obvious to
I was able to think of others
something to say

Stepping Out of
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Some points to remember when reviewing your video …

• Most people initially dislike seeing themselves and hearing their voices on video. An initial
“yuck” factor is therefore expected when you first watch your video back. We recommend
watching your video a minimum of four times which will help you to watch your video as
objectively as possible.
• Pay close attention to how you look in the video rather than how you felt during the
experiment (or how you are feeling while watching yourself on video). It is important that
you focus on whether the video matches up with your original predictions.
• Try to be as objective as possible when watching your video back. Watch your video as if
you were watching a friend or someone you care about. Look at the whole picture, rather
than just honing in on one particular aspect that you dislike. Ask yourself, “If I wasn’t
specifically looking for signs of anxiety, would this symptom stand out to me as an objective
indicator that this person is anxious?”
• There may be aspects of your performance that you want to improve or do differently after
watching the video. That’s ok. Remember the goal of this experiment is to test the
observability of your anxiety – not evaluate your social performance! Stay focused on
whether your initial predictions match up to what you see on the video.
• You may also wish to ask a partner / friend / family member to review your
video to ensure you are being as objective as possible in your review.

Stepping Out of
Social Anxiety
Behavioural experiment record

Describe your prediction. /10 Specifically, what could you Specifically, what do you need What happened? What clear What conclusion follows from your results?
Specifically, what do you think How anxious do you do to test these thoughts? to look for to confirm or evidence did you collect? How can you keep this new information in mind?
will happen? feel? disconfirm your thoughts? Stick to unambiguous facts. How can you find more opportunities to test your

Stepping Out of
Social Anxiety
Module Summary
• It is common for people with social anxiety to hold negative thoughts and images about how
they come across to others. These images are typically guided by people’s feelings of anxiety
rather than objective feedback about how they actually appear.
• Holding negative thoughts or images about how you appear to others can maintain social
anxiety by increasing your perception of social threat, increasing self-focused attention, and
increasing your urge to escape/avoid.
• You can challenge negative thoughts about how you appear to others by conducting
behavioural experiments with video feedback. It is important to be creative with your
behavioural experiments to ensure you believe the evidence you are collecting.
Coming Up…
negative ‘core beliefs’ can keep your
social anxiety going. We will show how
to start identifying unhelpful core beliefs
that relate to your social anxiety. We
will introduce strategies to help start to
change unhelpful core beliefs.

Stepping Out of
Social Anxiety
About the Modules

CONTRIBUTORS


BACKGROUND
http://dx.doi.org/10.1017/S0033291720003001
Rapee, R. M., Gaston, J. E., & Abbott, M. J. (2009). Testing the efficacy of theoretically derived
improvements in the treatment of social phobia. Journal of Consulting and Clinical Psychology, 77, 317–
327.
REFERENCES
McEvoy, P. M., Saulsman, L. M., & Rapee, R. M. (2018). Imagery-enhanced CBT for social anxiety disorder.
Guilford Press.
Hackmann, A., Bennett-Levy, J., & Holmes, E. A. (Eds., 2011). Oxford Guide to Imagery in Cognitive
Therapy. Oxford: Oxford University Press.
Kemp, N., Thompson, A., Gaston, J., & Rapee, R. (2003). Cognitive behavioural therapy-enhanced for
social anxiety disorder: group treatment program. Centre for Emotional Health, Macquarie
University.
10.1111/ap.12406.


Stepping Out of
Social Anxiety
Module 8
Challenging Core Beliefs
What are core beliefs? 2

Core beliefs in Social Anxiety 3
Identifying core beliefs 3-4
Challenging core beliefs 4
• Evidence-testing 5-9
Module Summary 10
Stepping Out of
Social Anxiety
Introduction
By now, you are probably becoming familiar with the process of challenging your thinking in a range of
social situations. You know how to identify the thoughts that are causing you distress, and how to challenge
them or test them out through behavioural experiments to develop more balanced thinking. However, you
might have noticed that there are times when it is harder to believe the new balanced thoughts, because
the old unhelpful thoughts seem to be very powerful.
A possible explanation for this difficulty in letting go of an unhelpful thought is that there may be a strong
core belief at the root of that unhelpful thought. Core beliefs are the very essence of how we see
ourselves, other people, the world, and the future. Sometimes, these core beliefs become “activated” in
certain situations. Here’s an example:
Andrew is generally able to challenge his unhelpful thinking about social situations. However he
has noticed that he has a great deal of trouble challenging his thinking when it comes to
situations where he is the centre of attention and is forced to speak, such as when talking with
a group of people. Even after working through his thought diary, he has a tendency to believe
the negative statements such as “I don’t have anything interesting to say”, and continue to feel
bad. In these situations, he has recognised that he has extremely high standards for his social
performance. In fact, when he really looks hard at his thinking, he can see that often the
underlying self-statement is, “I’m boring and incompetent”.
This self-statement that Andrew identified is an example of a core belief, and core beliefs guide how we
think and how we behave in our day-to-day lives. In this module, we will discuss ways to identify and modify
some of these core beliefs, so that we can reduce the negative impact that these beliefs can have on our
approach to social situations and to life in general.
What are Core Beliefs?

Core beliefs are beliefs that we hold about ourselves, other people, and about the world we live in. These
beliefs often sit at the ‘core’ of the thoughts and mental images that we experience in the ‘here-and-now’.
We may or may not be consciously aware of these beliefs at work – some of our beliefs may remain
reasonably unconscious and require a bit of work to uncover, while other beliefs may be quite noticeable
and easily retrieved in our minds.
Here are other common features of core beliefs:

• They are not necessarily conscious thoughts or images, but are more
like ‘unwritten’ laws or ‘absolute’ statements through which people
interpret what is happening around them.
• They can act like ‘filters’ that guide our perceptions and expectations
in the here-and-now.
• They are usually fairly powerful (linked to intense emotions),
pervasive (present in many areas of life), and often long-standing.
Core beliefs develop over time, usually from childhood and through the experience of significant life events
or particular life circumstances. Some of the core beliefs that we have developed can be helpful (e.g., “It’s
important to be kind and respectful to others”); however, we may also hold beliefs that are more unhelpful
or rigid. These unhelpful core beliefs might have formed to protect us in some ways (e.g., “The world is
dangerous”) or to help us to strive at some point in our lives (e.g., “I must never make a mistake”). When
we apply these core beliefs too rigidly, and to most or all areas of our lives, they are likely to have a
negative impact on how we feel about ourselves, and how we relate to people around us.
Module 8: Challenging Core Beliefs Page 2

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Core Beliefs in Social Anxiety

Many people with social anxiety can recall early life events (from childhood, adolescence, or early
adulthood) that were associated with significant social anxiety. There may be one or two situations, or
many early experiences, that you identify as contributing to your social anxiety. For example, if I was bullied
I may have formed beliefs such as “I am unlikeable” or “I am inferior”. I might also have come to believe
that “others are hostile or critical”. As a consequence, when I think about entering a social situation now, I
view my ‘inferiority’ as being obvious to others and I expect to be criticised by others.
Examples of some common beliefs for people who experience social anxiety
include:
• “If I am not liked by everybody, I am worthless.”
• “I’m unlovable.”
• “I’m inadequate.”
• “People will reject/hurt me.”
However, it might be helpful to note that even people without social anxiety can
also hold some or all of these beliefs.
Holding such core beliefs can maintain and even exacerbate social anxiety by biasing our interpretation of
events (through our thoughts and expectations) and influencing our focus of attention (we selectively look
for evidence that supports our beliefs, and tend to ignore evidence that contradicts it). To continue with
the example of Andrew from the previous page, Andrew focuses on any feedback from other people or
from the situation that isn’t positive, and then uses this to confirm yet again that he is boring and
incompetent. Even neutral statements from other people can often be interpreted as negative. Over the
years, this narrow focus gives strength to the belief that “I’m boring and incompetent”, and Andrew no
longer thinks to question it. It is just totally and absolutely accepted. It is not surprising, then, that these
types of beliefs are the hardest to shake.
By being able to identify our core beliefs, we can challenge them directly, just like the thoughts and
expectations that spring from them. Understanding our core beliefs can also provide a useful ‘shortcut’ for
challenging our thoughts and expectations, as often the same one or two beliefs will underlie most
situations in which you feel socially anxious.
Identifying Core Beliefs

Identifying themes from your thought diaries
There are several methods that we can use to uncover core beliefs. One method, which you might have
used already, is to look for recurring themes that come up in your thought challenging records. You might
notice that there are certain patterns to the images or thoughts, perhaps one or two common themes in
the things you say about yourself (“I am…”), other people (“Others are…”), the world (“The world is…”),
or the future (“The future is…). Take some time now to consider some of the themes you may have
noticed that you hold, and record them in the space below.
About myself… About others… About the world/future… Other themes…

E.g., “I am a failure”, “I E.g., “People are critical” E.g., “The future is hopeless”
am stupid”

Stepping Out of
Social Anxiety
Downward Arrow Technique
Some core beliefs are easily retrieved from our minds, like the themes you may
have noticed in the earlier exercise. If you were not able to identify specific
themes, or you are still a bit unsure, another useful way of uncovering core
beliefs is to use the “Downward Arrow” technique. This technique is not a great
deal different from what you have already been doing in your thought
challenging records. Essentially you start with a common thought or prediction
from your monitoring, and work downwards by asking yourself at each level,
“What does this say or mean about me/others/the world?” End this exercise
when you arrive at an absolute statement about yourself, others, or the world
(core belief). This process is like sifting through the layers of self-talk to get to
what is at the bottom layer.
Take a look at the example on the left panel below, and then have a go at using the downward arrow for
your own example in the right panel.
IDENTIFYING CORE BELIEFS: AN EXAMPLE MY EXAMPLE
Situation (from your Thought Challenging Record) Situation (from your Thought Challenging Record)
Talking to my friend Michelle
Initial thoughts/expectations Initial thoughts/expectations
“I don’t think Michelle likes me”
What does this say or mean about me? What does this say or mean about me/others/world?*
“Whenever I get close, people end up disliking me”
“I’ll never have a close relationship”
“I’m unlikeable” (Core belief)
As you can see, it takes a bit of work to get to the actual core of what you believe. You may not need as
many prompts as the example given to arrive at your core belief or you may need to use a few more.
Challenging Core Beliefs

Now that you have identified one or more core beliefs, you are ready to challenge them. Even though these
beliefs are strongly held, they can be challenged just like any unhelpful thoughts. Because core beliefs are
often long-held and can be emotionally provocative, this process of challenging your core beliefs may not be
an easy one. If you find the process too difficult or distressing, consider seeing a mental health professional
and discussing this with them.

Stepping Out of
Social Anxiety
Evidence-Testing
An important way that we can start to challenge a core belief directly is by paying attention to, and
recording, evidence that this belief is not 100% true. This is not as easy as it sounds, as often these beliefs
have been there a long time and are hard to shake. A good example of the power of core beliefs is the
difficulty many people have with accepting compliments, and the discomfort this creates. This is because
this information (the compliment) is often contrary to what people believe about themselves, and therefore
people’s first reaction is to deny or downplay the information, thereby keeping their core belief intact. To
be able to challenge the core belief, it is therefore important to keep track of all the evidence that might
disagree with a core belief, even if it seems small or unimportant.
Step 1. Choose a core belief to test

Choose a core belief that you would like to evaluate and rate how strong your belief is before challenging it
between 0 (completely untrue) to 10 (completely true).
Core belief to be challenged: e.g., “I’m unlikeable”, “I’m incompetent”
Strength of belief (0 = completely untrue – 10 = completely true)

Before challenging: ___ After challenging (leave this for after Step 3): ___
Step 2. Record evidence that shows this belief is not completely true 100% of the time
Ask yourself “What experiences do I have that show that this belief is not completely true all the time?”
Use the space below to list as many experiences, and be as specific, as possible. Remember to write down
everything even when you’re not sure if it is relevant – even very small experiences count. This can include
instances from the past, including from when you were a child, all the way to examples from the present
day. You might have to look really hard (and to look regularly, over a period of time), because you are
probably not used to seeing the good things about this area of your life.
In the example of Andrew, some of the experiences that go against his core belief that “I’m boring and
incompetent” might be:
Experiences that show that this belief is not COMPLETELY true ALL the time:
1. I got promoted to assistant manager at the store I used to work at.
2. I meet with my high school friend Joe about once a month for a coffee. He asks me a
lot of questions about what I’m doing and how I’m going, and often tells me that he
enjoys our catch-ups.
3. I am good at chess and often win when I play with my family or online.
4. When I was 12, I was invited to present a speech at the graduation assembly.
Try to be as specific as possible when describing the evidence. For example, instead of “I have some friends
who find me interesting”, the evidence becomes more powerful and compelling when we can describe
specific people, events, and actions (as shown in Andrew’s description of his friend Joe in point 2 above).

Stepping Out of
Social Anxiety
You might find it difficult to come up with evidence all at once. That’s understandable
because it takes time to shift core beliefs that have developed over many years. You may
choose to do this exercise over the course of a week or two, writing down at least one
piece of evidence each day. Once you can find a piece of evidence nearly every day, try
looking for two or three bits of evidence every day. Don’t worry if the things you write
down seem trivial or if you are unsure if they “count”. When you have 20 or so items on
your list you can look at them all and draw an overall conclusion about whether your
original negative core belief accurately describes your whole experience.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.

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Step 3. Develop an alternative, balanced core belief

When you have considered all the experiences you have written down, develop an alternative, balanced
core belief. Remember that these experiences show that your unhelpful core belief is not completely true
all the time.
For Andrew, his new, balanced core belief might be: “Although there are things I don’t know or haven’t
done, I do have knowledge and experiences that people find valuable or interesting.”
What would be an appropriate balanced and helpful core belief for your example? Write this down.
Balanced core belief:
Strength of this belief: ____ (0 = completely untrue – 10 = completely true)
It is also helpful to revisit your rating of the strength of your original negative core belief before challenging
(i.e., go back to Step 1), and re-rate how much you believe in it after challenging. This allows you to see the
contrast between your old and new core beliefs, and the impact from taking on board the different pieces
of evidence you have collected.
The following page puts all three steps together into a worksheet that you can use to test other beliefs that
you may have.

Stepping Out of
Social Anxiety
Recording Evidence that a Core Belief is Not 100% True

Core belief to be challenged:
Strength of belief (0 = completely untrue – 10 = completely true)

Before challenging: ___ After challenging: ___
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
When you have considered all the experiences you have written down, develop an alternative, balanced
core belief. Remember that these experiences show that your unhelpful core belief is not completely true
all the time. What would be an appropriate balanced and helpful core belief? Write this down.
Strength of this belief: ____ (0 = completely untrue – 10 = completely true)

Stepping Out of
Social Anxiety
Remember!
New core beliefs take time to develop and to make them more believable. Even after
you have created a more balanced core belief, it is important to continue collecting
evidence regularly (from past and present events) to help “feed” and strengthen it.
Writing the evidence down in a log book can be useful so that you can refer back to it
if you experience a setback and need some reminders about your new core beliefs.
You might also find it useful to write your balanced core belief(s), along with a few key
pieces of supporting evidence, onto small cards that you can carry around with you as a
reminder when your old core beliefs are activated.
In the next module, we will talk about more ways to strengthen our new core beliefs. We will focus on
setting goals and taking action in various areas of our daily lives to follow through with these new beliefs.

Stepping Out of
Social Anxiety
Module Summary
• Sometimes, it may be difficult to believe balanced thoughts in certain situations because
there is a strong core belief operating in that particular situation.
• Core beliefs are the very essence of how we see ourselves, other people, the world, and
the future. They are strongly-held, rigid, and inflexible beliefs that are maintained by the
tendency to focus on information that supports the belief and ignoring evidence that
contradicts it. Such beliefs are often unquestioned – they are just totally and absolutely
accepted.
• Core beliefs can be identified by looking over your thought diaries to see if your ‘hot’
thoughts have any common themes. Alternatively, you can get to the core of what you
believe by asking yourself “What does that mean?” after an unhelpful thought or a ‘hot’
thought (the ‘Downward Arrow’ technique).
• To evaluate and challenge your unhelpful core beliefs, ask yourself, “What experiences do I
have that show that this belief is not completely true all the time?” Record past and present
experiences, and try to be as specific as possible.
• Keeping a log book of evidence or writing the new beliefs and their supporting evidence
down on small cards are ways to remind yourself of your new core beliefs when the old
beliefs are activated.
Coming Up…
you can strengthen your new and more
balanced core beliefs.

Stepping Out of
Social Anxiety
About the Modules

CONTRIBUTORS


BACKGROUND
REFERENCES
10.1111/ap.12406.


Stepping Out of
Social Anxiety
Module 9
Strengthening New Core Beliefs
Strengthening new beliefs through action 2

Core belief action plans 2-4
Action plan worksheet 5-6
Module Summary 7
About the Modules 8
Stepping Out of
Social Anxiety
Introduction
In the previous module, we worked on discovering and challenging negative core beliefs, and developing
more balanced, helpful beliefs. As you continue to work on challenging these beliefs, you may find that parts
of the older core beliefs still ring true for you, while the more balanced core beliefs are still new and you
might not believe in them as strongly. This is normal, as you are likely to pay more attention to things that
confirm the old beliefs, and discount information that supports the new beliefs. This is a habit that your
brain has been practising for a long time! You are also likely to act in ways that fit with the old beliefs,
rather than acting against them.
Strengthening new beliefs will require repeated reminders of the new beliefs, and ongoing collection of
evidence to support this new, more balanced, view of yourself or others. This means paying attention to
information from past and present events, as well as looking out for appropriate evidence in the future.
Another important means for strengthening our new beliefs is to act in ways that are consistent with the
updated views about ourselves. In this Module, we will look at setting goals and taking action in various
areas of our daily lives to follow through with our new core beliefs.
Strengthening New Beliefs through Action

The best way to build conviction in your new core beliefs is to live your life “as if” they are
true, because changing our behaviour is the most powerful way to change our beliefs
(behavioural experiments are a prime example of that). So if you start operating in a way
that is consistent with your new positive core beliefs, you will strengthen them over time.
If you have previously avoided doing certain things because of your unhelpful core belief, now is the time to
make a plan for approaching these things and trying them out, so that you are acting more in line with your
new beliefs. Ask yourself, “If I really believed my balanced belief, what are the things I would do?” Then, go
out and do them. You may not believe the balanced beliefs straightaway, and will most likely feel anxious
about trying these things – remember, you have already started to loosen the grip of the old core beliefs,
and taken steps to approach a range of different anxiety-provoking situations through your behavioural
experiments. Over time, you will find that if you continue to apply these strategies consistently, your
conviction in your old negative core beliefs will reduce and your conviction in your new balanced core
beliefs will improve.
Core belief action plans are a tool for helping us to generate ideas for how we want to operate within our
new core belief system. Take a look at the next section to get started on your personal action plan.
Core Belief Action Plans

The core belief action plan assists you in identifying areas of your life that you would like to work on in
relation to your new core beliefs, such as relationships, family life, work/study/career, leisure/hobbies, and
health/well-being. The action plan then prompts you to plan different tasks and actions to ‘act out’ these
new beliefs in your daily life. You can treat each task that you set within your action plan as a behavioural
experiment, and evaluate if the results are consistent with your new, more balanced core beliefs.
For Andrew, here is an example of how he would like to strengthen his new core beliefs:
• New core beliefs to strengthen: Self as caring and capable, others as supportive.
• Life domain: Hobbies
• Target for change (i.e., Goals): Volunteer at the animal shelter
Module 9: Strengthening New Core Beliefs Page 2

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Next, Andrew needs to identify a situation, or experiment, that he can take specific action in, and set a
timeframe for taking action:
• Specific action(s): Attend the volunteer information session, and submit the
application form on the day. Ask some questions about available roles.
• Timeframe: Complete the volunteer application form this weekend, and submit it
at the information session on Tuesday.
As plans do not always work out on the first attempt, it helps to have some ideas for how to overcome
potential obstacles to taking action. For Andrew,
• Strategies to overcome potential obstacles: Use my thought challenging

skills if I feel anxious about attending the information session. Tell a
friend about my plan to sign up as a volunteer, so that I am less likely
to procrastinate, and will be more motivated to attend the session.
The next thing Andrew would need to do is to implement his plan and evaluate whether he was able to
meet his goals, or see what strategies he would need to use if he encountered any roadblocks along the
way. If Andrew was able to attend the volunteer session and sign up as a volunteer, he can then plan the
next action (e.g., attending his first shift) to advance his progress on this goal.
Here is another example from Su-Lin, who has identified “relationships” as a life domain that she would like
to work on as part of her core belief action plan. As you can see, we have taken the same prompts from
Andrew’s example above, and organised the goals and actions into a table so that you can create your plan
step-by-step:
SU-LIN’S EXAMPLE:
New Core Beliefs Life Target for Specific Strategies to Timeframe
(self, others, world) domain change actions overcome
potential
obstacles
Self: likeable Relationships Initiate more Contact friend If friend does not Call friend
Others: friendly social outings who I haven’t answer the first time, tomorrow and
World: safe talked to in a call again the next ask if she
few months to day or send a text. wants to catch
organise a Might need to give up for coffee
catch-up more notice. next week
Now you can have a go at developing your personal core belief action plan!
Creating my personal core belief action plan
Start by identifying the core beliefs that you want to strengthen about yourself, others, and/or the world:
My New Core Beliefs
Self:
Others:
World:

Stepping Out of
Social Anxiety
Next, have a think of which life domains could help you to target these core beliefs. Ask yourself, “If I really
believed my new core beliefs, would I be doing things differently in these areas of my life?”:
□ Relationships
□ Family Life
□ Work/Study/Career
□ Leisure/Hobbies
□ Health/Well-being
□ Other: ____________________________________
Now, choose one specific life domain from the list above, and let’s get more specific – think about
exactly what you could do to collect more evidence for your new core beliefs. Creating new opportunities
for more experiences that will support your new core belief may involve:
• Approaching rather than avoiding situations that may, or that used to, provoke anxiety
• Sticking with challenges rather than escaping
• Dropping safety behaviours, and approaching activities and tasks without taking precautions
• Doing pleasant things for yourself (e.g., hobbies, self-care activities, giving yourself a treat)
• Being active and engaged in life
• Being assertive
Your ideas from this become “targets for change” and we can narrow this down further into “specific
actions” that we plan to undertake to build new experiences and opportunities. Ask yourself: What new
behaviours will you need to try out? How will you be behaving differently to before? Record your ideas into
the ‘Target for change’ and ‘Specific actions’ columns of the “My Example” table below. Also remember to
set a realistic timeframe for when you would like to implement these goals and actions.
MY EXAMPLE:
New Core Beliefs Life Target for Specific Strategies to Timeframe
(self, others, world) domain change actions overcome
potential
obstacles
Finally, identify potential obstacles that may come up. Based on what you have developed from the modules
so far, what skills and strategies do you now have to manage these obstacles if they arise? Record them
under the “Strategies to overcome potential obstacles” column.
On the following two pages is the Action Plan worksheet which gives you an opportunity to plan for
different areas of your life. Once you have some ideas written down on your action plan, the next step is to
go out and do it! You now have a toolbox of skills to draw upon when faced with anxiety-provoking social
situations – in the final module, we will discuss how you can maintain the gains you have made, and how to
enhance your well-being.

Stepping Out of
Social Anxiety
Action Plan Worksheet

New Core Beliefs that I would like to strengthen
About myself… About others… About the world/future…
Life domain Target for change Specific actions Strategies to overcome Timeframe
potential obstacles
My Relationships
My Family Life
Work/Study/Career
(Continued on next page)

Stepping Out of
Social Anxiety
Life domain Target for change Specific actions Strategies to overcome Timeframe
potential obstacles
My Leisure/Hobbies
My Health/
Well-being
Other Important
Areas of My Life
Taking Action!
Once you’ve written down some ideas on your action plan, the next step is to have a
go at implementing these actions. You can treat each task or action as a behavioural
experiment - are the results consistent with your new, more balanced core beliefs?
Remember that strengthening new core beliefs takes time, and can feel challenging at
first – the more we act according to our new beliefs, the easier it will get over time!

Stepping Out of
Social Anxiety
Module Summary
• In addition to ongoing collection of evidence to support your new, more balanced core
beliefs, it is also important to act in ways that are consistent with these updated core
beliefs.
• Follow through on your balanced core beliefs by putting them into action with the Core
Belief Action Plan.
• Strengthening new core beliefs takes time, and can feel challenging at first – the more we
act according to our new beliefs, the easier it will get over time.
Coming Up…
In the final module we will discuss how
you can maintain the gains you have made,
and how to enhance your well-being.

Stepping Out of
Social Anxiety
About the Modules

CONTRIBUTORS


BACKGROUND
REFERENCES
10.1111/ap.12406.


Stepping Out of
Social Anxiety
Module 10
Maintaining Your Gains and Dealing with
Setbacks
Introduction 2
Summary of Skills 2
Dealing with Setbacks 3
My Dealing with Setbacks Plan 4
Maintaining My Gains 5
Module Summary 5
About the Modules 6
full disclaimer and copyright statements available at www.cci.health.gov.au regarding the
Stepping Out of
Social Anxiety
Introduction
Congratulations on making it to the end of this workbook! The most important thing for you to do now is
to keep going! This means continuing to apply the strategies you have learned through reading these
modules. If you continue to practise the skills you have learned, they will become more like habits that
have been integrated into your lifestyle. In this final module, you will find a summary of all of the important
strategies introduced to you in the previous modules. We will also discuss how to manage future setbacks
which may occur with your social anxiety.
Summary of Skills
Throughout this set of modules, we have covered a range of new skills and strategies which are
summarised below. Consider how helpful each of these strategies has been for you and commit to applying
them regularly. This will allow you to maintain the gains you have made, and build on your gains over time.
Thought challenging
Our initial negative thoughts may ‘just’ be thoughts rather than facts. In Module 2, you practised ‘tuning in’
to your specific negative thoughts and images about social situations, learnt how to start looking for
contrary evidence that does not fit your thoughts, and started to consider alternative, more realistic
thoughts.
Behavioural experiments
Avoiding situations that trigger our anxiety stops us from directly testing our negative thoughts
and therefore keeps our social anxiety going. Modules 3 and 4 introduced behavioural
experiments to directly test your negative thoughts. Behavioural experiments involve:
• Being very specific about your predictions
• Planning how you could test the predictions
• Carefully considering what evidence you need to observe to check how accurate your
predictions are
• Doing the experiment
• Reflecting on the results
• Making conclusions based on the results
Behavioural experiments can teach us that our negative thoughts are less likely to occur than we may
expect, and that even when aspects of our negative thoughts do come true we can cope.
Dropping safety behaviours

Module 5 discussed the importance of dropping safety behaviours. We use safety behaviours to prevent
our fears from coming true…or so we thought! Safety behaviours actually keep our anxiety going because
they are just more subtle forms of avoidance. They also keep us self-focused, can create negative
evaluation rather than prevent it, and ultimately stop us from directly testing our fears. If things go well, we
conclude that the safety behaviour saved us…rather than learning that our fears were just less likely to
happen than we thought.
Attention training and focusing

When our attention is focused on ourselves and/or looking for threat in the environment, we cannot be
focused on the task at hand. Self- and environment-focused attention just distracts us from the task we are
engaged in (e.g., conversation), which is then likely to affect our memory of the social situation in three
ways. First, we are only likely to remember negative aspects of the situation (e.g., how anxious we were
feeling) because that’s what we were most focused on. Second, we are likely to miss positive aspects of the
situation that would challenge our fears (e.g., positive feedback from others). Third, it is going to be much
more difficult to keep up with the task at hand (e.g., topic of the conversation) because we are so
distracted with ourselves. In Module 6, we learned how to be more aware of where our attention is
(attention training) and how to shift our attention back onto the task at hand (attention focusing).
Module 10: Maintaining Your Gains and Dealing with Setbacks Page 2
Stepping Out of
Social Anxiety
Video-feedback
It is common for people with social anxiety to overestimate how noticeable their anxiety
is to others. For this reason, it can be helpful to conduct a behavioural experiment to
test out how observable your anxiety actually is when you are anxious. As discussed in
Module 7, an example of a good way to do this would be to record yourself giving a
speech to see if your ‘self-image’ is accurate or not. You may learn that even when you
are highly anxious your symptoms are not as obvious as you think, and that you don’t need
to be too concerned about other people noticing your anxiety.
Identifying and challenging my core beliefs

Core beliefs are often at the root of unhelpful thoughts that are particularly difficult to change. Modules 8
and 9 looked at core beliefs and how to change them. This involved use of the downward arrow technique
to identify your core beliefs, challenging these core beliefs by looking for evidence against them, and
strengthening new, more helpful core beliefs by developing action plans.
Next, we will develop a plan for recognising early warning signs of a setback in your social anxiety so that
you can ‘get back on board’ with the strategies and continue moving forward towards your values and
goals.
Dealing with Setbacks

As you continue to apply your skills, it is important to recognise that you can expect some ups and downs
along the way. The road to recovery is rarely a smooth ride. It is normal to experience setbacks in your
social anxiety from time to time, for example, if you experience a particularly difficult social situation or if
your life circumstances change so that you are not getting as much exposure to social situations. The
important thing is how you respond to these setbacks, not that they have occurred in the first place. Try
not to focus too much on any setbacks that you experience. Instead, focus your attention on what you will
do next to get back on track. If you respond to a setback by thinking in unhelpful ways like “I’m back to
square one” you will probably start to fall back into old habits. If you try and learn something about the
experience then you can use this information to build resilience over time.
It may be helpful to create a personalised Dealing with Setbacks Plan to help you to recognise the signs of a
setback and take action as soon as possible. This way you can prevent a small setback from turning into a
large one.
On the next page is a Dealing with Setbacks Plan worksheet for you to identify:
• My Triggers. These are the types of situations that could potentially trigger a setback in your
social anxiety in the future.
• My Warning Signs. Clues you can keep watch for that indicate you might be starting to become
more socially anxious again.
• Action Plan. What do you need to focus on and remind yourself when a social anxiety setback
occurs? What do you need to do when a social anxiety setback occurs? Which strategies from
your Summary of Skills will be important for you to put in place?
Remember that avoiding social situations plays a large role in maintaining social anxiety. Therefore it is
important to remember that the main reason for identifying potential triggers for your social anxiety is not
so that you can avoid your triggers. Rather, by being aware of your early signs and potential triggers, you
will be in a better position to “spot” a setback in your social anxiety and then take early action to prevent it
from becoming worse.
Stepping Out of
Social Anxiety
My Dealing with Setbacks Plan

Setbacks are normal – it is how I respond to setbacks that is most important
My Triggers (When are setbacks in my social anxiety more likely to occur? In what types of
circumstances do I tend to have a setback?)
My Warning Signs (How do I know when I have had a setback in my social anxiety? Are there any
emotional, thinking, behavioural or physical signals? E.g., avoidance, reliance on safety behaviours,
more concerns about others judging me)
ACTION PLAN:
What do I need to focus on and remind myself What do I need to do when a social anxiety
when a social anxiety setback occurs? setback occurs? E.g., review Summary of Skills,
review modules, recommence thought
challenging and behavioural experiments
Stepping Out of
Social Anxiety
Maintaining My Gains
Congratulations again on making it to the end of this information package! The most important thing now
is to continue using the strategies we have covered in these modules, and which are all summarised in the
Summary of Skills. It may be helpful to revise the modules from time to time, especially if you are going
through a difficult period. It may also be helpful to take this opportunity to consider whether there are any
strategies in the Summary of Skills you think you would benefit from using more often. Are there any
specific situations you still need to confront to overcome remaining anxieties? Is it time to start
confronting these situations in your next set of behavioural experiments, to continue to build on the gains
you have made?
There are some important things to remember about maintaining your gains:
Expect Slip-Ups
Slip-ups in progress can happen at any time and are to be expected. Use your new skills to start moving
forward again when this situation occurs. It might be useful to remind yourself that most people have
‘down days’ or days where life’s hassles are harder to deal with – it’s part of being human!
You can also use setbacks as a way of learning something new about yourself to help avoid similar problems
in the future. Ask yourself, what made this particular situation difficult for me? What could I do to manage
it differently next time? What skills could I use to help prepare myself for similar situations in the future?
Regularly consult the Summary of Skills and your Dealing with Setbacks Plan.
Social Support
It is wise to find someone with whom you can sit down and have a good talk. This doesn’t mean a
therapy session where you pour your heart out but rather just a chance to talk through what’s
going on in your life, what your goals are, and generally just to ventilate with someone you trust.
Social support has been found to be very important in preventing relapse. Often problems
seem bigger than they really are when a person tries to deal with them on their own. Talking
through difficulties can help to put them into perspective.
Remember – progress is a bumpy road, but if you continue making small steps you will get there.
Module Summary
• To maintain and build on the gains you have made, continue to apply the strategies you have learned
through reading these modules:
• Thought challenging
• Behavioural experiments
• Behavioural experiment hierarchies
• Dropping safety behaviours
• Attention training and focusing
• Developing a more accurate self-image of how you appear to others when anxious
• Challenging negative core beliefs
• Acting consistently with new, more positive core beliefs
• Expect setbacks, but rather than focussing on them, use your Dealing with Setbacks Plan to recognise
them early and get back on track.
Stepping Out of
Social Anxiety
About the Modules

CONTRIBUTORS


BACKGROUND
REFERENCES
10.1111/ap.12406.

what is
social anxiety?
Almost everyone gets a little anxious or embarrassed in front of other people now and then, though
some of us are more shy than others. Sometimes, though, the anxiety can be so intense that it stops us
from doing the things we enjoy, or starts interfering in our daily lives. If this sounds familiar to you, this
information sheet can help to give you a better idea of what social anxiety is.
Social anxiety is used to describe feelings of Physical

anxiety and fear that occur in response to social
When you are in particular social situations, or
situations. Even the most confident of people can get a
thinking about social situations, you may experience a
little anxious before a presentation, or when they’re
number of physical reactions. Perhaps you are sitting at
meeting new people, but in social anxiety this distress
work one day and your boss asks you to sit in on a
can be so overwhelming that it feel’s as though it‘s
meeting with some new clients. Your anxiety increases
difficult to cope. Often, that overwhelming anxiety is
and all of a sudden, you become flustered; you start to
experienced when just thinking about the situation or
feel warm, your breathing becomes irregular, your
remembering a previous event. You may also have
heart beats faster, you feel a little lightheaded and you
heard the term “social phobia” used to describe these
have to close your eyes to try and settle yourself
feelings.
down. You may recognise some of these symptoms in
relation to your own response to social situations.
Perhaps you feel highly anxious and distressed only in
some specific situations, such as presenting to a group Heart palpitations, or racing and pounding heart
of people, or perhaps you feel this anxiety across most Sweating
situations that generally involve other people. Do you
Trembling or shaking
feel extremely anxious in any of the following
Shortness of breath or a choking feeling
situations?
Chest pain or a tightness in your chest
Being the center of attention Nausea
Meeting new people
Lightheadedness, dizziness, or feeling faint
Talking to people in authority
Chills or hot flushes
Presentations or talking in front of people
Parties and social gatherings Numbness or tingling sensations
Being watched while doing something, such as Blushing
signing your name, eating, or drinking Dry throat and mouth
These situations commonly cause distress for people
with social anxiety, though there are certainly others. Avoidance
Whatever situation you might feel anxious in, there are You may have been in a few social
a number of symptoms that you may feel in response situations where you’ve wanted to hide
to social situations. away from everyone. As a result, you
may have avoided these types of
situations for some time – trying to
Thoughts
escape from as many as you can, and feeling intense
Do you worry a lot about what other people think, or
distress during the situations you can’t avoid.
worry that you will do something embarrassing in front
of others? Perhaps you really want other people to like
If you can relate to these symptoms, then social
you, or you want to do the right thing by others, and
anxiety might be a problem in your life. Talk to
become really worried that you’ll “mess it up”. You
your doctor or mental health professional about
might focus on other people’s reactions, wondering
the kinds of symptoms that you get in social
how you look or what they are thinking about you.
situations, and let them talk to you about what you
People with social anxiety are often very concerned
can do to ease your anxiety.
that other people will think negatively of them and are
especially worried about situations where they may be
Centrelinical
for
evaluated, criticised or embarrassed. C Interventions
This document is for information purposes only. Please refer to the full disclaimer and copyright statement available at
http://www.cci.health.wa.gov.au regarding the information from this website before making use of such information.
See website www.cci.health.wa.gov.au for more handouts and resources.
what can be done about
social anxiety?
If you have been affected by social anxiety, you might naturally be wondering what you can do about it.
There are a number of different options that you may wish to consider. If you are looking for ways that
you can start reducing your anxiety in social situations, be sure to talk to your doctor or a mental
health practitioner for more information about these and other options available to you.
Medication
tension. To help the body restore itself to a calmer
Medication has been used to reduce anxiety state and reduce the physical symptoms of anxiety you
symptoms in social situations. While there are a can use some relaxation techniques. Some people use
number of different medications that may help to yoga or meditation to help them relax. You can also
reduce anxiety symptoms, it is often difficult to use some simple calming techniques by slowing your
know which one will work the best. You should breathing down. You’d be surprised how much
always speak to your doctor if you have any changing our breathing can change how our bodies
queries about medication, and if your doctor respond to anxiety!
prescribes them, make sure you follow all the
instructions, and report any side effects.
Thoughts
If you feel very anxious when it
comes to social situations, you may
Cognitive-Behavioural Strategies find that your thinking influences
how anxious you feel. For example, being concerned
Another option for reducing social anxiety is to that people will think poorly of you, focussing on
use cognitive-behavioural strategies. These negative feedback, or worrying about future and past
strategies involve addressing the three events, can all increase your anxiety levels.
components that specifically contribute to anxiety
in social situations. These components include By looking at these thoughts, or cognitions, and
thoughts, physical reactions and avoidance. In this determining how you change unhelpful thoughts into
way, cognitive-behavioural strategies seek to more helpful thoughts, you can start to reduce the
change the anxiety habits that may have developed anxiety that you feel in social situations.
in response to social situations.
Behaviour
Physical Reactions One of the most important factors that needs to be ad-
You may have felt a number of dressed in social anxiety is the avoidance of social
physical reactions in response to situations. The more you don’t go into these situations,
anxious social situations such as the more you’ll believe that you can’t go into them.
rapid breathing, pounding heart, That doesn’t necessarily mean that you should take on
sweating, clammy palms, and muscle your biggest fear straight away. There are ways to
gently confront those situations one step at a time.
C entre for
CI linical
nterventions
Breathing
Retraining
Everyone knows that breathing is an essential part of life, but did you know that breathing plays an
essential role in anxiety? This information sheet will briefly discuss the role of breathing in anxiety
and guide you through a simple breathing retraining technique that uses breathing patterns to help
deal with anxiety.
Breathing is a powerful determinant of physical Gaining control over your breathing involves both
state. When our breathing rate becomes elevated, slowing your rate of breathing and changing your
a number of physiological changes begin to occur. breathing style. Use the following steps to be well
Perhaps you’ve noticed this yourself when you‘ve on your way to developing a better breathing habit.
had a fright; you might suddenly gasp, feel a little 1 Ensure that you are sitting on a comfortable
breathless and a little light-headed, as well as feeling chair or laying on a bed
some tingling sensations around your body. Believe 2 Take a breath in for 4 seconds (through the
it or not, the way we breathe is a major factor in nose if possible
producing these and other sensations that are 3 Hold the breath for 2 seconds
noticeable when we are anxious. 4 Release the breath taking 6 seconds (through
the nose if possible)., then pause slightly
Anxious breathing
before breathing in again.
You probably already know that we breathe in to
5 Practise, practise, practise!
obtain oxygen and we breathe out to expel carbon
dioxide. The body naturally maintains optimal levels
of oxygen and carbon dioxide, and this balance is in
Breathing tips
part maintained through how fast and how deeply  When you first begin changing your breathing, it
we breathe. When we exercise, for example, we may be difficult to slow your breathing down to
breathe faster and more deeply in order to replace this rate. You may wish to try using a 3-in, 1-
the oxygen being used and expel the extra carbon hold, 4-out breathing rate to start off with.
dioxide produced by metabolic changes.  When you are doing your breathing exercises,
make sure that you are using a stomach
Anxiety causes an increase in our breathing rate, as breathing style rather than a chest breathing
part of the physical fight or flight response to a style. You can check this by placing one hand on
perceived threat. However, when our breathing your stomach and one hand on your chest. The
rate increases without any physical exertion, we hand on your stomach should rise when you
breathe out too much carbon dioxide. If the body breathe in.
cannot quickly return carbon dioxide levels to the
optimal range, we experience further symptoms  Try to practise at least once or twice a day at a
such as dizziness, light-headedness, headache, time when you can relax, relatively free from
weakness and tingling in the extremities and muscle distraction. This will help to develop a more
stiffness. relaxed breathing habit. The key to progress
really is practise, so try to set aside some time
The normal rate of breathing is 10-14 breaths per each day.
minute – what’s your breathing rate?
By using breathing retraining you can slow your
Breathing Retraining breathing down and reduce your general level
anxiety. With enough practice, it can even help
While temporary overbreathing and to better cope with anxiety when you are in an
hyperventilation are not specifically dangerous (it’s anxious situation.
even used in medical testing!), continued
overbreathing can leave you feeling exhausted or
C entre for
“on edge” so that you’re more likely to respond to
stressful situations with intense anxiety and panic.
CI linical
nterventions
•Psychotherapy•Research•Training
progressive muscle
relaxation
One of the body’s reactions to fear and anxiety is muscle tension. This can result in feeling “tense”, or
can lead to muscle aches and pains, as well as leaving some people feeling exhausted. Think about how
you respond to anxiety. Do you “tense up” when you’re feeling anxious? Muscle relaxation can be
particularly helpful in cases where anxiety is especially associated to muscle tension. This information
sheet will guide you through a common form of relaxation designed to reduce muscle tension.
Muscle tension Relaxation sequence

Muscle tension is commonly associated with stress,
anxiety and fear as part of a process that helps our 1. Right hand and forearm. Make a fist with your right
bodies prepare for potentially dangerous situations. Even hand.
though some of those situations may not actually be 2. Right upper arm. Bring your right forearm up to
dangerous, our bodies respond in the same way. your shoulder to “make a muscle”.
Sometimes we don’t even notice how our muscles 3. Left hand and forearm.
become tense, but perhaps you clench your teeth
4. Left upper arm.
slightly so your jaw feels tight, or maybe your shoulders
become. Muscle tension can also be associated with 5. Forehead. Raise your eyebrows as high as they will go,
backaches and tension headaches. as though you were surprised by something.
6. Eyes and cheeks. Squeeze your eyes tight shut.
Progressive Muscle Relaxation 7. Mouth and jaw. Open your mouth as wide as you can,
One method of reducing muscle tension that people as you might when you‘re yawning.
have found helpful is through a technique called 8. Neck. !!! Be careful as you tense these muscles. Face
Progressive Muscle Relaxation (PMR). In progressive forward and then pull your head back slowly, as though
muscle relaxation exercises, you tense up particular you are looking up to the ceiling.
muscles and then relax them, and then you practise this 9. Shoulders. Tense the muscles in your shoulders as you
technique consistently. bring your shoulders up towards your ears.
preparing for relaxation 10. Shoulder blades/Back. Push your shoulder blades
back, trying to almost touch them together, so that your
When you are beginning to practice progressive muscle chest is pushed forward.
relaxation exercises keep in mind the folloing points. 11. Chest and stomach. Breathe in deeply, filling up your
• Physical injuries. If you have any injuries, or a lungs and chest with air.
history of physical problems that may cause muscle 12. Hips and buttocks. Squeeze your buttock muscles
pain, always consult your doctor before you start. 13. Right upper leg. Tighten your right thigh.
• Select your surroundings. Minimise the distraction
to your five senses. Such as turning off the TV and 14. Right lower leg. !!! Do this slowly and carefully to
radio, and using soft lighting. avoid cramps. Pull your toes towards you to stretch the
• Make yourself comfortable. Use a chair that calf muscle.
comfortably seats your body, including your head. 15. Right foot. Curl your toes downwards.
Wear loose clothing, and take off your shoes. 16. Left upper leg. Repeat as for right upper leg.
• Internal mechanics. Avoid practicing after big,
17. Left lower leg. Repeat as for right lower leg.
heavy meals, and do not practice after consuming any
intoxicants, such as alcohol. 18. Left foot. Repeat as for right foot.
general procedure
Practice means progress. Only through practice can you
1 Once you’ve set aside the time and place for
relaxation, slow down your breathing and give become more aware of your muscles, how they respond
yourself permission to relax. with tension, and how you can relax them. Training your
2 When you are ready to begin, tense the muscle group body to respond differently to stress is like any training –
described. Make sure you can feel the tension, but not practising consistently is the key.
so much that you feel a great deal of pain. Keep the
muscle tensed for approximately 5 seconds.
3 Relax the muscles and keep it relaxed for
approximately 10 seconds. It may be helpful to say
something like “Relax” as you relax the muscle.
4 When you have finished the relaxation procedure,
remain seated for a few moments allowing yourself to Centrelinical
for
become alert. C Interventions
improving
how you feel
People often believe that the feelings and emotions they remember that feelings are not thoughts. For example, you
experience are caused by external events, situations, and the might hear a person saying “I think I’m anxious,” but they’re
behaviour of others. For example, we might hear ourselves probably thinking “Everyone will laugh at me,” and feel
say, “My partner made me so angry,” “My boss made me so anxious. More commonly, you might hear someone saying
nervous,” “This trip down south made me feel so relaxed,” something like “I feel that my boyfriend doesn’t appreciate
or “I’m depressed because I didn’t get the job I wanted.” the gift I bought for him,” when they are actually thinking
What is the assumption underlying these statements? That “My boyfriend doesn’t appreciate the gift I bought for him,”
someone or something other than ourselves was directly and feel hurt.
determining the feelings we experienced. However, if we
stop to analyse the process that links an external situation Unhelpful Thinking Styles
to our emotional responses, we will find that there is a step
in between. What sorts of thoughts are unhelpful? Unhelpful thoughts
are those that tend to focus on the negative aspects of a
situation, or those that overestimate the chances of a
What Influences My Feelings?
negative event occurring, or those that place unrealistic
What really makes us feel and respond the way demands on yourself or others. These are also often
we do, is not the situation or the words and known as unhelpful thinking styles because they are patterns
actions of another person, but how we perceive of thinking that have become a habit and contribute to a
that situation or that person’s actions. It is our person feeling unhelpful negative feelings.
thoughts and beliefs about an event that significantly
influences our feelings and actions. What Can I Do?
Here’s an example. Suppose you went to a party and your Plenty! There are lots of things you can do to help yourself
host introduces you to Mike. As you talk to him, you notice feel better, and this next suggestion has been proven to be
that he does not look directly at you but often looks around pretty effective. If unhelpful thoughts lead to distressing
the room. How would you feel if you thought, “Boy, this emotions, then it might be quite reasonable to say that the
guy is so rude! He won’t even look at me while I’m talking most effective thing to do would be to change those
with him! How nasty!” What if you thought, “Mike must unhelpful thoughts to helpful ones! Yeah? Okay, so, how
think that I’m really unattractive and uninteresting. I must can you do that?
be a really boring person. Nobody wants to talk to me!”
What about if you were to think, “Mike’s probably waiting First, identify how or what you are feeling. Then, ask
for a friend to come. Maybe he’s getting a bit anxious.” yourself “What am I thinking? What conclusions am I
You probably realised that you felt three different emotions making?” to see how and why you are feeling distressed.
as a result of those three different thoughts. Often, we are Remember, unhelpful thoughts will lead to you feeling
not aware of our thoughts and beliefs because they are so upsetting emotions.
automatic and happen quickly. But they are there, and they
affect the way we feel. The next step is to challenge your thinking by
exploring other possible explanations and looking at
a situation from different points of view. You might
Why do I feel distressed?
ask yourself, “What other ways are there of viewing
We’ve talked about the way our thoughts affect how we this situation? How might someone else view this
feel. If we are feeling happy and excited, chances are we situation? What other explanations could there be?”
have been thinking positive thoughts and about positive
things. On the other hand, if we are feeling anxious, The final step is to ask yourself, “How can I revise my
depressed, and upset, it is very likely that we have been original thoughts to take into account these other possible
thinking negative thoughts. We call these unhelpful thoughts viewpoints?” Then, think of an alternative explanation. This
(simply because they lead to unpleasant feelings or unhelpful becomes your new, balanced, and helpful thought. A
actions!). All of us, at times, think things that make us feel balanced and helpful thought or belief is one that takes into
sad or anxious, and that is a normal part of life. However, if consideration alternative viewpoints and helps you feel
you often feel distressed or upset, you might need to better. Replace your original, unhelpful thought with this
examine your thinking in order to improve how you feel. new, balanced, and helpful belief. Once you have done this,
you will probably find that you feel better and your mood
Feelings are not Thoughts will be improved.
When we first try to distinguish thoughts from feelings, it

C
This document is for informa on purposes
only. Please refer to the full disclaimer and entre for
can be easy to confuse them. We might be used to talking
about thoughts and feelings as being part of the same
copyright statement available at h p://
www.cci.health.wa.gov.au regarding the infor‐
ma on from this website before making use of
CI linical
nterventions
experience, but it is more helpful to separate them and such informa on. •Psychotherapy•Research•Training
thinking
& feeling
People often believe that the feelings and emotions they Automatic thoughts
experience are determined by external events, situations, and
the behaviour of others. For example, we may hear Just as we are not always conscious of the way we walk or how
ourselves say, “My boss made me so nervous,” “My partner we drive a car, we are often not aware of our thinking. Some
made me so angry,” “This trip down south made me feel so of our thinking is so habitual that it is automatic, and just like
relaxed,” or “I’m depressed because I didn’t get the job I driving, when things are automatic, we might not be conscious
wanted.” What is the assumption underlying these of them. All of the time, our brains are turning over thoughts
statements? That someone or something other than and ideas. However, we are not consciously aware of most of
ourselves was directly determining the feelings we them because it happens relatively fast and we are not
experienced. accustomed to slowing them down. Our automatic thoughts,
however, play an important role in our emotional well-being.
We come to these conclusions automatically without asking
ourselves if this assumption is true. However, if we stop to There are three kinds of automatic thoughts:
analyse the process that links an external situation to our Neutral thoughts, e.g. "I think I will buy some bread today."
emotional responses, we will find that there is a step in
between. Positive thoughts, e.g. "This is something I can do really
well."
How Our Thoughts Influence Our Feelings Negative thoughts, e.g. "I often find it hard to concentrate –
What really makes us feel and respond the way we do, is I must be really stupid."
often not the situation or the words and actions of another
person, but how we perceive that situation or that person’s Automatic thoughts often reflect worries and
actions. It is how we see something or someone and what concerns, however they can be about anything at
we think about it or them that really influences how we feel. all, anything we have ever seen, heard or learned.
It is our thoughts and beliefs about an event that significantly In addition, it can be anything we know about
influences our emotions and actions. from any source at all. Obviously, though, negative
automatic thoughts are the ones that can cause us
Here’s an example. Suppose you went to a party and your emotional distress. People who are depressed tend to think
host introduces you to Mike. As you talk to him, you notice negative thoughts about themselves, the world about them, and
that he does not look directly at you but often looks around their future, and it is these thoughts that can be changed to lift
the room. How would you feel if you thought, “Boy, this guy your depression.
is so rude! He won’t even look at me while I’m talking with
him! How nasty!” What if you thought, “Mike must think Feelings are not Thoughts
that I’m really unattractive and uninteresting. I must be a
When we first try to distinguish thoughts from feelings, it can
really boring person. Nobody wants to talk to me!” What
be easy to confuse them. We might be used to talking about
about if you were to think, “Mike’s probably waiting for a
thoughts and feelings as being part of the same experience, but
friend to come. Maybe he’s getting a bit anxious.” You
it is more helpful to separate them and remember that feelings
probably realised that you felt three different emotions as a
are not thoughts. For example, you might hear a person saying
result of those three different thoughts. Often, we are not
“I think I’m anxious,” but they’re probably thinking “Everyone
aware of our thoughts and beliefs because they are so
will laugh at me,” and feel anxious. More commonly, you might
automatic and happen quickly. But they are there, and they
hear someone saying something like “I feel that my partner
affect the way we feel.
doesn’t appreciate the gift I bought for him,” when they are
actually thinking “My partner doesn’t appreciate the gift I bought
What am I Feeling? for him,” and feel hurt.
It is often difficult to know exactly what we are feeling, and
sometimes it can also be difficult to put it into words. The
list below contains words that describe feelings, and this Being aware of your feelings and your thoughts is the first step
might be a useful starting point in you being able to towards feeling better. If thinking influences feelings, then it
understand the connection between your thinking and your makes sense that if you want to change the way you feel, you
feelings. need to change the way you think. Look out for the
information flyer entitled “Changing the Way You Think” for
Words That Describe Feelings more details on how to do this.
Tense Enraged Frightened Cheerful
Annoyed Happy Panicky Euphoric
Unhappy Exhilarated Frustrated Mad
Exuberant Keyed-up Scared Uneasy
Anxious Irritated Flat Sad
Depressed Joyful Tired Discouraged
C
Angry Excited Nervous Jealous This document is for informa on purposes
This is only a limited list but it should give you an idea of the
kinds of words we could use to describe our feelings.
CI linical
nterventions
such informa on. •Psychotherapy•Research•Training
analysing
your thinking
We’ve talked about the way our thoughts affect how we feel. How to Uncover Your Unhelpful Thoughts
If we are feeling happy and excited, chances are, we have
been thinking positive thoughts and about positive things. By asking yourself a number of questions, you can uncover any
On the other hand, if we are feeling anxious, depressed, and other unhelpful thoughts underlying an initial thought. Let’s use
upset, it is likely that we have been thinking negative the example of being at the party to identify the unhelpful
thoughts. We call these unhelpful thoughts (simply because thoughts underlying the initial thought "I don't want to be
they lead to unpleasant feelings or unhelpful actions!). All of here." The following is a description of the thoughts that might
us, at times, think things that make us feel sad or anxious, be going through your head as you uncover other unhelpful
and that is a normal part of life. However, if you often feel thoughts. The questions in bold are your unhelpful thought
distressed or anxious, you might need to examine your discovery questions.
thinking to improve how you feel.
If unhelpful thoughts lead to distressing emotions, then it

"I don't want to be here".
might be quite reasonable to say that the most effective thing
to do is to change those unhelpful thoughts to helpful ones! "I don't want to be here because…?"
So, how can you do that? To start influencing the "…people will look at me and know that I
way you feel, you need to learn to be aware of, and am depressed"
“capture,” those unhelpful thoughts and beliefs, "…and that is bad because…?"
with the ultimate aim of changing them. To do
that, let’s start with doing an ABC analysis. "Well, they will think something is wrong with me"
"…and what is bad about that..?"
The ABC analysis begins with identifying the ‘A’ which stands
"….They will think I'm crazy!"
for ‘Activating Event.’ Simply write down an event or a
situation in which you experienced a strong negative "…and what does that say about me?"
emotion, such as, depression. Record the situation the same "…..that I must be crazy."
way a video camera might record it – just the facts. This
means that you do not include your thoughts about why the Your task is to become an expert at identifying your unhelpful
situation occurred, who was responsible, and how you felt thoughts. Sometimes, one or two thoughts might not
about it. Just describe the event simple, without any ‘frills.’ represent the other unhelpful ones you might have had. As
such, to get to those other thoughts, you might need to ask
The next step is to identify the ‘C’ which stands for some of the following questions, called Thought Discovery
‘Consequences,’ and this includes both your feelings and Questions:
your actions/behaviour. Write down the words that best
describe your feelings. When you have written down these “What is bad about that?”
words, rate the intensity of the emotion from 0 to 100. The “What is it that I see happening in this situation?”
higher the number, the more intense the emotion. Have a “What am I concluding about myself or others in this
look at all those feelings and then choose the feeling that best situation?”
represents the emotion you actually felt at the time and “… and that is bad because …”
underline it. You might also want to note any actions that “… and what does this say about me …?”
you carried out, for example, drawing all the curtains, putting
on the answering machine, and going to bed. It is best to be as specific as you can, even if some of your
unhelpful thoughts sound stupid or embarrassing when you
Now, bearing in mind the situation and the feelings you think about them. Discovering your unhelpful thoughts, no
experienced, identify the ‘B,’ which represents your ‘Beliefs’ matter how silly they sound, is important in learning how to
or thoughts, expectations, perceptions, and attitudes. Ask better manage your mood.
yourself “What was I thinking of when the event occurred?”
“What was going through my mind at the time?” Write After you have done this, the next step is to do some
down all of these thoughts in a list. When you have ‘Detective Work‘ and ‘Disputation.’ At this point, it is
completed this task, read through each statement and then important that you understand how to identify your feelings
underline the thought that is most associated with the and thoughts surrounding a particular situation, especially one
primary emotion you felt during the ‘A‘. We’ll now call it in which you experienced unhelpful, negative emotions. When
your hot thought. Now rate how much you believe this a person experiences unhelpful emotions, they might get a
thought on a scale from 0 to 100. stronger physical reaction in their body, such as a tightness in
the chest when anxious, an increase in blood pressure when
Let’s look at an example. Imagine walking into a party and angry, or a sense of heaviness when depressed. Emotions such
feeling anxious. To do an ABC analysis, you might ask as depression, guilt, fear, rage, and anxiety might also lead to
yourself, "How am I making myself anxious? What am I avoidance and unhelpful behaviours towards yourself and
thinking?" You might identify a thought such as, "I don’t others, get in the way of effective problem solving, and
want to be here." If you only had this thought, you’d contribute to long term difficulties such as hypertension, heart
probably not experience a strong emotion but only feel disease, interpersonal problems, and psychological problems.
mildly anxious. If you do experience a strong emotional Doing the ABC analysis is taking the first step toward learning
response to this thought, it probably indicates that there are to better manage your mood and helping yourself feel better.
other thoughts underlying this thought. Therefore, the
thought, "I don’t want to be here" is only an initial thought,
and you would need to discover what other unhelpful
C
thoughts were present to invoke such a strong emotional only. Please refer to the full disclaimer and entre for
response.
CI linical
nterventions
changing your
thinking
In the handout ‘Thinking & Feeling,’ we established that it Detective work and disputation is about trying to be
is our thoughts that influence our feelings, emotions, and objective about our thoughts. It is about analysing them,
behaviours – the thoughts and feelings connection. We assessing, and evaluating them to see if they are indeed
also discussed and identified some unhelpful thinking valid and true, as opposed to accepting these thoughts
patterns and styles that we frequently use. Often, a and believing them without question.
depressed person will think negative thoughts that are
characterised by these unhelpful thinking patterns, which The End Result
lead them to feel depressed, miserable, and distressed.
This, in turn, maintains and perpetuates the depression. We’ve spent some time examining the link between thinking
and feelings, and discussed how to identify your unhelpful
The key to changing the way we feel is found in thoughts and thinking styles. We’ve also talked about
challenging and changing our unhelpful thoughts and looking for evidence that might prove or disprove your
beliefs. This begins with you taking a good hard look at unhelpful beliefs as well as considering other alternative
ways of viewing the situation. Now let’s look at how you
them. Imagine that you are a detective and a lawyer, and
can change the way you are thinking in order to improve
your unhelpful thoughts and beliefs are to be investigated how you are feeling.
or on trial.
By this time, you would have learned how to describe an
To assess whether or not your thoughts and beliefs are Activating Event, identify your automatic and unhelpful
valid, you need to gather and examine evidence. As Beliefs and thoughts (including the Hot Thought) that have
such, we liken this process to that of being a detective. contributed to your experiencing distressing emotions
This is the fourth step (or D) that follows on from the (Consequences), and recognise a few unhelpful thinking
ABC Analysis. styles you might have used. You would have also used the
Detective Work and Disputation section to challenge your
Detective Work hot thought. Now, take a good look at the evidence you
have listed and the answers to the other challenging
“D” stands for “Detective Work” where you look for questions. Is there enough evidence to believe that your
evidence that does or does not support your thoughts hot thought is true all of the time? Are there other
and beliefs. Like all good detectives, we need to find out alternative explanations?
the facts, and gather the evidence. Here are some
helpful questions: At this point, ask yourself, “How can I revise my hot
thought to take into account all the evidence I have listed?”
Then, write out an alternative explanation. This becomes
• Where is the evidence (or proof) that
your new, balanced thought. A balanced and helpful thought
my thoughts/beliefs are true? or belief is one that takes into consideration all the
• Are there any evidence that disproves evidence, objective information, and alternative viewpoints.
my thoughts/beliefs? This is the fifth step of the ABC analysis – the End Result,
• How do I know that my thoughts/beliefs are true? where you replace your original, unhelpful thought with this
• Are there facts that I’m ignoring or I’ve new, balanced, and helpful belief.
overlooked?
• What other explanations could there possibly be? After you have written down your new, balanced thought or
• How realistic are my thoughts, beliefs, and belief, ask yourself, “How do I feel now?” Look at the most
expectations? intense emotion you identified in section C, and re-rate
how intense that emotion feels for you now. Often, you
Disputation will find that it is not as extreme and distressing.
“D” also stands for ”Disputation.” Remember, you are Finally, read through the Detective Work and Disputation
also like a lawyer, asking questions that challenge your section again, and re-rate how much you believe the hot
thoughts, beliefs and expectations, ultimately testing and thought now.
challenging whether or not they stand true, and whether
they help or hinder you. Here are some other helpful This final step of replacing your unhelpful (hot) thoughts
questions to ask yourself: with balanced thoughts is very important. Challenging your
beliefs and evidence testing is the process of change, but the
final step is where you MAKE the change. You’ll probably
• What other ways are there of viewing the find that this process becomes easier after some practice.
situation? So keep it up. Keep practising and remember that you can
• How might someone else view the situation? be your own expert at managing your moods!
• If I were not depressed, how might I view the
situation differently?
• Realistically, what is the likelihood of that
C
happening?
• Is it helpful for me to think this way?
CI linical
nterventions
unhelpful
thinking styles
When a person experiences an unhelpful emotion (eg, depression or anxiety), it is usually preceded
by a number of unhelpful self-statements and thoughts. Often there is a pattern to such thoughts
and we call these, "unhelpful thinking styles". One of the things we have noticed is that people use
unhelpful thinking styles as an automatic habit. It is something that happens out of our awareness.
However, when a person consistently and constantly uses some of these styles of thinking, they can
often cause themselves a great deal of emotional distress. This information sheet describes a
number of "unhelpful thinking styles". As you read through them, you might notice some thinking
patterns and styles that you use consistently. Some of these styles might sound similar to one
another. They are not meant to be distinct categories but to help you see if there is a kind of
pattern to your thoughts.
Mental Filter:
This thinking styles involves a "filtering in" and
"filtering out" process – a sort of "tunnel vision," Shoulding and Musting:
focusing on only one part of a situation and Sometimes by saying “I should…” or “I must…”
ignoring the rest. Usually this means looking at you can put unreasonable demands or pressure
the negative parts of a situation and forgetting the on yourself and others. Although these
positive parts, and the whole picture is coloured statements are not always unhelpful (eg “I should
by what may be a single negative detail. not get drunk and drive home”), they can
sometimes create unrealistic expectations.
Jumping to Conclusions:
We jump to conclusions when we assume that Overgeneralisation:
we know what someone else is thinking When we overgeneralise, we take one instance in
(mind reading) and when we make the past or present, and impose it on all current
predictions about what is going to or future situations. If we say “You always…” or
happen in the future (predictive “Everyone…”, or “I never…” then we are
thinking). probably overgeneralising.
Personalisation: Labelling:
This involves blaming yourself for everything that We label ourselves and others
goes wrong or could go wrong, even when you when we make global statements
may only be partly responsible or not responsible based on behaviour in specific
at all. You might be taking 100% responsibility situations. We might use this label
for the occurrence of external events. even though there are many more
examples that aren’t consistent with that label.
Catastrophising:
Catastrophising occurs when we “blow things out Emotional Reasoning:
of proportion“., and we view the situation as This thinking style involves basing your view of
terrible, awful, dreadful, and horrible, even situations or yourself on the way you are feeling.
though the reality is that the problem itself is For example, the only evidence that something
quite small. bad is going to happen is that you feel like
something bad is going to happen.
Black & White Thinking:
This thinking style involves seeing only one Magnification and Minimisation:
extreme or the other. You are either wrong or In this thinking style, you magnify the positive
right, good or bad and so on. There are no in- attributes of other people and minimise your
betweens or shades of gray. own positive attributes. It’s as though you’re
explaining away your own positive characteristics
C entre for
CI linical
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what are
core beliefs?
By now you are probably becoming used to the This process is like sifting through the layers of self-talk to get
process of challenging your thinking in a range of at what is at the bottom layer. Now, you are ready to
situations. You know how to identify the thoughts challenge your core beliefs. Even though these beliefs are
that are causing you distress and how to challenge strongly held, it is important that they are challenged, just like
them and replace them with more balanced thoughts. any unhelpful thoughts. Once you have fully identified what you
However, you might notice that there are times when it is are telling yourself, you can begin to see if your core beliefs
harder to believe the new balanced thought and the old hold up against all that you have experienced. This process of
unhelpful thoughts seem to be very powerful. You might challenging your core beliefs may not be an easy one. If you
notice that this happens in certain kinds of situations. find the process too difficult or distressing, do consider seeing
a mental health professional and discussing this with them.
A possible explanation for this ‘difficulty in letting go’ of an
unhelpful thought is that there may be a strong core belief at Challenging Your Core Beliefs
the root of that unhelpful thought. Core beliefs are the
very essence of how we see ourselves, other people, the To evaluate and challenge your core beliefs, ask yourself “What
world, and the future. Sometimes, these core beliefs become experiences do I have that show that this belief is not
‘activated’ in certain situations. Here’s an example: completely true all the time?” List as many experiences, and be
as specific, as possible. Remember to write down everything
Erica is able to challenge her thinking in most situations. even when you’re not sure if they are relevant.
However, she has noticed that she has trouble challenging her When you have considered all the experiences you have
thinking in situations involving her flatmates and friends. In written down, develop an alternative, balanced core belief.
these situations, she has recognised that her thinking is often Remember that these experiences show that your unhelpful
about being unlikeable. In fact, when she really looks hard at core belief is not completely true all the time. What would be
her thinking, she can see that often the underlying self- an appropriate balanced and helpful core belief? Write this
statement is, “I’m unlovable.” down.
Core beliefs, such as the one from the above example, Behavioural Experiments
develop over time, usually from childhood and through the You could also try doing a behavioural experiment to challenge
experience of significant life events or particular life those hard-to-budge unhelpful core beliefs. The purpose of
circumstances. Core beliefs are strongly-held, rigid, and doing an experiment is to find out how true your core beliefs
inflexible beliefs that are maintained by the tendency to focus are. Here’s how you could conduct an experiment.
on information that supports the belief and ignoring evidence
that contradicts it. For example, Erica focuses on any 1. Write down the core belief you want to test
feedback from her flatmates that isn’t positive and then uses 2. Think of a few tasks you could do to test your core belief
this to confirm that yet again she is unlikeable. Even neutral 3. Write down what you would expect would happen if your core
statements from her flatmates and friends are often belief were true
interpreted as negative. Over the years, this narrow focus 4. Carry out the tasks
gives strength to the belief and Erica no longer thinks to 5. Record what actually happened when you carried out the tasks
question it. It is just totally and absolutely accepted. It is not 6. Compare the actual results with your prediction and write down
surprising, then, that these types of beliefs are the hardest to what you might have learned from the experiment. Then, write
shake. down a new balanced belief that fits with your conclusion.
Identifying Themes from Thought Diaries Following Through

So, how can you start identifying your core beliefs? The first You might find it useful to write your balanced core beliefs
step is to look over your Thought Diaries to see if your ‘hot’ onto cards that you can carry around with you as a reminder
thoughts have any common themes. You might notice that when this type of thinking is triggered. Once you’ve developed
there are certain patterns to your thoughts – similar themes balanced core beliefs, follow through on them. Balanced core
that occur in the B columns. Look closely at these to identify beliefs require careful nurturing and ‘tender loving care.’ Affirm
the patterns. You may become aware of one or two yourself by using positive self-statements, remind yourself of all
common themes found in the things you say about yourself, the evidence against the unhelpful core belief. Also, act
others, and the world. against your unhelpful core belief. Ask yourself, “If I really
believed my balanced belief, what are the things I would do?”
Identifying A Core Belief Then, go out and do them. The more you do these things, the
more you will come to believe your balanced beliefs. Over
The process of identifying a core belief is not a great deal time, these new core beliefs will be integrated into your belief
different from what you have already being doing in your system.
thought diaries. Essentially, the idea is to extend the hot
thought further to reveal the bottom line or root of what
C
you might be thinking. Use questions such as: “If that’s true,
what does that mean?“ “What’s bad about that?” “What
does that say about me?”
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nterventions
Situational
exposure
One of the ways that people avoid feeling anxiety in certain situations is to avoid those situations
wherever possible. However, by not exposing yourself to those situations you don’t get the chance to
disconfirm your fears, which in turn can make those fears even stronger. If being in those situations is
important to you, you will need to face your fears in a real situation and begin to turn social activity into
a positive experience. This information sheet is designed to show you how you can begin to do that.
Graded Exposure Building Steps Towards Your Goal

Some people might encourage you to tackle your biggest Now that you have a personal, realistic,
fear first – to “jump in the deep end” and get it over and achievable, measurable, and specific goal
done with. However, many people prefer to take it “step- that you’d like to achieve, you can plan
by-step”, what some people call “graded exposure”. By your “graded exposure” program. This
using graded exposure you start with situations that are involves breaking the goal down so that 80
easier for you to handle, then work your way up to more you can work step-by-step towards 75
65
challenging tasks. This allows you to build your confidence your major goal. Of course, goals with 50
slowly, to use other skills you have learned, to get used to high distress (eg a rating of 80+) will 35
the situations, and to challenge your fears about each need more steps than a medium
situational exposure exercise. By doing this in a structured distress goal (eg a rating of 40+). You can break your
and repeated way, you have a good chance of reducing your goal into smaller steps by changing WHO is there,
anxiety about those situations. WHAT you do, WHEN you do it, WHERE you do it,
and HOW long you do it for. Follow the PRAMS criteria
Situations That You Avoid for developing each step. Here’s an example.
The first thing to do is to think about the situations that you
fear and try to avoid. For example, some people might fear GOAL: To go out to a pub on a weekend DISTRESS
and avoid going to social places, or being assertive with 0-100
night with friends and stay there for at least 2
others. Make a list of these situations. hours 80
Once you have made the list, indicate how much distress
you feel in those situations by giving them each a rating on a
STEP DISTRESS
scale of 0 to 100.
0-100
0 – You are perfectly relaxed Go to the local pub on a weekday afternoon
25-49 – Mild: You can still cope with the situation
1 (with a friend who knows about the problem),
50-64 – Moderate: You are distracted by the anxiety, but are buy a soft drink and stay for 10min 35
still aware of what’s happening
65-84 – High: Difficult to concentrate, thinking about how Go to the local pub on a weekday afternoon
to escape 2 (with a friend who knows about the problem),
85-100 – Extreme: The anxiety is overwhelming and you just buy a soft drink and stay for 30min 45
want to escape from the situation
Go to the local pub on a weeknight (with a
Planning Your Goals 3 friend who knows about the problem), staying
55
from 7pm to 8pm
Now you can start to turn the situations you avoid into
goals that you’d like to achieve. For example, a situation that Go to the local pub on a weekend night (with
you avoid might be “Going to pubs“, which has a distress
4 a friend who knows about the problem), and
rating of 75. A goal for this might be “To go out to a pub on a stay for 30 minutes 65
weekend night with friends and stay there for at least 2 hours”.
When you are developing a goal, it helps to follow the Go to the local pub on a weekday night (with
PRAMS criteria: 5 a friend who knows about the problem),
staying from 8pm to 10pm 70
Personal: It needs to be important to you
Realistic: It needs to be possible to achieve Go to the local pub on a weekend night
Achievable: It needs to be probable that you can achieve it 6 (some of the friends don’t know about the
Measurable: It needs to be easily assessed (eg compare problem), staying from 8pm to 10pm 80
“Staying for 2 hrs” with “Being friendly” - what does
‘friendly’ mean?)
Specific: It needs to be as clear (eg compare “To eat in pub-
lic” with “To eat lunch in a local restaurant on my own.” Centrelinical
for
C Interventions
Situational exposure
Climbing Steps Towards Your Goal climbing the steps
Once you have developed the steps that you can take 1) One step at a time. Climbing a
towards your main goal, you can make an appointment with stepladder is not about taking one giant leap,
yourself to start on your first step. Here are a few tips for it’s about taking one small step at a time.
how you can progress through your situational exposure You begin with the least difficult step and
steps. gradually work your way up the step ladder
getting used to the anxiety you feel at each
step. Your primary aim at each step is to
before the first step complete that step and that step alone.
1) Coping with anxiety. Before you start on a situational 2) Over and over again. Do a step frequently and
exposure exercise, it is useful to have developed ways of repeatedly, and try to do them in close succession to make
coping with the distress you might feel in the situation. sure you are comfortable with the situation before you
Using well practised breathing techniques can help to move onto the next step. This might take 3 or 4 times.
reduce the physical response to anxiety. Reducing your
general level of anxiety through muscle relaxation 3) Use your skills. Work through any unhelpful thoughts
techniques can also help to prepare you for entering the about the situation after you have completed each step, or
situation. repeated a step. Allow yourself to unwind with a
relaxation session.
2) Challenging negative thoughts. Another way to
prepare yourself is to challenge negative thoughts that 4) Acknowledge the steps you’ve made. When you are
you might have about yourself or the situation. If you comfortable with a particular step, admit to your
spend time working through these thoughts you can successes and acknowledge the steps that you’ve made so
come up with some helpful ways of thinking about the far.
situation. 5) Stepbacks. We all have our up and down days, and
These strategies are discussed in other information sometimes you might think you’ve taken a ‘step-back’
sheets in this series. because the situational exposure exercise didn’t go as well
as you hoped. If you are having difficulties with a particular
step then it might be useful to take a “step back“ and
completing a step work on the previous step again or design an “in between”
step between the one you’ve completed and the difficult
1) Expect some anxiety. When you enter the situation – one. That’s why doing a step over and over is so helpful.
at any step - remember that you’ll probably experience Remember – take it one step at a time.
some anxiety or discomfort. That’s why it’s important to
start small, and work your way up. use a diary to record your progress
2) Use your skills. Just as used your coping skills to A diary can help you to keep track of the steps you’ve
prepare for the situation, use them while you are in the completed, and how you can cope with any difficulties you’ve
situation. Use your breathing to reduce your physical had. You could use the following columns
anxiety response and challenge negative thoughts that
you might have. • Situation: Describe the step and the situation
• Expected Distress: Indicate the distress level you
3) Stay in the situation. While it might be tempting to expected (0-100)
leave if you feel uncomfortable, try to stay in the • Actual Distress: Indicate the level of distress you actually
situation until the anxiety goes down. In this way you experienced
can see that, as frightening as the feelings are, they are • Outcome: Indicate whether you completed the step and
not dangerous, and they do subside. the skills you used that were helpful, OR, if you had
4) Stay involved. ‘Staying away' can happen in many difficulties, describe how you can prepare for the next
different ways, such as sitting away from others, or time.
avoiding eye contact. Stay involved in the situation by
noticing what is happening and really experiencing the If you’re having difficulties with situational exposure
situation. Really taking part in these situations is the only tasks, talk to a professional so that they can guide
way to make sure you get used to the anxiety. you through the process.
5) Stay sober. Staying involved means being fully aware of
what is happening. This means not taking alcohol or
drugs to try to “mentally escape” the situation.
Centrelinical
for
C Interventions
What are
Safety behaviours?
What are safety behaviours? Why are safety behaviours a problem?
Safety behaviours are used in an attempt to prevent Safety behaviours may seem helpful, because they reduce
fears from coming true and to feel more comfortable in anxiety in the short-term. Unfortunately they keep anxiety
situations we are anxious about. going in the longer term because...
If we believe that a situation will not go well, we are  Safety behaviours stop us from directly testing our
likely to feel anxious and to have an urge to avoid the fears. Although we haven’t avoided the situation
situation. If we can’t avoid the situation all completely, by using our safety behaviours we are not
together, we might use subtle forms of directly testing our fear. Our untested fears will
avoidance or precautions to try to continue to arise in the future.
prevent our fears from coming true. We
 Safety behaviours can become ‘self-fulfilling
call these safety behaviours.
prophecies’. Safety behaviours can
Safety behaviours may be very different for different actually cause the outcomes we are
people. It is not what you do, but why you are doing it trying to prevent by using them. For
that determines whether something is considered a instance, imagine if I stay quiet at
safety behaviour. Here are some examples... work meetings because I am worried
about saying something wrong and
my boss being annoyed. My boss might actually get
Behaviour Fear the behaviour is
more frustrated with me for not contributing to
intended to prevent
meetings than they would have if I did contribute from
Staying quiet in social If I talk I might say something time to time.
situations stupid and I would feel
humiliated  If our fears don’t come true we mistakenly ‘thank’ the
Not touching things in If I touch something in public I safety behaviour. If we use our safety behaviours and
public could get sick and die our fears don’t come true, we might believe that the
safety behaviours ‘prevented’ our fears. As a result we
Bringing my water bottle If I get anxious I will get a dry can become very dependent upon our safety
everywhere mouth and choke behaviours and start to feel even more anxious if they
Wearing headphones on If someone tried to speak to can’t be used. The truth may be that our fears might
public transport me I wouldn't know what to not have come true even without the safety behaviour,
say and they would think I am but we never discover this as long as we continue
an idiot relying on them.
 Safety behaviours increase our self-focused attention.

Some of these are behaviours people might engage in Safety behaviours often take our focus off the ‘task at
without anxiety. For example, someone hand’, and instead our awareness becomes overly
might wear headphones on public focused on ourselves (e.g. our thoughts, how we are
transport to listen to music for feeling), which can lead to further anxiety.
enjoyment, rather than because they are
anxious about speaking to people. This If anxiety stays high after repeatedly confronting a
highlights that it is not the behaviour itself, but the situation, you are likely using safety behaviours that are
function of the behaviour that is important. preventing you from directly testing your fears. It’s
important to recognise safety behaviours so you can plan
If you are uncertain whether something is a safety
to stop using them in anxiety-provoking situations.
behaviour or not, ask yourself: how anxious would I feel if
I could not do this? If you would feel anxious without the
This document is for information purposes only. Please refer to the full disclaimer and
behaviour, it is probably a safety behaviour. copyright statement available at http://www.cci.health.wa.gov.au regarding the infor-
mation from this website before making use of such information.
staying
healthy
Whatever form of treatment you have been receiving 4. Expect slip-ups and down days
for your difficulties – medication or psychotherapy –
Slip-ups in progress can happen at any time and are to
it‘s important that you maintain whatever gains you
be expected. Try not to fall into the trap of believing
have made. If you have been seeing a mental health
that you are ‘back to square one’ as this will only make
practitioner, keep practising the strategies you might
you feel worse. Use your skills of challenging your
have learned in therapy. This means continuing to apply
thinking to help when this situation occurs. It might be
all the useful skills and insights about yourself you might
useful to remind yourself that most people have ‘down
have gained and they will soon be integrated into your
days’ or days where life’s hassles are harder to deal
lifestyle.
with – its part of being human! Also, you can use
setbacks as a way of learning something new about
There are also some other things you can do in order
yourself to help avoid similar problems in the future.
to make the most of what you have learned to stay well
or gain that extra improvement. Here are some
Remember – progress may be a bumpy road at times
suggestions:
but it will be a rewarding journey on the whole!!!
1. Keep to a balanced routine & lifestyle

Use the spaces below to jot down a few things you
A chaotic lifestyle can be stressful in itself. Try to keep could do to remain healthy.
to a reasonably structured routine and a balanced
Thinking
lifestyle. This means making sure you maintain good
eating, sleeping, and exercising habits, and engage in
social activities that can be both fun and challenging.
Social Activities Pleasant Activities

2. Develop a good social support network
It is wise to find someone with whom you can sit down Healthy
and have a good talk. This doesn’t mean a therapy
session where you pour out your heart but rather just
a chance to talk through what’s going on in your life,
what your goals are, and generally just to ventilate with Exercise Relaxation
someone you trust. Often, problems seem bigger than

they really are when a person tries to deal with them
on their own. Hearing yourself talk through something
can help to put it into perspective. Socialising is also
ME
fun and will help you to keep on track with scheduling
of pleasant events. Professional Support Social Support
3. Develop a good professional support network

Professional help is an important resource. Find a
doctor or mental health practitioner with whom you
can have a good professional relationship based on
mutual trust and respect. Talk to them about your
needs and concerns. Learn as much as possible about
C
your illness and take an active role in making decisions only. Please refer to the full disclaimer and entre for
about treatment and after-care.
CI linical
nterventions
Anxiety Symptoms Worksheet
Anxiety symptoms can be often be grouped into 3 categories. Some
symptoms are of the somatic or physiological type, which are those that
are related to physical sensations, for example: shortness of breath,
tightness in the chest, lightheadedness, etc. Some symptoms are of the
cognitive type (thought responses) and affective type (emotions), such as:
fear of having a heart attack, going crazy, feeling frightened, etc. The third category of
symptoms is to do with how you act and behave, for example: not going out, avoiding people
or objects, going out only with people you are close to, etc.
SOMATIC/ COGNITIVE/ BEHAVIOURAL

PHYSIOLOGICAL AFFECTIVE
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Daily Record of Your Breathing Rate
Instructions 1..2..3..4.. CALMING TECHNIQUE
• Monitor your breathing rate at the times 1. Ensure that you are sitting on a comfortable chair or laying on a bed
shown below.
2. Take a breath in for 4 seconds (through your nose if possible)
• If you have just done some form of activity
3. Pause for 2 seconds
(e.g. walking upstairs, etc.) that increases
your breathing rate, take your breathing 4. Release the breath taking 6 seconds (through your mouth).
rate about 20 minutes after you have
finished the activity.
10:00 a.m. 2:00 p.m. 7:00 p.m.
• Try to be sitting or standing quietly when
you count your breathing. Don’t try to Date Before After Before After Before After
alter your breathing rate as you are
counting.
• Breathing Exercise:
a) put your writing hand on your stomach
and the other hand on your chest,
b) breathe in through your nose and out
through your mouth. Remember…jaw
relaxed, breathe low and slow
c) Do this for approximately 5 minutes
three times per day.
• Remember to: 1) monitor your breathing
rate, 2) practise the breathing exercise,
and 3) monitor your breathing rate again.
Centrelinical
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Monitoring Your Relaxation Level
It is important to practice relaxation to achieve the best results, as this is a new skill that you are learning. You can monitor you own progress
by keeping a relaxation diary that records the when, where and how of your practice. This will help you to identify particular situations and / or
times of the day when you are most tense. Use the scale to indicate your level of relaxation before and after you complete your relaxation.
The most relaxed and The most tense or anxious

0 1 2 3 4 5 6 7 8 9 10
Relaxation Relaxation
Comments /
level before level after
Date & Time Comments / Reactions Reactions:
• What parts of your
body relaxed easily?
• What sensations
were you aware of
in your body?
• Was your mind
relaxed?
• What sorts of
images were most
relaxing for you?
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Weekly Activity Schedule Week Beginning:
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
8 to 9 am
9 to 10
10 to 11
11 to 12 pm
12 to 1
1 to 2
2 to 3
3 to 4
4 to 5
5 to 6
6 to 7
7 to 8
8 to 10
10 to 12 am
entre for
C linical
nterventions This document is for information purposes only. Please refer to the full disclaimer and copyright statement available at
CI
6 to 8 am
8 to 10
10 to 12 pm
12 to 2
2 to 4
4 to 6
6 to 8
8 to 10
10 to 12 am
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CI
entre for
C linical
nterventions This document is for information purposes only. Please refer to the full disclaimer and copyright statement available at
CI
Weekly Activity Schedule
Use the schedule below to plan your activities for the coming week. Make sure you balance fun
and pleasurable activities with your daily responsibilities and duties.
Mon Tues Wed Thur Fri Sat Sun
8 to
9am
9 to
10
10 to
11
11 to
12pm
12 to
1
1 to 2
2 to 3
3 to 4
4 to 5
5 to 6
6 to 7
7 to 8
8 to
10
10 to
12 am
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•Psychotherapy•Research•Training http://www.cci.health.wa.gov.au regarding the information from this website before making use of such information.
Weekly Goals Record Name: Signature:
TASKS TO BE How Monday Tuesday Wednesday Thursday Friday Saturday Sunday Done? Impact?
COMPLETED often? Date: Date: Date: Date: Date: Date: Date: Y/N 0-4
Reading
T T T T T T T
Calming Technique
T T T T T T T
Thought Diaries
T T T T T T T
Pleasant Events
T T T T T T T
T T T T T T T
Exposure tasks
T T T T T T T
T T T T T T T
Other behavioural goals
T T T T T T T
T T T T T T T
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Impact Ratings: 0 = Definitely did not find task useful 1 = Not very useful 2 = Not sure if it was useful 3 = Quite useful 4 = Very useful
•Psychotherapy•Research•Training This document is for information purposes only. Please refer to the full disclaimer and copyright statement available at
nf
See website www.cci.health.wa.gov.au for more handouts
an and resources.
Making the Connection
Part One
Instructions: Read the following scenarios and identify the feelings that may result from the self-
statements.
SCENARIO 1:
You’ve had a rather long and tiring day at work where you were helping a colleague move boxes of
stationery and office equipment. You arrive home to find the front door ajar and two sets of muddy
footprints (your son’s and his dog’s) on your cream-coloured carpet leading from the front door all the
way to the back door.
A) You say to yourself: Possible Feelings:
“What! N@!^#*M!! I’ve had such a tiring day at work and

now I come home to this!?!! What have I done to deserve
this! We just had the carpet cleaned last week! That naughty
boy! All he cares about is himself! That inconsiderate, selfish
brat! I’m gonna ground him for 2 years!!!”
B) You say to yourself: Possible Feelings:
“I’ve told him a thousand times not to bring the dog into the
house and he never listens to me. My kids don’t obey even
the simplest instructions. I must be the worst mother in the
world. If I can’t even get this right, I must be a terrible
failure.”
SCENARIO 2:
One evening, your parents ask you to go over to their house for dinner. As you arrive, you noticed that
it was all dark and there were no lights on. You knock on the door and ring the doorbell but no one
comes to answer the door. You turn the doorknob and find that the door is unlocked. You step in and
find that the house is in total darkness. Suddenly, you hear a chorus of voices shouting, “Surprise!” The
lights come on and you see a group of your friends and relatives singing “Happy Birthday” to you.
You say to yourself: Possible Feelings:
“Wow! I didn’t even remember that it was my birthday!

What a really nice surprise! Hey, even uncle James and aunt
Bertha came and they live in the country! Everyone must
think I’m pretty important to throw me this party!
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an and resources.
Part Two
Instructions: Read the following scenarios and now fill in the self-statements that lead to the
feelings experienced.
SCENARIO 1:
You arrive home to find a note from your flatmate telling you that they have moved out. You look
around and find that everything that belongs to them is gone. Moreover, their share of the rent has not
been paid.
A) You say to yourself: Feelings:
Angry
B) You say to yourself: Feelings:
Hurt
SCENARIO 2:
You just finished cooking dinner for you and you partner. Your partner calls to say that he/she will not
be home for dinner because he/she has to work late.
A) You say to yourself: Feelings:
Disappointed
B) You say to yourself: Feelings:
Concerned
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Thought Diary 1
A Activating Event B Beliefs

This may include an actual event or 1. List all self-statements that link A to C. Ask yourself: “What was I
situation, a thought, mental picture or thinking?” “What was I saying to myself?” “What was going through my
physical trigger. head at the time?”
2. Mark the most distressing (hot) thought and mark it with an asterisk (*).
3. Rate how much you believe this thought between 0 to 100.
C Consequences
1. Write down words describing how you feel.
2. Mark the one that is most associated with the
activating event using an asterisk (*).
3. Rate the intensity of this feeling between 0 to
100.
4. Jot down any physical sensations you

experienced or actions carried out.
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Thought Diary 2

situation, a thought, mental picture or thinking?” “What was I saying to myself?” “What was going through my
physical trigger. head at the time?”
2. Find the most distressing (hot) thought and mark it with an asterisk (*).
C Consequences
2. Mark the one that is most associated with
the activating event using an asterisk (*).
3. Rate the intensity of this feeling between 0
to 100.
Unhelpful Thinking Styles

Do you recognise any unhelpful thinking styles you might have been
using? (Mental filter, jumping to conclusions, personalisation,
catastrophising, black & white thinking, shoulding & musting,
overgeneralisation, labelling, emotional reasoning, disqualifying/
ignoring positives)

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D Detective Work & Disputation
Detective Work: Now refer to the hot thought, and ask yourself, “What is the factual evidence for and
against my hot thought?”
My HOT Thought:
Factual Evidence For My HOT Thought Factual Evidence Against My HOT Thought
Disputation: Ask yourself the following questions ...

y What other ways are there of viewing the situation? y How might someone else view the situation?
y If I were not feeling this way, how would I view the situation? y Does it really help me to think this way?
y Realistically, what is the likelihood of that happening? y Think of some helpful self-statements
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Thought Diary 3

situation, a thought, mental picture or thinking?” “What was I saying to myself?” “What was going through
physical trigger. my head at the time?”
2. Find the most distressing (hot) thought and mark it with an asterisk (*).
C Consequences
2. Mark the one that is most associated with the
activating event using an asterisk (*).
3. Rate the intensity of this feeling between 0 to
100.
Unhelpful Thinking Styles

Do you recognise any unhelpful thinking styles you might have been
using? (Mental filter, jumping to conclusions, personalisation,
catastrophising, black & white thinking, shoulding & musting,
overgeneralisation, labelling, emotional reasoning, disqualifying/
ignoring positives)

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nf
an and resources.
D Detective Work & Disputation
Detective Work: Now refer to the hot thought, and ask yourself, “What is the factual evidence for and
against my hot thought?”
My HOT Thought:
Factual Evidence For My HOT Thought Factual Evidence Against My HOT Thought
Disputation Questions:
Disputation: Ask yourself the following questions ...

y What other ways are there of viewing the situation? y How might someone else view the situation?
y If I were not feeling this way, how would I view the situation? y Does it really help me to think this way?
y Realistically, what is the likelihood of that happening? y Think of some helpful self-statements
E End Result
Balanced Thoughts: After looking at all the evidence for and against your hot thought, and having
considered the disputation questions, replace the hot thought with helpful, balanced thought/s.
Re-rate Emotion: Now, re-rate the emotion you underlined in C, from 0 to 100.
Re-rate Hot Thought: Read through Detective Work & Disputation. Now re-rate
how much you believe the hot thought, between 0 to 100.
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OBJECTIVE:
This Thought Diary aims to help you
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understand the difference between thoughts linical
and feelings. nterventions
INSTRUCTIONS:
Begin with section A:

Write about an event or situation in which you
felt distressed or upset. Record the situation in
the same way that a video camera might record
it – simply the facts.
Then go to section C:
Write down the words that best describe your
Thought
Diary
feelings. Choose one that best describes how
you feel in this situation. Underline this word &
rate the intensity of the emotion from 0 to 100.
When you have finished, also write down any
actions you may have carried out.
Now look at the situation in A and

complete section B:
List all the thoughts, beliefs, values, attitudes, and
expectations you had about “A” that caused the
feelings and actions in “C.” Use the automatic
thought discovery questions available. Find the
“Hot thought”, the thought that best relates to Name:
the emotion you underlined in “C”. Rate how
much you believe this statement on a scale from Day & Date:
0 to 100.
This may be either: An actual event or situation, a 1. List all statements that link A to C. Ask yourself: “What
thought, mental picture or recollection. was I thinking?” “What was I saying to myself?” “What
was going through my head at the time?”
2. Find the most distressing (hot) thought and underline it
3. Rate how much you believe this thought between 0 to
100.
C Consequences
2. Underline the one that is most associated with the
activating event.
3. Rate the intensity of that feeling (0 to 100).
1. Jot down any physical sensations you experienced

or actions carried out.
COMPLETE THIS SECTION LAST
OBJECTIVE:
This Thought Diary aims to help you analyze
C entre for E Evaluation: Balanced Thought
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your thinking and challenge unhelpful linical After looking at all the evidence for and against your hot
thoughts. nterventions thought, and having considered the disputation questions,
replace the hot thought with helpful, balanced thought/s.
INSTRUCTIONS: • Psychotherapy • Research • Training
Begin with section A:
Write about an event or situation in which you
felt distressed or upset. Record the situation in
the same way that a video camera might record
it – simply the facts.
Then go to section C:
Write down the words that best describe your
feelings. Choose one that best describes how
you feel in this situation. Underline this word &
Thought
Diary
rate the intensity of the emotion from 0 to 100.
When you have finished, also write down any
actions you may have carried out.
Now look at the situation in A and

complete section B:
List all the thoughts, beliefs, values, attitudes, and
expectations you had about “A” that caused the
feelings and actions in “C.” Use the automatic
thought discovery questions available. Find the
“Hot thought”, the thought that best relates to
the emotion you underlined in “C”. Rate how
much you believe this statement on a scale from Name:
0 to 100.
Day & Date:
Turn to section D, the section in which you
concentrate on change and coping. Go through Re-rate Emotion: re-rate the emotion
the disputation questions. you underlined in C, from 0 to 100:
Finally, complete section E: Balanced Re-rate Hot Thought: re-rate how

much you believe the hot thought,
Thinking and re-rate your previous thought and This document is for information purposes only. Please refer to
the full disclaimer and copyright statement available at between 0 to 100:
feeling. http://www.cci.health.wa.gov.au regarding the information from
this website before making use of such information.
A Activating Event B Beliefs D Disputation
This may be either: An actual event or situation, a thought, 1. List all statements that link A to C. Ask yourself: “What was I 1. List the factual evidence for and against the Hot
mental picture or recollection. thinking?” “What was I saying to myself?” “What was going Thought that you underlined in B.
through my head at the time?” 2. Ask yourself the disputation questions
2. Find the most distressing (hot) thought and underline it
3. Rate how much you believe this thought between 0 to 100. Factual evidence for my Hot Thought:
Factual evidence against my Hot Thought

C Consequences
2. Underline the one that is most associated with the
activating event.
3. Rate the intensity of that feeling (0 to 100).
Disputation Questions: eg
“What other ways are there of viewing the situation?”
“If I was giving advice to someone I care about who was
thinking this, what would I say?”
Unhelpful Thinking Styles:

Mental Filter
4. Jot down any physical sensations you experienced or Jumping to Conclusions
actions carried out. (Mind reading/emotional reasoning)
Personalisation
Catastrophising
All or Nothing
Shoulding & Musting
Labelling
Overgeneralisation
Disqualifying/Ignoring positives
Core Beliefs Worksheet
Core belief to be challenged:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Core belief to be tested:
Task/s: Prediction: What actually happened:
Conclusion:
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Building Steps
GOAL: DISTRESS
80
75
65
50
35
STEP DISTRESS
Situational Exposure
Break the goal into smaller steps by changing:

• WHO is there • WHERE you do it
• WHAT you do • HOW long you do it for
• WHEN you do it
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Behavioural Experiment Monitoring
Prediction Experiment Evidence to Look For Actual Outcome What Have I Learned?
Specifically what are you How will you test your What will I/others observe (stick to facts)
afraid will happen? prediction? if prediction is true?
Remember…
• You will experience

anxiety; stick with it
rather than fight it so
you can test your Predicted Distress: Actual Distress:
prediction
• Make sure you don’t

engage in anxiety re-
ducing behaviours
(e.g. distraction),
unless specifically Predicted Distress: Actual Distress:
part of your hierar-
chy
• Record whether
your prediction came
true
Predicted Distress: Actual Distress:
• Rate predicted and
actual distress (0-
100)
for
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• Psychotherapy •Research•Training
Thinking
Social Activities Pleasant Activities
Healthy
Exercise Relaxation
ME
Self-Care Goals
Social Support
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Goal Setting Date:
Think back to the last 3 to 6 months. Ask yourself, “What have I achieved or done well at? Can I
do better in some areas?”
What I have achieved (or done well) Some areas for improvement
in the last 3 to 6 months
Set some goals for yourself for the next 3 to 6 months. Be specific. What would
you like to achieve? What would you like to see happening in your life? How would
you like to change? (Remember to make your goals realistic — that means that they
should be achievable within the time frame you have set).
Goals:
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Facing Your Feelings
Module 1
Understanding Distress Intolerance
Introduction 2
What Is Distress Intolerance? 2
The Paradox… 3
Am I Distress Intolerant? 4
Healthy Distress Tolerance 5
How Does Distress Intolerance Develop? 5
Distress Intolerant Beliefs 6
Distress Escape Methods 7
Distress Intolerance Model 8
My Distress Intolerance Model 9
The Good News… 10
Module Summary 11
Centrelinical
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Introduction
We all experience emotions. Emotions are an important part of being human, and are essential to our
survival. As humans we are designed to feel a whole range of emotions, some of which may be comfortable
to us, and others may be uncomfortable.
Most people dislike feeling uncomfortable. There are many different ways that humans can feel
uncomfortable…we can be hot, cold, tired, in pain, hungry, unwell, and the list could go on. The type of
discomfort we will be talking about in these modules is emotional discomfort, or what is often called
distress. We may not like it, but experiencing uncomfortable emotions is a natural part of life.
However, there is a difference between disliking unpleasant emotions, but nevertheless accepting that they
are an inevitable part of life and hence riding through them, versus experiencing unpleasant emotions as
unbearable and needing to get rid of them. Some people tell us that they “can’t face”, “can’t bear”, “can’t
stand”, or “can’t tolerate” emotional distress. Being intolerant of experiencing emotional discomfort can
actually breed a whole bunch of problems, as it interferes with living a fulfilling life, and can make worse any
emotional discomfort we might be experiencing. If difficulty facing your feelings or tolerating distress
sounds like you, then read on to learn ways to overcome this pattern.
What Is Distress Intolerance?

There are many different definitions of distress intolerance. What we mean by distress intolerance is a
perceived inability to fully experience unpleasant, aversive or uncomfortable emotions, and is
accompanied by a desperate need to escape the uncomfortable emotions. Difficulties tolerating
distress are often linked to a fear of experiencing negative emotion. Often distress intolerance centres on
high intensity emotional experiences, that is, when the emotion is ‘hot’, strong and powerful (e.g., intense
despair after an argument with a loved one, or intense fear whilst giving a speech).
However, it could also occur for lower intensity emotions (e.g., nervousness about an upcoming medical
examination, sadness when remembering a past relationship break-up). It is not the intensity of the
emotion itself, but how much you fear it, how unpleasant it feels to you, how unbearable it seems, and how
much you want to get away from it, that determines if you are intolerant of distress.
There are varying types of negative emotions that could potentially be distressing for people. We thought
it might be helpful to categorise these emotions into the following 3 clusters:
The Sad
This group includes emotions that reflect sadness at varying degrees of intensity. This would include
disappointment, hurt, despair, guilt, shame, sadness, depression, grief, misery, etc. These emotions
can be accompanied by either low physiological arousal (e.g., low energy, fatigue, heaviness) or
heightened physiological arousal (e.g., intense crying, restlessness), thoughts of hopelessness, loss,
regret and inadequacy, and the urge to hide away from life.
The Mad
This group includes emotions that reflect anger at varying degrees of intensity. This would include
irritation, agitation, frustration, disgust, jealousy, anger, rage, hatred, etc. These emotions are
usually accompanied by high physiological arousal (e.g., tension, increased heart rate, feeling sweaty
or hot, etc), thoughts of unfairness, injustice and wrong doing, and the urge to lash out in some way.
The Scared
This group includes emotions that reflect fear at varying degrees of intensity. This would include
nervousness, anxiety, dread, fear, panic, terror, etc. These emotions are usually accompanied by
high physiological arousal (e.g., increased heart rate, increased breathing, tension, sweating, shaking,
butterflies in stomach, etc), thoughts of threat, vulnerability and helplessness, and the urge to avoid
or escape.
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For some people their distress intolerance might be very broad, in that they find all negative emotions
distressing, for other people their distress intolerance might be very select to just one type of emotion
(e.g., anxiety). How about you? What Negative Emotions do you find difficult to deal with?
______________________________________________________
______________________________________________________
______________________________________________________
Note: Some people can be distressed by positive emotions, not just the negative ones. It is not uncommon for people to be
concerned that positive emotions will make them lose control in some way. These modules will only focus on intolerance related
to negative emotions, but some of the strategies may be relevant if you have trouble experiencing positive emotions too.
It is important to realise that the term distress that we are using throughout these modules, refers to
emotions that are experienced as aversive, unpleasant, uncomfortable and upsetting. Now, the 3 clusters
of negative emotion previously mentioned, are not necessarily in themselves distressing. For example,
some people like the empowering feeling of being angry, and don’t find it at all an upsetting emotion. Some
people like watching horror movies because they enjoy the feeling of being scared. Some people don’t
mind feeling sad, because it gets their creative energy going when it comes to art, music or writing, or they
may hold the attitude “it’s good to have a cry every now and then”. These examples show that negative
emotion in itself is not necessarily distressing, and as you will see in the next module, these emotions
are normal and often helpful to us. We only begin to feel distressed when we evaluate our
emotional experience as a bad thing.
The Paradox…
Now, it makes a lot of sense to try to get away from things that feel unpleasant. This strategy seems to
work for other things that make us uncomfortable (e.g., heat, cold, pain, hunger, etc). However, when we
apply the same strategy to our emotions, it seems to backfire. This is the paradoxical nature of distress
intolerance. That is, the more we fear, struggle with, and try to avoid any form of distress,
generally the worse that distress gets. Our fear and avoidance of the distress actually magnifies the
distress.
Imagine your emotional distress is a puddle of water blocking your path. If you can recognise that
emotional distress is not something to be feared, nor something to run away from, then all you have is a
puddle of water. If you just wait there it will eventually dry up enough to jump over it, or you could just
splash through it and keep on going. However, if instead you fear your distress, struggle with it and try
everything to escape from it, all you do is add more and more water to the puddle, and very soon you are
faced with a deep pond that it impossible to jump over or splash through. The bigger the pond, the harder
to find a way through it, and hence the longer you will feel stuck and unable to move forward.
Fear
Distress
puddle Distress
pond
Escape
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Am I Distress Intolerant?
If you are still a bit unclear as to whether distress intolerance is a problem for you, take a look at the
following statements. Put a tick next to the statements you strongly agree with.
Feeling distressed or upset is unbearable to me

When I feel distressed or upset, all I can think about is how bad I feel
I can’t handle feeling distressed or upset
My feelings of distress are so intense that they completely take over
There is nothing worse than feeling distressed or upset
I don’t tolerate being distressed or upset as well as most people
My feelings of distress or being upset are not acceptable
I’ll do anything to avoid feel distressed or upset
Other people seem to be able to tolerate feeling distressed or upset better than I can
Being distressed or upset is always a major ordeal for me
I am ashamed of myself when I feel distressed or upset
My feelings of distress or being upset scare me
I’ll do anything to stop feeling distressed or upset
When I feel distressed or upset, I must do something about it immediately
When I feel distressed or upset, I cannot help but concentrate on how bad the distress actually feels
The above statements are an adaptation of the Distress Tolerance Scale (Simons & Gaher, 2005)
If you find yourself agreeing with a lot of the above statements, then this can be a sign of having difficulties
with tolerating emotional distress.
To get an even better idea if distress intolerance is a problem in your life, keep a tally over the next week
or so of any negative emotions you feel. Then make a rating of how intolerable (i.e., unbearable,
unmanageable) these feelings were for you. Also note how you reacted to these emotions (i.e., Did you
frantically try to stop the feeling? Did you ride it out? Did you do things that seemed helpful or unhelpful to
coping with the emotion?). You could use a notepad to keep track of these things, and it might look
something like the example below. After having tuned in closely to how you tolerate negative emotions,
you may then be in a better position to assess if distress intolerance is a problem for you.
Day/Time Negative Emotion Intolerable (0-5) My reaction to the emotion

0 tolerable – 5 intolerable
Monday 8am Anxious 4 Stopped the anxiety by calling in sick
to work. This was unhelpful given how
many sick days I have had, and I will
just have to face work tomorrow
Monday 2pm Angry 3 Did some breathing, watched TV, the

feeling passed
Monday 8pm Sad 5 Drank, felt worse, hungover
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Healthy Distress Tolerance

An important thing to consider when assessing your own level of distress tolerance, is that like many things
in life, doing anything at the extreme can be unhelpful. Think of distress tolerance as a continuum where at
one end people can be extremely intolerant of distress, and at the other end people can be extremely
tolerant of distress. Sitting at either end of the spectrum isn’t good for you.
If you were always overly tolerant of experiencing all unpleasant emotions, then problems might result such
as tolerating bad situations or bad people in your life. If you were tolerant in the extreme, you would
never take action to change unhappy circumstances in your life that need to be changed. As you read
through the rest of this module, you will get a sense of all the negative consequences that occur on the
other side of the spectrum when people are intolerant of distress. When working through these modules
we will be aiming for somewhere in the middle of the continuum, so that you learn to balance tolerating
emotional discomfort when it does arise, with taking action to improve your emotional experiences.
You might like to put a cross to mark where you think you are on this continuum at the moment.
Extremely Intolerant of Extremely Tolerant of

Distress Distress
Healthy Distress Tolerance
How Does Distress Intolerance Develop?

It is likely a combination of biological and environmental factors that lead some people to be more
intolerant of emotional distress than others.
There is some suggestion that biologically some people are more sensitive to negative emotions,
experiencing negative emotions more easily, at a higher level of intensity, and for a longer duration than
other people. This may mean that some people experience negative emotions as more painful, and hence
have greater difficulty coping with the experience.
It is likely your experiences growing up through childhood, adolescence and through adult life, may shape
how you deal with emotions. Some people may not have been shown ways to tolerate emotional
discomfort appropriately, for example being punished for expressing normal emotions like crying when they
were sad. Others may have only been shown unhelpful ways of dealing with their emotions, such as seeing
a loved one use alcohol to deal with their own emotions.
Finally, if we have stumbled upon unhelpful ways to escape our emotions, these methods may have been
reinforced by temporarily making us feel better. As such, we keep using unhelpful methods and don’t have
a reason to look for other more helpful ways of dealing with our distress.
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Distress Intolerant Beliefs

Regardless of how a person’s distress intolerance emerged, we take the view that this intolerance keeps
having a hold over people’s lives due to certain beliefs they have developed about experiencing negative
emotions. These beliefs tend to centre on the notion that negative emotion is bad in some way,
unbearable, unacceptable, or will lead to disastrous consequences. These beliefs tend to make any negative
emotion that we may feel, become a highly distressing emotional experience. Below are some of the
common beliefs that people with distress intolerance have when they start to experience negative emotion:
I can’t stand this

It’s unbearable
I hate this feeling
I must stop this feeling
I must get rid of it
Take it away
I can’t cope with this feeling
I will lose control
I’ll go crazy
This feeling will keep going on forever
It is wrong to feel this way
It’s stupid and unacceptable
It’s weak
It’s bad
It’s dangerous
Let’s try to uncover your common Distress Intolerant Beliefs. Firstly, do any of the statements above
ring true for you? If so, jot down the statements relevant to you. Secondly, ask yourself the following
questions:
What does it mean to me when I start to feel uncomfortable emotions? What do I think will happen if I let
myself feel distressed? What must I do when I feel any emotional discomfort?
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
I can’t stand it!
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Distress Escape Methods
As mentioned earlier, a clear sign of distress intolerance is when someone takes desperate urgent
measures to escape or get rid of uncomfortable emotions. This can be done in a number of different ways,
and each way can lead to significant problems in a person’s life.
Avoidance
One method is via avoidance, and avoidance can take many forms. Firstly, there is
situational avoidance. This is when you avoid any situation, scenario, place,
person, cue or activity that you know is likely to bring on distressing emotions.
Examples of this might be avoiding a particular family member with whom you
become angry, avoiding studying because you become frustrated, avoiding
socialising or leaving the house because you become anxious, avoiding things that
change your physical state because you feel nervous (e.g., sitting in a hot car,
drinking caffeine), avoiding medical appointments or tests because you are
frightened, or avoiding reminders of the past or certain topics of conversation because they sadden you.
A second method, is a more subtle form of avoidance known as reassurance seeking or checking. This
is when you try to quickly allay your distressing emotions by excessively seeking reassurance from other
people or engaging in some repetitive checking behaviour. Checking or reassurance seeking temporarily
brings you comfort and takes away your distress, but the relief is short lived and you have to keep doing
these things the next time you feel distressed. Examples might include having to repetitively check things
on your body (e.g., a physical sensation, symptom or feature) or in your environment (e.g., around the
home), over-preparing for things (e.g., projects, work, social events), keeping things in excessive order, or
overly questioning or consulting other people’s opinions to calm you down (i.e., family, friends, medical or
mental health professionals, internet research).
Finally, there is a third method called distraction and suppression which involves trying to push away
the distress, rather than sitting with the emotion and feeling what needs to be felt (i.e., telling yourself to
“stop it” as soon as you feel any distress, finding any mental or physical activity to distract yourself from the
slightest hint of emotion such as counting or repeating positive statements, etc). The problem with
distraction and suppression is that you can’t keep it up for long, and the emotion ends up being like a beach
ball you are trying to hold under the water with your hands. You can only hold it at bay for so long, it
becomes exhausting, and eventually it pops back up and hits you in the face!
Numbing & Withdrawing

Numbing and withdrawing capture things you do to tune out from the distress. The most common ways of
doing this would be by using alcohol or drugs to escape emotional discomfort. Binge eating is also a
common method used to try to alleviate distress. Excessive sleep can also be used in an unhelpful way to
zone out from and escape unpleasant emotions.
Harmful Releases
We have used the term ‘harmful releases’ to capture behaviours we might engage in to release or vent our
distress, that are also directly physically damaging to ourselves. Rather than allowing our emotions to run
their natural course, we might injure or harm ourselves as a way of stopping the emotional discomfort.
Such behaviours might include scratching, picking, biting, punching, hair pulling, head banging, cutting or
burning. The degree of harm we cause to ourselves could be minor or major, but the key is that doing
harm to ourselves is being used to get rid of distressing emotions.
Please Note: Whilst these modules may be helpful to people who use drugs, alcohol or self-
harm as a means of tolerating emotional distress, it is important to recognise that these are
very serious problems in their own right that can cause a person significant harm. We
strongly advise seeking help from a GP or mental health professional to address these
concerns, rather than relying solely on these Modules to overcome the problem.
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We have just outlined the most common ways people escape their distress. You may be able to think of
other unhelpful methods. The important thing is to recognise your common Distress Escape Methods.
Ask yourself, what do I do to get rid of unpleasant emotions? Take some time to jot these down now.
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
The issue with each of these escape methods is that they only work in the short-term. In the short-term,
as soon as you avoid or numb or release yourself, you experience instant relief from whatever distressing
emotion you are trying to flee. In this way it may seem like a really good strategy, and that is probably why
you have been using it, because there is some pay off. However, over the longterm it all falls apart because:
• The escape strategy itself is damaging and causes other problems in your life,
• Your negative emotions usually worsen because you feel you haven’t coped well,
• By continually using your escape strategy, you never learn other more helpful ways of tolerating
emotional distress, and
• By continually using your escape strategy you never have the opportunity to stay with the emotional
distress and therefore challenge the beliefs you hold about not being able to tolerate negative emotions
(maybe you can tolerate them, but you have just never given yourself the chance???)
Distress Intolerance Model

We have covered a lot of issues surrounding distress intolerance. Let’s put together everything we have
covered so far to help make sense of what is going on when you are having difficulties dealing with
emotional distress.
Distress usually starts with some sort of trigger which can be big (e.g., a relationship break-up) or small
(e.g., watching a distressing story on TV), internal (e.g., noticing a thought, image, memory, emotion,
physical sensation, etc) or external (e.g., a certain situation, event, person, place, cue, etc). We will look at
your triggers in more detail in Module 4. For now, think back to past times you haven’t coped well with
distress, what sorts of things were your Triggers?
______________________________________________________
______________________________________________________
______________________________________________________
Whatever the trigger, we start to feel some sort of negative emotion. Now the emotion in and of itself is
not necessarily distressing, unless we also hold distress intolerant beliefs which tell us the emotion is bad in
some way and must be stopped. As a result of our beliefs, we start to experience the emotion as highly
distressing and upsetting to us, and therefore engage in our unhelpful escape methods to stop it. In the
short-term this takes the emotional pain away, but in the longterm makes everything much worse.
This chain of events captures what we mean by distress intolerance, and is mapped out in the model on the
next page. Try filling in each box to make the model specific to you, so you can see your distress
intolerance ‘chain’. You will be able to fill in the Triggers, Negative Emotion, Distress Intolerant Beliefs,
and Distress Escape Methods sections from what you have already written earlier in this module.
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My Distress Intolerance Model
Triggers
(big, small, internal, external)
Negative Emotion
e.g., sad, fear, anger, etc
Distress Intolerant Beliefs

e.g., “I can’t bear this feeling…it’s bad…it must stop”
Distress
Negative emotion is experienced as
highly upsetting & uncomfortable
Distress Escape Methods

e.g., avoidance, numbing & withdrawing, harmful releases
Consequences
Short Term = relief
Long Term = more distress, more life problems, by escaping I miss the opportunity
to practice other helpful ways of tolerating distress, by escaping I miss the
opportunity to stay with the distress and hence test if my distress intolerant beliefs
are actually true. So next time I face a trigger the cycle starts again…
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The Good News…
The good news is that it doesn’t have to be this way! No matter how
your distress intolerance has come about, no matter what emotions you
have trouble dealing with, and no matter how unhelpful your escape
methods are, you can learn ways of tolerating distress.
Distress tolerance is a good life skill for anyone to learn. Instead

of fearing and fighting uncomfortable emotions and desperately trying to
get rid of them, these modules we will teach you how to sit with and
tolerate emotional distress, such that you learn the emotion will pass and
that you can cope.
We will focus on things you can change in the here and now, particularly your escape methods and distress
intolerant beliefs. Modules 2 & 3 will teach you specific techniques for tolerating distress that focus on
both accepting distress and improving distress. Module 4 will draw all this work together in a Distress
Tolerance Action Plan, and give you ideas for how to practice this plan, which over time will tackle the
distress intolerant beliefs that are driving the problem.
When using self-help materials, some people might skip sections or complete things in a different order.
The modules in this information package have been designed to be completed in the order they appear.
We recommend that you work through the modules in sequence, finishing each module before moving on
to the next one in the series. We believe that by doing this, you will maximise the benefits you might
receive from working through this information package.
Emotional discomfort is impossible to get rid of, as it is an inevitable part of being human. So we all need
to learn how to live with it, and not let our fear of distress restrict how we live our lives. You may have
been telling yourself for some time now that you “can’t stand it!” But stick with us to find out how you can
face your feelings and learn to tolerate your distress.
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Module Summary
• Distress intolerance is a perceived inability to fully experience unpleasant, aversive or

uncomfortable emotions, and is accompanied by a desperate need to escape the uncomfortable
emotions.
• Sadness, anger and fear are the 3 clusters of negative emotion people may find distressing, and
people may have trouble with all negative emotions or just one specific type.
• Negative emotion in itself is not necessarily distressing. We begin to feel distressed when we
evaluate our emotional experience as aversive.
• Distress intolerant beliefs are central to this problem, as people commonly hold beliefs that
negative emotion is bad in some way or that experiencing negative emotion will be unbearable or
will lead to disastrous consequences.
• Avoidance (e.g., situational, reassurance seeking, checking, distraction, suppression), numbing &
withdrawing (e.g., alcohol, drugs, binge eating, excessive sleep), and harmful releases (e.g., self
injury) are common unhelpful escape methods people use to get rid of emotional distress.
• Escaping from distress only works in the short-term. In the long-term the distress gets worse, it
creates bigger life problems, and the opportunity is missed to learn healthy ways to tolerate
negative emotion or to test if your fears about experiencing negative emotion are truly valid.
• Emotional distress is impossible to get rid of, as it is an inevitable part of being human. Learning
how to tolerate emotional discomfort is an important skill for everyone to learn.
Coming up next …
In Module 2, you will learn specific
techniques to help you accept
emotional distress…
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About The Modules

CONTRIBUTORS
Dr Lisa Saulsman (MPsych1; PhD2) Paula Nathan (MPsych1)
Centre for Clinical Interventions Director, Centre for Clinical Interventions
Adjunct Senior Lecturer, School of Psychiatry and Clinical
Neuroscience, The University of Western Australia
1 2
BACKGROUND
practice, primarily Cognitive-Behavioural and Mindfulness-Based Therapies. These modules are based on
the approach that distress intolerance is a result of problematic cognitions (thoughts) and behaviours.
REFERENCES
These are some of the professional references that informed the development of modules in this
information package.
Allen, L.B., McHugh, R.K. & Barlow, D.H. (2008). Emotional disorders: A unified approach. In D.H. Barlow
(Ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed., pp. 216-249).
New York: Guilford Press.
Clen, S.L., Mennin, D.S. & Fresco, D.M. (2011). Major depressive disorder. In M.J. Zvolensky, A. Bernstein
& A.A. Vujanovic (Eds.), Distress Tolerance: Theory, Research, and Clinical Applications (pp. 149-170). New
York: Guilford Press.
Gratz, K.L. & Tull, M.T. (2011). Borderline personality disorder. In M.J. Zvolensky, A. Bernstein & A.A.
Vujanovic (Eds.), Distress Tolerance: Theory, Research, and Clinical Applications (pp. 198-220). New York:
Guilford Press.
Leahy, R.L. & Tirch, D., & Napolitano, L.A. (2011). Emotion Regulation In Psychotherapy: A Practitioner’s Guide.
Lynch, T.R. & Mizon, G.A. (2011). Distress overtolerance and distress intolerance: A behavioral
perspective. In M.J. Zvolensky, A. Bernstein & A.A. Vujanovic (Eds.), Distress tolerance: Theory, research,
and clinical applications (pp. 52-79). New York: Guilford Press.
Simons, J.S., & Gaher, R.M. (2005). The Distress Tolerance Scale: Development and validation of a self-
report measure. Motivation and Emotion, 29, 83-102.
“FACING YOUR FEELINGS”

We would like to thank Bruce Campbell for the title of this module that forms part of the InfoPax series.
Saulsman, L., & Nathan, P. (2012). Facing Your Feelings: Learning to Tolerate Distress. Perth, Western
Australia: Centre for Clinical Interventions.
ISBN: 0 9757995 7 6 Created: May 2012
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Module 2
Accepting Distress
Introduction 2
Seeing Emotions Differently 2
What Is Acceptance? 3
How To Accept Distress 3
Practicing Acceptance 5
Practicing Acceptance When Distressed 7
Module Summary 9
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C Interventions Module 2: Accepting Distress Page 1
Introduction
We assume you are still reading because you have worked out that distress intolerance is a problem in
your life. Now that you know what distress intolerance is, the next step is to learn how to become more
tolerant. You probably don’t realise that over time you have learnt to tolerate lots of different things (e.g.,
people you don’t like, or physical pain, or not getting your own way, or doing things you don’t feel like
doing, or bad drivers on the road, etc), and so emotional distress will just be one more thing to add to the
list. Learning how to tolerate distress when you have been in a pattern of constantly trying to escape it,
may require practice, patience and persistence. This module will help you build your tolerance by learning
strategies to help you accept emotional distress and face your feelings.
Seeing Emotions Differently

The first step to accepting distress is to start seeing your feelings and emotional
experiences in a new light. As we discussed in Module 1, emotional discomfort is a
very normal universal human experience. Negative emotions such as sadness, anger
and fear are part of being human. These emotions are not just common, normal and
OK, they are actually important and useful to us.
For example, fear is extremely helpful to our survival. Fear is helpful when it kicks in at
appropriate times, like when there is a real threat to our safety (e.g., a gun pointed at us or a wild ferocious
animal coming our way) or when the fear is proportional to the situation (e.g., nervousness before a big
exam). At these times the fear we experience and all the physiological sensations that accompany that fear,
help us to effectively deal with that situation. Heart pumping, breathing faster, feeling hot, sweaty, all these
things are signs that the body has gone into ‘fight or flight’ mode. Being in this mode prepares us to either
face the danger (e.g., study like hell) or escape the danger (e.g., run like hell from the gun or wild animal).
In this way fear can be a very good thing. If we were really relaxed and didn’t study or didn’t try to get
away from the gun or wild animal, we would have big problems.
Similarly, anger is a helpful emotion to have. Imagine if some wrong or injustice was being done towards
ourselves or someone else, and we weren’t phased at all by it. If we didn’t experience anger then we
would probably allow all sorts of bad treatment to come our way, or allow harm to be done to other
people. Anger can spur us into action to try to change things for the better, for both ourselves and others.
Sadness is a tricky one. How on earth could sadness be helpful? Probably the easiest way to see how
sadness is helpful is to think instead of what it would mean if we didn’t feel sadness. We generally tend to
feel sadness when we lose something important to us in some way (e.g., a person, job, possession,
someone’s attention or affection, etc). If we didn’t feel sadness when these things occurred, it would mean
that nothing was important to us. It would mean we didn’t appreciate or value the things we had, and we
weren’t interested in or connected to our lives or other people. So sadness inadvertently helps us to live a
fulfilling life, because it means we care about the things in our life and don’t want to lose them.
I guess the take home message to remember is that negative emotions are important to our
survival, rather than something to be feared and avoided at all costs.
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Another way you might start to see your emotions differently is to recognise that
your emotions are not permanent. Instead you might start to consider your
emotions as changing experiences that are always fluctuating but eventually pass.
When we feel distressed it can seem like the distress is going to go on and on
forever, just getting worse and worse, until we emotionally combust. But we know
this isn’t how emotions work. Instead emotions act more like a wave, at times
increasing and becoming more intense, but inevitably always reaching some plateau,
subsiding and finally passing. Some times the emotion may rear up again, setting off
another wave or smaller ripple. But the key is that emotions move and change, they are
not permanent. This is particularly so when you don’t fight against and try to block the
emotion. Sometimes just being able to remind yourself that emotions pass like a wave,
may allow you to better tolerate whatever upsetting feelings you are experiencing.
What Is Acceptance?
First, let’s consider what the effect is of urgently needing to get rid of your distress? If you were following
Module 1 closely, you may now be realising that it just ends up making your distress worse. The alternative
to urgently trying to rid yourself of your distress, may well be adopting an attitude of willingly accepting the
distress. A radical concept we know given the likely long history you have with pushing your distress away.
If you are still a little concerned about this notion of accepting distress, another question to ask yourself is
whether pushing your distress away has worked for you so far? It is likely that you are saying “of course it
hasn’t worked or I wouldn’t be reading this module!” So it might be time to try something quite
different…like acceptance.
Accepting distress is not about having to like emotional discomfort, or being resigned to feeling miserable,
or wallowing in negative emotions. Instead, accepting distress is about seeing the negative emotion for
what it is, and changing how you pay attention to the emotion. Reacting in an accepting way towards your
emotion, often changes the effect the emotion has on you.
This approach is often referred to as learning to watch your emotions “mindfully”. Mindfulness is state of
being where you are in the present moment, watching whatever you happen to be experiencing at that
time, with an attitude of curiosity, and without judging or trying to change your experience. In this way our
emotions are not some tumultuous chaotic vortex we are sucked into and from which we react
impulsively. Instead we become the watcher of our emotions, noticing what is happening to us like a third
person, observing and watching our distress with a sense of distance or detachment. As such we don’t
have to engage with, react to or stop our emotions. Instead we take the stance of just allowing, observing
and making space for the emotion until it passes.
How To Accept Distress

There is no right or wrong when it comes to practicing accepting emotional distress, but below are some
steps or guidelines that might help with the process. We stress that this is just a guide, and at the end of
the day being able to watch and accept your emotions is something you will need to experience via trial
and error practice, rather than something you can read about.
Watch or Observe
Foremost is adopting the stance of watching or observing your emotions, paying attention
like a third person to whatever you are feeling in the present moment. Observing as the
intensity might increase, hold its course, decrease or shift and evolve into a different
feeling. Regardless of what the emotion is doing, you are not your emotions, you are the
watcher of your emotions (Tolle, 2010).
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Label or Describe
When being the watcher of your emotions you might find it helpful to label or describe to yourself the
emotion you are experiencing. It is a little bit like being the commentator of your emotional experience.
The self-talk that goes with this might sound something like “…there is fear, I can feel it in the fast beating
of my heart”, or “…there is sadness, I can feel it in the heaviness of my shoulders”, or “…there is anger, I
can feel it in the tightness of my jaw”.
Curious and Non-judgemental

You’ll notice that the language used to describe your experience has a sense of curiosity and non-
judgement. The fear or sadness or anger that you feel is not deemed good or bad, or right or wrong, it is
what it is.
Imagery
The use of imagery can often be helpful in allowing yourself to foster this detached observer perspective.
Different images work for different people.
Some people like the image of an ocean wave* as we have already discussed. Previously you
might have panicked in the wave, fiercely treading water and thrashing your arms against the wave,
getting exhausted and feeling close to drowning. Instead when you are being mindful of your
emotions you don’t fight the wave, but instead allow the wave to carry you over its crest and down
the other side, or you might choose to surf the wave allowing it to carry you into shore.
Others like to think of their distress as a non-stop express train**, in

that it is impossible to stop the train, and it would be very dangerous
to try to get on board while it is moving. Instead you just watch
your emotions pass by like an express train until it is safely through
the station.
Some people like to imagine their emotions as clouds in the sky** or leaves on a stream***.
With either image you can’t stop the emotions, but you can imagine each cloud
or leaf as your emotions. As such, you can just watch your emotions floating
by you in their own time, eventually passing out of sight.
Some people like to imagine themselves as an empty room* with a front and back door.
Emotions enter through the front door and leave through the back, coming and going. Some
emotions may take their time in the room, others may move quickly, and some may re-enter the
room a number of times. But, they all eventually leave.
Or some like to think of their emotions like a naughty child** throwing a tantrum at
the supermarket. There is no point trying to stop the child because the tantrum just
gets worse, and it would be dangerous to abandon the child in the supermarket.
Instead you might just keep a watchful eye over the child from a distance, until they
exhaust themselves and settle of their own accord.
* These images are adapted from Eifert, McKay & Forsyth (2006)
**These images are adapted from Wells (2006)
*** This image is adapted from Eifert & Forsyth (2005)
Maybe you can think of another image that works better for you. This may require some trial and error to
discover what image you identify with. You also don’t need to be someone who can imagine things in vivid
detail. Most people have trouble doing this, and a more general ‘felt’ sense of the image is ok. The key is
that if you can relate to your emotions like they are a wave or cloud or express train or whatever image
works for you, then you are watching them for what they are, paying attention to them in a helpful way,
and ultimately tolerating them rather than trying to rid yourself of them.
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Present Moment
Once you feel you have fully watched and experienced the negative emotion, feeling it come to its natural
conclusion, it might then be time to gently direct your attention to the present moment. This could be
anything sensory, a particular task you are doing, a sound, taste, smell, sight or feeling of touch you may not
have realised you were experiencing that you can now tune into. And if you can’t think of anything to be
present-focused on, there is one thing you can guarantee will always be present to practice on…your
breath. Whatever you choose to anchor you to the present moment, become aware of its sensory
intricacies and details, and allow yourself to fully experience it.
Dealing with Emotional Comebacks

Be aware that no matter how expert you are at doing all the previous steps just mentioned, it is normal for
negative emotions to sometimes reappear. This does not mean that you have failed at being mindful of
your emotions. The key is to be aware that the emotion has made a comeback, congratulate yourself for
catching this rather than getting sucked in or swept up in the emotion, and repeat the steps as before. It
doesn’t matter how many times you have to catch and watch your emotions, because that in itself is the
task…catching and watching your emotions. Sometimes people mistakenly think the goal is to be so
completely absorbed in the present moment that they don’t feel any emotions, and hence they get
frustrated by any resurgence of emotion. When an emotion pops back it is just another wave, or express
train, or cloud, or whatever it is that allows you to again be the watcher of your emotions.
And remember, if you do get frustrated by an emotion popping up again or bored when doing your
mindfulness practice, just realise that these too are emotions that you can practice watching mindfully.
Practicing Acceptance
A good way to develop the skill of accepting distress is to start by being mindful of your emotions generally
when you are not feeling distressed. This will give you some practice at the skill of watching your emotions
under easier circumstances (i.e., when you are not distressed), so you might be better able to apply the skill
under harder circumstances (i.e., when you are distressed). Over the page is a short script to guide you
through the process of being mindful of your emotions at any time. You could start by practicing this new
approach to your emotions daily when you are not distressed, and record your experiences on the Diary
provided below. It may be helpful to record the mindfulness script onto tape, and then listen to the tape as
part of your practice.
Mindfulness of Emotion Daily Diary
Time
Duration
Experiences
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Mindfulness of Emotions Script
Position yourself comfortably in the chair…feet flat on the floor, arms placed comfortably, chair fully
supporting your body… allow your eyes to close…begin by paying attention to your breathing, taking a few
long breaths to get settled…
Now gently guide your attention to how you are feeling emotionally within yourself at this moment…note
whatever feelings arise within you whether they be positive, neutral or negative…whether they be strong
or weak in intensity…they are all just emotions…all just feelings to be felt. Whatever feelings arise, remind
yourself that it is OK to allow yourself to feel it. Remember that you are not your emotions, you are the
watcher of your emotions. Take some time just to observe your emotional experience, making no attempt
to change how you are feeling…
You might label the emotion to yourself (i.e., “ah there is calmness/ happiness/ indifference/ surprise/
boredom/ frustration/ fear/ sadness, etc”)...You might describe where and how you feel the emotion in
your body…take time to notice the physical signs that you are feeling the way you feel…
Watch as the emotion changes in intensity and nature. Bring whatever image to mind that helps you be the
watcher of your emotions (e.g., seeing your emotion like an ocean wave, express train, cloud floating in the sky,
leaf floating on a stream, an empty room, a naughty child, etc)…
You don’t have to buy into your emotions and get swept up in them. You don’t need to change your
emotions, fight them or get rid of them. You are just here to watch, observe and experience what is going
on right now. See if you can make some space for the emotion, seeing it as part of a broader landscape
within you that contains lots of things like other feelings, thoughts, memories, body sensations, etc. Your
emotions are just emotions…your feeling just feelings…nothing more and nothing less…
When you have fully experienced whatever emotion is there, and the experience has run its natural course,
redirect your attention towards your breath…note each inhalation and each exhalation…bind your
attention to the back and forth movement of the belly as you breathe in and out…note the sensations in
your body as you draw breath in and then out again. Take some time now to allow your breath to be your
anchor to the present moment…
If your mind wanders away from the breath to an emotion, or thought or sensation. That’s ok, that’s what
minds do. Congratulate yourself for noticing, and give your mind the time to again observe and watch what
you are experiencing… Once that observation has run its natural course, again gently bring your attention
back to the breath as your anchor to the present…
Try to continue your mindfulness practice for the next 10 minutes or more…
When you feel ready, you can gradually open your eyes, bringing this mindfulness exercise to a close…
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Practicing Acceptance When Distressed
Now that you are getting a good sense of how to be mindful of your emotions generally, another way to
develop the skill of accepting distress is to plan specifically how you will extend this new attitude to dealing
with the distressing emotions you most often struggle with. To help with this, you can devise your own
step-by-step mindfulness plan of what to do when emotional distress arises for you. This is really about
jotting down a few key words, phrases or images that will cue you into being mindful of your negative
emotions at times when it is harder to do.
Below is an example of the types of phrases that might be helpful. Take a look through the example script
and then see if you can draft a script personalised to your needs on the next page. Your personalised
script should be short and to the point, as you don’t want to read through a mountain of stuff when you
are distressed. You can draft your personalised script by either picking out the phrases from the example
scripts that best suit you, or coming up with your own phrases. The aim is to find a few phrases that help
get you in the mode of being the non-judgemental watcher of your distress.
Example Mindfulness of Distress Script
Recognise & Allow Emotion:

Aha! I’m feeling…[angry/sad/scared]. It is OK, I can allow myself to have this feeling…I can make space for
it…I don’t have to be afraid of it or try to get rid of it.
Watch Emotion:
I can just watch this feeling and see what it does, I don’t have to get caught up in it.
Let’s see, where do I notice the emotion in my body?
This is just an emotion, just a feeling to be felt, nothing more and nothing less.
I am not my emotions, I am the watcher of my emotions.
The feeling is just like a…[ocean wave…I don’t need to fight the wave frantically…I can just go with the wave,
letting it bob me up and down, or riding it into shore]
Be Present:
I will turn my attention back to the task I am doing now …noticing what I can feel…hear... see… smell…
taste…
OR
I will turn my attention towards my breath…the breath being my anchor to the present moment…noticing
each in breath and each out breath
Deal with Emotional Comebacks:

I feel the emotion returning…that’s OK, that’s what emotions do, they like to rear their head again. I will
just go back to watching it again…it is just another [ocean wave]…
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Personalised Mindfulness of Distress Script
Watch Emotion:
Be Present:
Now you know how to watch your emotions generally, and have a script for how to adopt this attitude
when distressing emotions arise, it is now time to get some practice with the emotions that distress you.
There are 2 ways we can get this practice. One is putting what you have learnt into practice as best you
can the next time distressing emotions spontaneously arise for you. The other method is to gradually seek
out distressing emotions with the intention of practicing your new acceptance skills. The first option we
will look at now, the second option we will look at in Module 4.
The Next Time I Am Distressed…

This involves having a clear plan for the next time you feel distressed. You might
make a commitment to yourself that the next time I feel distressed I will get out my
personalised mindfulness script and try to watch my distress instead of engaging in
my old escape methods (e.g., avoidance, numbing & withdrawing, harmful releases).
If you think this will be a very difficult thing to do, you may decide to put a time limit
on how long you will try to be mindful of your distressing emotions (e.g., “I will just
do it for 5mins to start off with, at the end of those 5mins I will see if I can try it for
another 5mins”). In this way you can gradually and gently start to ‘expose’ yourself
to the distress you have been dreading. If you get to the end of your time limit and
find you just can’t go any longer being mindful of your distress, that is OK, you have
made a start at accepting rather than avoiding your distress. If this is the case, try using skills from the next
Module (Improving Distress), rather than going back to your old escape methods.
Having made this plan to be mindful of your distress next time it arises, be aware if there is anything you
will need to make your plan work. For example, a timer if you are setting a limit on how long you will
practice being mindful of your distress. Also, consider the best place to keep your mindfulness script so it
is easily accessible to you no matter where you are when you next feel distressed (e.g., on the fridge,
stored in your mobile phone, on a piece of paper in your wallet). Take a moment to think about the
logistics of making your plan work. Good luck!
Please note. If the distress you experience is extremely intense unbearable emotional pain,
such that you are currently unable to apply the acceptance strategies outlined in this module,
then skip ahead to the next module on tips for how to improve your distress. This is
particularly relevant for people who engage in self-harm, or drug and alcohol use to manage
their distress.
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Module Summary
• Remember that negative emotions are important to your survival, rather than something to be
feared and avoided at all costs. Also remember that distress is not permanent, but a changing
experience that is always fluctuating and eventually passes.
• Accepting distress is about seeing the negative emotion for what it is, and changing how you pay
attention to the emotion. In essence you become the watcher of your emotions, and this skill is
often referred to as “mindfulness”.
• Being mindful of your emotions involves: watching or observing your emotions, labelling or
describing your emotions, being curious and non-judgemental towards your emotions, using
imagery to detach from your emotions, focusing on the present moment, and dealing with
emotional comebacks.
• Being mindful of your emotions is about learning to catch and watch your emotions, not about
being so absorbed in the present moment that you don’t feel any emotions.
• Being mindful of your emotions is a skill that takes practice, patience and persistence. It is best to
practice when you are not distressed, so you might be better able to apply the skill when you are
distressed.
Coming up next …
In Module 3, you will learn specific
techniques to help you improve
emotional distress…
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About The Modules

CONTRIBUTORS
1 2
BACKGROUND
REFERENCES
Eifert, G.H., & Forsyth, J.P. (2005). Acceptance and commitment therapy for anxiety disorders. U.S: New
Harbinger Publications.
Eifert, G.H., McKay, M., Forsyth, J.P. (2006). Act on life not on anger: The new acceptance and commitment
therapy guide to problem anger. U.S: New Harbinger Publications.
Tolle, E. (2010). The power of now: A guide to spiritual enlightenment. Australia: Hachette Australia.
Wells, A. (2006). Detached mindfulness in cognitive therapy: A meta-cognitive analysis and ten techniques.
Journal of Rational-Emotive & Cognitive-Behavior Therapy, 23 (4), 337-355.

ISBN: 0 9757995 7 6 Created: May 2012
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Module 3
Improving Distress
Introduction 2
Balancing Acceptance & Improvement 2
Improving Distress 2
Opposite Action 3
Distress Improvement Activities 4
Improving Distress Practice 7
Problem Solving 8
Module Summary 14
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C Interventions Module 3: Improving Distress Page 1
Introduction
The previous module focused on developing ways of accepting emotional distress. This module takes a
very different focus of learning how to improve your distress when you experience it. To improve distress
we focus more on your behaviours, looking at what to do and what not to do when you experience
emotional distress. Depending on the type of escape methods you typically use (i.e., avoidance, numbing &
withdrawing, or harmful releases), the strategies we will suggest for improving your distress will vary
slightly. This module will focus on helping you discover a variety of things you can try to improve your
distress, so you can experiment and find out what works for you.
Balancing Acceptance & Improvement

Accepting and improving distress are quite different approaches, and maintaining a balance
between acceptance and improvement is the key to building distress tolerance. It is unhelpful
to be at either extreme (i.e., only accepting how you feel or only trying to improve how you
feel). To tolerate distress you really need to learn how to do both. Our aim is to help you
learn how to accept your negative emotions, and with that in mind, then work on improving your
emotional experience. Imagine if you only tried to improve your distress without being able to accept it
first, if this were the case then your efforts to find something to improve your negative feelings would be
pretty frantic and desperate. If instead you could accept your distress, then your efforts to improve the
distress would more likely be calm, considered and calculated.
We have purposely put Accepting Distress before Improving Distress in this series of Modules, as we don’t
want “improving” to become just another strategy for avoiding your emotions. In summary, you need to
feel the emotion first, accept it, ride through it, and then take action to improve it.
However having said that, if as you work through these modules the distress you experience is extremely
intense and unbearable emotional pain, then you may not be able to apply the acceptance strategies
outlined in the previous module just yet. If this is the case, then it is ok to move straight to this module
and focus on improving your distress (particularly the Distress Improvement Activities on page 5). This is
particularly relevant for people who engage in self-harm or drug and alcohol use to manage their distress. In
these situations, temporary distractions may be necessary to help you get through the intense distress you
might be experiencing, and avoid engaging in behaviours that are damaging to you.
Improving Distress
As we have seen, being distress intolerant can manifest is very different sorts of behaviours or escape
methods. Some people avoid certain situations that make them distressed, engage in reassurance seeking
or checking to alleviate their distress, or use distraction and suppression to stop their distress. Other
people numb and withdraw via engaging in alcohol
or drug use, binge eating or using sleep to escape Alcohol or Binge Eating
Drugs
their emotions. And other people may engage in
harmful releases, hurting themselves in some Sleep
physical way as a means of dealing with their Self Injury
distress. Although these behaviours are very Distress

different, and hence the strategies for improving Distraction &
distress can vary too, the common guiding principle Reassurance Suppression
for improving distress is to do the opposite of your Seeking or
Avoid
Checking
escape urge, and find specific activities that improve Situations
your emotional state.
Please Note: As mentioned in Module 1, whilst these modules may be helpful to people who use drugs, alcohol or self-harm as a
means of tolerating emotional distress, it is important to recognise that these are very serious problems in their own right that
can cause a person significant harm. We strongly advise seeking help from a GP or mental health professional to address these
concerns, rather than relying solely on these Modules to overcome the problem.
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Opposite Action
In Module 1, you identified your particular escape methods. Below is a table summarising the opposite
actions for each distress escape method we have covered. Look through the table and circle the opposite
action box corresponding to your particular escape method(s). There is also a box at the bottom for if you
engage in a particular escape method that we have not covered in these Modules. If this applies to you,
maybe you could try to think of what the opposite action would be.
Drop Escape Method Do Opposite Action
Situational Avoidance* Don’t avoid situations that distress you. Instead

gradually face these situations and stay in them,
until you have ridden through the distress.
Remember to reward your efforts when you are
done, by doing things that are active or soothing.
Reassurance Seeking or Checking Minimise or eliminate reassurance seeking or

checking behaviours. Try to cope independently
with the distress you feel, riding through these
feelings without resorting to checking things or
seeking the reassurance of others. Remember to
reward your efforts when you are done, by doing
things that are active or soothing.
Distraction & Suppression Don’t push away distressing feelings. Instead allow
and experience these feelings. Remember to
reward your efforts when you are done, by doing
things that are active or soothing.
Alcohol or Drugs Don’t numb the distress by using alcohol or drugs.

Instead allow and experience these feelings. Also
do things that are active or soothing, rather than
withdrawing from life.
Binge eating Don’t numb the distress by binge eating. Instead

allow and experience these feelings. Also do
things that are active or soothing, rather than
Excessive sleep Don’t numb the distress by using sleep. Instead

allow and experience these feelings. Also do
things that are active or soothing, rather than
Harmful Releases Self-soothe and be active in the moment, rather

than harming yourself.
* Note: This module deals with general avoidance driven by not wanting to feel emotional distress. If you identify very strongly with your
avoidance being specifically related to social situations, or fear of having a panic attack or fear of having a serious health problem, then you may
want to look at the ‘Shy No Longer’, ‘Panic Stations’ and ‘Helping Health Anxiety’ Information packages respectively to target these specific
problems.
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You will notice that most of the opposite actions initially require that you stay with, ride through, allow and
experience the distress, rather than escaping it. As such, the acceptance strategies of Module 2 will be
relevant in helping you do this. You will also notice that most of the opposite actions require engaging in
some activity that is either about being active in the moment, or about soothing yourself in some way. The
Distress Improvement Activities that follow this section will help you with ideas for activities that may help
you achieve these aims.
Also notice that for the first 3 escape methods (i.e., situational avoidance, reassurance seeking or checking,
distraction & suppression), distress improvement activities should be used as a reward after having faced
and stayed with the distress until it naturally subsides of its own accord. For the remaining escape
methods, engaging in distress improvement activities may be done sooner than this, as you do not
necessarily have to wait until you feel the distress subside.
It is also worth mentioning that doing these opposite actions can be challenging, and so words of
encouragement and compassion to ourselves may be important when we are finding it tough. It can be
useful to think “what encouragement would I give to
someone else feeling this way?”, “what would I say to
them and what tone would I use?” Some other
examples of helpful self-talk might be things like... “I
can stay with this feeling”; “it is good practice for me to “I can get through this!”
get comfortable being uncomfortable”; “I can get
through this”; “I can tolerate this”; “It will pass”; “this is
good for me in the longrun”; “I can focus on just getting
through this moment”; “I can breathe with this feeling”;
“this is helping me build my tolerance”...
Distress Improvement Activities

Finding small ways to participate and be active in the moment when distressed, or to self-soothe and self-
nurture when you are feeling distressed, are important for improving your emotional experience. Activities
that centre on the concepts of activating and soothing we will call ‘distress improvement activities’, and a list
of these is featured on the next page. The activities in the left-hand column are more about
participating actively in the moment (i.e., being involved, active and absorbed in something
that may improve your distress), whilst the activities on the right-hand side are more about
soothing yourself (i.e., activities that make us feel a sense of warmth and being cared for and
that help us get through things). You will notice there is a lot of overlap between activities
that are about activation and activities that are about soothing, so don’t get too caught up
in which column you pick activities from. Also, some of the listed activating and
soothing activities you may also find rewarding, and you can use them in this
way if needed.
The idea is not that you have to use each activity on the list, but that some may appeal to you to try and
others won’t. Also, by having such a large list, it may help you to brainstorm other distress improvement
activities that may work for you. Look at the list and underline any activities you may like to experiment
with when you are feeling distressed, and feel free to add other activities that come to mind in the space
provided. Remember, the aim of these activities is not to take your distress away, but to make
your distress more tolerable.
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Distress Improvement Activities
Activate Soothe
Exercise Have a good meal

Walk Have a nice snack
Jog Favourite drink (non-alcohol)
Gym Have a picnic
Weights Light a candle
Exercise class Look at beautiful art or scenery
Boxing Watch the stars
Cleaning Go to a beautiful place
Washing Soothing or invigorating music
Dishes Enjoy sounds of nature
Vacuuming Singing
Dusting Be aware and let sounds come and go
Gardening Favourite perfume
Cooking Favourite lotion
Call a friend Enjoy smells of nature or flowers
Go out to lunch, dinner, a coffee Bubble bath
Shopping Shower
Favourite movie Massage
Favourite book Pat dog or cat
Favourite music Soak feet
Favourite TV show Brush hair
Books/movies/music that create a different emotion Do nails
Magazines Imagine a relaxing scene/safe place
Newspaper Imagine coping/distress flowing away/distress passing
Games Create meaning/purpose from distress
Puzzles Read/think of your spiritual values
Volunteer somewhere Focus on any positive aspects in your life
Give someone a present Pray
Do something thoughtful Relaxation tape
Make something for someone Tense and release muscles
Slow breathing
______________________________________ Count to 10
Smile
______________________________________ Laugh out loud
Take a break (stay in bed for 20mins)
______________________________________
______________________________________ __________________________________________
______________________________________ __________________________________________
______________________________________ __________________________________________
______________________________________ __________________________________________
______________________________________ __________________________________________
Adapted from Linehan (1993).
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The only way to get a sense of what distress improvement activities work well for
you, is to start experimenting with those that sound promising, and then evaluate
what impact they have on your distress. Below is a table to keep track of the
findings from your experiments. The next time you feel distressed you might try
one of the distress improvement activities you highlighted, recording the date you
tried it, what the activity was and the outcome. By outcome we mean what actually
happened when you tried it. Did it work well at improving your distress? Did it
make no difference? Or did it make your distress worse? Based on the outcome
you can then evaluate what you learnt from it, whether it is a worthwhile strategy to do again, or whether
you need to redo it because you are still unsure if it is useful.
Date Distress Improvement Activity Outcome Evaluation

What happened? What did I learn?
Should I use this activity again?
10/05/2012 Warm Shower Felt groggy after. Didn’t Not sure if this is the best activity
feel great, but probably to use. I could use it again, but I
less angry than I was. might try music next time.
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Improving Distress Practice
Now that you have some general ideas of things not to do when you feel distressed (i.e., my
usual distress escape methods), and things you can do to improve your distress (i.e.,
opposite actions and distress improvement activities), it is good to personalise and clarify
these ideas for your own situation. Below gives two examples of what a personalised list
might look like. The first example is of someone who numbs & withdraws by binge
eating and sleeping, and also engages in harmful releases by scratching themselves. The
second example is of someone who situationally avoids by not leaving the house, distracts
themselves when they do venture out, and seeks reassurance from their family to deal with their distress.
Following these examples is the opportunity to draft your personalised list of ideas. Use the examples
below, the “opposite action” section(s) you circled on page 3, and what you learnt from your distress
improvement experiments on page 6, to assist you with drafting your own ideas.
Example Improving Distress Ideas

What Not To Do What To Do
Scratching myself when I feel distressed. Allow the distress rather than trying to get rid of it.
Binge eating when I feel distressed. Try active and soothing activities like... listening to my
Sleeping when I feel distressed. favourite CD, rubbing nice moisturiser on my arms
where I would normally scratch, walking around the
block, taking a shower, calling my friend Emma, enjoying
a good coffee, sitting in the sunshine, reading an
inspirational book, patting my cat.
Encourage myself: “I can get through this”, “It will pass”,
“I can tolerate this feeling”.
Example Improving Distress Ideas

Avoiding leaving the house, because it makes me Face the distress by leaving the house, without
distressed. headphones, and not relying on family to reassure me.
Distracting myself when I do have to leave the house, by Stick with it until I feel my distress come down.
always listening to music on my headphones. Encourage myself: “I can cope through this distress”,
Constantly seeking reassurance from my family about “this is good for me in the longrun”, “breathe with this
anything distressing me. feeling”, “focus on the task I am doing”.
Reward my efforts with active or soothing activities, once
I have felt the distress subside (e.g., quality time with my
family, making a nice meal for myself, buying myself a
new book).
Personalised Improving Distress Ideas

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Problem Solving
Once you have been able to tolerate rather than escape your negative emotions,
and your distress has somewhat subsided, it may be worth asking yourself
whether the distress you are experiencing is regarding a situation you can
actually do something about? That is, is your distress regarding something you
have some control over, and could take action with to improve how you are
feeling?
If the answer is ‘no’, then keep going with all that we have covered so far in
Module 2 and 3 to keep building your tolerance to the distress.
However, if the answer is ‘yes’, then once the distress has subsided, you might
be in a better position to problem solve regarding the situation that is distressing you. Problem solving
involves working your way through the problem in a systematic, step-by-step, structured manner. This
means identifying the problem that is distressing you, thinking through all the options for solving the
problem, looking at the advantages and disadvantages of the options most preferable to you, picking one or
more options to put into place, listing the steps required to put those options into action, and specifying a
plan for when you will take each step. Finally, it requires taking action to put your plan in place, then
evaluating the outcome, and reassessing if the problem has been solved or requires further action. As you
can imagine, problem solving is difficult to do when you are in the thick of distress, but is a good thing to
try once the distress is more manageable.
Below is an example of problem solving in action. If problem solving seems relevant to improving your
distress, space is then provided for you to follow the same problem solving steps.
Step 1: Identify/Define Problem

Try to state the problem as clearly as possible. Be objective and specific about the behaviour, situation,
timing, and circumstances that make it a problem. Describe the problem in terms of what you can observe
rather than subjective feelings.
Problem Definition
The gas and phone bills are due at the same time. I don’t have enough money to
cover both this month.
Step 2: Generate Possible Solutions/Options

List all the possible solutions. Be creative and forget about the quality of the solutions. If you allow
yourself to be creative, you may come up with some options that you would not otherwise have thought
of.
List All Possible Solutions

• Ring both companies – see if I can negotiate to pay it off gradually
• Prioritise – I can live without the phone for a while, but not the gas, so I will pay the gas
bill first
• Borrow money from family or friends to pay both bills
• Pay bills on my credit card – then pay that off later
• See a financial counsellor – they may be able to help me sort it out
• Get a second job
• Sell some of my possessions to pay the bills
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• Don’t pay the bills and move in with a friend instead
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Now eliminate the less desirable or unreasonable alternatives only after as many possible solutions have
been listed. Then, list the remaining options in order of preference.
Preferred Solutions/Options
1. Ring both companies – see if I can negotiate to pay it off gradually.
2. See a financial counsellor – they may be able to help me sort it out.
3. Prioritise – I can live without the phone for a while, but not the gas, so I will pay the gas
bill first.
4. Get a second job.
Step 3: Evaluate Alternatives

Evaluate the top 3 or 4 plans in terms of their advantages and disadvantages
Advantages Disadvantages
Potential I may be able to keep both the phone I will feel embarrassed having to ring
Solution #1 and gas on. the companies.
I will feel I have done something. I may not get what I want.
I will still have to pay eventually.
Potential They are experienced and will know I will need to do some research to find
Solution #2 what to do. a free service – this will take some
I’ll have support. effort.
Someone to help me.
Companies may listen to them.
Potential The gas will stay on. I won’t have a phone on hand if I need
Solution #3 I can still use the pay phone. it.
I will survive. I may have difficulties getting the
Problem will be reduced. phone reconnected in future.
Potential More money. I will be too busy – no time for myself.
Solution #4 This won’t solve the immediate
problem.
Step 4: Decide On A Plan

Decide on one, two or more of the plans. Specify who will take action, when the plan will be implemented
and how the plan will be implemented.
Action Steps Who When

Contact gas and phone companies to negotiate options for Me Monday morning
paying the bills (pay off gradually or extend payment).
If that doesn’t resolve the problem, contact Centrelink to Me Monday afternoon

ask about free financial counsellors.
Visit financial counsellor for advice. Me Tuesday
If that doesn’t resolve the problem, pay gas bill and use pay Me Wednesday
phone temporarily.
Step 5: Implement Plan

Implement your plan as specified above.
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Step 6: Evaluate the Outcome
Evaluate how effective the plan was. Decide whether the existing plan needs to be revised, or whether a
new plan is needed to better address the problem. If you are not pleased with the outcome, return to Step
2 to select a new option or revise the existing plan, and repeat the remaining steps.
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Problem-Solving
1. Identify and Define Problem Area/Issue
Problem Definition
2. Generate Possible Solutions/Options

List All Possible Solutions Preferred Solutions/Options
1.
2.
3.
4.
5.
6.
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3. Evaluate Alternatives
Advantages Disadvantages
Potential Solution #1
4. Decide on a Plan
Action Steps Who When
Step 5: Implement Plan

Implement your plan as specified above.
Step 6: Evaluate the Outcome

• How effective was the plan?
• Does the existing plan need to be revised or would a new plan be needed to better address the
problem?
• If you are not pleased with the outcome, return to Step 2 to select a new option or revise the existing
plan, and repeat Steps 3 to 6.
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Module Summary
• Maintaining a balance between acceptance and improvement is the key to building distress
tolerance. You need to feel the emotion first, accept it, ride through it, and then take action to
improve it.
• The common guiding principle for improving distress is to do the opposite of your distress escape
methods, and find specific activities that improve your emotional state.
• Acting opposite to your escape urge involves dropping your escape methods (i.e., situational
avoidance, reassurance seeking or checking, distraction and suppression, alcohol or drugs, binge
eating, excessive sleep, harmful releases, etc), allowing and experiencing the distress, and
participating in activities that are activating or soothing.
• Activities that are activating or soothing we call ‘distress improvement activities’, and you will need
to experiment with these activities when you are distressed to find out what works for improving
your distress.
• Once your distress is more manageable, it may be worth questioning if there is something you can
change about your situation to further improve the distress. If it is a situation you have some
degree of control over, then you can use the 6 problem solving steps as a way of working through
the problem systematically.
Coming up next …
In Module 4, you will put together and
practice your Distress Tolerance
Action Plan...
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About The Modules

CONTRIBUTORS
1 2
BACKGROUND
REFERENCES
Linehan, M. M. (1993). Skills Training Manual For Treating Borderline Personality Disorder. New York: Guilford
Press.

ISBN: 0 9757995 7 6 Created: May 2012
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Module 4
Tolerating Distress
Introduction 2
Distress Tolerance Action Plan 2
My Distress Tolerance Action Plan 6
Distress Exposure 7
Adjusting Distress Intolerant Beliefs 10
Adjusting My Distress Intolerant Beliefs 12
Maintaining Your Gains 13
Emotional Wellbeing 13
Module Summary 14
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C Interventions Module 4: Tolerating Distress Page 1
Introduction
By working your way through Modules 2 and 3, we have introduced you to all the skills you need to start
tolerating your distress. In this Module we will pull together all that you have learned in a Distress
Tolerance Action Plan. It is then just a matter of lots and lots of practice, and we will give you some ideas
on how to get the practice you need. As you will see, if you can apply your action plan regularly, then over
time you can change the distress intolerant beliefs that are at the heart of your difficulties dealing with
distress.
Distress Tolerance Action Plan

A good Distress Tolerance Action Plan requires 5 steps. Let’s look at each in turn:
1. Triggers
For an action plan to be useful, you need to first have some awareness
of the common things that trigger your distress. Being more aware of
what ignites your distress, will give you a ‘heads up’ for when you might
particularly need to be using your action plan. These triggers could be
external, such as certain situations, events, people, cues in the
environment, etc. Or these triggers could be internal, such as certain
thoughts, memories, images, bodily sensations, etc. A good way to get
in touch with your common triggers is to think of past examples of not
being able to deal with distress. That is, past times you used your old
escape methods (i.e., situational avoidance, reassurance seeking or
checking, distraction and suppression, alcohol or drugs, binge eating,
excessive sleep, harmful releases, etc). See if you can work out what
triggered off or led you to these behaviours in the first place. Below are
some common triggers of distress, tick any that apply to you or note
others that are specific to you that are not listed.
Relationship problems Hearing bad news Other:

Friendship problems Seeing family
Family problems Seeing friends
Partner/spouse behaviour Arguments
Anniversaries People being unfair or rude
Socialising Medical appointments
Financial problems Work or study stress
Unemployment Thinking about the past
Body sensations/symptoms Thinking about the future
Going out in public Being disorganised
Untidiness Health problems
Thinking about myself negatively Physical sensations
Comparing myself to others Physical appearance
2. Warning Signs
In addition to being aware of common triggers of your distress, it is also useful to be
aware of the warning signs that tell you that you are having trouble dealing with your
distress, and hence need to focus on using your action plan. Warning signs are the
feelings, thoughts, physical sensations, and behavioural urges or actions that signal you
are feeling overwhelming distress, and need to decide how best to handle this feeling.
Like before, we have listed some common warning signs over the page. Underline any
that apply to you or note others that are specific to you that are not listed.
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Feelings Thoughts Physical Sensations Urges or Actions

Disappointment, Hurt, I can’t cope Low Energy, Fatigue, Pace, Can’t Sit Still
Despair, Guilt, Shame, This is hopeless Heaviness, Crying Withdraw/Isolate Self
Sadness, Depression, Excessive Energy,
This is unbearable Lash Out, Yell, Throw
Grief, Misery Tension, Increased
This isn’t going to get Things
Irritation, Agitation, Heart Rate, Fast
better Avoid, Reassurance
Frustration, Disgust, Breathing, Sweating,
I am losing control Seeking, Checking
Jealousy, Anger, Rage, Hot, Shaking, Stomach
Hatred I can’t deal with this Problems, Chest Distraction, Suppression
Nervousness, Anxiety, I’m a mess Pressure, Restlessness, Alcohol or Drug Use
Dread, Fear, Panic, I am weak Fidgety Binge Eating
Terror I have to stop this Excessive Sleep
Harming Self
Other: Other: Other: Other:
3. Commit To Dropping Escape Method & Doing Opposite Action

Once you acknowledge your distress, via being more aware of your
triggers and warning signs, you are then in a better position to make a
commitment to dropping your usual escape methods (i.e., situational
avoidance, reassurance seeking or checking, distraction and suppression,
alcohol or drugs, binge eating, excessive sleep, harmful releases, etc). In
Module 3 we saw how important it is to try to do the opposite of our
escape methods. Our escape methods are usually automatic habits we
quickly jump to when we feel distressed, hence the decision not to go
down this path sometimes slips past us. By being more aware of
triggers, warning signs and our distress, we can choose to take a
different path of doing the opposite action.
The commitment you make might sound something like…
”I will try to tolerate this distress, rather than using my old habit of drinking to dull the pain”
or
“I will stay with this feeling, rather than avoiding situations that make me feel this way”
Making a commitment to drop your usual escape methods and do the opposite, could be something you do
mentally, or say out loud to yourself, or write down, or tell someone else about. It is up to you. The main
thing is making your actions a conscious choice, rather than an automatic habit.
Take time to write a statement that reflects the commitment you might like to make to dropping your
usual escape method and instead doing the opposite action. You might gain inspiration from what you have
already written in the What Not To Do and What To Do section of Module 3, page 7.
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
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4. Accepting Distress
In essence, this step is about applying all that you learnt in Module 2.
Your Personalised Mindfulness of Distress Script (see Module 2, page 8)
is of most relevance here. The script you devised and have been
practicing will help you to:
i) recognise and allow the emotion;
ii) watch the emotion by detaching from it, describing it and
using imagery;
iii) be present focused on a task or your breath; and
iv) deal with the inevitable emotional comebacks.
5. Improving Distress
In essence, this step is about applying all that you learnt in Module 3. List all the distress improvement
activities (both active and soothing) that you have discovered work for you, the words of encouragement
that can help you through the moment of distress, and aspects of problem solving that may be relevant
when you do have some control over the situation distressing you.
Now we want to put all 5 steps together on a single page that becomes
the most important page of all these Modules. Try to keep this page
somewhere easily accessible (you may even make multiple photocopies to
put in various places). The idea is that when you are facing emotionally
difficult times, you can look at this sheet to guide you through the new
process of practicing distress tolerance, rather than giving in to old habits.
As always, there is an example Distress Tolerance Action Plan on the next
page, followed by a blank copy for you to complete using what you have
already written in this Module and Modules 2 & 3. Put time and effort into
your personalised Distress Tolerance Action Plan, refining it each time
you use it, until you have a plan that works really well for you.
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Distress Tolerance Action Plan - example
My Triggers (external or internal)
Any relationship, friendship or family problem. Arguments. Thinking negatively about myself, the
past or the future.
My Warning Signs (feelings, thoughts, physical sensations, urges or actions)

Sadness, Hurt, Despair, Depression
Thinking this is “hopeless”, “unbearable”, “unchangeable”, “what’s the point to anything”
Low energy, heavy, tired, want to cry
Isolate myself from everyone, urge to drink to dull pain
My Commitment to Dropping Escape Method(s) & Doing the Opposite Action

I will stay with this feeling, rather than isolating myself and trying to escape with alcohol
Accepting My Distress (personalised mindfulness of distress script)

Aha! I’m feeling sad. This is a normal emotion to have. I can allow myself to have this feeling…I don’t
have to be afraid of it or try to get rid of it.
Watch Emotion:
I can just watch this feeling…make space for it…see what it does…I don’t have to get caught up in it.
I notice the emotion in my stomach and shoulders. I notice my body feels lethargic and heavy.
This is just an emotion, just a feeling to be felt, nothing more and nothing less. I am not my emotions, I
am the watcher of my emotions.
I can just observe the feeling like a cloud floating past in the sky – it will just hang around of its own
accord until it drifts out of sight.
Be Present:
I will turn my attention back to the task I am doing now …noticing what I can feel…hear... see… smell…
taste…OR to my breath – noting each in and out breath
I feel the sadness returning…that’s OK, that’s what emotions do, they like to rear their head again. I will
just go back to watching it again…it is just another cloud in the sky…
Note: remember if the distress I experience is extremely intense unbearable emotional pain, such that I am currently unable to apply the acceptance
strategies, then skip ahead to the next step of ‘improving’. This is particularly relevant for people who engage in self-harm, or drug and alcohol use
to manage their distress, as it is more important to avoid engaging in behaviours that are damaging to myself.
Improving My Distress (active & soothing distress improvement activities, words of self-encouragement, problem solving if relevant)
Walk around block Enjoy sunshine
Get out of house – beach, park, shops, friends Singing
Clean the kitchen Shower
Water the garden Pat my dog
Baking Focus on any positive aspects in my life
Plan and make a nice dinner Laugh out loud
Call best friend Favourite energetic music
Encourage myself: “I can get through this”, “This feeling will pass”.
Is it a situation I can control? If yes then problem solve: what’s the problem, list all possible options for
solving, look at pros and cons, pick a solution(s), break into steps, plan when to do each step, take action,
revisit options if needed.
Note: remember that if I am dropping the following escape methods – situational avoidance, reassurance seeking or checking, distraction &
suppression – then it is best to leave doing any distress improvement activities until after I have faced the distress and experienced it naturally
subside. In this way the distress improvement activities become a reward for approaching rather than avoiding my distress.
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My Distress Tolerance Action Plan

My Triggers (external or internal)
My Warning Signs (feelings, thoughts, physical sensations, urges or actions)
My Commitment to Dropping Escape Method(s) & Doing the Opposite Action
Accepting My Distress (personalised mindfulness of distress script)

Watch Emotion:
Be Present:
Note: remember if the distress I experience is extremely intense unbearable emotional pain, such that I am currently unable to apply the acceptance
strategies, then skip ahead to the next step of ‘improving’. This is particularly relevant for people who engage in self-harm, or drug and alcohol use
to manage their distress, as it is more important to avoid engaging in behaviours that are damaging to myself.
Improving My Distress (active & soothing distress improvement activities, words of self-encouragement, problem solving if relevant)
Note: remember that if I am dropping the following escape methods – situational avoidance, reassurance seeking or checking, distraction &
suppression – then it is best to leave doing any distress improvement activities until after I have faced the distress and experienced it naturally
subside. In this way the distress improvement activities become a reward for approaching rather than avoiding my distress.
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Distress Exposure
Aside from practicing your Distress Tolerance Action Plan the next time (and anytime) you happen to
experience distress, another way to gain confidence that you can deal with your distress is to purposely
seek it out. In other words, purposely expose yourself to emotional discomfort, and apply your action
plan. Now, this approach may not be for everyone, but it is a good way of gaining practice and building
confidence in your distress tolerance abilities, and reducing any fear of negative emotion you may have.
Distressing Situations I Could Approach

If you would like to give distress exposure a go, then the first step is to think of a variety of situations,
places, people, activities, etc, that may bring on emotional distress for you. The key being that we are
looking for situations that will allow you the opportunity to practice your Distress Tolerance Action Plan.
Here are some examples of potentially distressing situations. Note those relevant to you, and add others
you can think of.
Emotional movies, TV shows, music, books

Watching the News
Looking at old photos/memorabilia
Visiting the cemetery
Thinking about the past or future
Emotional conversations with family or friends
Stating my opinion or raising an issue that might lead to an argument
Situations that make me anxious like public places, shops, socialising, public transport, etc
Activities that bring on physical sensations that make me anxious, like heavy exercise, sitting in a
hot car, caffeine, breathing rapidly, spinning on the spot, etc
Activities that make me angry like driving, standing in a queue, debating topics, etc.
Others: _______________________________
_______________________________
_______________________________
Distress Exposure Stepladder

Now you can create a Distress Exposure Stepladder. This is a list of activities
likely to be distressing for you, that you can now start doing gradually as a way of
practicing your new distress tolerance skills. The first step is to work out your
goal – that is, what would you like to be able to do, but can’t because you fear
feeling distressed. Each step can then be about working towards that goal.
Your steps could involve a variety of activities (like the stepladder example given
over the page) or could involve just one activity. If it is just one activity that
distresses you, then each step on your stepladder might involve increasing the
amount of time you spend doing that activity, or changing who you do that
activity with, or where you do that activity, or when you do it, etc. The main
thing is trying to create manageable steps that go from easier activities to harder
activities, and that each activity generates some distress which you can use to
practice your Distress Tolerance Action Plan.
When planning your steps make a note of the distress rating (0-100) that you would give each step, that is,
how much distress you think you will experience when doing each step. This rating scale is a good way to
check that you have your steps in order from easiest to hardest, that you are starting with a manageable
first step, and that your steps are fairly evenly spaced without huge jumps in between each step.
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Distress Exposure Stepladder - Example
GOAL: Watch an emotional movie in one sitting DISTRESS (0-100)
85
STEP DISTRESS
1 Listen to an emotional song 25
2 Watch the TV news, without switching channels when a sad story comes on 35
3 Listen to an emotional CD in full 45
4 Watch an emotional TV show 55
5 Read an emotional book – 20mins at a time 65
6 Watch an emotional movie – in 30min intervals 70
7 Watch an emotional movie in 2 sittings 75
8 Watch an emotional movie in one sitting 85
My Distress Exposure Stepladder

GOAL: DISTRESS (0-100)
STEP DISTRESS
1
2
3
4
5
6
7
8
Distress Exposure Guidelines

Now that you know what the first step is, it is time to do it. But before you do, here are a few guidelines
to keep in mind to ensure that your distress exposure is effective.
1. Apply your Distress Tolerance Action Plan. Don’t forget to put the action plan you have
worked so hard on, into practice each time you take a step on your stepladder. After all, distress
exposure is your opportunity to practice distress tolerance, and fine-tune any teething problems.
2. Stay in the situation. As much as possible, try to stick with each activity by using your Distress
Tolerance Action Plan, until you experience your distress subside. If you pull out too soon before
you have experienced your distress drop, you will feel like the distress has gotten the better of
you, and it may rock your confidence.
3. Repetition, repetition. With each step on your stepladder, repeat it until you no longer feel
that activity is a problem for you, before moving on to the next step. This way your progress will
be steady and solid.
4. Reward your successes and learn from any negative experiences. Building distress
tolerance is a learning process. Purposely confronting your distress in order to put your Distress
Tolerance Action Plan into practice is a big deal. So recognise this and reward yourself! However,
when we are learning a new skill, we can’t expect things to always go smoothly. If things don’t go
to plan, try to sit back and learn from it. How could you do it differently next time? Do you need
to refine anything on your Distress Tolerance Action Plan? Do you need to go back to an easier
step on your stepladder and do some more repetition, before tackling the harder step again?
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Distress Exposure Diary
You can use the following table to record your stepladder progress. You can describe what you planned to
do, and your Distress ratings for how distressed you both expected to be and how distressed you actually
were. The last column asks you to jot down any comments about the experience – were you able to do
the activity you planned? Were you able to put your Distress Tolerance Action Plan into practice? If so,
how did it go? If you experienced a great deal of difficulty, you can note down why you think this might
have been the case, and how you can approach it next time or rework your action plan.
Distress exposure step Expected Actual Did you do it? Did you use your Distress Tolerance
DISTRESS DISTRESS Action Plan? How did it go?
0-100 0-100 OR
Describe what made it difficult to complete the step
and how you can prepare for next time?
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Adjusting Distress Intolerant Beliefs

As was introduced back in Module 1, at the heart of distress intolerance are certain negative beliefs about
what it means to experience negative emotions. These beliefs tend to centre on the notion that negative
emotion is either:
• bad in some way (e.g., “distress makes me weak”, “it is wrong or bad to be emotional”, “it’s
stupid”, “it’s unacceptable”), or
• unbearable (“I can’t bear feeling distressed, I hate it, I can’t stand it, I must get rid of it”), or
• will lead to disastrous consequences (e.g., “if I feel negative emotion, then I won’t be able to cope/
I will lose control/ I will go crazy/ I will be a mess/ I won’t be able to function/ it will be
dangerous”).
In Module 1 (page 6 & 9) you identified your Distress Intolerant Beliefs. Let’s double check these beliefs by
answering the following questions.
If I experience emotional distress then…
What will happen?_________________________________________________________
What will it be like?________________________________________________________
What will it mean about me?__________________________________________________
What will I need to do?______________________________________________________
See if you can summarise your answers above into one key Distress Intolerant Belief you strongly hold.
Emotional distress is bad because…
____________________________________________________________________________
It is important to realise that if you keep using your Distress Tolerance

Action Plan, and keep facing your distress rather than trying to escape it,
then over time your distress intolerant beliefs will weaken and erode. This is
because by the very act of tolerating your distress, you will be gathering
evidence and experiences that show you these beliefs are not true. This
adjustment process does rely on time, and your persistence in practicing
what you have learned throughout these modules. However, let’s see if we
can help the process along a little by working through the worksheet on the
next page. As always, we have provided a completed example, followed by a
blank worksheet for you to work on. The worksheet will guide you through
a series of questions that will challenge your distress intolerant beliefs,
allowing you to start adjusting them and developing more distress tolerant beliefs. “What is a distress
tolerant belief?” I hear you ask. This might sound something like…
Negative emotions are normal and nothing to be feared

Feeling distressed doesn’t have to lead to disaster
Negative emotions pass if you don’t fight or avoid them
I can stand uncomfortable emotions
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Adjusting Distress Intolerant Beliefs - example
The Distress Intolerant Belief I want to adjust is:
I can’t handle any emotional distress
Do I have any evidence or experiences that go against this belief, particularly from when I
have used my Distress Tolerance Action Plan (either spontaneously or via planned distress
exposure):
I have been able to use my action plan to deal with distress on a number of occasions:
• After a bad exam mark
• After a fight with mum
• After watching a sad movie
• After an argument with my partner
• When I had to do public speaking
• After many times of just sitting with my negative thoughts about everything
• …
Friends turn to me for support when they are upset, which shows I can be emotionally strong.
I have had to cope with a lot of emotional things during my life, and I am still here so I must have some
emotional strength I am not always aware of.
Why is distress not necessarily a bad thing, and may even be important? (see Module 2, page 2)
Negative emotions like sadness, fear and anger are normal and important to the survival of human
beings; they can protect us, keep us safe, and show that certain things in our life are important to us. If
we didn’t feel negative emotions we would be like lifeless robots. Experiencing distress may allow me to
be more sensitive to other people’s distress.
What is a realistic expectation of human beings, when it comes to experiencing distress?

All human beings experience distress. It would be unnatural if people didn’t experience negative emotions
when something went wrong for them.
If a friend held the same distress intolerant belief for themselves, what advice would I give to
them?
Yes you can get through times of distress, it is just that you don’t believe you can…the distress will pass,
just take it one moment at a time, and remember all the times you have handled distressing emotions
What would be a new Distress Tolerant Belief I would like to hold?

Distress is uncomfortable, but I can deal with it
What would I need to do to be living my life in accordance with this new belief?
Keep using my Distress Tolerance Action Plan when I feel distressed, and make a note of times I use it
effectively so I remember that I can do it.
Challenge myself by purposely doing something that makes me feel distressed, to reinforce to myself
that I can handle distressing emotions.
Don’t avoid distress by using drugs, or avoiding emotional situations.
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Adjusting My Distress Intolerant Beliefs
The Distress Intolerant Belief I want to adjust is:
Do I have any evidence or experiences that go against this belief, particularly from when I
have used my Distress Tolerance Action Plan (either spontaneously or via planned distress
exposure):
Why is distress not necessarily a bad thing, and may even be important? (see Module 2, page 2)
What is a realistic expectation of human beings, when it comes to experiencing distress?
If a friend held the same distress intolerant belief for themselves, what advice would I give to
them?
What would be a new Distress Tolerant Belief I would like to hold?
What would I need to do to be living my life in accordance with this new belief?
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Maintaining Your Gains
Congratulations! You have made it to the end of these Modules.
You should feel proud of yourself for sticking with it. Now, at the
end of the day the important thing is to keep going! Expect that
changing how you deal with distress will take time, practice,
persistence and patience. Expect that you will have good days and
bad. Expect you will have days you feel like you are tolerating your
distress really well, and days you feel like you have slipped back to
being ‘intolerant’. The old saying of “two steps forward, one step
back” is very true. If you expect setbacks when you sign up for the
journey of learning how to tolerate your distress, then when you
face a bump in the road, you will be less likely to criticise your
efforts and give up. As such, you will be better able to keep going
with your Distress Tolerance Action Plan, to help you get back on
track.
If you are struggling…don’t give up! Revisit the earlier Modules, take your time, and find someone who can
support you through developing these new distress tolerance skills. If you are finding that you are
continuing to use your old escape methods, particularly drug or alcohol use and self-harm, then we strongly
advise seeking professional assistance. Contact your GP to find a mental health professional who can help.
Emotional Wellbeing
Whilst these modules have focused on helping you learn skills to better tolerate emotional distress, we
hope that they lead to much more than just ‘tolerance’ of emotional discomfort. These modules are
ultimately about building a sense of emotional wellbeing and resilience. This journey hasn’t been
about changing who you are as a person, but instead finding space and strength within yourself to face your
feelings. Developing confidence that you can better cope with your emotions through applying the skills
introduced in these Modules, will likely have flow on effects to feeling more content in your life and feeling
a healthier human being all round.
The take home message of these modules is that emotional discomfort is not the problem, it is how we
react to our emotions that is the issue. If we can see emotional pain as a normal and inevitable human
experience that we don’t need to fear and avoid, but instead can ride through, then our distress no longer
has power over us. Distress is just something to be tolerated, by balancing both accepting our distress
with improving our distress. Remember, that your new distress tolerance skills and beliefs will be a ‘work
in progress’ initially. But, if you keep at it consistently over time, you will soon be able to face your feelings
with the new attitude…“I can stand it!”
I CAN STAND IT!
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Module Summary
• A Distress Tolerance Action Plan requires 5 key steps:
o Identifying triggers of distress
o Identifying warning signs of distress
o Committing to dropping escape methods and doing the opposite action
o Accepting distress using mindfulness skills
o Improving distress via distress improvement activities (e.g., active and soothing activities),
self-encouragement, and problem solving.
• Your Distress Tolerance Action Plan can be used at times when distress spontaneously arises for
you, or at times you actively seek out distress – which is what we call distress exposure.
• Distress exposure is purposely confronting situations that cause you emotional distress. This is
done in a gradual, stepladder fashion. It requires applying your Distress Tolerance Action Plan
when you face these situations, staying in the situation until your distress subsides, repeating steps
to gain confidence before moving to the next step, rewarding your successes and learning from any
difficulties. Distress exposure is designed to help you gain practice and confidence in your new
distress tolerance skills.
• If you keep using your Distress Tolerance Action Plan, and keep facing your distress rather than
trying to escape it, then over time you will weaken the Distress Intolerant Beliefs that are at the
heart of your difficulties in dealing with distress.
• Congratulations on making it through these Modules, now is the time for practice and persistence!
The End!
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About The Modules

CONTRIBUTORS
1 2
BACKGROUND
REFERENCES
Allen, L.B., McHugh, R.K. & Barlow, D.H. (2008). Emotional disorders: A unified approach. In D.H. Barlow
(Ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed., pp. 216-249).

ISBN: 0 9757995 7 6 Created: May 2012
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unhelpful thinking styles
mental filter
often cause themselves a great deal of emotional distress. One of these thinking styles is called a
“mental filter”.
mental filter
When we use a mental filter, we "filter in" some
What do you think the effect of this thinking style will
information, while we "filter out" other types of
have on the way you feel?
information. Although we might sometimes consider
this a useful process by focusing on what we consider
Notice that in this example you are
important, it can also become a sort of "tunnel vision" -
dwelling on a single detail out of the very
where we focus on only one part of a situation and
many details that occurred during the
ignore the rest. Often, this means looking at the
entire night. Notice that the detail you
negative parts of a situation and forgetting the positive
are dwelling on happens to be negative.
parts.
You have excluded other details of the whole picture,
which means that you are not remembering all the other
Here is an example:
positive experiences of the night. If you focus on this
Maybe you are out with your partner having a romantic
negative bit, then it is likely that you'll keep experiencing
dinner, and at the end of dinner you have a
the negative feelings that go along with it.
disagreement about whether to leave a tip or not.
Perhaps you stew on this disagreement in the car all the
way home.
Can you think of a situation where you have used this thinking style?
Briefly describe the situation. What were the thoughts that went What feelings did you experience
through your mind? consequent to your thinking?
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jumping to conclusions
by a number of unhelpful self-statements and thoughts. Often there is a pattern to such thoughts and
we call these, "unhelpful thinking styles". One of the things we have noticed is that people use
often cause themselves a great deal of emotional distress. One of these thinking styles is called
“jumping to conclusions”.
Jumping to conclusions If you jumped to these conclusions without looking

Most of us would have heard the phrase “You’re closely at all the evidence, such as the fact that the
jumping to conclusions!” meaning that a conclusion is person is expecting an important phone call soon, do
being made without really knowing if there is any you think you’d end up feeling happy or distressed?
evidence to support it. Although we might like to think Often these conclusions are a reflection of how we think
that if we “have a hunch” about something it is usually about ourselves, eg, "I think I'm boring," "I think I'm not
right, there are times when we are not right. There good enough", "I always do things wrong". Often we
are times that we keep jumping to the wrong jump to the conclusion that because we think poorly of
conclusion, or the conclusions are usually negative. ourselves, then others must too.
When we do this consistently then we can cause
ourselves quite a bit of distress. There are two ways in Predictive thinking
which we often jump to conclusions – mind reading and We also jump to conclusions when we begin
predictive thinking. making predictions about what is going to
happen on some future occasion, like we‘re
Mind reading gazing into a crystal ball. This is a very
As the name suggests, this is where we jump to common way to increase anxiety and stress.
conclusions because we assume that we know what These are often predictions where you overestimate the
someone else is thinking, or we know the rationale negative emotions or experiences you are going to
behind someone else's behaviours. This happens to be encounter. Think through this example. You’re asked to
a very common style of thinking. give a talk to a group of people, and you think “I’m going
Have you ever had this experience? You are talking to to get in there and forget what I’m supposed to say,
someone, and during the conversation they look at stumble over my words, and completely stuff up the
their watch? Perhaps you’ve thought, “they must think presentation, and this will be terrible”. You believe this
I’m a really boring person”, or "they don't want to be despite the fact that you have delivered many successful
here with me." presentations in the past. How might you feel if you
believed this overprediction?
Can you think of a situation where you have used these thinking styles?
Mind reading
Predictive Thinking
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personalisation
“personalisation”.
personalisation
Can you think of some occasions when something
If you were to consistently say to yourself, “This is my
hasn’t gone quite as you wanted, or the way you
fault”, “I’m to blame” – how do you think you’d start to
expected, and you’ve blamed yourself totally for what’s
feel?
happened? The toast burns at breakfast, and you blame
yourself not the toaster, your child plays a wrong note
Carrying 100% of the responsibility is a rather large
at a concert, and you blame yourself for not making
burden to bear, and one that’s likely to leave you feeling
him practice harder. Without realising it, you relate
discouraged or overwhelmed. It’s tough trying to carry
external negative events to something you have or have
the world on your shoulders.
not done.
Although accepting responsibility for
your actions is considered a positive
When you personalise something, you take total
characteristic, it is unhelpful to
responsibility for external events occurring, and
accept total responsibility for events
ignoring other important factors. As a consequence
that are beyond your control, or to
you end up blaming yourself for everything that goes
accept more responsibility than is
wrong or that could go wrong - even when you may
your share.
only be partly responsible, or not responsible at all.
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catastrophising
“catastrophising”.
catastrophising All of these examples get at the essence of this unhelpful

When someone says “you’re blowing things out of thinking style - that the person views the situation as
proportion”, or “you’re making a mountain out of a terrible, awful, dreadful and horrible. Sometimes
molehill”, chances are the person is catastrophising. unhelpful thoughts will also include other unhelpful
This style of automatic thinking often begins with the thinking styles – notice, for example, the appearance of a
following phrases; "What if !!!" or "Oh no! …" bit of overprediction and a bit of jumping to conclusions,
as well as catastrophising.
Let's try some examples.
Let's look at this final example. Have you ever submitted
"What if I blush in front of people …. and they realise I
am anxious!" a project, perhaps at work, and then realised that you’d
made a small error? You might think “I can’t believe I
"Oh no! I have a chest pain! …… I might made that mistake. This is going to be a poor submission,
be having a heart attack" I’m going to lose the account and probably lose my job.
"What if I disagree with my partner on this I’ll probably never find work in this city again!” What do
….. I will lose an important relationship!" you think it would be like for someone with this style of
thinking ? Even though the reality is that the problem
“I feel depressed this morning...what if I
itself is quite small, when we catastrophise, things can get
will stay depressed?"
very big very quickly, and we can work ourselves up to a
point where it all seems beyond our control.
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black & white thinking
by a number of unhelpful self-statements and thoughts. Often there is a pattern to such thoughts and
we call these, "unhelpful thinking styles". One of the things we have noticed is that people use
often cause themselves a great deal of emotional distress. One of these thinking styles is called “black
& white thinking”.
black & white thinking

We call this all-or-nothing thinking, or black-and-white
When it comes to sports, you may have heard some
thinking because you will tend to see only one extreme
people say something like “There are no prizes for
or the other. With this thinking, you are either right or
second place” suggesting that there is only one winner
wrong, you are either good or bad - there are no in-
and the rest are losers. It’s almost as if being the
betweens, no shades of grey, and no middle ground.
second best in the world is nothing to be proud of.
Similarly, the student who comes
If you used this kind of thinking consistently, how do you
home with a report card with a B
70% think you’d start to feel?
for Math and A’s for everything else
and thinks “I’m a failure.” is using
When we judge ourselves, others, or the situation,
black and white thinking.
based on these extremes, without seeing the shades of
grey in-between, it can be very easy to feel negative
Perhaps you’ve said something
emotions, such as disappointment, frustration, anger, and
similar to yourself, “If my partner
anxiety if we think that we, or others, are not clearly in
and I don’t always agree, then we have a bad
the desired category of “good” or “right” and so on.
relationship”, or “If I’m not the best at what I do, then
I’m worthless”.
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“shoulding” & “musting”
When a person experiences an unhelpful emotion (eg, depression or anxiety), it is usually preceded by
a number of unhelpful self-statements and thoughts. Often there is a pattern to such thoughts and we
call these, "unhelpful thinking styles". One of the things we have noticed is that people use unhelpful
thinking styles as an automatic habit. It is something that happens out of our awareness. However,
when a person consistently and constantly uses some of these styles of thinking, they can often cause
themselves a great deal of emotional distress. One of these thinking styles is called “shoulding and
musting”.
“shoulding” & “musting”

How do you think someone would
It is quite common in everyday language to hear people
feel after making these kinds of
use “I should”, and “I must” statements. Sometimes it’s
statements over and over again –
not necessarily unhelpful to think, "I should get my work
consistently setting the bar too high
in on time" and it can even be quite important to think “I
to reach? Chances are, they’ll feel
should not get drunk and then drive home”. However,
guilty or disappointed in themselves.
these types of statements become unhelpful when you
use "should" and "must" statements to put unreasonable
We may also use these types of statements when we are
demands or pressure on yourself.
talking about other people
“She should know better than that”,
We might say
“People should always keep their promises”,
“I should get things right”, or
“I can‘t believe they just cut in front of my car! They shouldn‘t
“I must never get upset with my partner”, or
drive like that!”.
"I should always cook exquisite meals."
You might have guessed that these kinds of statements
Using “should” and “must” in this way often leads to
leave us feeling frustrated or angry and disappointed in
unrealistic expectations.
others.
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overgeneralisation
themselves a great deal of emotional distress. One of these thinking styles is called
“overgeneralisation”.
overgeneralisation
overgeneralisations. Have you ever said, or heard,
The key element in this unhelpful thinking style is to take something like, “You never do anything romantic for
one instance in the here and now, and to impose this on me”, or “I always have to take out the garbage”, or
all future situations. “Everyone keeps having a go at me”, or “Every night I
come home, those kids have always left a mess!”
Perhaps you’ve said to yourself in the past “This is just
so typical!” telling yourself that this is “how things always Notice that these unhelpful thinking styles often include
are”, or “everyone’s like that”, or "things never turn out words like, "all", "never", "always" and "every", when, in
well for me", when, in fact, there are only a few most cases, the “always” and “never” are not as solid as
examples to go by. Making broad, generalised and global we might think they are. How do you think someone
conclusions on the basis of only a little evidence can would feel if they used this thinking style? They may feel
leave us thinking that things are really uncontrollable, frustrated, discouraged, depressed, or annoyed, amongst
inevitable and out of our hands. A other things.
sense of helplessness often
accompanies such Typical!
overgeneralisations.
If you think about personal

relationships, you might notice a few
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labelling
themselves a great deal of emotional distress. One of these thinking styles is called “labelling”
labelling
You can probably think of times when you’ve If you were to consistently
bumped something off the table, or dropped a glass label yourself or others in this
while washing the dishes and perhaps thought to way, what effect do you think
yourself, “I’m such an idiot!” Or perhaps a friend this would have on how you
doesn’t call you to say they can’t make it to your feel?
birthday dinner and you think, “They are so
inconsiderate”. It’s a little like overgeneralising If you were to step back from the situation and
about people. take a closer look, you might realise that breaking a
glass doesn’t mean that you’re an “idiot”, and the
When we make global statements about ourselves fact that you are competent in your job, or can
or other people, which are based only on communicate effectively with your family, might
behaviour in specific situations, then we are suggest otherwise. Similarly, your friend may have
labelling. The problem is, that by defining a person acted kind and considerate at other times, but
by one specific behaviour - and - usually one that something may have prevented them from calling.
we consider negative, we ignore the other positive
characteristics and actions.
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emotional reasoning
When a person experiences an unhelpful emotion (eg, depression or anxiety), it is usually preceded by a
number of unhelpful self-statements and thoughts. Often there is a pattern to such thoughts and we call
these, "unhelpful thinking styles". One of the things we have noticed is that people use unhelpful thinking
styles as an automatic habit. It is something that happens out of our awareness. However, when a
person consistently and constantly uses some of these styles of thinking, they can often cause themselves
a great deal of emotional distress. One of these thinking styles is called “emotional reasoning”
emotional reasoning
This is a style of unhelpful thinking whereby you
For example, you might be walking down the street
base your view of situations, yourself, or others, on
and think “I feel anxious, so I know something
the way you are feeling.
dangerous is going to happen”, or “I feel so
depressed, this must be the worst place to work
Have you ever felt anxious about something and
in”.
thought to yourself, "I know this isn't going to work
out well" and everything turned out just fine? If you
It’s like we’re saying to ourselves “I feel, therefore
have, it’s likely that you
it is” - rather than looking at what real evidence
were using emotional
there may be. There might be no other evidence to
reasoning. In this case, we
suggest that something dangerous might happen, or
evid nal
tend to take our emotions

ence
that it is the worst place to work in. The only

io
as being evidence for the

emot
evidence you may be using is how you feel.

truth.
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magnification and minimisation
themselves a great deal of emotional distress. One of these thinking styles is called “magnification and
minimisation”.
magnification and minimisation

When you use this binocular style of thinking, you
This is the binocular effect on thinking. Often it
ignore the positives about yourself, discounting
means that you enlarge (magnify) the positive
them as though they are not important.
attributes of other people and shrink (minimise)
your own attributes, just like looking at the world
through either end of the same pair of binoculars.
Disqualifying your own attributes for achievement

has negative effects. Think of the times in your
own life where you might have said, or heard
others say,
In this way you might ’water down’ positive
experiences, and even transform them into negative
“Oh, that doesn’t count, I was just lucky”, or
ones. It’s as though you’re being so humble you’re
“They don’t really mean it, they were just being polite”.
putting yourself down.
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challenging unhelpful
thinking styles
Evidence Testing is all about trying to be objective about our thoughts. It is about asking
yourself questions that will help you look for other information and make an informed decision
about your thoughts, instead of just accepting them as fact.
1. CHECK THE EVIDENCE
If this thought was put on trial, what evidence would the defence present (what
facts support the thought being true)?
What evidence would the prosecution present against (what information

works against the thought or shows that it isn’t true all the time)?
2. CHALLENGE UNHELPFUL THINKING STYLES
Unhelpful Thinking Style Disputation Questions

Consider the whole picture
Mental Filter - Am I taking all the information into account?
- What else is going on that I’m ignoring?
You know what they say about assuming…
Jumping to Conclusions - How do I know this?
- What are some alternative explanations for this?
- If I was feeling differently, would I still think this?
Find all the causes
Personalisation - Was this entirely my responsibility?
- What other factors might have affected the outcome?
Put it in perspective
Catastrophising - What are the possible outcomes – best, worst, most
likely?
- Am I jumping ahead of myself?
- How important is this in the scheme of things?
Find the shades of grey
Black and White Thinking - Am I being extreme or rigid?
- Is there an in-between where things are not perfect but
not a disaster?
Be flexible
Shoulding and Musting - Is this a strict rule, or is it a desire or possibility that didn’t
work in this instance?
- Can I replace this with a “could” or “would have liked to”?
Judge the situation, not the person
Labelling - Does this behaviour or situation reflect how things always
are?
- Are there examples where this label hasn’t been true?
Be specific
Overgeneralising - Does this apply to all situations or am I overgeneralising?
- What are the facts and what are my interpretations?
Acknowledge the good
Disqualifying / Ignoring the - Am I downplaying or ignoring some of the evidence?
Positives - What are the good things in this situation?
3. CHANGE MY PERSPECTIVE
What other ways are there of viewing the situation?
If I was giving advice to someone I care about in this situation, what would I say?
If I want to act in a certain way, how would I have to think differently?
sleep hygiene
7) No naps. It is best to avoid taking naps
What is Sleep Hygiene? during the day, to make sure that you
are tired at bedtime. If you can’t make it
‘Sleep hygiene’ is the term used to describe good sleep habits. through the day without a nap, make
Considerable research has gone into developing a set of sure it is for less than an hour and
guidelines and tips which are designed to enhance good before 3pm.
sleeping, and there is much evidence to suggest that these 8) Sleep rituals. You can develop your own rituals of things to
strategies can provide long-term solutions to sleep difficulties. remind your body that it is time to sleep - some people find
it useful to do relaxing stretches or breathing exercises for
There are many medications which are used to treat insomnia, 15 minutes before bed each night, or sit calmly with a cup of
but these tend to be only effective in the short-term. Ongoing caffeine-free tea.
use of sleeping pills may lead to dependence and interfere
9) Bathtime. Having a hot bath 1-2 hours before bedtime can
with developing good sleep habits independent of medication,
be useful, as it will raise your body temperature, causing you
thereby prolonging sleep difficulties. Talk to your health
to feel sleepy as your body temperature drops again.
professional about what is right for you, but we recommend
Research shows that sleepiness is associated with a drop in
good sleep hygiene as an important part of treating insomnia,
body temperature.
either with other strategies such as medication or cognitive
therapy or alone. 10) No clock-watching. Many people who struggle with sleep
tend to watch the clock too much. Frequently checking the
Sleep Hygiene Tips clock during the night can wake you up (especially if you turn
on the light to read the time) and reinforces negative
1) Get regular. One of the best ways to train your body to thoughts such as “Oh no, look how late it is, I’ll never get to
sleep well is to go to bed and get up at more or less the sleep” or “it’s so early, I have only slept for 5 hours, this is
same time every day, even on weekends and days off! This terrible.”
regular rhythm will make you feel better and will give your
body something to work from. 11) Use a sleep diary. This worksheet can be a useful way of
making sure you have the right facts about your sleep, rather
2) Sleep when sleepy. Only try to sleep when you actually than making assumptions. Because a diary involves watching
feel tired or sleepy, rather than spending too much time the clock (see point 10) it is a good idea to only use it for
awake in bed. two weeks to get an idea of what is going and then
3) Get up & try again. If you haven’t been able to get to perhaps two months down the track to see how you
sleep after about 20 minutes or more, get up and do are progressing.
something calming or boring until you feel sleepy, then 12) Exercise. Regular exercise is a good idea to
return to bed and try again. Sit quietly on the couch with help with good sleep, but try not to do strenuous
the lights off (bright light will tell your brain that it is time exercise in the 4 hours before bedtime. Morning
to wake up), or read something boring like the phone walks are a great way to start the day feeling refreshed!
book. Avoid doing anything that is too stimulating or
interesting, as this will wake you up even more. 13) Eat right. A healthy, balanced diet will help you to sleep
well, but timing is important. Some people find that a very
4) Avoid caffeine & nicotine. It is best to avoid consuming empty stomach at bedtime is distracting, so it can be useful
any caffeine (in coffee, tea, cola drinks, chocolate, and to have a light snack, but a heavy meal soon before bed can
some medications) or nicotine (cigarettes) for at least 4-6 also interrupt sleep. Some people recommend a warm glass
hours before going to bed. These substances act as of milk, which contains tryptophan, which acts as a natural
stimulants and interfere with the ability to fall asleep sleep inducer.
5) Avoid alcohol. It is also best to avoid 14) The right space. It is very important that your bed and
alcohol for at least 4-6 hours before going to bedroom are quiet and comfortable for sleeping. A cooler
bed. Many people believe that alcohol is room with enough blankets to stay warm is best, and make
relaxing and helps them to get to sleep at sure you have curtains or an eyemask to block out early
first, but it actually interrupts the quality of morning light and earplugs if there is noise outside your
sleep. room.
6) Bed is for sleeping. Try not to use your bed 15) Keep daytime routine the same. Even if you have a bad
for anything other than sleeping and sex, so that your body night sleep and are tired it is important that you try to keep
comes to associate bed with sleep. If you use bed as a your daytime activities the same as you had planned. That is,
place to watch TV, eat, read, work on your laptop, pay don’t avoid activities because you feel tired. This can
bills, and other things, your body will not learn this reinforce the insomnia.
connection.
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sleep diary
Use this sleep diary to make an accurate assessment of how much you sleep and
other factors associated with your sleep. This will help you to identify patterns and
areas for improving sleep hygiene. Also, many people who struggle with sleep
difficulties make negative assumptions about their sleep (e.g. “I never sleep more than
5 hours a night”) and this worksheet can help you to check if this is really the case.
Pre-sleep information Bed/sleep pattern

Day/Date Naps (what Caffeine, Medication Pre-bed Day fatigue Tension in In-bed Lights out Time to fall Waking Hours slept Woke up? Rest score
time & how alcohol, nico- (day total & activity level (0-5, 5 bed (0-5, 5 activities (time) asleep time (number of (0-5, 5
long?) tine? (day before bed) (what did most tired) most tense) (minutes) times, how most rest-
total & 4 hrs you do?) long) ed)
before bed)
Example: 2pm, 40 2 coffees, 1 Nil. watched TV 3 - felt a bit 4 - felt very Read for 1 10:30pm 40 min 5:10am 6 hrs 40 Once at 3 - felt
minutes beer, nothing after dinner, tired today tense when I hour min 2am, back somewhat
after 4pm 3 hours went to bed to sleep rested when
after 20 I woke up
minutes
C entre for
See website www.cci.health.wa.gov.au for more handouts and resources. CI linical
nterventions

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Helping Health Anxiety

Helping Health Anxiety

Helping Health Anxiety

What Is Health Anxiety?

Health concerns can become a problem when they:

Never Occasionally Often Very

BUT I HAVE REAL SYMPTOMS?!?!

Negative Impacts of Health Anxiety

What You Can Expect From This Information Package

Module 1: Understanding Health Anxiety

About The Modules

Dr Lisa Saulsman (MPsych1; PhD2)

“HELPING HEALTH ANXIETY”

ISBN: 0 9757995 6 8 Created: August 2011

Helping Health Anxiety

Negative Health Experiences

Having family members or others around you experience a serious illness

Death of a family member or someone known to you

Having experienced a medical problem yourself

Negative information from the media or internet

Heightened Health Vulnerability

Protecting Ourselves: Unhelpful Health Rules and Assumptions

Health rules may include:

Health assumptions may include:

Health rules and assumptions can also be combined as follows:

Protecting Ourselves: Increased Health Sensitivity

Unfortunately, focussing on a symptom can sometimes amplify the intensity of the

Negative Health Experiences  Heightened Health Vulnerability

Attempt to protect health via:

Unhelpful Health Rules & Increased Health Sensitivity

Increased susceptibility to health anxiety.

Negative Health Experiences  Heightened Health Vulnerability

Attempt to protect health via:

My Health Rules & Assumptions Increased Health Sensitivity

Increased susceptibility to health anxiety.

The Good News…

About The Modules

Dr Lisa Saulsman (MPsych1; PhD2)

“HELPING HEALTH ANXIETY”

ISBN: 0 9757995 6 8 Created: August 2011

Helping Health Anxiety

How Health Anxiety is Triggered

Catastrophic interpretation of bodily sensations

Catastrophic interpretation of health related information

Increase in Anxiety Symptoms

Activates unhelpful health rules / assumptions

Unhelpful health related thoughts

Focussing on Checking & Avoidance &

Short term consequences

Long term consequences

Activates unhelpful health rules / assumptions

Unhelpful health related thoughts

Focussing on Checking & Avoidance &

Short term consequences

Long term consequences

More Good News…

About The Modules

Dr Lisa Saulsman (MPsych1; PhD2)