Appendix C

EET Eight-Session Protocol

Included here are session-by-session outlines for delivering the eight-session EET protocol, and all scripts, handouts, and worksheets in single-page format, for copying. Note that all handouts and worksheets are also available for download at http://www.newharbinger.com/34039.

The session overview for group therapy is as follows:

Session 1: Emotion Awareness
Session 2: Mindful Acceptance: Emotion Surfing
Session 3: Values-Based Action: Part 1
Session 4: Values-Based Action: Part 2
Session 5: Mindful Coping: Relaxation and Self-Soothing
Session 6: Mindful Coping: Coping Thoughts and Radical Acceptance
Session 7: Mindful Coping: Distraction and Time-Out
Session 8: Consolidating, Troubleshooting, and Wrap-Up

EET Session 1: O+A

Components Covered: Emotion Awareness (chapter 2)

Session 1 is dedicated to introducing group members to EET. It’s also designed to help clients develop a sense of what’s possible by learning how to have a new relationship with emotions. Clients also learn what emotions are, how they work, and how they are experienced. In addition, Session 1 sets the tone for treatment, establishing guidelines about the structure for the session, participation expectations, and between-session skills practice.

Materials

What You Can Expect from Emotion Efficacy Therapy handout
What Is Emotion Efficacy? handout
Emotion Awareness handout
Anatomy of an Emotion handout
Emotion Watching Worksheet
Feelings Word List handout
Session 1 Skills Practice handout
Skills Practice Record

Overview

Welcome and administration of pretreatment measures

Introduction of leader and group members

Overview of EET treatment and structure

Psychoeducation on emotions and emotion awareness

Emotion watching exercise

Introduction to skills practice and the Skills Practice Record

Session 1 skills assignment

Procedures

1. Welcome and administration of pretreatment measures

If you are using pretreatment measures, administer them at the very beginning of group. (A list of recommended measures is provided in chapter 10, and full versions are available in Appendix A.)

2. Introduction of leader and group members

When working within a group format, there are several dynamics you’ll want to be prepared to address. First, take some time in the beginning of treatment to create comfort and rapport with the group. You can do this by articulating the intention to create a safe space.

Take a few minutes to introduce yourself to the group, and allow enough time for each person to introduce him- or herself. Depending on the context and the group, you may ask clients to share something about their relationship with their emotions, ranging from what their most difficult emotion is to what brings them to treatment. As an icebreaker, you might ask group members to share their least favorite emotion. This will help establish some connection among group members and to normalize the common struggle with emotions that has brought each client to treatment.

Review guidelines for disclosure as well as confidentiality. While you cannot legally enforce confidentiality among participants, you’ll want to ask them to keep what is shared private so that the group will be a safe space to engage in the treatment. In addition, you can remind your clients that while at times they will be asked to share or to give feedback, it is up to them whether to disclose anything personal. Participation in the group is intended to focus on learning EET skills, which does not depend on disclosing personal or specific details.

3. Overview of EET treatment and structure

Using the What You Can Expect from Emotion Efficacy Therapy handout, review EET treatment and outline the session structure for the group:

Mindful acceptance practice
Skills practice review and troubleshooting problems with homework
Review of previous session’s skill(s)
Psychoeducation on new skill for the coming week
Practice new skills using imaginal exposure
Homework via Skills Practice Record

You’ll want to emphasize that EET treatment involves regular skills practice between and outside of group sessions, and that the effectiveness of treatment will depend, in part, on how willing clients are to practice the skills on their own.

Using the handouts What You Can Expect from Emotion Efficacy Therapy and What is Emotion Efficacy?, introduce clients to the concept of emotion efficacy and to the skills they will be learning.

4. Psychoeducation on emotions and emotion awareness

Using the handouts Emotion Awareness and Anatomy of an Emotion, introduce clients to what emotions are, how they work, and what they’re made of. (See chapter 2 for further detail on how to introduce this.)

5. Emotion watching exercise

Using the Emotion Watching Worksheet, have group members identify a situation that evokes strong emotion, and have them name the four parts of the emotion that go with it. Refer them to the Feelings Word List handout for help identifying the feeling label that goes with the emotion.

6. Introduction to skills practice and the Skills Practice Record

Explain the importance of skills practice outside of session. Then introduce them to the Skills Practice Record. Emphasize that emotion efficacy is like a muscle that needs to be exercised to build up. Skills practice between sessions will allow clients to become more efficient and effective at using the skills. It will also give them a chance to figure out where they need help troubleshooting.

7. Session 1 skills assignment

Use the Session 1 Skills Practice handout to review the skills practice for the week and to give clients a reminder of what they should practice.

What You Can Expect from Emotion Efficacy Therapy

EET will help you learn skills so you can be more powerful in how you respond to your emotions:

• You can learn to watch your emotions, seeing them rise and fall like a wave, rather than being overwhelmed or controlled by them.
• You can see the parts of your emotions—thoughts, feelings, physical sensations, and urges—so they are less mysterious and less outside of your awareness.
• You can learn to experience difficult emotions instead of feeling like you have to run away from them. You can learn to accept the emotion without being driven to do something that hurts you, your relationships, or your life.
• You can learn to recognize the “moment of choice”—when you can either do what your emotion is driving you to do, or choose to do something that expresses your values that will enrich your life.
• You can identify your core values—how you want to show up, even when you’re emotionally triggered and upset.
• You can learn to act on your values in the moment of choice, rather than act on what your emotions tell you to do.
• You can learn new strategies to dial down your emotions, even when they are very intense.
• You can practice watching, accepting, and dialing down your emotions until you are really good at it.

What Is Emotion Efficacy?

Emotion efficacy is how well you can—and believe you can—respond to emotions, including intense emotions, effectively. This might mean responding by doing nothing, doing something that reflects what you care about in the moment, or practicing skills that decrease the emotion to keep from making the situation more difficult.

This treatment is based on the idea that pain is an inescapable part of being human, as are the emotions that go with it. And while we cannot avoid pain or difficult emotions, the good news is that we can reduce suffering and increase our quality of life by how we understand and respond to our emotional experience. Another way of saying this is that, while we can’t escape painful emotions, we can choose how we respond to them. That’s what emotion efficacy is all about.

The skills you’ll learn from emotion efficacy therapy (EET) will help increase your emotion efficacy through the following five components:

• Emotion awareness: recognizing and understanding your emotional experience
• Mindful acceptance: observing and accepting emotions, instead of reacting to them
• Values-based action: responding to painful emotions with actions that reflect your values, instead of your emotions
• Mindful coping: when necessary, using skills to decrease the intensity of your emotions
• Exposure-based skills practice: using EET skills in an emotionally activated state

We’ll be talking about these skills in every session, and by the end of treatment you’ll know about and have experience using each of them.

Emotion Awareness

What Are Emotions?

What are emotions, really? Most simply, emotions are signals that help you respond to what your brain thinks is happening. Here’s how they work: the brain responds to internal and external cues (events or observations from our environment). Then the brain produces biochemical messengers, which we experience as emotions. These emotions motivate us to make choices. For example, the emotion we know as anxiety helps us choose to avoid danger. Anger helps us choose to fight when we feel threatened. Sadness helps us choose to withdraw when we need to process a loss or failure.

From birth, our amazing brains are evolutionarily wired to protect us from harm—to help us survive. That means any time your brain is sensing a threat to your well-being, it will do everything it can to send you emotional messages to motivate you to protect yourself. You may have heard about this process referred to as “flight, fight, or freeze,” all of which are common responses to intense emotions.

However, while our emotional wiring has been adaptive for the survival of the human race over time, the survival wiring doesn’t always serve us when it gets activated in a non-survival situation. Over time, your brain develops a “negativity bias,” whereby it constantly scans your environment for anything negative that could be interpreted as a threat so it can protect you. The downside of this protective negativity bias is that you can end up in a state of constant anxiety, or you can be easily triggered—whether or not there is an actual threat.

Author and psychotherapist Tara Brach explains how the negativity bias impacts us: “The emotion of fear often works overtime. Even when there is no immediate threat, our body may remain tight and on guard, our mind narrowed to focus on what might go wrong. When this happens, fear is no longer functioning to secure our survival. We are caught in the trance of fear and our moment-to-moment experience becomes bound in reactivity. We spend our time and energy defending our life rather than living it fully” (2003, p. 168).

EET can help you learn how to respond to non-survival emotions using skills that will help you respond effectively.

Why Do Some People Struggle with Emotions?

You’ve probably noticed that some people tend to be more emotionally reactive than others. We are all unique human beings, and how we experience emotions also depends on the wiring in our brains. While we are all born wired for survival, some of us are born with a tendency toward heightened emotional sensitivity. Others develop this tendency as a result of difficult experiences that leave them more emotionally reactive to certain cues.

If you are someone who has heightened sensitivity, you may have an increased vulnerability to stress. Even more, the heightened sensitivity to certain cues can become so ingrained and the emotional reactions so automatic that you may forget you have choices when you get triggered. Unfortunately, this emotional reactivity can negatively affect your well-being, quality of life, relationships, personal goals, and long-term health.

For this treatment, we will focus on how you can respond to distressing emotions and increase your emotion efficacy. You will learn how to stop being controlled by your emotions, how to respond in ways that reflect your values, and how to create more of what you want in your life.

Anatomy of an Emotion

There are four components that make up your experience of an emotion:

• Thoughts: Thoughts are the content of what you’re thinking. For example, “I never do anything right,” or “I want to get out of here.”
• Feelings: Feelings are the label or interpretation we give the emotion, for instance, sadness, frustration, joy, and so on.
• Sensations: Sensations are anything you feel in the body. This might be a sense of looseness and ease in the body when relaxed or muscle tension when anxious.
• Urges: Urges are impulses to do something—or not to do something. Examples include the urge to leave, the urge to yell, the urge to withdraw.

Let’s consider one example: If something great happens, you may have the thought, “There is so much to look forward to!” The feeling may be excitement. You may notice sensations of looseness and energy in your body. You may experience the urge to engage with people and/or dance around.

Two more examples: When you feel sad, you may have the thought, “I will always be alone.” You may sense tightness in your stomach and a lack of energy in your body. You may have the urge to withdraw from people. If someone threatens you, you may feel angry, you may think, “How dare he say that?!” You may notice the sensation of increased heart rate and energy. You may have the urge to attack the person.

Emotion Watching Worksheet

Observing the Four Components of Emotion

Use this worksheet to record the four components of emotion you experience from specific triggers.

Triggers	Thoughts	Feelings	Sensations	Urges

Embarrassed

Lively

Suspicious

Worried

Worthless

Worthy

Session 1 Skills Practice

Using the Emotion Watching Worksheet, practice emotion awareness by observing and recording the four components of emotion when you get emotionally triggered. If you don’t find yourself able to practice when you get triggered, you can find something to intentionally activate your emotions. For example, recall a recent difficult situation or a distressing memory. If it’s helpful, you can use the list of feeling words to identify the specific feeling label that goes with the emotion.
Practice observing the parts of emotion for at least 10 minutes a day.
Record the four parts of the emotion on the worksheet.
Record your skills practice in the first row on your Skills Practice Record.
Bring all of these materials to review in your next session.

Skills Practice Record

Emotion Efficacy Therapy

Directions: Place a check mark next to the skill you practice each day. Record any triggers at the bottom. Bring this record to your next session.

	Day 1	Day 2	Day 3	Day 4	Day 5	Day 6	Day 7
Observe the four parts of an emotion: sensations, feelings, thoughts, and urges.
Observe, accept, and surf your emotion wave, with SUDS.
Observe, accept, and choose a values-based action.
Observe, accept, and choose a relaxation skill.
Observe, accept, and choose a self-soothing skill.
Observe, accept, and choose a coping thought.
Observe, accept, and choose to practice radical acceptance.
Observe, accept, and choose a distraction strategy.
Observe, accept, and choose a time-out.

Emotional triggers: Record any events or emotions that are distressing during this week.

EET Session 2: O + A

Components Covered: Mindful Acceptance, Emotion Surfing, and Exposure-Based Skills Training (chapters 3 and 4)

Session 2 is the most content-heavy of all the sessions. Group members add the key component of mindful acceptance to emotion awareness, which is used in every exposure-based skills training both within and outside of session for the duration of treatment. The types and consequences of emotion avoidance are also highlighted to increase motivation for trying new behaviors. Finally, clients begin working with emotion exposure and learning how to do their own exposure-based skills practice both in session and between sessions.

Materials

Mindful Acceptance | Observe + Accept handout
Script for Guided Mindful Acceptance
Consequences of Emotion Avoidance handout
Emotion Avoidance Consequences Worksheet
Rumination handout
Script for Guided Emotion Surfing
Introduction to Exposure handout

Session 2 Skills Practice handout

Skills Practice Record

Emotion Surfing Practice handout

Values Clarification Worksheet (for homework)

Overview

Skills practice review
Psychoeducation on mindful acceptance
Mindful acceptance practice
Introduction to emotion avoidance
Psychoeducation on emotion surfing
Psychoeducation on exposure and practice
Skills practice assignment

Procedures

1. Skills practice review

Using the Skills Practice Record, ask group members to share how their skills practice went since the last session, providing validation and an opportunity for troubleshooting. If necessary, briefly review the concept of emotion efficacy and the four parts of emotion.

2. Psychoeducation on mindful acceptance

Using the Mindful Acceptance | Observe + Accept handout, introduce clients to the idea of observing and accepting their emotions.

3. Mindful acceptance practice

Using the Script for Guided Mindful Acceptance, lead your clients through mindful acceptance practice. Be sure to leave time for feedback both as an opportunity for troubleshooting and to consolidate learning.

Remind group members that each session will begin with mindful acceptance practice. Tell them that, as part of their homework for the remainder of treatment, they should practice this for at least ten minutes a day and record it on their Skills Practice Record.

4. Introduction to emotion avoidance

Use the Consequences of Emotion Avoidance handout to introduce your clients to the different kinds of avoidance, as well as how emotion avoidance negatively impacts their lives. Then have them assess the pros and cons using the Emotion Avoidance Consequences Worksheet.

5. Psychoeducation on emotion surfing

Introduce clients to emotion surfing, emphasizing what happens to emotion when we try to avoid the emotion versus accepting it and “riding the wave.” Set up the exposure and lead clients through an emotion surfing exercise practicing mindful acceptance using the following script.

Be sure to leave time for feedback both as an opportunity for troubleshooting, and to consolidate learning.

Mindful Acceptance | Observe + Accept

Mindful acceptance is derived from the practice of mindfulness, which has been shown to reduce psychological stress and improve well-being in numerous studies. The practice of mindful acceptance is essential for emotion efficacy because it will help you better tolerate difficult emotions, recover more quickly, and respond in ways that enrich your life moment to moment.

Mindful acceptance will help you practice observing and accepting emotions instead of reacting to them, avoiding them, or trying to control them. It doesn’t mean you have to “like” your emotions; it simply means that you don’t resist what you are experiencing.

One helpful metaphor is to think of yourself as the atmosphere and your emotions as the weather. The atmosphere is constant, while the weather is ever-changing. In mindful acceptance, you simply observe and accept changing weather, without reacting, while you as the observer remain constant.

There are many benefits to using mindful acceptance when you are emotionally triggered:

• Practicing mindful acceptance can help you tolerate pain without acting on it.
• Practicing mindful acceptance can help you recover more quickly from the distress of the trigger.

• Practicing mindful acceptance can help you find the space you need to thoughtfully and consciously choose how you will respond to the pain.

Mindful acceptance is practiced by learning to observe and accept the four parts of emotion: sensations, feelings, thoughts, and urges. Following is a simple description for practicing mindful acceptance you can use as you do your skills practice outside of session. Try to practice for at least 10 minutes a day when you are resting or when you get emotionally triggered.

Sensation Acceptance

Scan your body for sensations with the intention of observing and accepting them instead of reacting to them. Just notice all the details of the sensations: size, shape, temperature, tension, and movement. See if you can soften to the sensation and make space for it, without trying to change it…just allowing it to be exactly as it is.

Feeling Labeling
Try to identify the feeling that goes with the emotion. Name it and allow it to be exactly as it is, without judging it.

Thought Watching

Clear your mind, and then wait and watch for each thought as it arises; let the thought go without getting involved in it. Come back to the present moment and wait for the next thought to show up. When a thought arises, you might say to yourself, “There’s a thought,” and then just let it go. If you find yourself struggling to let the thought go, you might just acknowledge it as a “sticky thought,” and then let it go.

Urge Noticing

The more you practice these mindful acceptance skills, the bigger your emotion efficacy muscle will grow. It will get easier and easier to observe and accept your emotions instead of acting on them. Practicing mindful acceptance will also prepare you to use the other skills you will learn in EET.

Script for Guided Mindful Acceptance

For the next ten minutes I’m going to lead you through a mindful acceptance practice exercise. You will practice observing and accepting your emotional experience in the present moment. Practicing mindful acceptance in a neutral state will build your emotion efficacy muscle and make it easier for you to use this skill when you are triggered.

First, just sit comfortably, and either close your eyes or relax your gaze and pick a spot to focus on in front of you.

Now, take a few minutes to notice any sensations in your body. Scan your body until you find a sensation and rest your attention on it. See if you can let it be just as it is and get curious about it. Notice its size and shape; whether it’s moving or staying the same; if there’s any temperature or tension to it. See if you can soften to it, or even lean into the sensation…

Now, see if you can identify a feeling label that goes with the sensation…just name it and allow it to be as it is without judgment or reacting to it.

Next, we’ll spend a few minutes just noticing and watching our thoughts. Our brains produce different kinds of thoughts all the time, and the key is not to get involved with them. Instead, as each thought arises, you can simply say, “There’s a thought,” and then let the thought go. Then, just return to the present moment, and wait for the next thought to arise. For the next few minutes, notice your thoughts until I say stop…

Okay, now stop. Next, see if there’s an urge that goes with your sensations, feelings, or thoughts. It could be an urge to do something or not do something. Try to just sit with the urge. Notice what it’s like not to act on the urge, to just surf it.

[Allow the client to sit with the urge for 30 seconds. Then repeat the sequence one more time.]

Before you come out of this exercise, take a few deep breaths and slowly open your eyes as you bring your attention back to the room.

Consequences of Emotion Avoidance

There are at least five types of emotion avoidance that researchers believe are at the root of many emotion problems.

Situational: people, places, things, and activities

Cognitive: thoughts, images, and memories

Somatic: internal sensations such as racing heart, palpitations, breathlessness, overheating, fatigue, or unwanted sexual arousal

Protective: avoiding uncertainty through checking, cleaning, perfectionism, procrastination, or reassurance seeking

Substitution: avoiding painful emotions with replacement emotions, numbing out, alcohol, drugs, bingeing, or gambling

Why not just keep on avoiding? Because the consequences of emotion avoidance are usually worse than the experience of what we try to avoid.

• Since distress, discomfort, and anxiety are all a guaranteed part of life, emotion avoidance is often only a temporary and superficial “solution.”
• Emotion avoidance reinforces the idea that discomfort/distress/anxiety is “bad” or “dangerous.” It reduces your ability to face and tolerate necessary pain.
• Emotion avoidance often requires effort and energy. It’s exhausting and time-consuming.
• Emotion avoidance limits your ability to fully experience the present.
• Emotion avoidance can keep you from moving toward important, valued aspects of life.
• Emotion avoidance often doesn’t work. When you tell yourself not to think about something, you have to think about not thinking about it. When you try to avoid an emotion, you often end up feeling it anyway.
• Emotion avoidance often leads to suffering: addiction, helplessness, hopelessness, depression, damaged relationships, and lost opportunities.

By allowing yourself to experience fears—and difficult thoughts, feelings, sensations, and urges—you can learn to decrease your suffering.

Emotion Avoidance Consequences Worksheet

Emotion	Pros of Avoiding	Cons of Avoiding	Cons of Experiencing	Pros of Experiencing

Script for Guided Emotion Surfing

After the provoking scene is “shut off,” a typical emotion surfing exercise might look like this:

What do you notice in your body right now? Can you describe the sensations? [Client responds.]

What are the feelings that go with that? [Client responds.]

If there are thoughts, can you just watch them and let them go? Any time a thought shows up, just say so. Any thoughts now? [Client responds.] See if you can just let go of any thoughts that arise.

Where are you on the wave? [Client responds.] SUDS? [Client responds.]

Any urges? Does the emotion make you want to do something? [Client responds.] Notice how you can just observe the urge. You don’t have to act on it.

What’s happening in your body right now? [Client responds.]

Can you label your feelings? [Client responds.] See if you can just allow the feelings without reacting to them.

Remember to watch and let go of any thoughts. Are thoughts showing up? [Client responds.]

Urges? Something the emotion wants you to do? [Client responds.] See what it’s like to just notice the urge without acting on it.

Where are you on the wave? SUDS? [Client responds.]

What are you experiencing in your body right now? [Client responds.] Can you make room for that and just allow that sensation?

Your feelings? [Client responds.] Can you just allow that feeling? Can you let it be there without trying to control or stop it?

Watch the thoughts and let them go. [Client responds.]

Urges? [Client responds.]

Check the wave. Where are you? [Client responds.] SUDS? [Client responds.]

6. Psychoeducation on exposure and practice

Using the Introduction to Exposure handout, orient clients to exposure and how it will be used to enhance skills training. If you have a group where multiple members have a history of severe trauma, you may consider adopting guidelines to prevent clients from triggering each other. For example, you may want to ask that no details of the situations they choose for imaginal exposure be shared during feedback. Rather, they can just share the course of their emotion wave and SUDS level at the beginning, middle, and end of exposure practice.

Setting up exposure in a group setting requires some extra time and attunement. Some people—such as those with high anxiety, a severe trauma history, or panic disorder—may need to set their target SUDS levels lower in the beginning, while others can target the recommended 5 to 6 range.

You’ll easily identify clients struggling with imaginal exposure during the group practice. After having clients close their eyes and locate themselves in the triggering scene, ask them to raise their hands when they get to their SUDs level. This will allow you to know when to proceed to the next phase of exposure. Often, the clients who struggle to become activated will not raise their hand, and you’ll want to check in with them during the exposure feedback or after session. They can still practice exposure in the group, but the research shows the best outcomes occur when clients’ SUDS are elevated, so you’ll want to work with clients to find a way to do skills practice in an activated state.

Following is a script and the Introduction to Exposure handout you can use to help clients figure out how to find the right “stretch” with exposure.

Therapist-Client Dialogue Example: Setting Up Exposure in a Group

Therapist: So we’ve talked about how it’s important to practice skills in the same emotional state as you’ll be in outside of group. It’s important to choose situations that you know can activate you emotionally, but they shouldn’t be so upsetting that you can’t recover after the exercise.

Client A: Yeah… I’m afraid if I choose the wrong scene I’ll get totally overwhelmed.

Therapist: Right, so I’m going to give you some suggestions about how to choose a situation that works for you. Has anyone heard of the SUDS? It’s an acronym for a fancy scale you can use to rate how upset you are. It stands for the subjective units of distress scale: S-U-D-S [draws a continuum on the white board with 0 on the far left, 5 in the middle, and 10 on the far right].

Therapist: Basically, if you were in no distress you would rate your SUDS as a 0; if you are in the most distress you can imagine you would rate yourself at 10. For our exposure exercises, you want to try to pick scenes to work with that will activate you somewhere between a 5 or 6 SUDS.

Client B: So how do we predict that?

Therapist: Great question. It can take some practice to get good at predicting. Everyone is different, and some people can get activated at a high SUDS level very quickly, and others may have a hard time getting activated at all. The best way to figure it out is to start with something that’s not too distressing when you think about it, but immediately activates emotion. In others words, you don’t want to pick something that will leave you feeling too exposed or inside out. Does that make sense?

Client C: So like if I think about the fight I just had with my partner, and I immediately start to feel tense?

Therapist: Exactly. And do you have some idea about how upsetting it might make you to revisit that scene?

Client C: Well, it’s not horrible or anything…not like the car accident I had last year…that would be like a 10 on the SUDS!

Therapist: Right. So where do you predict your SUDS might be if you use the fight with your partner?

Client C: Probably around a 6. I was pretty upset and have been for the last few days.

Therapist: That sounds like a good scene to work with. It’s likely you’ll have a sense of what you can handle. The important thing is that you want to stretch yourself enough to get the benefit of the exposure. If you’re not very activated, you won’t experience the shift in distress tolerance that exposure can provide.

Therapist: [To Client A] Do you feel like you can find a scene to work with that’s in the 5 to 6 SUDS range?

Client A: I’m not sure… I understand what you’re saying, but sometimes I can’t predict how I’m going to feel. I can go straight to panic and down the rabbit hole.

Therapist: I’m glad you brought that up. It may help you to start by choosing a scene you don’t predict is too activating. If it ends up being too low—under a 5—you can always switch it for the next practice.

Client A: Okay. But what if I end up getting really upset during the exercise and start to panic?

Therapist: Any time you start to sense you may be getting too distressed to recover, you can just come out of the exercise, open your eyes, and ground yourself by counting your breaths or focusing on feeling your feet on the floor. If you still feel too distressed, you can leave the room.

Client A: Well, that might be embarrassing.

Therapist: It sounds like you’re concerned about drawing attention to yourself?

Client A: Yeah, and I don’t want to mess it up for the rest of the group.

Therapist: I appreciate that. But it’s really important that you know how to take care of yourself during the treatment. If you need to come out of the exposure or leave the room, please do that. Everyone here is on his or her own path, and each person has different challenges with their emotions.

Client A: I get it. I’ll try.

Therapist: Great. After each exposure, we will have time to check in and share feedback. If you still feel distressed after the exposure and feedback time, I’d like you to check in with me once the session has concluded. Does that work for everyone? Any questions?

While it might seem daunting to conduct an exposure-based treatment in a group setting with clients struggling with emotions, using exposure in a group format, as compared to individual, showed no treatment difference (Barrera, Mott, Hofstein, & Teng, 2013). In fact, there are many benefits from doing EET in a group format. Having multiple treatment participants normalizes the struggle with emotions, allows the group members to learn from each other’s challenges, and can provide a supportive context for treatment.

Introduction to Exposure

In this treatment we’ll be doing some skills practice we’ll call “exposure exercises.” The exercises are intended to help you “expose” yourself to the experience of difficult emotions so you can learn how to recover from distress as well as learn new ways of responding that enrich your life. Research shows that when you face distress instead of avoiding it, you can not only increase your tolerance of the distress but also recover more quickly.

Here’s how it works. First pick a situation or scene that is distressing to you. For example, try to recall the last time you got upset, and see if you can feel yourself getting activated when you think about it. Then, assess whether it is activating enough to use for your exposure using the following SUDS tool.

The SUDS Rating

The SUDS rating stands for subjective units of distress scale. In plain terms, this just means how much distress you experience when you think about the situation on a scale of 1 to 10, with 1 being no distress and 10 being the most distress you can imagine. For each situation, you want to predict how upset you might become if you expose yourself fully to the emotion of the situation. Ideally, your distress will be in the 5 to 7 range. If your distress is too low, the exercise is unlikely to be effective, and if it’s too high, you may become distracted and unable to stay engaged.

1 = no distress
3 = noticeable distress
5 = moderate distress
7 = distressing and uncomfortable
10 = worst distress imaginable

If at any point in the exposure exercise you begin to feel too distressed to stay with it, you should let the therapist know and stop the exercise. You are in the driver’s seat. Once you have done a few exposures, you may want to try to use situations that you predict will take you higher, to an 8 or 9.

7. Session 2 skills assignment

Use the following handout (available in downloadable format at http://www.newharbinger.com/34039) to review the skills practice for the week and to give clients a reminder of what they should practice.

Session 2 Skills Practice

Practice mindful acceptance for at least 10 minutes a day by observing and accepting the four components of emotion when you get emotionally triggered, or using emotion exposure to a difficult event, situation, or emotion. Observe all four parts of the emotion, and surf the emotion wave. Record your mindful acceptance skills practice in the first row of your Skills Practice Record.
Using the Emotion Surfing Practice handout, practice emotion surfing using emotion exposure. First, find something to intentionally activate your emotions (e.g., recall a recent difficult situation or a distressing memory) that gets your SUDS up in the 5 to 7 range. Practice observing and accepting the parts of emotion. Notice and record your SUDS level at the end of your exercise. Record your skills practice in the second row on your Skills Practice Record.
Review the Values Clarification Worksheet and select (circle) the 10 values that most closely reflect your core values.
Record any events that trigger you during the week at the bottom of your Skills Practice Record.
Bring all of these materials to review in your next session.

Skills Practice Record

Emotion Efficacy Therapy

Directions: Place a check mark next to the skill you practice each day. Record any triggers at the bottom. Bring this record to your next session.

	Day 1	Day 2	Day 3	Day 4	Day 5	Day 6	Day 7
Observe the four parts of an emotion: sensations, feelings, thoughts, and urges.
Observe, accept, and surf your emotion wave, with SUDS.
Observe, accept, and choose a values-based action.
Observe, accept, and choose a relaxation skill.
Observe, accept, and choose a self-soothing skill.
Observe, accept, and choose a coping thought.
Observe, accept, and choose to practice radical acceptance.
Observe, accept, and choose a distraction task or activity.
Observe, accept, and choose a time-out.

Emotional triggers: Record any events or emotions that are distressing during this week.

Emotion Surfing Practice

Once you’re emotionally activated, take note of your SUDS level and then begin to practice emotion surfing following the sequence below:

Ask yourself, “What sensations do I notice in my body?”
Ask yourself, “What’s the feeling that goes with it?”
Watch and let go of thoughts.
Notice urges. Locate the moment of choice instead of acting on the urges.
Ask yourself, “Where am I on the wave?” Determine your SUDS rating.
Ask yourself, “What’s happening in my body?” Try to allow that sensation.
Ask yourself, “What’s happening to the feeling?” Try to allow and make room for that feeling.
Watch thoughts and notice urges. Try not to get involved with them.
Ask yourself, “Where am I on the wave?”
Ask yourself, “What’s the sensation in my body?” Try to accept that sensation.
Ask yourself, “What’s my feeling?” Try to allow and make room for that feeling.
Watch thoughts and notice urges. Try not to get involved with them.
Ask yourself, “Where am I on the wave?”

Keep going until the distress improves or the emotion shifts. Record your SUDS level when finished.

Values Clarification Worksheet

Review the list below and circle your top 10 values.

Accountability

Continuous improvement

Honesty

EET Session 3: O + A + Choose VBA

Components Covered: Values-Based Action Part 1 and Exposure-Based Skills Practice (Chapter 5)

Session 3 begins the first of two sessions focused on values-based action (VBA). Group members will learn the key skill for choosing alternatives to emotion-driven behaviors: locating the moment of choice. In addition, they begin to clarify values in each of their life domains and to identify how they can express these values when they are emotionally triggered. Finally, clients begin working with VBA using imaginal exposure both in session and between sessions.

Materials

Script for Guided Mindful Acceptance
Moment of Choice handout
Values Domains Worksheet
Filled-Out Values Domains Worksheet
Benefits of Values-Based Action Worksheet
Session 3 Skills Practice handout
Skills Practice Record

Overview

Mindful acceptance practice and feedback
Skills practice review
Psychoeducation on the moment of choice
Introduction to values-based action
Whiteboard exercise with values and emotional barriers
VBA using imaginal exposure and feedback
Skills practice assignment

Procedures

1. Mindful acceptance practice and feedback

For the first ten minutes of session, lead group members through mindful acceptance practice using the Script for Guided Mindful Acceptance. Ask clients to provide feedback about their experience as an opportunity for learning and troubleshooting.

2. Skills practice review

Briefly review Session 2 skills and ask clients to share feedback about their weekly practice using their Skills Practice Record.

3. Psychoeducation on the moment of choice

Using the Moment of Choice handout, introduce clients to the moment of choice. Emphasize that finding this “pause” is critical for being able to make choices that are effective and that will help them create lives that reflect their values.

4. Introduction to values-based action

Give clients the sample Values Domain Worksheet, as well as the blank Values Domains Worksheet, and ask them to complete it using their Values Clarification Worksheet from Session 2.

5. Whiteboard exercise with values and emotional barriers

Lead a whiteboard exercise using client examples. First, list a core value. Second, identify a recent situation when a client was emotionally triggered. Third, identify the values-based action he or she could have chosen to reflect the core value. Do at least two to three examples to reinforce how VBA works and to prepare clients for the group exercise, Monsters on the Bus.

Next, have clients complete the Benefits of Values-Based Action worksheet. Then solicit feedback.

6. VBA using imaginal exposure and feedback

Following is a guide to helping your clients practice using VBA with imaginal exposure. Be sure to explain that this is the way they will practice VBA using imaginal exposure outside of session during the week. You may also encourage clients to try to use VBA in vivo when any triggers arise.

Step 1: Select a distressing situation. Ask clients to describe a recent distressing event in which they became emotionally triggered and responded with experiential avoidance or other emotion-driven behavior. Check in to be sure each client has identified a situation to work with before moving forward.
Step 2: Identify the value and the VBA. Explore which of the clients’ values relate to the situation they have chosen. Then prompt clients to identify a specific VBA that they would have preferred to enact. You’ll want to get the clients to articulate exactly what this alternative behavior would look like—everything the clients say and do, including tone of voice and body language.
Step 3: Visualize enacting the VBA. Have the clients briefly visualize using the values-based action, mentally rehearsing the scene several times until they are clear about what they will do.
Step 4: O+A+C. Begin the exposure by having clients form a clear image of the triggering scene. Encourage them to notice the environment where the trigger occurred: watch the action in the scene, hear what’s said, feel whatever physical sensations are part of the scene, notice if there’s an urge to do something or not to do something. As the clients become emotionally activated, ask them to continue to describe the sensations, thoughts, feelings, and urges that come up. Encourage an accepting attitude whereby the client “makes room” for the emotion, allowing it to be what it is with no effort at controlling or avoiding it.
While still visualizing the triggering event, have the clients observe any action urges that arise. Is there a desire to be verbally aggressive, to withdraw, to stonewall, to be defensive? Have the clients describe such urges and notice that the urges don’t have to become action. This is the moment of choice, and it’s important for the clients to stay with it for several minutes: observing the emotional pain, accepting and allowing the pain to be there without avoidance, and choosing not to act on emotion-driven urges.

Step 5: Imaginal exposure with VBA. Now that your clients have identified the moment of choice, check for SUDS and introduce the values-based action as a guided visualization. Ask your clients to continue the distressing scene, and, instead of imagining the emotion-driven behavior that accompanied the actual scene, have them visualize the alternative VBA they rehearsed earlier. As noted before, encourage clients to watch themselves saying and/or doing the new behavior, with tone of voice and posture matching the VBA. For the next three to five minutes, have clients repeat this visualization, moving from the triggering scene (and the moment of choice) through the new values-based responses several times. Ask clients to rate their SUDS at the end. The entire exposure sequence—O+A+C + values-based action—should last eight to ten minutes.

Step 6: Consolidating what was learned. Consolidate what the clients have learned through a brief conversation. Did observing and accepting the target emotion decrease their distress? What did they observe about the moment of choice? How did visualizing an alternate response (VBA) impact them? Did it reduce their distress? Increase their distress tolerance? Did it increase confidence that the client could choose VBAs in distressing situations?

7. Session 3 skills assignment

Use the following handout to review the skills practice for the week and to give clients a reminder of what they should practice.

Script for Guided Mindful Acceptance

First, just sit comfortably, and either close your eyes or relax your gaze and pick a spot to focus on in front of you.

Now, see if you can identify a feeling label that goes with the sensation…just name it and allow it to be as it is without judgment or reacting to it.

Okay, now stop. Next, see if there’s an urge that goes with your sensations or thoughts. It could be an urge to do something or not do something. Try to just sit with the urge. Notice what it’s like not to act on the urge, to just surf it.

[Allow the client to sit with the urge for 30 seconds. Then repeat the sequence one more time.]

Before you come out of this exercise, take a few deep breaths and slowly open your eyes as you bring your attention back to the room.

Moment of Choice

As humans, we don’t have control over whether or not we have emotions. Emotions will arise naturally in response to what’s happening inside us and around us. But we can control how we respond to our emotions, and that’s where we find true emotion efficacy.

This concept was illuminated by neurologist and psychiatrist Victor Frankl as follows:

Between stimulus and response there is space.
In that space lies our freedom and power to choose our response.
In those choices lie our growth and happiness. (n.d.)

How effectively we respond to difficult emotions depends on being able to locate this “moment of choice.” This moment is the time when you realize that you’re emotionally triggered, and you realize you have the power to choose how to respond. You might think of it as a “sacred pause” when you can either react, avoid, or try to control it—or you can choose a response that is life enriching.

In EET, you’ll learn a variety of skills you can choose to use in your moment of choice to help you respond to your emotions in a way that brings you close to what you want to create in the moment.

EET Model = Observe + Accept Emotions > Locate Moment of Choice > Choose EET Skill

Values Domains Worksheet

1. Intimate relationships Value: I = A =

Values-Based Action:

2. Parenting Value: I = A =

Values-Based Action:

3. Education/learning Value: I = A =

Values-Based Action:

4. Friends/social life Value: I = A =

Values-Based Action:

5. Physical self-care/health Value: I = A =

Values-Based Action:

6. Family of origin Value: I = A =

Values-Based Action:

I = Importance A = Action: How much action did you take in the last seven days toward your value?

Rate: Rate:
0 = unimportant 0 = no action
1 = moderately important 1 = one or two actions
2 = very important 2 = three or four actions
3 = five or more actions

7. Spirituality Value: I = A =

Values-Based Action:

8. Community life/citizenship Value: I = A =

Values-Based Action:

9. Recreation Value: I = A =

Values-Based Action:

10. Work/career Value: I = A =

Values-Based Action:

11. Value: I = A =

Values-Based Action:

12. Value: I = A =

Values-Based Action:

I = Importance A = Action: How much action did you take in the last seven days toward your value?

Rate: Rate:
0 = unimportant 0 = no action
1 = moderately important 1 = one or two actions
2 = very important 2 = three or four actions
3 = five or more actions

Values Domain Worksheet

(Client Sample)

1. Intimate relationships Value: Caring I = 2 A = 0

Values-Based Action:

Express concern, interest re: difficulty getting organized

2. Parenting Value: Supportive I = 2 A = 0

Values-Based Action:

Talk with gentleness/love when they didn’t listen or are sassy

3. Education/learning Value: Learn how to write I = 1 A = 0

Values-Based Action:

Enroll in community college class

4. Friends/social life Value: Listen I = 1 A = 2

Values-Based Action:

Ask about what’s going on, be interested. Don’t interrupt or judge.

5. Physical self-care/health Value: Healthy stamina I = 1 A = 1

Values-Based Action:

Cardio exercise 3x week

6. Family of origin Value: I = 0 A = 0

Values-Based Action:

7. Spirituality Value: I = 0 A = 0

Values-Based Action:

8. Community life/citizenship Value: Volunteering I = 1 A = 0

Values-Based Action:

Help at children’s school

9. Recreation Value: I = 0 A = 0

Values-Based Action:

10. Work/career Value: Support co-workers I = 2 A = 2

Values-Based Action:

Ask how their projects are going

Benefits of Values-Based Action Worksheet

Now that you’ve identified your values—and you understand that the moment of choice presents an opportunity to make a helpful decision about how to respond in an emotion-filled situation—let’s explore possible reactions. Answer the following questions about your values, your intentions, and your actions around your values.

How does values-based action affect my relationships with friends and family?

How does values-based action affect my relationship with my spouse or partner, or my living situation?

How does values-based action affect my relationships when I am emotionally triggered?

How does values-based action affect my work or school?

How does values-based action affect my financial situation?

How does values-based action affect my health?

How does values-based action affect my long-term goals?

How does values-based action affect my safety and security?

Session 3 Skills Practice

Practice mindful acceptance for at least 10 minutes a day by observing and accepting the four components of emotion when you get emotionally triggered, or using emotion exposure to a difficult event, situation, or emotion. Observe all four parts of the emotion, and surf the emotion wave. (Refer to the mindful acceptance directions from Session 2 Skills Practice, if needed.) Record your mindful acceptance skills practice in the first row of your Skills Practice Record.
Practice using values-based action with imaginal exposure by taking the following five steps:
- Step 1: Identify the value and the VBA for the distressing situation you want to work with.
- Step 2: Imagine the distressing situation and describe it to yourself until you are activated and you have reached your target SUDS level.
- Step 3: Practice mindful acceptance (observe + accept all parts of the emotion: thoughts, feelings, sensations, and urges), and locate the moment of choice.
- Step 4: Note your SUDS level, and visualize enacting your VBA for 3 to 5 minutes.
- Step 5: Record your SUDS level at the end of your exercise. Record your skills practice on the third row of your Skills Practice Record.
Record any events that trigger you during the week at the bottom of your Skills Practice Record.
Bring all of these materials to review in your next session.

Skills Practice Record

Emotion Efficacy Therapy

Directions: Place a check mark next to the skill you practice each day. Record any triggers at the bottom. Bring this record to your next session.

	Day 1	Day 2	Day 3	Day 4	Day 5	Day 6	Day 7
Observe the four parts of an emotion: sensations, feelings, thoughts, and urges.
Observe, accept, and surf your emotion wave, with SUDS.
Observe, accept, and choose a values-based action.
Observe, accept, and choose a relaxation skill.
Observe, accept, and choose a self-soothing skill.
Observe, accept, and choose a coping thought.
Observe, accept, and choose to practice radical acceptance.
Observe, accept, and choose a distraction task or activity.
Observe, accept, and choose a time-out.

Emotional triggers: Record any events or emotions that are distressing during this week.

EET Session 4: O + A + Choose VBA

Components Covered: Values-Based Action Part 2 and Exposure-Based Skills Training (Chapter 6)

Session 4 is the second of two sessions focused on values-based action. Using a group experiential exposure, Monsters on the Bus, clients drill down further on the experience of accepting difficult emotions and tolerating their distress in order to choose values-based action. The consequences of choosing to avoid painful emotions are highlighted to increase willingness and motivation for clients to choose VBAs in the moment of choice. Group members continue working with VBA using imaginal exposure as well as in vivo.

Materials

Script for Guided Mindful Acceptance
Session 4 Skills Practice handout
Skills Practice Record

Overview

Mindful acceptance practice and feedback
Skills practice review
Monsters on the Bus exercise
VBA using imaginal exposure and feedback
Session 4 skills assignment

Procedures

1. Mindful acceptance practice and feedback

For the first ten minutes of session, lead group members through mindful acceptance practice using the guided script. Ask clients to provide feedback about their experience as an opportunity for learning and troubleshooting.

2. Skills practice review

Briefly review Session 3 skills and ask group members to share feedback about their weekly practice using their Skills Practice Record.

3. Monsters on the Bus exercise

First, ask a group member to volunteer for the exercise; the client will be working with values-based action and the barriers that show up when trying to choose VBA.

Next, ask the volunteer to choose a situation from one of his or her life domains that is distressing. Then have the volunteer identify what value he or she would like to express in the situation. Make sure that the value is rated as very important to ensure the likelihood that group members will be motivated to try a new behavior.

Ask the volunteer to identify the values-based action that could be enacted to move in the direction of his or her value in that particular domain, and help the volunteer be very specific about how the VBA would be enacted in the situation.

Ask the volunteer what emotional barriers come up when he or she visualizes enacting a VBA. Make a list of all the barriers—thoughts, feelings, sensations, and urges—writing each one on its own piece of paper. These pieces of paper will represent the “monsters” for the exercise. If you have time and are so inclined, you can even draw a picture of the monster for each emotional barrier.

Instruct the volunteer to stand up at one end of the room. Place a sheet of paper with the VBA written on it at the other end, so that it’s visible to the volunteer. Place the pieces of paper with the emotional components, which serve as the “monsters,” in any order in a row between the volunteer and the VBA.

Tell the volunteer that you will be going on the journey as his or her guide toward the VBA. Explain that the volunteer will be driving a bus in the direction of his or her VBA, and along the way he or she will encounter “monsters”—the barriers to reaching his or her VBA. Let the volunteer know that, while you are guiding him or her, he or she is in complete control of what he or she chooses to do along the way.

Ask for more volunteers from the group to act as the barriers, or “monsters.” Explain to them that, when you cue them, they should come and stand in front of the volunteer driving the bus and say their line. For example, if the barrier identified was the thought “I will never be good enough,” have a volunteer say that. Or if the barrier is a feeling of anxiety, have another volunteer say, “You’re feeling anxious.” If the barrier is a sensation, have an additional volunteer say what it is, for example, “tingling in the fingers” or “hot flashes.”

Take the first volunteer—now the bus driver—on the journey, and when he or she encounters a monster, ask the bus driver how he or she can get past the monster. The rule is that the monster will not let the bus by, and the only choices are: veer off the path and onto the road to emotion avoidance, or let the monster on the bus and keep driving.

At each barrier, or monster, ask the driver if he or she wants to stay on the path to his or her VBA or veer off and onto the road to emotion avoidance. At least once, if the driver doesn’t choose it, suggest to the client that he or she might take the path to emotion avoidance to see what it’s like.

When the driver does choose the path to emotion avoidance, guide the driver to the side and ask him or her to take a moment to experience the pros and cons of emotion avoidance. If the client is able to recognize the consequences of avoiding, he or she will choose to get back on the values-based path.

Once the client has successfully made it to his or her value, take a moment to review how being able to choose values-based action means being clear on what it is for that situation, and then being willing to experience all the uncomfortable emotions while moving in a valued direction.

For a more detailed therapist-client dialogue, refer to the Therapist-Client Dialogue Example: Monsters on the Bus, in chapter 6.

If you have time, repeat the Monsters on the Bus exercise a second or third time, trying to involve each group member in either the bus driver or monster roles. After each experiential, ask if group members learned anything about their relationship with their emotions from the exercise.

4. VBA using imaginal exposure and feedback

For the session exposure practice, repeat imaginal exposure + VBA using the following guide:

Step 1: Select a distressing situation. Ask clients to describe a recent distressing event in which they became emotionally triggered and responded with experiential avoidance or other emotion-driven behavior. Check in to be sure each client has identified a situation to work with before moving forward.
Step 2: Identify the value and the VBA. Explore which of the clients’ values relate to the situation they have chosen. Then prompt clients to identify a specific VBA that they would have preferred to enact. You’ll want to get the clients to articulate exactly what this alternative behavior would look like—everything the clients say and do, including tone of voice and body language.
Step 3: Visualize enacting the VBA. Have the clients briefly visualize using the values-based action, mentally rehearsing the scene several times until they are clear about what they will do.
Step 4: O+A+C. Begin the exposure by having clients form a clear image of the triggering scene. Encourage them to notice the environment where the trigger occurred: watch the action in the scene, hear what’s said, feel whatever physical sensations are part of the scene, notice if there’s an urge to do something or not to do something. As the clients become emotionally activated, ask them to continue to describe the sensations, thoughts, feelings, and urges that come up. Encourage an accepting attitude whereby the client “makes room” for the emotion, allowing it to be what it is with no effort at controlling or avoiding it.
While still visualizing the triggering event, have the clients observe any action urges that arise. Is there a desire to be verbally aggressive, to withdraw, to stonewall, to be defensive? Have the clients describe such urges and notice that the urges don’t have to become action. This is the moment of choice, and it’s important for the clients to stay with it for several minutes: observing the emotional pain, accepting and allowing the pain to be there without avoidance, and choosing not to act on emotion-driven urges.

Step 6: Learning consolidation. Consolidate what the clients have learned through a brief conversation. Did observing and accepting the target emotion decrease their distress? What did they observe about the moment of choice? How did visualizing an alternate response (VBA) impact them? Did it reduce their distress? Increase their distress tolerance? Did it increase confidence that the client could choose VBAs in distressing situations?

5. Session 4 skills assignment

Your clients have now had two sessions on values-based action and may be ready to practice in vivo. Invite them to think of a situation that is going to present itself in the week ahead. Ask them to consider practicing mindful acceptance and then choosing a VBA when they get triggered.

Remind clients that they have the Exposure with Values-Based Action handout to help them practice this skill again between sessions.

Script for Guided Mindful Acceptance

First, just sit comfortably, and either close your eyes or relax your gaze and pick a spot to focus on in front of you.

Now, see if you can identify a feeling label that goes with the sensation… just name it and allow it to be as it is without judgment or reacting to it.

[Allow the client to sit with the urge for 30 seconds. Then repeat the sequence one more time.]

Before you come out of this exercise, take a few deep breaths and slowly open your eyes as you bring your attention back to the room.

Session 4 Skills Practice

Practice mindful acceptance for at least 10 minutes a day by observing and accepting the four components of emotion when you get emotionally triggered, or using emotion exposure to a difficult event, situation, or emotion. Observe all four parts of the emotion, and surf the emotion wave. (Refer to the mindful acceptance directions from Session 2 Skills Practice, if needed.) Record your mindful acceptance skills practice in the first row of your Skills Practice Record.
Using the Exposure with Values-Based Action handout, practice using VBA with imaginal exposure or in vivo by taking the following steps:
- Step 1: Identify the value and the VBA for the distressing situation you want to work with.
- Step 2: Imagine the distressing situation and describe it to yourself until you are activated and you have reached your target SUDS level.
- Step 3: Practice mindful acceptance (observe + accept all parts of the emotion: thoughts, feelings, sensations, and urges), and locate the moment of choice.
- Step 4: Note your SUDS level, and visualize enacting your VBA for 3 to 5 minutes.
- Step 5: Record your SUDS level at the end of your exercise. Record your skills practice on the third row of your Skills Practice Record.
Record any events that trigger you during the week at the bottom of your Skills Practice Record.
Bring all of these materials to review in your next session.

Skills Practice Record

Emotion Efficacy Therapy

Directions: Place a check mark next to the skill you practice each day. Record any triggers at the bottom. Bring this record to your next session.

	Day 1	Day 2	Day 3	Day 4	Day 5	Day 6	Day 7
Observe the four parts of an emotion: sensations, feelings, thoughts, and urges.
Observe, accept, and surf your emotion wave, with SUDS.
Observe, accept, and choose a values-based action.
Observe, accept, and choose a relaxation skill.
Observe, accept, and choose a self-soothing skill.
Observe, accept, and choose a coping thought.
Observe, accept, and choose to practice radical acceptance.
Observe, accept, and choose a distraction task or activity.
Observe, accept, and choose a time-out.

Emotional triggers: Record any events or emotions that are distressing during this week.

EET Session 5: O + A + Choose Mindful Coping

Components Covered: Mindful Coping Through Relaxation, Self-Soothing, and Exposure-Based Skills Practice (Chapter 7)

Session 5 introduces the last EET component, mindful coping. Unlike mindful acceptance and values-based action, mindful coping is only used when clients have tried to observe and accept painful emotions (mindful acceptance), and/or have attempted to choose a values-based action, but are too overwhelmed to execute them effectively. Instead, mindful coping skills are intended to facilitate a decrease in emotion activation. In this session, clients learn how to use relaxation and self-soothing to downregulate emotion. These mindful coping skills are practiced using emotion exposure in session, with time for feedback and troubleshooting.

Materials

Script for Guided Mindful Acceptance
Mindful Coping Through Relaxation handout
Mindful Coping Through Self-Soothing handout
Session 5 Skills Practice handout
Skills Practice Record

Overview

Mindful acceptance practice and feedback
Skills practice review
Psychoeducation on mindful coping
Introduction to relaxation and self-soothing
Relaxation skills practice with emotion exposure and feedback
Self-soothing skills practice with emotion exposure and feedback
Skills practice assignment

Procedures

1. Mindful acceptance practice and feedback

2. Skills practice review

Briefly review Session 4 skills and ask clients to share feedback about their weekly practice using their Skills Practice Record.

3. Psychoeducation on mindful coping

Mindful coping skills are used in combination with mindful acceptance and only when necessary—when clients are unable to choose a VBA or recover through the practice of mindful acceptance alone. Emphasize to clients that the goal of EET is to help them be more powerful when facing and tolerating difficult emotions and still move in the direction of their values; mindful coping skills are used only in crisis situations to help regulate their emotions when they are flooded, so they can recover enough to choose a VBA.

4. Introduction to relaxation and self-soothing

Relaxation and self-soothing skills work by using somatic stimulation and intention to decrease emotional activation. By learning how to intentionally let go of tension, and/or create pleasurable sensations in the body, clients learn to use relaxation and self-soothing to downshift emotion.

5. Relaxation skills practice with emotion exposure and feedback

Lead your clients through emotion exposure by selecting one of the relaxation skills on the Mindful Coping Through Relaxation handout, and then follow the step-by-step guide below. Be sure to leave at least ten minutes for feedback and troubleshooting after the exposure.

Step 1: Identify the relaxation skill. Prompt clients to identify the relaxation skill they want to use in the moment of choice.
Step 2: Select a distressing situation. Ask clients to identify a recent distressing event in which they became emotionally triggered and responded with experiential avoidance or other emotion-driven behavior. Check in to be sure each client has identified a situation to work with before moving forward.
Step 3: Initiate emotion exposure. Prompt clients to close their eyes or pick a spot to focus on in front of them while visualizing the triggering scene they have chosen, noticing the environment where the trigger occurred: watch the action in the scene; hear what’s said. After a few minutes, have clients rate their SUDS and indicate emotional activation by raising their hand.
Step 4: Initiate the practice of mindful acceptance. Instruct clients to practice observing and accepting the emotion, “making room” for any thoughts, sensations, feelings, or urges, allowing the emotion to be what it is with no effort at controlling or avoiding them. Have clients rate their SUDS before you move into the next step.
Step 5: Guide clients through the skill. Now ask clients to locate their moment of choice. Then instruct them to use the relaxation skill they’ve chosen for the next five minutes.
Step 6: Close the exposure and consolidate learning. Ask clients to rate their final SUDS, and check in with each client to confirm that either their activation has come down or that they are able to tolerate any remaining levels of activation. Ask clients for feedback about their exposure experience, and troubleshoot what obstacles got in the way, if any, of them being able to practice mindful acceptance or using their EET skill.

6. Self-soothing skills practice with emotion exposure and feedback

Next, lead your group through emotion exposure by selecting one of the self-soothing skills on the Mindful Coping Through Self-Soothing handout and then following the step-by-step guide below. Be sure to leave at least ten minutes for feedback and troubleshooting after the exposure.

Step 1: Identify the self-soothing skill. Prompt clients to identify the self-soothing skill they want to use in the moment of choice.
Step 2: Select a distressing situation. Ask clients to identify a recent distressing event in which they became emotionally triggered and responded with experiential avoidance or other emotion-driven behavior. Check in to be sure each client has identified a situation to work with before moving forward.
Step 3: Initiate emotion exposure. Prompt clients to close their eyes or pick a spot to focus on in front of them while visualizing the triggering scene they have chosen, noticing the environment where the trigger occurred: watch the action in the scene; hear what’s said. After a few minutes, have clients rate their SUDS and indicate emotional activation by raising their hand.
Step 4: Initiate the practice of mindful acceptance. Instruct clients to practice observing and accepting the emotion, “making room” for any thoughts, sensations, feelings, or urges, allowing the emotion to be what it is with no effort at controlling or avoiding them. Have clients rate their SUDS before you move into the next step.
Step 5: Guide clients through the skill. Now ask clients to locate their moment of choice. Then instruct them to use the self-soothing skill they’ve chosen for the next five minutes.
Step 6: Close the exposure and consolidate learning. Ask clients to rate their final SUDS, and check in with each client to confirm that either their activation has come down, or that they are able to tolerate any remaining levels of activation. Ask clients for feedback about their exposure experience, and troubleshoot what obstacles got in the way, if any, of them being able to practice mindful acceptance or using their EET skill.

7. Session 5 skills assignment

Your clients have now had their first session combining mindful acceptance and mindful coping skills. While they can still practice mindful acceptance with values-based action, invite them to try using relaxation and self-soothing skills—even if they don’t feel flooded—to help them begin to internalize how to use mindful coping. This way, when they are too triggered to choose VBA, they will have had practice in an activated state.

Script for Guided Mindful Acceptance

First, just sit comfortably, and either close your eyes or relax your gaze and pick a spot to focus on in front of you.

Now, see if you can identify a feeling label that goes with the sensation…just name it and allow it to be as it is without judgment or reacting to it.

[Allow the client to sit with the urge for 30 seconds. Then repeat the sequence one more time.]

Before you come out of this exercise, take a few deep breaths and slowly open your eyes as you bring your attention back to the room.

Mindful Coping Through Relaxation

When a powerful emotion has been triggered and you are suddenly facing your moment of choice, a mindful coping skill can help downregulate your emotions before you decide on a values-based action. Practice these relaxation techniques daily so that you can rely on them in your moment of choice.

Diaphragmatic Breathing

Place one hand on your abdomen, just above the belt line, and the other on your chest.

Take a slow, deep breath into the abdomen. The hand on the abdomen should move but not the hand on the chest.

If you are having difficulty pushing the breath into your abdomen (and the hand on your chest is moving), you can do one of two things:

• Press your hand into your abdomen, and then inhale so that the breath pushes your hand out.
• Lie down and put a phone book over your abdomen. Breathe so that your inhale pushes the phone book up.

Practice 15 diaphragmatic breaths three times a day.

Relaxation Without Tension

Choose a cue word. Identify a word or phrase that you associate with relaxation. This could be a color (golden light, sea blue), a place that calms you (Tuolumne, Shenandoah), a command (“relax now”), or a spiritual mantra (om, peace on earth, I let go). This cue word will become associated with, and soon trigger, deep relaxation.

Observe a muscle group (see next paragraph) and notice any tension. Take a deep, diaphragmatic breath. At the top of the breath, say to yourself the cue word. Now, as you exhale, relax away any tension in the target muscle group. Do this process twice with each muscle group, in any order.

The five muscle groups you will relax are:

• Face (forehead and jaw)
• Neck and shoulders
• Arms and hands
• Chest, back, abdomen
• Legs (buttocks, thighs, calves, feet)

Practice this skill three times a day.

Cue-Controlled Breathing

Use the same cue word you established with Relaxation Without Tension.

Take a deep, diaphragmatic breath. At the top of the breath, say to yourself the cue word. Now, as you exhale, relax away any tension throughout your body at once. Let your body slump forward slightly as you exhale and release all tension.

Take 15 cue-controlled breaths three times a day to practice this new skill.

Five-Senses Exercise

For 30 seconds, focus on every sound you can hear: voices, traffic noise, machinery noise such as the hum of an air conditioner, sounds of movement, sounds your body makes. Try to keep your attention fully on these sounds. If your mind wanders, gently bring it back to focusing on what you hear.

For 30 seconds focus on what you can smell: fragrances, odors, scents from your own body or the environment. Try to keep attention on what you smell; return to this focus when your mind wanders.

For 30 seconds focus on your sense of touch, including temperature and texture, noticing the pressure where your body touches the floor or chair. Return to your sense of touch when your mind wanders.

For 30 seconds focus on visual sensations, observing color and shapes, and noticing the objects in your environment. When you get distracted, bring your attention back to what you see.

For 30 seconds focus on your sense of taste. What residual tastes do you notice in your mouth—bitter, sweet, sour, salty? Are there more-subtle tastes? If you get distracted, bring your attention back to taste.

Practice this exercise twice daily as a way to focus attention away from negative thoughts and onto present-moment experience.

Mindful Coping Through Self-Soothing

This worksheet will help you identify some ways to soothe yourself using each of your five senses.

Sense of Smell

Using your sense of smell can activate specific thoughts, memories, or sensations that can be calming. If you identify smells that make you feel good in advance, you will be prepared to use them when triggered. Following are some examples, and feel free to add your own ideas:

Burn scented candles or incense that you like.
Wear scented oils, perfume, or cologne that makes you feel happy, confident, or sexy.
Carry perfumed cards from magazines, or ones that you make, in your purse, wallet, or car.
Go someplace where you know the scent is pleasing to you, such as a bakery or coffee shop.
Lie down in a park where you can smell grass, flowers, or other outdoor smells.
Buy flowers or find flowers in your neighborhood.
Hug someone whose smell makes you feel calm.
Other ideas:

Sense of Sight

Sight is an important sense for humans in that a large portion of our brain is devoted to what we see. What we look at can have powerful effects on our emotions, for better or for worse. If you identify images that make you feel good in advance, you will be prepared to use them when upset. Following are some examples, and a place for you to add your own ideas:

Look online, through magazines, and in books to select pictures you like. Make a collage of them to hang on your wall, add as a screensaver on your computer, or keep with you in your purse or wallet to look at throughout the day.

Find a physical place that’s soothing for you to look at, like a park, a lake, a museum, or other landmark. Or take a picture of that place.

Go online or to the bookstore and find a collection of photographs or paintings that you find relaxing, such as the nature photographs by Ansel Adams.

Draw or paint a picture that’s pleasing to you.

Carry a picture of someone you love, someone you find attractive, or someone you admire.

Other ideas:

Sense of Hearing

Certain sounds can be very soothing. For example, everyone has his or her own tastes or preferences in music. By identifying in advance songs or sounds you know are soothing for you, you will be prepared to use them to help calm down. Following are some examples, and a place for you to add your own ideas:

Listen to soothing music: classical, opera, oldies, new age, Motown, jazz, emo, whatever works for you. It might be instrumental or music with singing. Go online to iTunes and listen to a variety of music to determine what helps you relax. Look for preselected compilations for relaxation and meditation.

Listen to audiobooks or CDs. Many public libraries will let you check out audiobooks. Try some to see if they help you relax. You don’t even have to pay attention to the story line; sometimes just listening to the sound of someone’s voice can be relaxing.

Watch TV or stream shows on your computer. Find a show that’s boring or sedate, not anything activating, like reality TV, or that would make you angry, like the news. Keep the volume at a low level.

Listen to a gentle talk-show podcast, like a gardening or music show.

Listen to white noise, a fan, or sound machine. White noise is a blend of sounds that blocks out other distracting sounds. A sound machine has recorded sounds such as birds, waterfalls, wind, rain, and waves. Many people find these machines very relaxing.

Listen to the sounds of rushing or trickling water. Find a personal electronic water fountain or a nearby fountain in a park or a mall.

Listen to a relaxation or meditation exercise. Exercises like these help you imagine yourself relaxing in different ways.

Other ideas:

Sense of Taste

Our tongues have distinct regions on them that use taste buds to differentiate flavors and tastes of food. These sensations can also trigger memories and feelings. By identifying tastes you know are soothing for you in advance, you will be prepared to use them to deal with upsets. Following are some examples, and a place for you to add your own ideas:

Enjoy your favorite meal. Eat it slowly and mindfully so you can savor all of its various flavors.
Carry gum, mints, mouth spray, or other tasty treats with you to taste when you’re feeling upset.
Eat a “comfort” food that’s soothing to you.
Drink something you find soothing, such as tea, coffee, or hot chocolate.
Suck on a popsicle or ice cube, especially if you’re feeling warm.
Find a piece of ripe, juicy fruit and eat it slowly.
Other ideas:

Sense of Touch

Our skin is the largest organ in the body, and it’s completely covered with nerves that carry sensations to our brain. This makes skin a powerful emotional messenger. By identifying tactile sensations you know are soothing for you in advance, you will be prepared to use them to quiet your emotions. Following are some examples, and a place for you to add your own ideas:

Work in the garden, touching the cool earth.

Carry something soft or velvety in your pocket to touch when you’re upset.

Take a hot or cold shower and observe the sensations of water on your skin.

Take a warm bath with bubbles or scented oil.

Get a massage. If you’re not comfortable taking your clothes off, look for massage types such as Shiatsu, which simply requires you to wear loose-fitting clothes. Or find a seated chair massage for a shoulder and neck rub.

Massage yourself.

Play with a pet—yours or someone else’s. Stroking an animal’s fur or skin can provide a soothing tactile experience. In fact, having a pet can have many health benefits, such as lower blood pressure, lower cholesterol levels, and reduced risk for heart disease. If you can’t find a pet, visit your local animal shelter, where you can play with the rescued animals.

Wear your most comfortable clothes, for instance a worn-in T-shirt, baggy sweats, and so on.

Other ideas:

Session 5 Skills Practice

Practice mindful acceptance for at least 10 minutes a day by observing and accepting the four components of emotion when you get emotionally triggered, or using emotion exposure to a difficult event, situation, or emotion. Observe all four parts of the emotion, and surf the emotion wave. (Refer to the mindful acceptance directions from Session 2 Skills Practice, if needed.) Record your mindful acceptance skills practice in the first row of your Skills Practice Record.
Practice using relaxation or self-soothing skills with exposure, or in vivo if a situation presents itself, by taking the following steps:
- Step 1: Identify a relaxation or self-soothing skill you want to practice ahead of time.
- Step 2: Either find something to intentionally activate your emotions (e.g., recall a recent difficult situation or a distressing memory) or engage in a situation you know will be triggering. Pick something that you believe will take your SUDS up into the 5 to 7 range.
- Step 3: Get into the scene or triggering situation until you reach your target SUDS, or until at least 5 minutes have passed.
- Step 4: Practice mindful acceptance of the painful emotion (observe + accept all parts of the emotion: thoughts, feelings, sensations, and urges). Stay here for 5 minutes, if possible.
- Step 5: Identify the moment of choice and apply the relaxation or self-soothing skill you’ve chosen. Do this for at least 5 minutes.
- Step 6: Notice and record your SUDS level at the end of your exercise.
- Step 7: Record your skills practice on the fourth row of your Skills Practice Record.
Record any events that trigger you during the week at the bottom of your Skills Practice Record.
Bring all of these materials to review in your next session.

Skills Practice Record

Emotion Efficacy Therapy

Directions: Place a check mark next to the skill you practice each day. Record any triggers at the bottom. Bring this record to your next session.

	Day 1	Day 2	Day 3	Day 4	Day 5	Day 6	Day 7
Observe the four parts of an emotion: sensations, feelings, thoughts, and urges.
Observe, accept, and surf your emotion wave, with SUDS.
Observe, accept, and choose a values-based action.
Observe, accept, and choose a relaxation skill.
Observe, accept, and choose a self-soothing skill.
Observe, accept, and choose a coping thought.
Observe, accept, and choose to practice radical acceptance.
Observe, accept, and choose a distraction task or activity.
Observe, accept, and choose a time-out.

Emotional triggers: Record any events or emotions that are distressing during this week.

EET Session 6: O + A + Choose Mindful Coping

Components Covered: Mindful Coping Through Coping Thoughts, Radical Acceptance, and Exposure-Based Skills Practice (Chapter 8)

Session 6 continues with mindful coping skills, to be used only when clients have tried to observe and accept painful emotions (mindful acceptance), and/or have attempted to choose a values-based action, but are too overwhelmed to execute them effectively. While the skills in Session 5 are focused on using sensations to downregulate emotion, Session 6 skills focus on using cognition to decrease emotional activation through coping thoughts and radical acceptance. These mindful coping skills are practiced using emotion exposure in session, with time for feedback and troubleshooting.

Materials

Script for Guided Mindful Acceptance
Client Coping Thoughts handout
Replacing Automatic Thoughts with Coping Thoughts worksheet (blank)
Replacing Automatic Thoughts with Coping Thoughts worksheet (Filled-Out Sample)
The Art of Radical Acceptance handout
Radical Acceptance worksheet
Session 6 Skills Practice handout
Skills Practice Record

Overview

Mindful acceptance practice and feedback
Skills practice review
Psychoeducation on coping thoughts
Coping thoughts practice with emotion exposure and feedback
Psychoeducation on radical acceptance
Radical acceptance practice with emotion exposure and feedback
Session 6 skills assignment

Procedures

1. Mindful acceptance practice and feedback

2. Skills practice review

Briefly review Session 5 skills and ask clients to share feedback about their weekly practice using their Skills Practice Record.

3. Psychoeducation on coping thoughts

Use the Client Coping Thoughts handout to introduce your clients to coping thoughts. Tell them how coping thoughts can be helpful in the moment of choice. Then use the worksheets to let clients create their own coping thoughts as alternatives to automatic thoughts.

4. Coping thoughts practice with emotion exposure and feedback

Lead your clients through emotion exposure with a coping thought using the following step-by-step guide. Be sure to leave at least ten minutes for feedback and troubleshooting after the exposure.

Step 1: Identify the coping thought. Prompt clients to use their Client Coping Thoughts handout to identify one they want to use in the moment of choice.
Step 2: Select a distressing situation. Ask clients to identify a recent distressing event in which they became emotionally triggered and responded with experiential avoidance or other emotion-driven behavior. Check in to be sure each client has identified a situation to work with before moving forward.
Step 3: Initiate emotion exposure. Prompt clients to close their eyes or pick a spot to focus on in front of them while visualizing the triggering scene they have chosen, noticing the environment where the trigger occurred: watch the action in the scene; hear what’s said. After a few minutes, have clients rate their SUDS and indicate emotional activation by raising their hand.
Step 4: Initiate the practice of mindful acceptance. Instruct clients to practice observing and accepting the emotion, “making room” for any thoughts, sensations, feelings, or urges, allowing the emotion to be what it is with no effort at controlling or avoiding them. Have clients rate their SUDS before you move into the next step.
Step 5: Guide clients through the skill. Now ask clients to locate their moment of choice. Then instruct them to use the coping thought they’ve chosen for the next five minutes.
Step 6: Close the exposure and consolidate learning. Ask clients to rate their final SUDS, and check in with each client to confirm that either their activation has come down or that they are able to tolerate any remaining levels of activation. Ask clients for feedback about their exposure experience, and troubleshoot what obstacles got in the way, if any, of them being able to practice mindful acceptance or using their EET skill.

5. Psychoeducation on radical acceptance

Use the following handout to introduce your clients to radical acceptance and how it can be helpful in the moment of choice. Then have clients complete the worksheet to help them use radical acceptance with a specific situation or reality they are resisting and that is emotionally triggering for them.

6. Radical acceptance practice with emotion exposure and feedback

Lead your clients through emotion exposure with radical acceptance using the following step-by-step guide. Be sure to leave at least ten minutes for feedback and troubleshooting after the exposure.

Step 1: Identify a radical acceptance statement. Prompt clients to use the Art of Radical Acceptance handout to identify one radical acceptance statement to use in the moment of choice.
Step 2: Select a distressing situation. Ask clients to identify a recent distressing event in which they became emotionally triggered and responded with experiential avoidance or other emotion-driven behavior. Check in to be sure each client has identified a situation to work with before moving forward.
Step 3: Initiate emotion exposure. Prompt clients to close their eyes or pick a spot to focus on in front of them while visualizing the triggering scene they have chosen, noticing the environment where the trigger occurred: watch the action in the scene; hear what’s said. After a few minutes, have clients rate their SUDS and indicate emotional activation by raising their hand.
Step 4: Initiate the practice of mindful acceptance. Instruct clients to practice observing and accepting the emotion, “making room” for any thoughts, sensations, feelings, or urges, allowing the emotion to be what it is with no effort at controlling or avoiding them. Have clients rate their SUDS before you move into the next step.
Step 5: Guide clients through the skill. Now ask clients to locate their moment of choice. Then instruct them to use the radical acceptance statement they’ve chosen for the next five minutes.

Step 6: Close the exposure and consolidate learning. Ask clients to rate their final SUDS, and check in with each client to confirm that either their activation has come down or that they are able to tolerate any remaining levels of activation. Ask clients for feedback about their exposure experience, and troubleshoot what obstacles got in the way, if any, of them being able to practice mindful acceptance or use their EET skill.

7. Session 6 skills assignment

Your clients’ focus this week should be on practicing mindful acceptance with coping thoughts and radical acceptance. Again, they can still practice mindful acceptance with values-based action, but invite them to try using coping thoughts and radical acceptance—even if they don’t feel flooded—to help them begin to internalize how to use mindful coping.

Script for Guided Mindful Acceptance

First, just sit comfortably, and either close your eyes or relax your gaze and pick a spot to focus on in front of you.

Now, see if you can identify a feeling label that goes with the sensation…just name it and allow it to be as it is without judgment or reacting to it.

[Allow the client to sit with the urge for 30 seconds. Then repeat the sequence one more time.]

Before you come out of this exercise, take a few deep breaths and slowly open your eyes as you bring your attention back to the room.

Client Coping Thoughts

Coping thoughts can be used when you are facing a difficult emotion. They may be especially helpful after you’ve practiced observing and accepting the difficult emotion, and you’re still struggling with specific ruminations, or a repetitive automatic thought is fueling your emotion wave.

You now know that your emotions will follow whatever you pay attention to. If you’re triggered, you’re likely to have negative automatic thoughts. One way to tolerate the distress and shift your emotion is to replace the negative automatic thought with a coping thought. The key with a coping thought is that you believe it to be true and realistic. If you don’t believe the thought, it’s unlikely to be effective.

Following are some examples of coping thoughts:

“This situation won’t last forever.”
“I can feel anxious/sad/angry without reacting.”
“I can tolerate this emotion until the wave goes down.”
“This emotion won’t kill me, it just doesn’t feel good right now.”
“I’ve dealt with this situation before, and I can do it again.”
“I can take all the time I need to just let go and relax.”
“I can let this emotion run the show, or I can use values-based action.”
“Just because I feel this emotion, doesn’t mean I have to act on it.”
“I am not my emotions… I can choose my next action.”

Replacing Automatic Thoughts with Coping Thoughts

Use this worksheet to record specific triggers, the automatic thoughts that go with them, and alternative coping thoughts with which you can replace them.

Trigger	Automatic Thought	Coping Thought
1.	1.	1.
2.	2.	2.
3.	3.	3.
4.	4.	4.
5.	5.	5.

Replacing Automatic Thoughts with Coping Thoughts

(Client Sample)

Trigger	Automatic Thought	Coping Thought
1. Turning in a project to my boss.	1. My work isn’t as good as it should be.	1. I’m doing my best, which is all I can do.
2. Being at a party with people I don’t know.	2. If I don’t say the right thing at this party, people are going to think I’m a loser.	2. I can have this thought without acting on it.
3. My wife comes home and goes straight to the bedroom.	3. My wife doesn’t love me anymore.	3. My defectiveness schema is talking, but I’m not listening.
4. Anytime… …	4. Something’s wrong with me.	4. I have strengths and weaknesses, just like everybody else.
5. My boss doesn’t talk to me at the office-wide lunch.	5. My boss doesn’t like me.	5. It’s not my job to be liked. It’s my job to do my job.

The Art of Radical Acceptance

What It Is

Part of successfully navigating intense emotions is knowing when it’s time to try to improve your situation and when it’s time to accept it. Radical acceptance is another mindful coping skill that allows you to accept “what is” and stop suffering from rejecting the reality in front of you. We have a choice in every moment: to reject the reality of what is or to accept it. The choice we make will determine whether we continue to suffer or create space for something else to exist.

Our natural response to distressing emotions is to fight against the reality that we think caused them. In doing this, we can make ourselves and others miserable. Choosing radical acceptance—to accept “what is”—is a huge shift for most people. It feels like the opposite of what your emotions urge you to do when you encounter pain.

What It’s Not

Radical acceptance does not mean you like or condone what happened. It just means that you accept the reality that it happened. In other words, some situations in life are simply unjust or unfair. In other situations, you may share responsibility for what happened. Either way, just because you accept that it happened doesn’t mean you’re condoning it.

The more you practice radical acceptance, the easier it will become to stop resisting what you cannot change.

Following are a few examples of radical acceptance:

“My girlfriend broke up with me, but it doesn’t mean I have to retaliate or try to win her love back.”
“I have suicidal thoughts all the time, but that doesn’t mean I like having them or that I will act on them.”
“I didn’t set a reminder to pay that phone bill, so I will have to take responsibility for the consequences.”

Radical acceptance requires a willingness to look at things differently. Sometimes our disappointments and moments of frustration were preventable. We can also practice radical acceptance by accepting what we might have done differently, and taking responsibility for how we didn’t. For example, could you have prevented being late to an appointment, forgetting to do work assignments, or behaving in a way that was less than stellar? Moreover, could you have prevented lying to hurt someone or allowing yourself to be motivated by hate? Many times we have culpability in “what is.” Accepting that is key to practicing radical acceptance.

While the outcomes of these situations may have serious consequences, they can also be opportunities for growth if you can view them as moments of learning. Often people who struggle with intense emotions believe that life is something that “happens” to them, instead of recognizing their own power in creating their experience.

The good news is that if we have responsibility in the things happening, we also have the power to make different choices—choices that can alleviate suffering and bring us closer to living the life we want in accordance with our values.

Radical Acceptance

Assessing the Situation

Think of a situation you have no control over, but about which you struggle to accept. Then answer the following questions:

Describe briefly the distressing situation:

What past events led to the situation?

What role, if any, did you play in creating the situation?

What roles, if any, did others play in the situation?

What do you have control of in this situation?

What do you not have control of in this situation?

What was your response to this situation?

How did your response affect your own thoughts and feelings?

How did your response affect the thoughts and feelings of others?

How could you have changed your response to this situation so that it led to less suffering for yourself and others?

How could the situation have occurred differently if you had chosen to radically accept the situation?

How to Practice Radical Acceptance

Once you’ve identified the situation and have a clear understanding of it, you can use these steps to practice radical acceptance during imaginal exposure or when you get upset.

Recognize your resistance to the reality of “what is.”
Practice mindful acceptance of the emotion that goes with the situation or reality. Using the four components of emotion, make room for all your thoughts, feelings, sensations, and urges, allowing them to be there without reacting or acting on them.
Stop resisting by reminding yourself of the facts, such as: “This is just the way it is, I can’t change it” or “I have to accept the consequences of my actions.”

Session 6 Skills Practice

Practice mindful acceptance for at least 10 minutes a day by observing and accepting the four components of emotion when you get emotionally triggered, or using emotion exposure to a difficult event, situation, or emotion. Observe all four parts of the emotion, and surf the emotion wave. (Refer to the mindful acceptance directions from Session 2 Skills Practice, if needed.) Record your mindful acceptance skills practice in the first row of your Skills Practice Record.
Practice using coping thoughts or radical acceptance with exposure or in vivo by taking the following steps:
- Step 1: Identify a coping thought or a radical acceptance skill you want to practice ahead of time.
- Step 2: Either find something to intentionally activate your emotions (e.g., recall a recent difficult situation or a distressing memory) or engage in a situation you know will be triggering. Pick something that you believe will take your SUDS up into the 5 to 7 range.
- Step 3: Get into the scene or triggering situation until you reach your target SUDS, or until at least 5 minutes have passed.
- Step 4: Practice mindful acceptance of the painful emotion (observe + accept all parts of the emotion: thoughts, feelings, sensations, and urges). Stay here for 5 minutes, if possible.
- Step 5: Identify the moment of choice and apply the coping thought or radical acceptance skill you’ve chosen. Do this for at least 5 minutes.
- Step 6: Notice and record your SUDS level at the end of your exercise.
- Step 7: Record your skills practice on the fourth row of your Skills Practice Record.
Record any events that trigger you during the week at the bottom of your Skills Practice Record.
Bring all of these materials to review in your next session.

Skills Practice Record

Emotion Efficacy Therapy

Directions: Place a check mark next to the skill you practice each day. Record any triggers at the bottom. Bring this record to your next session.

	Day 1	Day 2	Day 3	Day 4	Day 5	Day 6	Day 7
Observe the four parts of an emotion: sensations, feelings, thoughts, and urges.
Observe, accept, and surf your emotion wave, with SUDS.
Observe, accept, and choose a values-based action.
Observe, accept, and choose a relaxation skill.
Observe, accept, and choose a self-soothing skill.
Observe, accept, and choose a coping thought.
Observe, accept, and choose to practice radical acceptance.
Observe, accept, and choose a distraction task or activity.
Observe, accept, and choose a time-out.

Emotional triggers: Record any events or emotions that are distressing during this week.

EET Session 7: O + A + Choose Mindful Coping

Components Covered: Mindful Coping Through Distraction and Exposure-Based Skills Practice (Chapter 9)

Session 7 completes mindful coping skills with the final skills: distraction and time-out. Distraction focuses on shifting attention of present-moment awareness away from the distressing stimulus or emotion to something that has more positive affect to downregulate emotion. Distraction is practiced using imaginal exposure in session, as well as in vivo, with time for feedback and troubleshooting.

Materials

Script for Guided Mindful Acceptance
Before You Act, Distract handout
Distraction Strategies worksheet
Take a Time-Out handout
Emotion Efficacy Therapy Skills handout
Personalized Emotion Efficacy Plan worksheet
Session 7 skills practice handout
Skills Practice Record

Overview

Mindful acceptance practice and feedback
Skills practice review
Psychoeducation on distraction and time-out
Distraction with imaginal or emotion exposure and feedback
Introduction to personalized emotion efficacy plan
Skills practice assignments

Procedures

1. Mindful acceptance practice and feedback

For the first ten minutes of session, lead clients through mindful acceptance practice using the guided script. Ask clients to provide feedback about their experience as an opportunity for learning and troubleshooting.

2. Skills practice review

Briefly review Session 6 skills and ask clients to share feedback about their weekly practice using their Skills Practice Record.

3. Psychoeducation on distraction and time-out

Use the following handouts to introduce clients to the mindful coping skills of distraction and time-out.

4. Distraction with imaginal or emotion exposure and feedback

Lead your clients through emotion exposure with distraction using the following step-by-step guide. Be sure to leave at least ten minutes for feedback and troubleshooting after the exposure.

Step 1: Identify a distraction. Prompt clients to use the Distraction Strategies handout to identify one task or activity they want to use in the moment of choice.
Step 2: Select a distressing situation. Ask clients to identify a recent distressing event in which they became emotionally triggered and responded with experiential avoidance or other emotion-driven behavior. Check in to be sure each client has identified a situation to work with before moving forward.
Step 3: Initiate emotion exposure. Prompt clients to close their eyes or pick a spot to focus on in front of them while visualizing the triggering scene they have chosen, noticing the environment where the trigger occurred: watch the action in the scene; hear what’s said. After a few minutes, have clients rate their SUDS and indicate emotional activation by raising their hand.
Step 4: Initiate the practice of mindful acceptance. Instruct clients to practice observing and accepting the emotion, “making room” for any thoughts, sensations, feelings, or urges, allowing the emotion to be what it is with no effort at controlling or avoiding them. Have clients rate their SUDS before you move into the next step.
Step 5: Guide clients through the skill. Now ask clients to locate their moment of choice. Then instruct them to use the distraction skill they’ve chosen for the next five minutes.
Step 6: Close the exposure and consolidate learning. Ask clients to rate their final SUDS, and check in with each client to confirm that either their activation has come down or that they are able to tolerate any remaining levels of activation. Ask clients for feedback about their exposure experience, and troubleshoot what obstacles got in the way, if any, of them being able to practice mindful acceptance or using their EET skill.

5. Introduction to Personalized Emotion Efficacy Plan

The Personalized Emotion Efficacy Plan is intended to help clients review and consolidate what they’ve learned. Having a plan written down will assist with this, giving them something to refer to after treatment has ended to practice and to prevent relapse. Encourage clients to take time to think about what has worked for them and what they want to continue to work on, as well as any questions they have about skills that were more difficult for them.

6. Session 7 skills assignment

Clients will practice mindful acceptance with distraction. As with previous weeks, invite them to try using distraction—even if they don’t feel flooded—to help them begin to internalize how to use mindful coping.

Clients will also review all the EET skills they’ve learned and complete the Personalized Emotion Efficacy Plan worksheet, which you’ll review in Session 8.

Script for Guided Mindful Acceptance

First, just sit comfortably, and either close your eyes or relax your gaze and pick a spot to focus on in front of you.

Now, see if you can identify a feeling label that goes with the sensation…just name it and allow it to be as it is without judgment or reacting to it.

[Allow the client to sit with the urge for 30 seconds. Then repeat the sequence one more time.]

Before you come out of this exercise, take a few deep breaths and slowly open your eyes as you bring your attention back to the room.

Before You Act, Distract

Emotions mirror what we pay attention to. If we pay attention to people, things, or situations that anger or upset us, our feelings will reflect that. And the intensity of those emotions can make it hard to act on our values. If we switch attention to something else, our feelings will reflect the new experience we’ve chosen. We have the power to shift how we feel by shifting our attention. There are several benefits from using distraction:

You’re less likely to be swept into destructive, emotion-driven behaviors.
Your upset is likely to subside more quickly than if you act on your emotion.
You’re more likely to feel able to act on your values.

Avoiding Avoidance

Sometimes it’s hard to tell if you’re using mindful coping to avoid your emotions or to move in the direction of your values. If you’re not sure, you can ask yourself this basic question: “Am I using this skill to move toward my values or to avoid my emotion?” Using distraction after you observe and accept your emotional experience can be a life-improving, values-consistent choice in situations when you’re getting overwhelmed and need to “downshift” an emotion wave.

Mindful Coping with Distraction

Follow these steps for mindful distraction:

Step 1: Select a triggering event. Visualize an upsetting event until you are at the target level of arousal (usually 5 to 6 SUDS).

Step 2: Observe and accept. Observe and accept the sensations, emotions, and urges that come up for at least 5 minutes. Make room for all the experience.

Step 3: Choose distraction. Begin using a distraction technique of your choice for at least 5 minutes. You may also choose additional distraction strategies, if you want.

Remember, if you experience a strong, painful emotion in the course of daily life, you can do one of two things: You can stay with the feeling, noticing the moment of choice, and responding with a values-based action. Or, if the pain is pushing you hard toward emotion-driven behavior and you can’t muster a values-based response, you can mindfully choose distraction (or any of the other mindful coping skills).

Distraction Strategies

The following handout will help you identify mindful coping ideas to distract yourself when you have already tried to use mindful acceptance and/or values-based action and are still feeling triggered.

Pay Attention to Someone Else

One effective way to shift your attention when you are emotionally triggered is to place your attention on someone else. Following are some examples of how you might do this, as well as a space for your own ideas:

Call your friends and ask if they need help doing something, such as a chore, grocery shopping, or housecleaning.

Ask any family members who live nearby if you can assist them with something: running errands, yard work, babysitting, walking the dog, etc.

Call your local soup kitchen, homeless shelter, volunteer organization, or advocacy group and sign up to help.

Bake cookies for a neighbor or coworker.

Send a “just because” card to someone you haven’t talked to in a while.

Write a thank-you email to someone who did something kind for you.

Write a handwritten letter to someone who has changed your life for the better and tell him or her why.

Make a list of people you admire and want to be like and write down why.

People-watch. Go to a local store, shopping center, bookstore, or park and notice what other people do, how they dress. Listen to their conversations. Observe as many details about other people as you can.

Play counting games while people-watching, for example, count the number of blue-eyed people versus brown-eyed people you see.

Think about someone you care about. What do you imagine he or she is doing right now?

Keep a picture of those you love in your wallet or purse. These people can range from family members to friends to public figures you admire. Look at the photo whenever you need comfort.

Imagine having a healing, peaceful conversation with someone you deeply care about or admire. What would he or she say to you that would help you feel better? Imagine him or her saying this to you.

Other ideas:

Pay Attention to Something Else

Our brains are amazing thinking machines. They produce millions of thoughts every day. Our emotions follow what we think about, and you can intentionally shift your thoughts when you’re triggered to decrease your emotional activation. Following are some examples of how you might do this, as well as a space for your own ideas:

Pay attention to the natural world around you. Observe the flowers, trees, sky, and landscape as closely as possible. Observe any animals that are around. Listen to all the sounds around you. Or, if you live in a city without much nature, observe what you can see and hear.

Keep a copy of your favorite prayer or saying with you. When you feel distressed, read it to yourself. Imagine the words calming and soothing you. Use imagery (such as white light coming down from the sky) to soothe you as you read the words.

Walk around your neighborhood or a park and notice the scenery, the colors, the textures of your surroundings.

Listen to music that’s pleasing to you. Also try listening to new music: from a different genre or from another country.

Listen to an engaging audiobook. Close your eyes and really try to pay attention.

Watch a TV show or movie you know will hold your attention and take your focus off yourself. Think about whether you would have written a different plot or ending.

Learn a new language.

Learn how to play a musical instrument.

Write a letter to God or your higher power.

Write in your journal.

Other ideas:

Be Productive

Many people don’t schedule time to take care of themselves or their living environments. Doing tasks and chores can be an effective way to shift your attention away from your distress. Following are some examples, and a place for you to add your own ideas:

Make a to-do list.
Wash the dishes.
Make phone calls to people with whom you are not angry and want to catch up with.
Clear your room or house.
Clean out your closet and donate old clothes.
Redecorate a room in your house.
Organize your books, files, drawers, etc.
Make a plan of action for finding a job, or for finding a better job if you already have one.
Make appointments with various people—doctor, dentist, optometrist, accountant, etc.—and arrive on time.
Get a new hairstyle or haircut.
Get a manicure or pedicure.
Get a massage.
Wash your car.
Plan something: a party, event, your next vacation.
Mow the lawn.
Plant a garden, or do gardening work in your own space or in a community garden.
Clean out your garage.
Do homework or other work.
Clean your bathtub and take a bath.
Go grocery shopping and cook a nice dinner for yourself.
Pay bills.
Other ideas:

Do a Pleasurable Activity

Call or text a friend.
Visit a friend or invite a friend to come over.

Exercise: lift weights; do yoga, tai chi, or Pilates, or take classes to learn how; stretch your muscles; ride your bike; go swimming or hiking; play something you can do by yourself, such as basketball, bowling, handball, miniature golf, billiards.
Get out of your house and go for a drive in your car, or ride public transportation.
Plan a daytrip to somewhere you’ve always wanted to go.
Sleep or take a nap.
Eat something you really like.
Cook your favorite meal.
Watch TV or stream shows on the Internet.
Go to a sporting event.
Play video games.
Join an Internet dating service.
Create your own blog or website.
Go shopping.
Go to a bookstore and read.
Go to your place of worship.
Sing or learn how to sing.
Take pictures.
Join a club or attend a meet-up group.
Make a movie or video with your phone.
Go to a flower shop and smell your favorite flowers.
Knit, crochet, or sew, or learn how.
Make a scrapbook.
Write a loving letter to yourself when you’re feeling good, and read it when you’re feeling upset.
Draw or paint a picture, or learn how.
Make a bucket list of things you want to do before you die.
Make a list of 10 things you’re good at or that you like about yourself.
Masturbate or have sex with someone you care about.
Join a public-speaking group and write a speech.
Pray or meditate.
Other ideas:

Alternatives to Self-Destructive Behaviors

Some people who struggle with overwhelming emotions use self-destructive behaviors to temporarily relieve their distress. Instead of continuing to hurt yourself, consider using some tools to help shift your emotions rather than acting on them. Following are some examples, and a place for you to add your own ideas:

Instead of hurting yourself, hold an ice cube in one hand and squeeze it. The sensation from the cold ice will be numbing and distracting.
Write on yourself with a red felt-tip marker instead of cutting. Draw exactly where you would cut. Use red paint or nail polish to make it look like you’re bleeding. Then draw stitches with a black marker. If you need more distraction, squeeze an ice cube in the other hand at the same time.
Snap a rubber band on your wrist each time you feel like hurting yourself. This is very painful, but it causes less permanent damage than cutting, burning, or otherwise mutilating yourself.
Dig your fingernails into your arm without breaking the skin.
Throw foam balls, rolled up socks, or pillows against the wall as hard as you can.
Scream as loud as you can into a pillow or scream someplace where you won’t draw attention, like your car or at a loud concert.
Cry. Sometimes people don’t cry because they’re afraid that if they start they’ll never stop. This never happens. In fact, the truth is that crying can make you feel better because it releases stress hormones.
Other ideas:

Take a Time-Out

Sometimes when you get emotionally triggered, the best thing you can do is leave, or take a “time-out.” If you find yourself in an extremely distressing situation with someone or something, and, after trying to practice mindful acceptance or enact a values-based action, you’re still very upset, it’s often best to distance yourself and shift your attention away from the trigger to a more positive present-moment experience.

Try to remember that if you’re already overwhelmed by your emotions, it will be more difficult to resolve your problem in a healthy way. If you stay in the situation, you may make it worse than it is already. If you can put some distance between you and the situation, and give yourself time to calm your emotions, you can better think about what to do next.

It may be helpful to rehearse doing this, or to write a short script ahead of time, so that you’ll know exactly how you want to excuse yourself from the situation. If you don’t feel you have time to excuse yourself, sometimes just walking away is the best you can do to keep from making a difficult situation worse.

Emotion Efficacy Therapy Skills

You now have a whole new set of skills to use to help you make choices that are effective and consistent with your values when you get triggered. Use the following list to review the EET skills you’ve learned and to complete the Personalized Emotion Efficacy Plan worksheet.

Mindful Acceptance

Sensation Acceptance
Feeling Labeling
Thought Watching
Urge Noticing
Emotion Surfing

Mindful Coping

Relaxation
Self-Soothing
Pleasurable Activities
Coping Thoughts
Distraction
Time-Out

Values-Based Action

Identify your value and the corresponding action in the moment of choice

Personalized Emotion Efficacy Plan

Use this list of EET skills to remember what works for you when you get emotionally triggered. In addition, there is space for you to write down what else you have learned or want to remember about your relationship with your emotions.

Mindful Acceptance Skills (O + A)

When I am triggered, I can practice the following mindful acceptance skills:

Sensation acceptance: Identify any sensations, describe them to myself, make room for them to be exactly as they are, without reacting or judging.
Feeling labeling: Identify any feeling labels, sit with the feeling, allow it to be exactly as it is without reacting or judging.
Thought watching: Watch my thoughts as they arise, and then let them go. Notice any “sticky” thoughts and let them be exactly as they are, without reacting or judging.
Urge noticing: Notice any urges to do something or not to do something. Notice what it’s like not to act on the urge.

Values-Based Action (O + A + Choose Values-Based Action)

When I’ve practiced mindful acceptance (observe + accept) and want to choose to move toward my values, I can choose the following values-based actions:

Situation VBA

Mindful Coping (O + A + Choose Mindful Coping)

When I have practiced mindful acceptance and/or have tried to use values-based action and still feel at risk of acting on destructive urges, I can choose the following skills:

Relaxation: Use diaphragmatic breathing, relaxation without tension, cue-controlled breathing, or the five-senses exercise to downshift emotion.
Self-soothing: Stimulate each of my five senses to downshift emotion.
Coping thoughts: Use a coping thought to reframe the situation and downshift emotion.
Radical acceptance: Practice radical acceptance to allow difficult situations instead of resisting them, to downshift emotion.
Distraction: Shift my attention to alternative present-moment experiences to downshift emotion.
Time-out: Remove yourself from situations that are triggering where you risk making a difficult situation worse.
Other: I want to remember the following about my relationship with my emotions:

Session 7 Skills Practice

Practice mindful acceptance for at least 10 minutes a day by observing and accepting the four components of emotion when you get emotionally triggered, or using emotion exposure to a difficult event, situation, or emotion. Observe all four parts of the emotion, and surf the emotion wave. (Refer to the mindful acceptance directions from Session 2 Skills Practice, if needed.) Record your mindful acceptance skills practice in the first row of your Skills Practice Record.
Practice using distraction with exposure or in vivo by taking the following steps:
- Step 1: Identify a distraction skill you want to practice ahead of time.
- Step 2: Either find something to intentionally activate your emotions (e.g., recall a recent difficult situation or a distressing memory) or engage in a situation you know will be triggering. Pick something that you believe will take your SUDS up into the 5 to 7 range.
- Step 3: Get into the scene or triggering situation until you reach your target SUDS, or until at least 5 minutes have passed.
- Step 4: Practice mindful acceptance of the painful emotion (observe + accept all parts of the emotion: thoughts, feelings, sensations, and urges). Stay here for 5 minutes, if possible.
- Step 5: Identify the moment of choice and apply the distraction skill you’ve chosen. Do this for at least 5 minutes.
- Step 6: Notice and record your SUDS level at the end of your exercise.
- Step 7: Record your skills practice on the fourth row of your Skills Practice Record.
Practice using time-out when an appropriate triggering situation arises.
Record any events that trigger you during the week at the bottom of your Skills Practice Record.
Bring all of these materials to review in your next session.

Skills Practice Record

Emotion Efficacy Therapy

Directions: Place a check mark next to the skill you practice each day. Record any triggers at the bottom. Bring this record to your next session.

	Day 1	Day 2	Day 3	Day 4	Day 5	Day 6	Day 7
Observe the four parts of an emotion: sensations, feelings, thoughts, and urges.
Observe, accept, and surf your emotion wave, with SUDS.
Observe, accept, and choose a values-based action.
Observe, accept, and choose a relaxation skill.
Observe, accept, and choose a self-soothing skill.
Observe, accept, and choose a coping thought.
Observe, accept, and choose to practice radical acceptance.
Observe, accept, and choose a distraction task or activity.
Observe, accept, and choose a time-out.

Emotional triggers: Record any events or emotions that are distressing during this week.

EET Session 8

Components Covered: Emotion Awareness, Mindful Acceptance, Values-Based Action, Mindful Coping, and Exposure-Based Skills Practice (chapters 2–9)

Session 8 attempts to pull together and consolidate everything clients have learned during EET treatment. The session begins with a review of the Personalized Emotion Efficacy Plans with ample time for feedback and troubleshooting. Clients will get to choose from their skills to do a final exposure using either emotion or imaginal exposure and an EET skill of their choice. Next, group members will rate their emotion efficacy and share how they think they can continue to increase it. Finally, clients receive validation for participating in treatment, especially for their willingness to learn and try new behaviors. Outcome measures would ideally be administered before clients leave session.

Materials

None

Overview

Mindful acceptance practice and feedback
Skills practice review
Review of Personalized Emotion Efficacy Plans, feedback, and troubleshooting
Imaginal or emotion exposure with EET skill and feedback
Rate emotion efficacy
Closing remarks and appreciations
Administration of any posttreatment questionnaires

Procedures

1. Mindful acceptance practice and feedback

2. Skills practice review

Briefly review Session 7 skills and ask clients to share feedback about their weekly practice using their Skills Practice record.

3. Review of Personalized Emotion Efficacy Plans, feedback, and troubleshooting

Using the completed PEEPs, ask each client to share what he or she recorded. Solicit any questions they have about the skills. Emphasize that treatment is only eight weeks and that skills that are more difficult will become easier the more they are practiced.

4. Imaginal or emotion exposure with EET skill and feedback

Lead your clients through a final exposure using a situation and skill of their choosing. Be sure to leave at least fifteen minutes for feedback.

Step 1: Identify the EET skill. Ask group participants to identify what skill they want to choose in the moment of choice. Be sure you have the list of EET skills for reference.
Step 2: Select a distressing situation. Instruct clients to identify a recent distressing event in which they became emotionally triggered and responded with experiential avoidance or other emotion-driven behavior.
Step 3: Initiate emotion exposure. Tell group participants to visualize the triggering scene, noticing the environment where the trigger occurred: watch the action in the scene; hear what’s said. Then instruct them to practice observing and accepting the emotion, “making room” for any thoughts, sensations, feelings, or urges, allowing the emotion to be what it is with no effort at controlling or avoiding them. Have clients rate their SUDS and record it.
Step 4: Initiate the practice of mindful acceptance. Instruct clients to practice mindful acceptance by observing and accepting any thoughts, feelings, sensations, or urges, without resisting or reacting to them. Have clients rate their SUDS and record it.
Step 5: Guide clients through the skill. Now ask clients to locate their moment of choice. Then lead them through the EET skill of their choice for the next five minutes or until their SUDS have dropped below a 2. Ask group participants to rate their SUDS at the end and record it.

5. Rate emotion efficacy

Now that treatment is coming to an end, you’ll want to ask clients to informally rate their emotion efficacy when they began treatment and now, at the end. You can use the Emotion Efficacy Scale as a brief measure pretreatment and posttreatment. Or, you can conduct an informal assessment by asking them to rate their emotion efficacy using a scale from 0 to 10, with 1 being no emotion efficacy, 5 being able to use skills about 50 percent of the time, and 10 being able to use skills every time they are emotionally triggered to choose a VBA. You might also ask group members what they think will help them increase their emotion efficacy.

6. Closing remarks and appreciations

As noted in chapter 1, changing behavior is difficult when people have been hardwired for survival, have a negativity bias, and—since these clients are seeking treatment for emotion problems—are usually highly reactive. Validate clients for being willing and flexible enough to try new behaviors and make choices that will often feel unnatural when they are first used. Remind them that they can continue to improve their emotion efficacy through practice, especially in an emotionally activated state.

This is also a time to speak to any specific challenges that were shared and overcome in the group, how the group may have supported each of its members, and what they were able to learn from each other.

7. Administer any posttreatment questionnaires

If you are using posttreatment measures, administer them at the end of this session. A list of recommended questionnaires is provided in chapter 10, and full versions are available in Appendix A: Outcome Measures.

Script for Guided Mindful Acceptance

First, just sit comfortably, and either close your eyes or relax your gaze and pick a spot to focus on in front of you.

Now, see if you can identify a feeling label that goes with the sensation…just name it and allow it to be as it is without judgment or reacting to it.

[Allow the client to sit with the urge for 30 seconds. Then repeat the sequence one more time.]

Before you come out of this exercise, take a few deep breaths and slowly open your eyes as you bring your attention back to the room.