The Unified Protocol for Transdiagnostic Treatment

of Emotional Disorders

Module Handouts and Homework Forms

David H. Barlow, Kristen K. Ellard, Christopher P. Fairholme,

Todd J. Farchione, Christina L. Boisseau, Laura B. Allen,
Jill T. Ehrenreich-May

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 Understanding our Emotions and our Behavior (The ARCs)

Emotions are a natural part of our daily lives. Experiencing emo-

tions is not problematic in and of itself. In order to understand how
or when our emotions become problematic or begin to interfere with
our lives, we need to understand the situation or context in which
our emotions and behavior occurs.

A large part of treatment will involve being better able to understand

and identify the situations or events that precede and may trigger
our emotions and the consequences of our emotional reactions. We
call this skill identifying the “ARC” of your emotional experiences.

The As - Antecedents – Situations that precede or trigger your emotions

& emotional reactions

Something precedes us behaving in a particular way. For example,

when you are driving and someone cuts you off, you then get angry
and might even yell. In this case, knowing that you were cut off
while driving helps us to understand why you responded by getting
angry and yelling.

In addition to events that occur immediately before we react, more

distant events can also influence our emotions and behavior. Building
on our previous example, suppose that earlier in the day you had
gotten into a fight with a significant other (family member, partner,
friend, etc.) and then someone cuts you off on the freeway later that
day. This earlier fight could also influence how you respond to being
cut off.

The Rs - Responses – The emotional reaction you may have in response

to these situations

This is the behavior or emotional reaction in question. In the above

example, the Bs would be getting angry and yelling.

The Cs - Consequences – What happens afterwards or as a result of

your emotional reaction

Our behaviors have consequences. For example, after getting angry

and yelling you might discover that you know the person and that
they were rushing to the hospital with a sick child. You then

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 feel embarrassed and/or ashamed. In this case, both the reaction and
the event that preceded your reaction help us to understand the
consequences.

This is a very important skill, and one that we will be spending a lot
of time practicing. You can use this skill in the future to help solve
problems or deal with any setbacks you might experience.

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 Definitions of Emotions

The following are some definitions of emotions we talked about

during session. These, of course, are not all of the emotions we expe-
rience, but these examples will begin to give you an idea of some of
the ways emotions function in our lives.

Fear

Fear is nature’s alarm system. It is a basic response to danger and

signals the need for immediate attention and action.

Sadness/Depression

Sadness/depression is extreme dejection, melancholy, and a sense of

hopelessness and inadequacy, which is a natural response to loss of a
loved one, or a personal set back for which no solutions are obvious.
It signals the need for withdrawal and reduction of activity so that
mourning may take place, resources can be gathered, and the event
can be processed appropriately.

Anxiety

Anxiety is a future-oriented emotion. It is a basic response to the

perceived unpredictability of, or lack of control over, upcoming,
potentially negative or dangerous events. It signals the need to be
vigilant, reduce activity, and refocus attention on possible sources of
future threat or danger. When we feel anxious, our bodies and minds
get into a state of “preparation” so that we aren’t caught off guard if
something bad happens.

Anger

Anger is a natural response to the perceived intentional injury, mis-

treatment, or victimization. It signals the need to increase activity
and mobilize efforts to defend oneself or a loved one. Anger is often
directed at the perceived source or cause of this threat (or feeling).

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 Understanding Emotions and Emotion Driven Behaviors (EDBs)

One of the key points about emotions is that under normal circum-
stances, emotions (e.g., fear, anxiety, sadness/depression, anger, etc.)
tell us very important things about what is going on in our lives
and motivate us to do something helpful or useful. We call these
resulting emotional behaviors “emotion-driven behaviors,” or EDBs,
because they are hard to resist (or change) when we get emotional.

Some examples of EDBs:

Fear

Imagine you are walking down the street and a car comes screeching
down toward you, you jump on to the sidewalk and pull your friend
away from the car.

What is the EDB? Jumping out of the way.

Sadness/Depression

Imagine you find out that a very close friend or family member has
passed away. You will probably feel intense sadness/depression and a
great sense of loss. You are also likely to feel as if you have no energy
and it is difficult to focus on anything except for disorganized
thoughts of your loved one and how you will cope. You may also feel
numb, and that the loss hasn’t really “sunk in.” These are typical
responses to experiencing a tragedy or traumatic event. As a result,
you might find that you are unable to do much of anything other
than focus on the loss in an effort to help yourself cope.

What is the EDB? Decreasing activities, focusing on the loss.

Anxiety

Imagine that you have a big presentation coming up at work/school,

which is going to be very important for your job/grade. Naturally,
you start to think about it more often as the date approaches and
you might even start to feel anxious. So, you start doing some
research on the topic – maybe you even stay really late at the library
to make sure you have all the information you need. You make the
presentation and practice it several times (you might even ask a

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 friend or family member to give you feedback on it). You’ll even
anticipate some of the questions people might ask so that you know
how you will respond. On the day of the presentation, you’ll prob-
ably get up early, put on your best suit and go over the presentation
again.

What is the EDB? Preparing for the presentation, to avoid doing badly.

Anger

Imagine that you are driving in your car on the freeway when some-
one suddenly cuts you off. You have to slam on your brakes to avoid
hitting the other driver. You honk your horn and yell at the other
driver, perhaps even cursing, and experiencing a strong impulse to
go after them.

What is the EDB? Honking the horn and yelling.

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 Three-Component Model of Emotion

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Feelings

Thoughts Behaviors

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Monitoring Emotions and EDBs in Context

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As Rs Cs
Antecedents Responses Consequences

Date/Time Situation, Triggers Thoughts Feelings Behaviors What happened next?

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 Decisional Balance Worksheet

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Thinking about changing or coming into treatment can be scary. When we think about changing, we
often don’t consider all “sides” in a complete way. Instead, we do what we think we “should” do and avoid
doing things we don’t feel like doing. We might even just feel confused or overwhelmed and give up think-
ing about it at all. Thinking through the pros and cons of both changing and staying the same, is one way
to help us fully consider a possible change and help the process feel more manageable. This can also help
us cope with difficult times that might arise along the way. Write all the pros and cons you can think of for
both changing and staying the same in the boxes below.

Pros/Benefits Cons/Costs

Change

Stay the
Same

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 Treatment Goal Setting Worksheet

Research has consistently shown that one of the most effective ways
to achieve successful behavior change is goal setting. When we talk
about goals, we are referring to future states or events that we are
interested in making happen or hoping to prevent from happening.
These can include more immediate things, such as: “going to the
gym tonight” or “finishing my treatment homework” and more dis-
tant things, such as: “making more friends” and “feeling happier.”
Research has also shown that setting specific, concrete, and manage-
able goals for behavior change greatly improves our chances of suc-
cessfully changing. Although you might have a general sense of what
your goals for treatment are, it will be helpful to explicitly record
these goals on this worksheet. Next, you will outline a series of
smaller goals or steps that will help you to achieve your larger, more
distant treatment goals. Take a moment to think about your most
important goal that you have for yourself during treatment.

My #1 goal for treatment is: ___________________________________________________

Making it More Concrete

Now, let’s take a moment to make this goal more concrete. What
would it look like once you have achieved this goal? What things
would you be doing, or not doing? What behaviors would you be
engaging in? What behaviors would you not be engaging in? Try to
be as concrete as possible here.
________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Taking the Necessary Steps

Next, think about some small manageable steps that you can take
towards reaching the specific treatment goals you’ve listed above.
These steps should take anywhere from a few days or a week up to
a month to achieve. What steps will you need to take? It can be

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 helpful to work backwards from your goal to help identify specific
steps you will need to take to get there. Use the behaviors you listed
above to help come up with your steps to achieving your treatment
goal.

Step 5:

________________________________________________________

Step 4:

________________________________________________________

Step 3:

________________________________________________________

Step 2:

________________________________________________________

Step 1:

________________________________________________________

People often have at least a few goals for treatment. Let’s take a
moment to list at least two more treatment goals you have. You
might find it helpful to repeat this process for additional goals as
well.

My 2nd goal for treatment is: __________________________________________________

Making it More Concrete

Take a moment to make this goal more concrete. What would it

look like once you have achieved this goal? What things would you
be doing, or not doing? What behaviors would you be engaging in
or not engaging in? Again, be as concrete as possible here, try to list
specific behaviors.

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

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 Taking the Necessary Steps

Next, think about some small manageable steps that you can take
towards reaching the specific treatment goals you’ve listed above.
These steps should take anywhere from a few days or a week up to a
month to achieve. What steps will you need to take? It can be help-
ful to work backwards from your goal to help identify specific steps
you will need to take to get there. Use the behaviors you listed above
to help come up with your steps to achieving your treatment goal.

Step 5:

________________________________________________________

Step 4:

________________________________________________________

Step 3:

________________________________________________________

Step 2:

________________________________________________________

Step 1:

________________________________________________________

My 3rd goal for treatment is: ___________________________________________________

Making it More Concrete

Take a moment to make this goal more concrete. What would it

look like once you have achieved this goal? What things would you
be doing, or not doing? What behaviors would you be engaging in
or not engaging in? Again, be as concrete as possible here, try to list
specific behaviors.
________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

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 Taking the Necessary Steps

Next, think about some small manageable steps that you can take
towards reaching the specific treatment goals you’ve listed above.
These steps should take anywhere from a few days or a week up to a
month to achieve. What steps will you need to take? It can be help-
ful to work backwards from your goal to help identify specific steps
you will need to take to get there. Use the behaviors you listed above
to help come up with your steps to achieving your treatment goal.

Step 5:

________________________________________________________

Step 4:

________________________________________________________

Step 3:

________________________________________________________

Step 2:

________________________________________________________

Step 1:

________________________________________________________

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 Practicing Emotional Awareness

The first step in changing how we experience and respond to our

emotions is to practice accurate awareness of our emotions.

Components of “emotional awareness”

1. Allowing oneself to fully experience emotions as they happen.

2. Focusing on being in the present moment, not “living” in the
future or in the past.
3. Noticing thoughts, feelings, and behaviors that are occurring at
that moment.
4. Allowing emotions to come and go, without trying to push
away feelings or trying to hold on to certain feelings. When
you allow yourself to experience a negative emotion, then you
are able to process it and move forward. If you don’t give
yourself permission to experience the emotion but push it
away, then it becomes a “tidal wave” of emotion that feels very
out of control.
5. Being aware of your emotions does not always “feel good.”
However, it will allow you to move past the experience, instead
of getting stuck trying to push it away, which only reinforces its
power.
6. Awareness does not necessarily mean acceptance of the
situation or environment. Instead, we are focusing on
acceptance of one’s emotional reaction to it, before possibly
acting in a different way.
7. Having some understanding for one’s own emotional
experience. Getting “mad” or “frustrated” with yourself or
saying “I’m so stupid for feeling this way” will only make you
want to control and resist emotional experience even more.
This treatment focuses on increasing the range of emotional
experience, instead of attempting to restrict it. This includes
allowing oneself to be sad, frustrated, anxious, as well as letting
it pass.

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 Natural Course of Emotions

When we do things to try to avoid our emotions or stop them from

occurring when they are at their most intense peak in a given situa-
tion, we add fuel to that emotion and will associate that situation in
the future with these intense emotions.

Emotions Avoidance

Time

However, if we allow them to just happen, without trying to avoid

them or stop them from occurring, the intensity of emotions will
actually start to decrease. This is the natural course of emotions. By
allowing them to run their course, we can begin to associate a given
situation with the natural ebb and flow of emotion, knowing what
goes up, must come down.

Emotions

Time

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 Natural Course of Emotions

In fact, by letting our emotions just happen in a given situation,

without trying to change them or control them or stop them from
occurring, we will start to experience our emotions as less and less
intense each time we are faced with the same situation in the future.
We have allowed ourselves to see that what goes up, must come
down, and have learned that we can in fact “ride the wave” of our
emotions and cope with the situation.

Emotions

Time

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 Mood Induction Recording Form

The purpose of this exercise is to practice noticing the thoughts, physical

sensations/feelings, and behaviors that come up during an emotional
experience. Try to find music and/or songs that bring up strong emotions
for you. As you listen, note your reactions to the music and/or the songs
you have selected. Use this form to record what you noticed after listening
to each piece. What was your first emotional response? How strongly did
you feel these initial emotions? What was your reaction to this initial
emotional response - what thoughts, sensations, or feelings did you
experience? Rate the intensity of your emotional experience using the
0–10 point scale below:

0 1 2 3 4 5 6 7 8 9 10
Not at all A Little Moderately Quite a Bit Extremely

Initial Intensity of Reaction to Emotional

Emotional Emotional Response
Response Response

Rate how Describe

Describe Describe
Song strongly you Describe behaviors
emotions sensations
Name felt these thoughts (e.g., fidgeting,
you experienced or feelings
emotions pacing, sighing)

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 Anchoring in the Present

At least once per day, practice anchoring yourself to the present by

noticing at least one thing going on around you. This can be a sound
you hear, something you see, or something you can physically feel
(like your chair, a computer keyboard, a dish sponge). You can use
your breath to help anchor yourself to the present moment. The goal
of this exercise is not to think about the meaning of what you notice,
nor is it to try to understand your reaction to it. The purpose of this
exercise is simply to practice paying attention to what is going on
around you right now. Also record any thoughts, feelings (physical
sensations) or behaviors that you may have noticed.

How effective were you at

anchoring yourself in the present?
What did you notice?
0 – 10

(not at all) (extremely)

Sun

Mon

Tues

Wed

Thurs

Fri

Sat

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 Non-Judgmental, Present Focused Emotional Awareness

Set aside a time, at least twice per day, to deliberately practice non-
judgmental present-focused awareness. The goal of this exercise is to
get used to paying attention to what is happening inside and around
you in the moment, observing your thoughts, physical sensations/
feelings, and behaviors. Practice acknowledging thoughts and feel-
ings just as they are, letting go of the need to critically judge, change,
or avoid your inner experience. With increased practice, these tech-
niques will become more automatic and eventually can become a
skill used at any time throughout the day and in any situation.

How effective were you at not

What did you notice?
judging your experience?

Physical Sensations/ 0 - 10
Practice Thoughts Behaviors
Feelings (not at all) (extremely)

1.
Sun
2.

1.
Mon
2.

1.
Tues
2.

1.
Wed
2.

1.
Thurs
2.

1.
Fri
2.

1.
Sat
2.

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 Looking At Your Interpretations

What were your automatic interpretations about the picture?

________________________________________________________

________________________________________________________

________________________________________________________

What factors contributed to your automatic interpretations (e.g.,

past experiences, memories, specific aspects you focused on in the
picture, etc.)?
________________________________________________________

________________________________________________________

________________________________________________________

Generate some alternative interpretations about what the picture

might mean (come up with at least 3 alternatives).
________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

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 Common “Thinking Traps”

Probability Overestimation (a.k.a. “Jumping to Conclusions”):

When you overestimate the likelihood of negative events happening.
You interpret things negatively when there is little or no evidence to
support that interpretation. Similarly, you may ignore evidence that
would suggest another, perhaps more likely outcome. Some common
examples of Probability Overestimation include:

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Catastrophizing (a.k.a. “Thinking the Worst”): When you automat-

ically predict that the worst possible scenario is going to happen,
without considering other possible outcomes. You also tend to
underestimate your ability to cope with this outcome if it does occur.
Some common examples of Catastrohpizing include:

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

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 Evaluating Automatic Appraisals

Questions to ask when evaluating automatic appraisals

Countering Probability Overestimation - Learning to reevaluate

Jumping to Conclusions

1. Do I know for certain that _____________________ will

happen?
2. Am I 100% sure these awful consequences will occur?
3. What evidence do I have for this fear or belief?
4. What happened in the past in this situation?
5. Do I have a crystal ball? How can I be sure that I know the
answer?
6. Could there be any other explanations?
7. How much does it feel like ________________ will happen?
What is the true likelihood that _________________ will
happen?
8. Is my negative prediction driven by the intense emotions I’m
experiencing?
9. Is ________________ really so important or consequential?
Decatastrophizing - Learning to reevaluate Thinking the Worst

1. What is the worst that could happen? How bad is that?

2. If _________________ happened, could I cope with it? How
would I handle it?
3. So what?
4. Even if __________________ happens, can I live through it?
5. Have I been able to cope with __________________ in the
past?
6. Is __________________ really so terrible?
Given the answers to these questions, what is an alternative way of
looking at this situation?

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 Introduction to Countering EDBs

Our emotions can drive us to behave in a particular way. For instance,

fear may cause us to escape or avoid danger, anger may lead us to
attack or defend ourselves, and sadness might lead us to withdraw
and reduce our energy levels. In the appropriate circumstances, these
types of emotion driven behaviors, or EDBs, can be helpful. However,
sometimes EDBs can interfere with our lives. For example, when we
feel sad it is common to not feel like doing anything or to withdraw
from social interaction. This can be an adaptive response to sadness,
providing us with time to pause, reflect, and put events into perspec-
tive. However, if every time we experience sadness we engage in these
same EDBs in response (perhaps in an attempt to alleviate the inten-
sity of the sadness), they can begin to interfere with our life. These
EDBs will begin occurring more frequently and rigidly, losing their
connection to the context in which they are occurring. This is when
EDBs begin to interfere with our lives.

Research has shown this to be one of the most effective ways for
breaking this cycle is by engaging in behaviors that are the exact
opposite of what our emotions are driving us to do – in essence
countering EDBs. By going against the automatic behaviors our
emotions are driving us to do, we can begin to break the cycle of
unhelpful EDBs, and can actually change how our emotions are
experienced. For example, if the EDBs for sadness are withdrawal
and activity reduction, in order to counter these EDBs we would
start engaging more in activities. Engaging in opposite behaviors are
effective strategies to counter unhelpful EDBs that have become less
useful to us and have begun interfering with the ability to fully live
our lives. This strategy can be applied to the full range of emotional
experiences. Below, are some examples of common EDBs and asso-
ciated incompatible behaviors for effectively Countering EDBs.

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 EDB(s) Incompatible Behaviors

Calling relatives to check on their safety Restricting contact/calling relatives

Perfectionistic behavior at work or home Leaving things untidy or unfinished

Checking locks, stove, or other appliances Repeatedly locking/unlocking and turning on/off until
memory is unclear

Leaving (escaping from) a theater, religious Move to the center of the crowd; smile or produce
service, or other crowded area non-fearful facial expressions

Social withdrawal Scheduling and engaging in social activities

Leaving (escaping) a social situation Staying in situation and approaching people

Verbally/physically attacking someone when in Remove self from situation and/or practice relaxation
an argument techniques

Hypervigilance Focus attention on specific task at hand; meditation;

relaxation

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 Identifying Automatic Appraisals

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IDENTIFY
SITUATION / TRIGGER AUTOMATIC APPRAISAL(s) EMOTION(s)
“THINKING TRAP”

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 Identifying & Evaluating Automatic Appraisals

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GENERATE
SITUATION/ AUTOMATIC IDENTIFY
EMOTION(s) ALTERNATIVE
TRIGGER APPRAISAL(s) “THINKING TRAP”
APPRAISAL(s)

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 What are EDBs?

EDBs are Emotion Driven Behaviors. These are actions we tend to

take in response to intense emotions. They are behaviors driven by
the emotion itself. EDBs are a natural response to emotions that can
motivate us to act in ways that are helpful to us, such as fear motivat-
ing us to jump out of the way of a moving car. But sometimes EDBs
can be less helpful.

When are EDBs NOT helpful?

If we are habitually acting in ways that ultimately allow us to escape

our emotions, these emotion driven behaviors are not as useful or
helpful to us. These EDBs are actually functioning as emotion avoid-
ance strategies, and may motivate us to act in ways that make threat-
ening or intense situations continue to feel threatening and intense.

Here are some examples:

Example 1:

You feel anxious at work, and are concerned your boss or your
coworkers don’t think you are doing a good enough job. You auto-
matically respond by pushing yourself be the “perfect” employee. In
this case, pushing yourself to be perfect is the emotion driven behav-
ior – your anxiety about being negatively evaluated are driving you
to perform at a level that will allow you to avoid criticism. However,
trying to be “perfect” (which is one way of trying to establish control
over a seemingly uncontrollable threatening situation) usually leads
to higher and higher standards for work, and more anxiety about
additional tasks. You now have anxiety not only about being evalu-
ated negatively, but also about being able to do what it takes to be
perfect.

The EDB – trying to do work “perfectly”

The consequences –

Short Term Long Term

You feel more in control You now have anxiety about being evaluated negatively and getting
your work done perfectly

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 Example 2:

You wake up feeling depressed and unable to face the day. Instead of
going to work, you decide to stay home and sleep, even though you
know you have sympathetic friends at work. In this case, the EDB is
staying home – your negative emotions are driving you to hole up
and hide from the world. However, staying home by yourself also
means being alone with your thoughts, and you begin to turn over
and over in your mind how sad and down you are, making it worse
and worse. In addition, by holing up in your house, you begin to feel
isolated and cut off from the world. You now not only feel down,
but you also feel lonely and isolated.

The EDB – staying home from working and “hiding” from the
world

The consequences –

Short Term Long Term

You feel safe and more in control because You now not only feel down and depressed but also
you will not have to face the day feel lonely and isolated

Example 3:

You are home alone and begin to feel anxious. You frantically start
calling your friends, looking for reassurance. In this case, the EDB is
calling your friends – your anxiety about being alone has driven you
to seek comfort and reassurance from others. However, the next time
you are by yourself, you are faced with the same uncomfortable feel-
ings.

The EDB – calling your friends seeking reassurance

The consequences –

Short Term Long Term

You start to calm down and feel less The next time you are alone, you not only feel anxious
anxious but also feel unable to cope without the help of your
friend

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 Emotional Avoidance Strategies

One way we attempt to control our emotional experiences is through

emotional avoidance. Emotional avoidance strategies can become
powerful habits that maintain the cycle of emotions. Emotional
avoidance is different from EDBs in that they tend to happen before
an emotion has a chance to occur, whereas EDBs tend to happen in
response to an emotion that has already been triggered.

Types of emotional avoidance strategies

1. Subtle behavioral avoidance

Subtle behavioral avoidance typically happens when a person enters

a situation associated with intense emotions, and escape from the
situation is not an option, which results in a variety of subtle behav-
iors of which the person may not be fully aware. Sometimes these
behaviors are related to preventing the physical sensations associated
with strong emotions. For example, someone who has frequent panic
attacks may avoid drinking caffeinated beverages or go to great
lengths to avoid perspiring by stripping away clothes or turning the
thermostat way down to prevent themselves from experiencing
physical sensations that may trigger panic. Other behaviors are
related to preventing the possibility of experiencing intense emo-
tions. For example, someone who is anxious in social situations may
not answer the phone or avoid eye contact in a social engagement
that cannot be escaped and may be emotionally arousing. Someone
else might avoid emotional greetings or goodbyes.

2. Cognitive avoidance strategies

Cognitive avoidance strategies are often difficult to identify, because

we may not even be aware we are using these strategies as emotional
avoidance. Some common examples of cognitive avoidance strate-
gies are distraction (e.g., reading a book, listening to music, watching
television) and “tuning out” (e.g., pretending we are not in the situa-
tion or not fully engaging in the experience of being in the situa-
tion). Distraction might seem useful because it keeps our minds
from “running away.” But this is also a form of emotional avoidance.
For example, someone who worries about the safety of loved ones

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 may watch television or keep busy when loved ones go out at night.
The person is fearful that if he or she does not distract him or herself
and prevent negative thoughts and feelings, they will become over-
whelming. Rationalization of problems can also be a form of avoid-
ance (different from the cognitive reappraisal techniques discussed
previously), if the rationalization is used as an attempt to “push
away” emotions as they happen. For example, a person who worries
about getting a bad grade on a paper may desperately try to provide
reasons why a bad grade would not matter. This would be an emo-
tional avoidance strategy if it were done with the intention of push-
ing away or avoiding emotions.

3. Safety signals

When someone is unable to directly avoid an emotionally provoking

situation, he or she may come to rely on “safety signals” in an attempt
to keep emotions from becoming overwhelming. Safety signals are
“talisman,” or any items that a person carries that make him/her feel
more comfortable, or would be calming in times of extreme distress,
despite the lack of any real utility in dealing with a potentially threat-
ening experience. Thus, safety signals have a magical or superstitious
quality to them. Common examples of safety signals are water bot-
tles, medication (or empty medication bottles), cell phones, prayer
books, pets, etc. Safety signals also prevent us from learning that the
situation is not dangerous, as we attribute being able to manage
emotions to the presence of the safety signal. Furthermore, the pres-
ence of the object reinforces the idea that uncomfortable emotional
experiences are unmanageable and overwhelming.

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 List of Emotional Avoidance Strategies

Barlow_Web Materials.indd 31
The purpose of this list is to begin to identify subtle ways that you may attempt to avoid uncomfortable
emotions. The list will help you later in treatment when you engage in emotion exposures, so that you can
eliminate these counterproductive strategies and ensure that the exposures are as effective as possible. In
the “subtle behavioral avoidance” column, list behaviors that you do that help you feel better when you are
experiencing intense emotions. These include taking medication, doing deep breathing exercises, etc. In
the “cognitive avoidance strategies” column, list any techniques you use to feel better when you are in a
situation you cannot physically escape. Some of these strategies include distracting yourself (by watching
TV. or listening to the radio), “tuning out” of a conversation with another person, or trying to force your-
self to think of something other than the situation at hand. Finally, in the “safety signals” column, list
anything that you carry with you, or that you do before going out, that makes you feel more comfortable.
This could include carrying a water bottle or medication, having your cell phone with you, carrying the
names of your doctor or other important people, etc. If you have trouble figuring out which columns to
put a strategy in, that’s okay. The most important part is that you begin to record the variety of emotional
avoidance strategies you are engaging in currently.

Subtle Behavioral Avoidance Cognitive Avoidance Safety Signals

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 CHANGING EDBs

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32
New (incompatible)
Situation / Trigger Emotion EDB Consequence
Response

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 Review of Treatment Concepts

1. Why we have emotions

It is important to recognize that emotions are not necessarily “bad”
or “dangerous,” although they can sometimes feel that way. Often
times when people come in for treatment for emotional disorders,
they want the therapist to “take away” or “stop” the negative emo-
tions. However, it is important to recognize that this would not be
helpful, or adaptive. One of the key points about emotions is that
emotions (e.g., fear, anxiety, depression, anger, etc.) tell us very
important things about what is going on in our lives and motivate
us to do something helpful or useful.
2. What is an emotion? The 3-component model
What exactly is an emotional experience? Sometimes our emotions
might feel like a big “cloud” of intense feelings, and it might seem
difficult to identify what our emotions are trying to tell us.
Emotional experiences can actually be broken down into three main
parts:
1. Physiological - How I Feel
2. Cognitive - What I Think
3. Behavioral - What I Do
By conducting a three-point check and identifying each of these parts,
our emotions can begin to feel a bit less overwhelming.
3. The “ARCs”
Emotions and EDBs are natural aspects of being human, and are not
problematic in and of themselves. However, it is important to under-
stand that our emotions and EDBs occur within a context. Something
precedes us responding in a particular way, and how we respond to
our emotions has consequences. In order to better understand the
context, we use the “ARC” of emotions:
The As (antecedents) – what precedes an emotion
The Rs (responses) – your emotional response and behaviors
you might engage in as a response to these
situations

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 The Cs (consequences) – the consequences of those responses

The first step towards better understanding our emotions is through

identifying the ABC’s of our emotional experiences.

4. Learned behaviors

When we experience strong emotions, they leave lasting impres-

sions. What triggers our emotions, and what happens when we have
them, stays with us and influences how we experience similar situa-
tions in the future. We learn to repeat things that make us feel good,
and to avoid things that make us feel bad. We also may learn to do
certain things in order to keep ourselves from potentially feeling
bad. These behaviors become well learned and can sometimes be
difficult to alter.

5. Non-judgmental emotional awareness

In order to gain a better understanding of our emotions and what

they are trying to tell us, it is important to become more aware of
our emotional experiences in a non-judgmental way, and the ways in
which we respond to these experiences. This is the first, important
step towards exploring the role emotional experiences play in our
lives. This means learning how to just let your emotions happen
when they happen and letting your reactions to them come and go,
without trying to reduce them, change them, or judge them as good
or bad. This also means learning to become more aware of the whole
context in which they occur, including what might have brought
them on, how they feel in the moment, and how you might respond
to your emotions in a way that will be the most helpful to you, given
the context of the current situation you are in.

6. Cognitive reappraisal

In any given situation, there are a large number of different aspects

that we can attend to or focus on. Additionally, there are a number
of different ways that the aspect of the situation we chose to focus on
could be interpreted or appraised. How we interpret or appraise a
situation (e.g., which aspects we focus on, how much meaning we
assign to them, etc.) has important consequences for our subsequent
emotions or how we feel. Similarly, how we feel can influence how

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 we interpret or appraise situations. Thoughts can influence emo-
tions, and emotions can influence thoughts.

Over time, individuals often develop a particular way or style of

appraising situations, and sometimes these automatic appraisals can
heavily rely on thinking traps, such as probability overestimation or
catastrophizing. One way out of these “traps” is to pay attention to
the appraisals we have, and evaluate them not as “truths,” but as one
possible interpretation of the situation.

7. Emotion Driven Behaviors (EDBs)

Emotion Driven Behaviors (EDBs) are actions we tend to take in

response to intense emotions. They are behaviors driven by the emo-
tion itself. EDBs are a natural response to emotions that can moti-
vate us to act in ways that are helpful to us, such as fear motivating
us to jump out of the way of a moving car. But sometimes EDBs can
be less helpful. If we are habitually acting in ways that ultimately
allow us to escape our emotions when they occur, these EDBs are
not as useful or helpful to us. These EDBs are actually leading us to
avoid our emotions, preventing us from fully experiencing and pro-
cessing our emotions. They can motivate us to act in ways that make
threatening or intense situations or emotions continue to feel threat-
ening and intense.

8. Emotional avoidance strategies

One way we attempt to control our emotional experiences is through

emotional avoidance. Emotional avoidance strategies can become
powerful habits that maintain the cycle of emotions. Emotional
avoidance strategies are different from EDBs in that emotional
avoidance strategies tend to happen before an emotion has a chance
to occur, whereas EDBs tend to happen in response to an emotion
that has already been triggered. Emotional avoidance strategies
include anything used to avoid or reduce the intensity or duration of
our emotions in specific situations. These include subtle behavioral
avoidance, cognitive avoidance, and safety signals.

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 Symptom Induction Test Form

Please complete each of the exercises (as described) below. Be sure to

engage in each exercise fully, and try to produce at least moderate
symptom intensity. After the exercise, please note:

1. the physical symptoms you experienced

2. the intensity of the symptoms (0 – 8 scale; 0 = no intensity, 8 =
extreme intensity)
3. the level of distress you experienced during the task (0 – 8
scale; 0 = no distress, 8 = extreme distress)
4. the degree of similarity to your naturally occurring symptoms
(0 – 8 scale; 0 = not at all similar, 8 = extremely similar)
Wait until the symptoms have mostly subsided before attempting
the next exercise. Use the other spaces provided to be creative and
come up with additional exercises that are specific to you. When you
are done, pick three of the exercises that produced the most anxiety
for you. Put a star next to those exercises.

PROCEDURE Symptoms Experienced Intensity Distress Similarity

Hyperventilation
(60 seconds)

Breath through thin straw

(2 minutes)

Spinning while standing

(60 seconds)

Running in place
(60 seconds)

Other:

(___ seconds)

Other:

(___ seconds)

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 Other:

(___ seconds)

Other:

(___ seconds)

Other:

(___ seconds)

Other:

(___ seconds)

Other:

(___ seconds)

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 Interoceptive Activation Form

Please complete each of the three exercises you chose over the
next week. However, this time, you will be engaging in the exercise
repeatedly, so you notice how your distress about the symptoms
decreases the more you are willing to confront it. Be sure to engage
in each exercise fully, and try to produce at least moderate symptom
intensity. Over time, it will be important to begin to gradually push
yourself further and further. After the exercise, please note:

1. The type of exercise you chose to do on the line next to DAY

2. the intensity of the physical symptoms you experienced (0 – 8
scale; 0 = no intensity, 8 = extreme intensity)
3. the level of distress you experienced during the exercise (0 – 8
scale; 0 = no distress, 8 = extreme distress)
4. the degree of similarity to your naturally occurring symptoms
(0 – 8 scale; 0 = not at all similar, 8 = extremely similar)
Engage in the exercise repeatedly, only waiting long enough in
between trials for your symptoms to mostly subside. Continue to
repeat the exercise until your distress only reaches a 2 or less when
you do the exercise. If your distress never reaches above a 2, DO
ANYTHING YOU CAN to make the exercise more difficult (e.g.,
combining the exercises, doing them in front of other people, trying
to induce symptoms when you already feel anxious, sad, or upset).
You should do at least one set of each of the assigned exercises EACH
DAY. Instead of watching the clock (which could be used as an emo-
tional avoidance strategy), use a timer or some other type of alarm to
help keep track of the time for you, then turn your full attention to
the exercise. Use the forms on the following pages to help you chart
your trials.

The three exercises you identified as most like symptoms you

regularly experience and will practice for exposures are:
1. ____________________________ for ____________ seconds

2. ____________________________ for ____________ seconds

3. ____________________________ for ____________ seconds

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 Interoceptive Activation Form

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DAY 1:________________________ DAY 2: ________________________ DAY 3: ________________________
Trial Intensity Distress Similarity Trial Intensity Distress Similarity Trial Intensity Distress Similarity
1. 1. 1.
2. 2. 2.
3. 3. 3.
4. 4. 4.
5. 5. 5.
6. 6. 6.
7. 7. 7.
8. 8. 8.
9. 9. 9.
10. 10. 10.
DAY 4:________________________ DAY 5: ________________________ DAY 6: ________________________
Trial Intensity Distress Similarity Trial Intensity Distress Similarity Trial Intensity Distress Similarity
1. 1. 1.
2. 2. 2.
3. 3. 3.
4. 4. 4.
5. 5. 5.
6. 6. 6.
7. 7. 7.
8. 8. 8.
9. 9. 9.
10. 10. 10.

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 Emotional/Situational Avoidance Hierarchy

Describe situations you are currently avoiding in order to prevent

uncomfortable emotions from occurring, starting with the worst or
most distressing situation. Rate the degree to which you avoid each
of the situations you describe, and the degree of distress they cause.
For each, write the applicable number in the space provided.

Do Not Hesitate To Enter But Usually Always Avoid

Avoid Rarely Avoid Sometimes Avoid Avoid

0 1 2 3 4 5 6 7 8

No Distress Slight Definite Strong Extreme

Distress Distress Distress Distress

Description Avoid Distress

1
WORST

10

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 Guidelines for Designing and Executing an Effective Emotion Exposure

1. Choosing your task

■ Pick something that is going to challenge you, but don’t try to
do a task that is too difficult.

■ The purpose of the exercise is to learn that you can master the
situation, even in the face of very intense anxiety, fear, or
depression.

■ Always complete exposures without emotional avoidance

strategies, so do something that is manageable.

■ The more difficult exposures you can complete, the better you
will do in the long-term.

2. BEFORE the exposure

■ As you notice yourself getting nervous before the task, use
some of the cognitive reappraisal strategies you learned to
reappraise the situation in order to complete the full exposure.

■ Remind yourself that facing your emotions is the only way to

make them more manageable.

■ Similarly, if you find that you “just don’t want to do it” because
you feel depressed or anxious, THIS IS THE MOMENT TO
PUSH YOURSELF EVEN HARDER. You cannot trust your
emotions in this moment –remember that what goes up, must
come down.

3. DURING the exposure

■ Practice awareness of your thoughts, feelings, behavioral urges,
and the situation around you.

■ Prevent yourself from engaging in any emotional avoidance

strategies. Don’t try to push away uncomfortable thoughts and
feelings – they are there and must be experienced head on in
order to change and to break the cycle.

■ Notice any EDBs you might have the urge to engage in and do
not engage in them. You will be reinforcing the negative cycle
of emotions if you do.

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 ■ STAY IN THE SITUATION until your emotional distress has
reduced. Notice what it’s like when your emotions are reducing
on their own. See how you are able to make a choice about
how you respond, instead of being driven by your feelings.

4. AFTER the exposure

■ Look back and evaluate how the exposure went.

■ Did what you fear would happen actually happen?

■ Did you do anything to prevent your emotions from becoming

too intense?

■ Did you stay in the exposure long enough?

■ What could you have done to challenge yourself even more?

IF YOU FIND YOURSELF AVOIDING THE EXPOSURE,

reevaluate your fears by answering some of these questions:

■ What did you fear would happen?

■ What do you imagine happening that would be so terrible?

■ What would be so bad about that happening

■ If you could be sure that that is all that would happen, would
you still be as afraid of it as you are?

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 Record of Emotion Exposure Practice

Exposure Task: _____________________________________________________________

Prior to the task:

Anticipatory Distress (0 – 8): _______

Thoughts, Feelings, and Behaviors you noticed before the task:

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Reevaluate your automatic appraisals about the task:

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

After completing the task:

Thoughts, Feelings, and Behaviors you noticed during the task:

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Number of minutes you did the task: _______

Maximum distress during the task (0 – 8): _____ Distress at the end of the task (0 – 8): _____

Any attempts to avoid your emotions (distraction, safety signals, etc.)?

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

What did you take away from this exposure task? Did your feared outcomes occur? If so, how
were you able to cope with them?
________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

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 COPING WITH EMOTIONS

This is a card to help you remember the steps for dealing with uncomfortable emotions.

1. Am I anchored in the present?

2. What emotions am I experiencing (the “three-piont check”)?
3. What triggered this reaction? What was I doing right before it happened?
4. What are some of my thoughts here? How can I be more flexible in my thinking by
considering other alternatives?
5. What is my EDB in this situation? How can I change it?
6. Am I doing anything else to avoid my emotions (e.g., emotional avoidance strategies?).
How can I bring awareness to my experience in this situation?

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 Treatment Review

Important things to remember

■ Emotions are normal, natural, and adaptive. They provide

important information about different types of experiences.
For this reason, we would not want to eliminate emotions like
anxiety, sadness, and fear – we need them to help us survive.

■ Emotions become maladaptive when they are not “in balance”

with the situation that is producing them. For example, it
would be appropriate to feel some anxiety about preparing for
an upcoming test (this anxiety would be useful because it
would motivate you to study). However, it would be
maladaptive if the anxiety was so intense that it prevented you
from studying or interfered with your ability to concentrate on
the test questions. It is important to recognize when your
emotions change from adaptive to maladaptive.

■ Throughout this treatment, you have learned a variety of

techniques to help you combat maladaptive emotions. These
include:

1. Becoming aware of the triggers and consequences of your

emotions
2. Recognizing and clarifying which emotions you are
experiencing
3. Preventing any emotional avoidance strategies that interfere
with new learning about the situation
4. Understanding how you typically react to that experience
(EDBs)
5. Changing how you typically react to emotions by engaging in
behaviors that are incompatible with EDBs
■ If you understand these principles, you should be able to
design and implement your own treatment plan, should you
have any future emotional difficulties. Remember though, a
“lapse” does not mean you have “relapsed.” Keep it all in
perspective, and any time you feel your emotions becoming
maladaptive, you know what to do!

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