Section VI: Anxiety

Action, Coping Skills, and Acceptance

Goals of the Exercise

1. Reduce overall frequency, intensity, and duration of anxiety so that daily functioning is not impaired.

2. Stabilize anxiety level while increasing ability to function on a daily basis.

3. Enhance ability to effectively cope with the full variety of life's responsibilities.

4. Learn and implement calming skills to reduce overall anxiety and manage anxiety symptoms.

Additional Problems for which this Exercise may be Useful

Suggestions for Processing this Exercise with Veterans/Service Members

The “Action, Coping Skills, and Acceptance” activity is designed for use with veterans/ service members who exhibit levels of anxiety that significantly impair their quality of life and ability to perform their military duties. It is designed to reduce anxiety by guiding the veteran/service member in correcting cognitive distortions and learned helplessness and shifting from a primarily external to a more internal locus of control. The techniques used in this activity are compatible with the evidence-based Cognitive Processing Therapy (CPT) model currently in use within the Department of Veterans Affairs. Follow-up or concurrent treatment activities could include bibliotherapy using one or more of the books listed for this issue in Appendix A of The Veterans and Active Duty Military Psychotherapy Treatment Planner and/or videotherapy using films suggested for the topic of “Emotional and Affective Disorders” in Rent Two Films and Let's Talk in the Morning, 2nd ed., by John W. Hesley and Jan G. Hesley, also published by John Wiley & Sons.

EXERCISE VI.A Action, Coping Skills, and Acceptance

Anxiety is one of the most uncomfortable emotions we can feel, but no one's life is completely free of it. In many cases it has survival value, so being without anxiety would not be in a person's best interests anyway—however, it's also clear that when anxiety gets too intense it can cause great suffering and prevent people from functioning effectively; it has even been linked to increased risk for several kinds of medical problems due to its negative impact on the immune system. So what each of us needs is a happy medium—enough anxiety to keep us from taking foolhardy risks, but not so much that it becomes a mental and emotional prison. Fortunately, there are some simple tools nearly anyone can use to help us tell the difference between useful anxiety and the unrealistic kind. This exercise will help you learn and practice some of these tools.

1. What methods have worked for you to control and cope with anxiety in the past? How about methods you've seen other people use, especially people with whom you have a lot in common?

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2. One of the things that we all tend to do is to let our thinking get distorted, and that can cause a lot of useless or needless worrying. In this exercise, we'll look at two of the most common problems. The first is the habit sometimes called “negative filtering.” Another way to put it might be that a person sees all the thorns but none of the roses, and although nearly every situation has both good and bad elements, they focus on the bad and overlook the good. They also tend to see the world as a much more negative place than if they had paid equal attention to all of it. Can you think of a recent example of negative filtering, either in your own thinking or in that of someone else? What was it about, and what good things were overlooked?

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One good way to get out of this mental trap is to make a “gratitude list.” It might sound dumb, but it works, and as the old saying goes, “If it's dumb but it works, then it isn't dumb.” To make a gratitude list, sit down in a quiet place where you can write without being interrupted and start writing a list of all the things in your life that you would miss if they were gone. This can include everything from physical health to important relationships to things like a song you enjoy every time you hear it or a favorite meal. If you make a regular habit of this, you'll find yourself noticing more of the good things in life as you go through your day and you'll probably have less anxiety because the world won't seem like such a dark and painful place.

3. Another mistake in thinking we often make that increases our anxiety levels is to underestimate our own strength and ability to cope with unpleasant experiences. Even when we're making the first mistake and catastrophizing about a situation, we tend to forget to ask ourselves the next logical question: “And if that worst-case outcome does happen, can I handle it? Do I have strengths and skills I could use to get through it? Have I coped with equally painful situations before?” To that question, if we think for a moment, the answer is nearly always, “Yes, it might be a very unpleasant experience, but I could cope with that event if it did happen.” Please briefly describe a situation in which something really bad happened and you struggled, got through it, and were able to keep functioning and go on with life:

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4. Finally, we want to think briefly about acceptance. There will always be some things in our lives we would change if we could, but they're beyond our power to affect. People often misunderstand the meaning of acceptance in regard to bad situations, and get angry if others suggest that they need to practice acceptance. The truth is that if I am practicing acceptance about a situation, it doesn't mean that I like the situation. It doesn't mean that I think it will always be the way it is, or that I won't try to improve it. All acceptance really means, if we use the word in the right way, is that I am acknowledging the way things are in the present moment. It's just being realistic instead of trying to live in a fantasy world, and we are free to use that present reality as a starting point from which to work at making things better. Acceptance can often bring a decrease in anxiety and an increase in our peace of mind; it helps us to think about our situations and possible courses of action more calmly and realistically; and to take actions that give us better results.

Please think of a situation that has caused you a lot of anxiety and worrying, either in the present or past, and use this space to briefly describe the situation. Describe what you were afraid would happen, explain what did happen, and describe how you handled that event:

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The more times you go through this process with different harsh experiences from different times in your life, the more you'll see that the worst possibility doesn't happen most of the time, and that when it does you are tougher, more resourceful, and more of a survivor than you've probably given yourself credit for.

Be sure to bring this handout back to your next session with your therapist, and be prepared to discuss your thoughts and feelings about the exercise.

Getting Away from Catastrophizing

Goals of the Exercise

1. Reduce overall frequency, intensity, and duration of anxiety so that daily functioning is not impaired.

2. Stabilize anxiety level while increasing ability to function on a daily basis.

3. Enhance ability to effectively cope with the full variety of life's responsibilities.

4. Learn and use calming skills to reduce anxiety and manage its symptoms.

5. Verbalize an understanding of the role that cognitive biases play in excessive irrational worry and persistent anxiety symptoms.

Additional Problems for which this Exercise may be Useful

Suggestions for Processing this Exercise with Veterans/Service Members

The “Getting Away from Catastrophizing” activity is created for veterans/service members with significant levels of anxiety focused on unrealistically dire anticipations of future events. It is designed to reduce anxiety by teaching the veteran/service member to recognize catastrophizing in his or her thinking and replace the worst-case view with a more balanced and realistic one. This activity is compatible with the evidence-based Cognitive Processing Therapy (CPT) model currently in use within the Department of Veterans Affairs. Follow-up or concurrent treatment could include bibliotherapy using books listed for this issue in Appendix A of The Veterans and Active Duty Military Psychotherapy Treatment Planner and/or videotherapy using films suggested for the topic “Emotional and Affective Disorders” in Rent Two Films and Let's Talk in the Morning, 2nd ed., by John W. Hesley and Jan G. Hesley, published by John Wiley & Sons.

EXERCISE VI.B Getting Away from Catastrophizing

What is catastrophizing? It's the mental and emotional habit of extreme pessimism, always anticipating the most disastrous possible future, having worst-case expectations like Chicken Little thinking the sky was falling or Eeyore from the Winnie the Pooh stories. Catastrophizing is a problem because it keeps a person constantly fearful, anxious, and obsessed with awful possibilities. It can make people unable to function in the military, in their jobs, or in their family lives; contributes to depression; and can even endanger a person's physical health through its weakening effect on the immune system. Fortunately, it's also a problem with a clear solution that anyone can apply if they want to change. This exercise will help you learn to identify and correct catastrophizing in your thinking.

1. Can you think of an example of catastrophizing that you've seen recently, either in your own thinking or in someone else's? If so, briefly describe the catastrophic event that you or the other person were afraid would happen, then describe what actually happened:

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2. A wise person once said that every problem starts out as the solution to another problem, and catastrophizing is no exception. We need the ability to recognize possible future dangers so that we can prepare and survive them—as long ago, in prehistoric times—usually by either fighting or running away. The ability to anticipate that falling asleep in the open might result in being eaten by a leopard would have been useful for survival. The problem is that what should be a reasonable degree of caution—just one part of our world—has outgrown its proper size and is dominating our minds and crowding out other kinds of thinking. It can be very much like the way a person with posttraumatic stress disorder (PTSD) may feel the need to always be on guard, anticipating that they might be attacked at any moment. Please list some situations or life experiences other than serving in combat that you think might cause a person to get in the habit of catastrophizing:

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3. Now for the solution—this is a simple solution, and although it helps to do it in writing at first, with some practice it becomes easier and easier until it's almost an automatic response. To start with, think for a moment about the situation you or another person has been catastrophizing about—briefly describe it on paper, then write down the worst-case outcome that the catastrophizing is predicting.

4. Now write down a range of four or five other possible outcomes ranging from not quite as bad as the catastrophizing up to the best possible turn of events.

Imagine that you have to place bets on what is most likely to happen in the situation—if you had 20 dollars, would you bet it all on that catastrophized worst-case outcome? Or if you divided your 20 dollars and bet parts of it on several or all of the possibilities, which would you bet the most money on? This is a good way to figure out what you really expect to happen, at a deeper level than the anxiety. Please use this space to record a brief description of the situation, a list of the possible outcomes you thought of, and how you placed your bets. If it's a real-world event in the near future you can come back to this page later and see how accurately you analyzed the situation.

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5. Finally, there's a second part to catastrophizing—our belief that if that worst-case event happened we would be unable to cope. Usually, though, we're under-estimating ourselves as badly as we're overestimating the likelihood of the catastrophic outcome. Along with putting the catastrophe in its place as just one possible outcome among several, and maybe not the most likely, we need to ask ourselves, “Okay, if that worst possible event did happen, could I cope with it?” And the best guide to answer that “what if” question about the future is to look to the past. To personalize it for yourself, think about some of the worst experiences you've had in your life, and reflect on the fact that you did get through them, even ones you wouldn't have believed you could handle if you'd known they were going to happen; please briefly describe one or two of those situations—what happened, and how you got through it:

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The more times you go through this process with different harsh experiences from different times in your life, the more you'll see that the worst possibility doesn't happen most of the time, and you'll see that when it does, you are tougher, more resourceful, and more of a survivor than you've probably given yourself credit for.

Be sure to bring this handout back to your next session with your therapist, and be prepared to discuss your thoughts and feelings about the exercise.