The Renfrew Unified Treatment for Eating Disorders and Comorbidity: An Adaptation of the Unified Protocol, Therapist Guide 0190920645, 9780190946425, 0190946423

Table of contents :
About TREATMENTS THAT WORK
Contents
Acknowledgments
PREPARING FOR TREATMENT
1 Introduction
2 How to Use This Manual
3 Therapist Materials for Preparing for Treatment
MODULE 1: MOTIVATION AND GOALS
4 Therapist Materials for Motivation and Regular Eating
5 Therapist Materials for Regular Eating
MODULE 2: UNDERSTANDING EMOTION
6 Therapist Materials for the Natural Function of Emotions
7 Therapist Materials for the Three Parts of Emotions (3- Component Model)
8 Therapist Materials for Tracking Emotions over Time (the “ARC”)
MODULE 3: MINDFUL EMOTION AWARENESS
9 Therapist Materials for Mindful Emotion Awareness
10 Therapist Materials for Mood Induction
11 Therapist Materials for Automatic Thoughts and Thinking Traps
12 Therapist Materials for Core Beliefs
MODULE 5: BEHAVIORAL FLEXIBILITY
13 Therapist Materials for Countering Avoidant Behaviors
14 Therapist Materials for Countering Emotion-Driven Behaviors
MODULE 6: CONFRONTING PHYSICAL SENSATIONS
15 Therapist Materials for Interoceptive Exposures
MODULE 7: EMOTION EXPOSURES
16 Therapist Materials for Skills for Emotion Exposures
RELAPSE PREVENTION
17 Therapist Materials for Continuing Progress into the Future
Appendix A
Appendix B

Citation preview

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The Renfrew Unified Treatment for Eating Disorders and Comorbidity

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T R E AT M E N T S T H AT W O R K

Editor-In-Chief David H. Barlow, PhD

Scientific Advisory Board Anne Marie Albano, PhD Gillian Butler, PhD David M. Clark, PhD Edna B. Foa, PhD Paul J. Frick, PhD Jack M. Gorman, MD Kirk Heilbrun, PhD Robert J. McMahon, PhD Peter E. Nathan, PhD Christine Maguth Nezu, PhD Matthew K. Nock, PhD Paul Salkovskis, PhD Bonnie Spring, PhD Gail Steketee, PhD John R. Weisz, PhD G. Terence Wilson, PhD

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T R E A T M E N T S   T H AT W O R K

The Renfrew Unified Treatment for Eating Disorders and Comorbidity An Adaptation of the Unified Protocol

THERAPIST GUIDE

H E AT H E R T H O M P S O N -​B R E N N E R MELANIE SMITH G AY L E B R O O K S REBECCA BERMAN ANGELA KALOUDIS H A L L I E E S P E L -​H U Y N H DEE ROSS FRANKLIN J A M E S   F. B O S W E L L

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1 Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries. Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America. © Oxford University Press 2021 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above. You must not circulate this work in any other form and you must impose this same condition on any acquirer. Library of Congress Cataloging-​in-​Publication Data Names: Thompson-Brenner, Heather, editor. Title: The Renfrew unified treatment for eating disorders and comorbidity : an adaptation of the unified protocol, therapist guide / Heather Thompson-Brenner, Melanie Smith, Gayle Brooks, Rebecca Berman, Angela Kaloudis, Hallie Espel-Huynh, Dee Ross Franklin, James F. Boswell. Description: New York : Oxford University Press, 2021. | Series: Treatments that work series | Includes bibliographical references and index. Identifiers: LCCN 2020056410 (print) | LCCN 2020056411 (ebook) | ISBN 9780190946425 (paperback) | ISBN 9780190946449 (epub) | ISBN 9780190946456 Subjects: LCSH: Eating disorders—Treatment. | Comorbidity. Classification: LCC RC552.E18 R5219 2021 (print) | LCC RC552.E18 (ebook) | DDC 616.85/2606—dc23 LC record available at https://lccn.loc.gov/2020056410 LC ebook record available at https://lccn.loc.gov/2020056411 DOI: 10.1093/​med-​psych/​9780190946425.001.0001 9 8 7 6 5 4 3 2 1 Printed by Marquis, Canada

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About

T R E AT M E N T S

T H AT W O R K ™

Stunning developments in healthcare have taken place over the last several years, but many of our widely accepted interventions and strategies in mental health and behavioral medicine have been brought into question by research evidence as not only lacking benefit, but perhaps, inducing harm (Barlow, 2010). Other strategies have been proven effective using the best current standards of evidence, resulting in broad-​ based recommendations to make these practices more available to the public (McHugh & Barlow, 2010). Several recent developments are behind this revolution. First, we have arrived at a much deeper understanding of pathology, both psychological and physical, which has led to the development of new, more precisely targeted interventions. Second, our research methodologies have improved substantially, such that we have reduced threats to internal and external validity, making the outcomes more directly applicable to clinical situations. Third, governments around the world and healthcare systems and policymakers have decided that the quality of care should improve, that it should be evidence based, and that it is in the public’s interest to ensure that this happens (Barlow, 2004; Institute of Medicine, 2001, 2015; McHugh & Barlow, 2010). Of course, the major stumbling block for clinicians everywhere is the accessibility of newly developed evidence-​ based psychological interventions. Workshops and books can go only so far in acquainting responsible and conscientious practitioners with the latest behavioral healthcare practices and their applicability to individual patients. This series, TreatmentsThatWork™, is devoted to communicating these exciting new interventions to clinicians on the frontlines of practice. The manuals and workbooks in this series contain step-​by-​step detailed procedures for assessing and treating specific problems and diagnoses. But this series also goes beyond the books and manuals by providing ancillary materials that will approximate the supervisory process in

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assisting practitioners in the implementation of these procedures in their practice. In our emerging healthcare system, the growing consensus is that evidence-​based practice offers the most responsible course of action for the mental health professional. All behavioral healthcare clinicians deeply desire to provide the best possible care for their patients. In this series, our aim is to close the dissemination and information gap and make that possible. This therapist guide is designed to give mental health professionals the necessary tools to provide integrated treatment for eating disorders and co-​occurring emotional disorders using the same set of adaptable tools. This therapist guide also provides suggestions for delivering this treatment in individual and group sessions, as well as considerations you may face as an individual practitioner versus part of a larger treatment team. Regardless of your training or specialty, some of these interventions will likely be familiar, and some new, or at least presented in a fashion that newly facilitates their use with more than one issue simultaneously. We have tried to include many of the materials that your patients will be seeing in their workbook so that you have everything you need, in one place, to implement a treatment with demonstrated effectiveness and scientifically sound principles. This manual has also been written to be inclusive, with many case studies featuring clients from a diverse range of racial/​ethnic backgrounds, as well as diverse sexual and gender identities. We have also included a section on therapist relational considerations—​“how to do it” as opposed to “what to do”—​that we hope will facilitate your therapy relationships and the effectiveness of your treatment. David H. Barlow, Editor-​in-​Chief TreatmentsThatWork™ Boston, MA

References Barlow, D. H. (2004). Psychological treatments. American Psychologist, 59, 869–​878.

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Barlow, D. H. (2010). Negative effects from psychological treatments: A perspective. American Psychologist, 65(2), 13–​20. Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new health system for the 21st century. National Academy Press. Institute of Medicine (IOM). (2015). Psychosocial interventions for mental and substance use disorders: A framework for establishing evidence-​based standards. National Academies Press. McHugh, R. K., & Barlow, D. H. (2010). Dissemination and implementation of evidence-​based psychological interventions: A review of current efforts. American Psychologist, 65(2), 73–​84.

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Contents

Acknowledgments  xi PREPARING FOR TREATMENT

MODULE 1

MODULE 2

MODULE 3

Chapter 1

Introduction  3

Chapter 2

How to Use This Manual  37

Chapter 3

Therapist Materials for Preparing for Treatment  47

MOTIVATION AND GOALS

Chapter 4

Therapist Materials for Motivation and Regular Eating  61

Chapter 5

Therapist Materials for Regular Eating  79

UNDERSTANDING EMOTION

Chapter 6

Therapist Materials for the Natural Function of Emotions  93

Chapter 7

Therapist Materials for the Three Parts of Emotions (3-​Component Model)  107

Chapter 8

Therapist Materials for Tracking Emotions over Time (the “ARC”)  117

MINDFUL EMOTION AWARENESS

Chapter 9

Therapist Materials for Mindful Emotion Awareness  129

Chapter 10

Therapist Materials for Mood Induction  145

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MODULE 4

MODULE 5

MODULE 6

COGNITIVE FLEXIBILITY

Chapter 11

Therapist Materials for Automatic Thoughts and Thinking Traps  163

Chapter 12

Therapist Materials for Core Beliefs  181

BEHAVIORAL FLEXIBILITY

Chapter 13

Therapist Materials for Countering Avoidant Behaviors  195

Chapter 14

Therapist Materials for Countering Emotion-​Driven Behaviors  209

CONFRONTING PHYSICAL SENSATIONS

Chapter 15

MODULE 7

Therapist Materials for Interoceptive Exposures  223

EMOTION EXPOSURES

Chapter 16

Therapist Materials for Skills for Emotion Exposures  237

RELAPSE PREVENTION

Chapter 17

Therapist Materials for Continuing Progress into the Future  253

Appendix A  259 Appendix B  281

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Acknowledgments

We would like to express our deep gratitude to individuals and groups who supported the development and study of this treatment program. First, we want to acknowledge that this treatment is itself an adaptation of another treatment, which in turn is comprised of core elements of psychotherapy that have worked across different populations for a wide range of emotional issues. There are many unique and creative aspects to every treatment manual, but the entire field of psychotherapy research has contributed to identifying and refining the treatment strategies that are presented here. More specifically, however, we would like to express our appreciation for the following individuals who were essential to the process of adapting, implementing, refining, and studying this protocol. At the Renfrew Center, we want to mention Sam Menaged, Susan Ice, Michael Lowe, Taylor Gardner, Shelby Ortiz, Christina Felonis, Amy Banks, Alex Goncalves, Heather Maio, Adrienne Ressler, and Rachel Dore. Many other important people have contributed to the work at the Renfrew Center and at Boston University, and were essential to the success of the program and the eventual publication of this manual. We would all like to acknowledge our families, as well, who have supported us through everything.

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Preparing for Treatment

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CHAPTER 1

Introduction

The Renfrew Unified Treatment model: a brief history The Renfrew Unified Treatment for Eating Disorders and Comorbidity (UT) is an integrative, transdiagnostic, principle-​based approach to address patterns of emotion avoidance, emotion sensitivity, and negative affect that produce and maintain the symptoms of eating disorders (EDs) and co-​occurring emotional disorders. The UT was developed through an extensive process of adapting the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP; Barlow et al., 2011) for use with patients with severe and diverse EDs. There is extensive research support for use of the interventions in the UT (and the UP) across diagnostic categories. They are drawn from cognitive-​ behavioral therapy (CBT) as well as other empirically supported interventions (e.g., motivational interviewing, mindfulness-​ based approaches) that have substantial research support and are empirically and theoretically consistent with the overarching principles of promoting emotion awareness, reducing emotion avoidance, and increasing emotion regulation. Because the available evidence-​based approaches to emotional disorders (including EDs, anxiety disorders, and depression) have also evolved over time in response to the same body of research, much of the content in the UT manual should be familiar to practitioners of other approaches. However, the UT and UP were not simply aggregated from existing treatment elements; they are also thoroughly integrated and informed by the focus on demonstrated mechanisms of psychopathology shared across emotional disorders: emotion avoidance, emotion intolerance, emotion dysregulation, negative beliefs about emotion, and maladaptive emotion-​driven behavior. The modules of the UT, though they

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may appear familiar and eclectic at first glance, are in fact distinct from other approaches due to their cohesive (internal and collective) focus on how each module addresses these shared maintaining mechanisms. The UT manual, like the UP manual, is cohesive, with continuous focus on the relationship between the interventions/​concepts included in each module and the overall goal of reducing emotion avoidance and promoting emotion regulation. However, it differs in several key ways: 1. The UT was adapted to be used for a group that has heterogeneous EDs as well as heterogeneous comorbid disorders, with examples of each concept and intervention applied to both EDs and co-​occurring emotional disorders throughout the manual. 2. The UT was adapted to be delivered in group therapy as well as individual therapy for heterogeneous patients with severe symptoms, including those treated at higher levels of care such as residential or intensive outpatient treatment. The therapist manual includes instruc­ tions for its use in a group and individual sessions, and suggestions about its optimal use in different settings. The therapist manual and client workbook materials are designed to be used with any combination of ED and co-​occurring disorder symptoms in any setting. 3. The UT was designed to be delivered alongside adjunctive treatment, including nutrition counseling, psychiatric treatment, medical checkups (e.g., weight and vitals), and other interventions that are commonly delivered by teams to clients with EDs as recommended by the American Psychiatric Association (Bermudez et al., 2016; Yager et al., 2014). The UP was chosen by The Renfrew Center, a national network of ED treatment programs, as the evidence-​based approach that was most suited to adaptation for multiple levels of care for EDs, including residential, day hospital, and intensive outpatient treatment. The process of adapting the UP to become the UT, led by the authors of this manual, is thoroughly described in two published manuscripts (Thompson-​ Brenner et al., 2018, 2019). When the treatment is delivered in the residential context—​with groups that occur multiple times daily and multiple adjunctive and intensive treatment elements—​ the Renfrew staff also utilize variations on the group exercises (to reduce repetition) and supplementary materials to guide

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clinicians from more diverse disciplines (e.g., nursing staff, milieu counselors). This published version of the manual includes as many therapy materials as possible to allow therapy to occur regardless of treatment setting and treatment-​team makeup, within the constraints necessary for a practical, usable manual. The manual is designed to be used by therapists and counselors of any discipline, including (but not limited to) psychotherapists and dietitians. However, adjunctive nutrition-​specific counseling, weight assessment, and psychiatric care are recommended as needed. Given the number of available evidence-​based psychotherapies (EBPs) for EDs that have been tested in clinical trials, it is important to explain why these alternative treatments—​such as Cognitive Behavioral Therapy-​ Enhanced (CBT-​ E), Dialectical Behavior Therapy (DBT), and Acceptance and Commitment Therapy (ACT)—​were not used as the basis of a cohesive, comprehensive treatment approach across a continuum of care. Prior to the adaptation and implementation of an EBP, the Renfrew clinical leadership team met regularly to consider the benefits and limitations of different protocols for application across their entire continuum of care. They paid particular consideration to the adaptability of the EBPs to their two large residential programs, where the treatment setting and population most differed from the context and population of randomized, controlled trials (RCTs) for EDs. In summary, evidence-​based treatment approaches for EDs were each judged to be inappropriate in their content (primarily applicable to outpatient therapy), too narrow (not generalizable to all severe co-​occurring disorders treated in groups), or too limited in their application to EDs (not enough published examples of their use with diverse EDs) at that time to be used as the foundation for integrated treatment in a complex continuum of care. In contrast, the UP was judged to be broad, flexible, and adaptable enough to be applied across the system (see Thompson-​ Brenner et al., 2018). Here are further details regarding each issue are provided: ■ All the available data on EBPs from RCTs had been collected in the outpatient setting, where it was appropriate to prioritize food regulation and ED behavioral symptoms (e.g., binge eating, purging) as targets of treatment. In the residential setting, however, food intake and behavioral symptoms are externally regulated through supervised

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meals, intensive staff oversight, and structural barriers such as limiting access to food and supervised bathroom visits. Interventions that are the focus of CBT for EDs (e.g., Fairburn, 2008; Fairburn et al., 2009) and family-​based treatment (e.g., Lock et al., 2010), such as regular eating, reducing restriction, and reducing binge/​ purge symptoms, were studied by the clinical leadership and then judged to have too limited application in the residential setting given that food and behavioral symptoms were already externally regulated in that environment. ■ The clinical leadership had long observed that clients in the residential and day hospital settings had needs that were not met by the available EBPs for EDs. Severe comorbidity is the norm in residential treatment (see Twohig et al., 2015), and all stakeholders agreed that it was fundamental to include psychotherapy interventions throughout treatment that address both EDs and serious comorbidities, such as posttraumatic stress disorder, substance use disorder, self-​harm, panic disorder, social phobia, and obsessive-​compulsive disorder, ideally using a cohesive, integrated approach. Several of the available EBPs, including CBT for EDs (Fairburn, 2008), Family-​Based Treatment (FBT; Lock et al., 2010), and Interpersonal Psychotherapy (IPT; Murphy et al., 2012; Wilfley et al., 2000), were studied and then judged as not adequate to address all these common and severe co-​ occurring disorders. In addition, the Renfrew organization already had the experience ■ of piloting some of the core interventions from other EBPs and found it difficult to apply these interventions to the full range of ED and comorbid symptom presentation in their setting. There is one published account of this difficulty, when a core intervention from CBT—​“regular eating”—​was implemented in one of Renfrew nonresidential programs. This implementation effort was judged a “failure,” and researchers attributed the difficulty to the clinicians’ perception that this approach was not appropriate to their population, due to the perceived lack of flexibility and perceived minimal attention to comorbidity and emotion regulation (Lowe et al., 2011). Some Renfrew programs piloted parent-​ focused interventions from FBT, with some success, but noted that the approach is explicitly an outpatient treatment intended as an alternative to residential and intensive outpatient care and therefore

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is not suitable for a comprehensive approach to all levels of care. Additionally, interventions from Dialectical Behavior Therapy (DBT; Bankoff et al., 2012; Safer et al., 2001, 2010) and Acceptance and Commitment Therapy (ACT; Berman et al., 2009; Hill et al., 2015; Sandoz et al., 2011) were tested, and clinicians found it difficult to apply the model to the full range of ED symptom presentation, as more limited eating clinical examples and data were available for these approaches at that time. The clinical leadership contemplated combining different components from different EBPs to create a more comprehensive, composite approach, but they feared this would feel unwieldy and confusing to the clients, that it would be impossible to train all the staff to competency in so many different approaches, and that this approach would likely fail to unify treatment across their programs and levels of care. When the clinical leadership at The Renfrew Center became aware of the UP, it was perceived to be adaptable, easy to pilot, and relatively feasible to implement because it was principle-​based, modular, and transdiagnostic. The principle-​based treatment lent itself to adaptation (Fixsen et al., 2005), the modules lent themselves to manageable trials, and the transdiagnostic application made it relatively simple to apply across diverse client groups. The UP was also judged to be compatible with the existing culture of the organization because it was emotion-​ focused: The modules of the UP are parts of a coherent process of identifying, approaching, and learning new lessons about emotion (see Table 1.1: UT Modules and Chapters, Techniques, Basic Research, and Treatment Research). From the earliest conversations with Renfrew, UP consultants emphasized their willingness to adapt the protocol for the population, setting, and organization. It is eminently true that the UP had no RCT demonstrating efficacy with primary EDs. However, it is important to note that there were almost no RCT data from residential and day hospital programs at all. Therefore the clinical leadership had to choose among approaches with different levels of empirical support from different populations with some overlapping characteristics to their own client population, with the awareness that any approach would have to be substantively adapted to work in their setting.

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Education and exercises to develop awareness of the three components of emotion (thoughts, behavior, physical sensations)

Education and exercises to develop awareness of the antecedent, response, and consequences (ARC) sequence of emotions

Chapter 8: Tracking Emotions over Time (the ARC)

Education and discussion of adaptive functions of emotions

Chapter 7: The Three Parts of Emotions (3-​Component Model)

Module 2: Understanding Emotion Chapter 6: The Natural Function of Emotions

Identifying goals and immediate steps for change, including eating regularly

Identifying pros and cons of change

Module 1: Motivation and Goals Chapter 4: Motivation and Regular Eating

Chapter 5: Regular Eating (Supplementary Session)

Techniques

UTM Modules, Chapters, and Aims

Motivational interviewing can improve motivation in patients with EDs.9,10

Treatment Research

Patients with EDs have poor awareness of Emotion awareness components are their emotions14 and emotion regulation included in CBT-​E,12 DBT,25 ICAT,13 problems15,16 and may have a tendency to EABT,26 and ACT for EDs.27,28 act impulsively (e.g., through bingeing and purging) to escape negative emotional experience.17,18 Difficulties with emotions are related to severity of ED symptoms,19,20 and negative affect and emotion awareness are observed to mediate the relationship between various ED risk factors and ED symptoms.21–​24

Motivation enhancement components Motivation and readiness for change are included in CBT for EDs,11 CBT-​E,12 predicts global symptom and binge eating and ICAT.13 outcome in EDs.3–​8

Patients with EDs have low motivation to change that varies over the course of treatment.1,2

Basic Supporting Research

Table 1.1  UT Modules and Chapters, Techniques, Basic Research, and Treatment Research

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Identifying avoidant behavior and engaging in alternative actions

Identifying emotion-​driven behavior and engaging in alternative action

Chapter 14: Countering Emotion-​Driven Behaviors

Identifying core negative appraisals (downward arrow exercise)

Education on subjectivity and the influence of mood on appraisals. Identifying and countering probability overestimation and catastrophizing

Exercises to develop mindful awareness in context of moods

Education and exercises to develop mindful (nonjudgmental, present-​ focused) awareness of emotion

Module 5: Behavioral Flexibility Chapter 13: Countering Avoidant Behaviors

Chapter 12: Core Beliefs

Module 4: Cognitive Flexibility Chapter 11: Automatic Thoughts and Thinking Traps

Chapter 10: Mood Induction

Module 3: Mindful Emotion Awareness Chapter 9: Mindful Emotion Awareness

Negative emotion precedes development of EDs46–​48 and serves as an antecedent to expression of ED symptoms such as binge eating, self-​induced vomiting, and dietary restriction.40,49–​51

Patients with EDs exhibit poorer cognitive reappraisal skills than healthy controls.35 Further, negative cognitions are associated with behavioral ED symptoms, for example in areas of thin-​ ideal internalization,36 body image and body checking,37 fear of weight gain,38 perfectionism,39 and exposure to stressful life events.40

Patients with EDs have difficulty remaining mindfully aware of emotions14,29 and have negative beliefs about their emotions (e.g., that the physical and cognitive aspects of emotion are intolerable).30 Systematic relationships are observed between poor emotional awareness, lack of emotional acceptance, and ED symptom severity.29,31,32

Related interventions or components are included in DBT,25 EABT,26,45 ICAT,13 ACT,27,28 and interpersonal psychotherapy for EDs.52

Related components are included in CBT44 and CBT-​E,12 EABT,26,45 and ACT.27,28

Cognitive therapy shows benefit for shape and weight concerns.41–​43

Mindfulness components are included in DBT,25 ICAT,13 EABT,26 and ACT for EDs.27,28

Mindfulness exercises have shown benefit for patients with EDs33 and have also shown efficacy for treatment of common comorbid disorders34 (i.e., depression, anxiety).

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Techniques

Developing hierarchy of avoided and Patients with EDs have poor awareness distressing situations of their emotions,14,63 emotion regulation 15,16,64 and negative beliefs about Designing and conducting exposures problems, 30,65,66 their emotions and tend to predict based on hierarchy that emotions are negatively influenced by Examining automatic appraisals pre-​ food and body image.38,67 and post-​exposure

Patients with EDs have low interoceptive awareness of emotional cues.29,53–​55 Low interoceptive awareness is related to emotion regulation difficulties and ED symptom severity.29,53–​60

Basic Supporting Research

Related components are included in CBT-​E12 (e.g., open weighing), EABT,26 and ACT.27,28

Exposure techniques have demonstrated utility to address body image concerns,68,69 food avoidance,68,70 and co-​occurring psychopathology.71,72

Some limited interoceptive practices, such as appetite awareness training, have benefited patients with EDs.61,62

Treatment Research

References   1. Geller, J., Zaitsoff, S. L., & Srikameswaran, S. (2005). Tracking readiness and motivation for change in individuals with eating disorders over the course of treatment. Cognitive Therapy and Research, 29(5), 611–625. https://doi.org/10.1007/s10608-005-5774-1   2. Vitousek, K., Watson, S., & Wilson, G. T. (1998). Enhancing motivation for change in treatment-resistant eating disorders. Clinical Psychology Review, 18(4), 391–420. https://doi.org/10.1016/ s0272-7358(98)00012-9   3. Carter, J. C., & Kelly, A. C. (2015). Autonomous and controlled motivation for eating disorders treatment: Baseline predictors and relationship to treatment outcome. British Journal of Clinical Psychology, 54(1), 76–90. https://doi.org/10.1111/bjc.12062   4. Clausen, L., Lübeck, M., & Jones, A. (2013). Motivation to change in the eating disorders: A systematic review. International Journal of Eating Disorders, 46(8), 755–763. https://doi.org/10.1002/eat.22156   5. Manasse, S. M., Espel, H. M., Forman, E. M., Ruocco, A. C., Juarascio, A. S., Butryn, M. L., Zhang, F., & Lowe, M. R. (2015). The independent and interacting effects of hedonic hunger and executive function on binge eating. Appetite, 89, 16–21. https://doi.org/10.1016/j.appet.2015.01.013   6. Vall, E., & Wade, T. D. (2015). Predictors of treatment outcome in individuals with eating disorders: A systematic review and meta-analysis. International Journal of Eating Disorders, 48(7), 946–971. https://doi.org/10.1002/eat.22411   7. Delinsky, S. S., Thomas, J. J., Germain, S. A., Ellison Craigen, K., Weigel, T. J., Levendusky, P. G., & Becker, A. E. (2011). Motivation to change among residential treatment patients with an eating disorder: Assessment of the multidimensionality of motivation and its relation to treatment outcome. International Journal of Eating Disorders, 44(4), 340–348. https://doi.org/10.1002/eat.20809   8. Sansfaçon, J., Gauvin, L., Fletcher, É., Cottier, D., Rossi, E., Kahan, E., Israël, M., & Steiger, H. (2018). Prognostic value of autonomous and controlled motivation in outpatient eating-disorder treatment. International Journal of Eating Disorders, 51(10), 1194–1200. https://doi.org/10.1002/eat.22901

Module 7: Emotion Exposures Chapter 16: Skills for Emotion Exposures

Module 6: Confronting Physical Sensations Chapter 15: Interoceptive Exposures Exercises evoking sensations similar to strong emotions to develop tolerance

UTM Modules, Chapters, and Aims

Table 1.1  Continued

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  9. Macdonald, P., Hibbs, R., Corfield, F., & Treasure, J. (2012). The use of motivational interviewing in eating disorders: A systematic review. Psychiatry Research, 200(1), 1–11. https://doi. org/10.1016/j.psychres.2012.05.013 10. Denison-Day, J., Appleton, K. M., Newell, C., & Muir, S. (2018). Improving motivation to change amongst individuals with eating disorders: A systematic review. International Journal of Eating Disorders, 51(9), 1033–1050. https://doi.org/10.1002/eat.22945 11. Manlick, C. F., Cochran, S. V., & Koon, J. (2013). Acceptance and commitment therapy for eating disorders: Rationale and literature review. Journal of Contemporary Psychotherapy, 43(2), 115–122. https:// doi.org/10.1007/s10879-012-9223-7 12. Fairburn, C. G. (2008). Cognitive behavior therapy and eating disorders. Guilford Press. 13. Wonderlich, S. A., Peterson, C. B., Crosby, R. D., Smith, T. L., Klein, M. H., Mitchell, J. E., & Crow, S. J. (2014). A randomized controlled comparison of integrative cognitive-affective therapy (ICAT) and enhanced cognitive-behavioral therapy (CBT-E) for bulimia nervosa. Psychological Medicine, 44(3), 543–553. https://doi.org/10.1017/S0033291713001098 14. Nowakowski, M. E., McFarlane, T., & Cassin, S. (2013). Alexithymia and eating disorders: A critical review of the literature. Journal of Eating Disorders, 1, 21. https://doi.org/10.1186/2050-2974-1-21 15. Svaldi, J., Griepenstroh, J., Tuschen-Caffier, B., & Ehring, T. (2012). Emotion regulation deficits in eating disorders: A marker of eating pathology or general psychopathology? Psychiatry Research, 197(1–2), 103–111. https://doi.org/10.1016/j.psychres.2011.11.009 16. Wildes, J. E., Ringham, R. M., & Marcus, M. D. (2010). Emotion avoidance in patients with anorexia nervosa: Initial test of a functional model. International Journal of Eating Disorders, 43(5), 398–404. https://doi.org/10.1002/eat.20730 17. Racine, S. E., Keel, P. K., Burt, S. A., Sisk, C. L., Neale, M., Boker, S., & Klump, K. L. (2013). Exploring the relationship between negative urgency and dysregulated eating: Etiologic associations and the role of negative affect. Journal of Abnormal Psychology, 122(2), 433–444. https://doi.org/10.1037/a0031250 18. Culbert, K. M., Lavender, J. M., Crosby, R. D., Wonderlich, S. A., Engel, S. G., Peterson, C. B., Mitchell, J. E., Crow, S. J., Le Grange, D., Cao, L., & Fischer, S. (2016). Associations between negative affect and binge/purge behaviors in women with anorexia nervosa: Considering the role of negative urgency. Comprehensive Psychiatry, 66, 104–112. https://doi.org/10.1016/j.comppsych.2016.01.010 19. Pisetsky, E. M., Haynos, A. F., Lavender, J. M., Crow, S. J., & Peterson, C. B. (2017). Associations between emotion regulation difficulties, eating disorder symptoms, non-suicidal self-injury, and suicide attempts in a heterogeneous eating disorder sample. 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International Journal of Eating Disorders, 44(5), 421–427. https://doi. org/10.1002/eat.20826 27. Merwin, R. M., Zucker, N. L., & Timko, C. A. (2013). A pilot study of an acceptance based separated family treatment for adolescent anorexia nervosa. Cognitive and Behavioral Practice, 20(4), 485–500. https://doi.org/10.1016/j.cbpra.2012.11.001 28. Sandoz, E., Wilson, K., & DuFrene, T. (2011). Acceptance and Commitment Therapy for eating disorders: A process-focused guide to treating anorexia and bulimia. New Harbinger Publications. 29. Lattimore, P., Mead, B. R., Irwin, L., Grice, L., Carson, R., & Malinowski, P. (2017). “I can’t accept that feeling”: Relationships between interoceptive awareness, mindfulness and eating disorder symptoms in females with and at risk of an eating disorder. Psychiatry Research, 247, 163–171. https://doi.org/10.1016/j.psychres.2016.11.022 30. Anestis, M. D., Holm-Denoma, J. M., Gordon, K. H., Schmidt, N. B., & Joiner, T. E. (2008). The role of anxiety sensitivity in eating pathology. Cognitive Therapy and Research, 32(3), 370–385. https:// doi.org/10.1007/s10608-006-9085-y

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31. Butryn, M. L., Juarascio, A., Shaw, J., Kerrigan, S. G., Clark, V., O’Planick, A., & Forman, E. M. (2013). Mindfulness and its relationship with eating disorders symptomatology in women receiving residential treatment. Eating Behaviors, 14(1), 13–16. https://doi.org/10.1016/j.eatbeh.2012.10.005 32. Espel, H. M., Goldstein, S. P., Manasse, S. M., & Juarascio, A. S. (2016). Experiential acceptance, motivation for recovery, and treatment outcome in eating disorders. Eating and Weight Disorders, 21(2), 205–210. https://doi.org/10.1007/s40519-015-0235-7 33. Wanden-Berghe, R. G., Sanz-Valero, J., & Wanden-Berghe, C. (2011). The application of mindfulness to eating disorders treatment: A systematic review. Eating Disorders, 19(1), 34–48. https://doi.org/10. 1080/10640266.2011.533604 34. Chiesa, A., & Serretti, A. (2011). Mindfulness-based cognitive therapy for psychiatric disorders: a systematic review and meta-analysis. 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Body image interventions in cognitive-behavioural therapy of binge-eating disorder: A component analysis. Behaviour Research and Therapy, 42(11), 1325–1339. https://doi.org/10.1016/j.brat.2003.09.001 42. Fairburn, C. G., Cooper, Z., Doll, H. A., O’Connor, M. E., Bohn, K., Hawker, D. M., Wales, J. A., & Palmer, R. L. (2009). Transdiagnostic cognitive-behavioral therapy for patients with eating disorders: A two-site trial with 60-week follow-up. American Journal of Psychiatry, 166(3), 311–319. https://doi.org/10.1176/appi.ajp.2008.08040608 43. Fairburn, C. G., Bailey-Straebler, S., Basden, S., Doll, H. A., Jones, R., Murphy, R., O'Connor, M. E., & Cooper, Z. (2015). A transdiagnostic comparison of enhanced cognitive behaviour therapy (CBTE) and interpersonal psychotherapy in the treatment of eating disorders. Behaviour Research and Therapy, 70, 64–71. https://doi.org/10.1016/j.brat.2015.04.010 44. Fairburn, C. G., Marcus, M. D., & Wilson, G. T. (1993). Cognitive-behavioral therapy for binge eating and bulimia nervosa: A comprehensive treatment manual. In C. G. Fairburn & G. T. Wilson (Eds.), Binge eating: Nature, assessment, and treatment (pp. 361–404). Guilford Press. 45. Wildes, J. E., Marcus, M. D., & McCabe, E. B. (2014). Emotion acceptance behavior therapy for anorexia nervosa. In H. Thompson-Brenner (Ed.), Casebook of evidence-based therapy for eating disorders. Guilford Press. 46. Stice, E. (2002). Risk and maintenance factors for eating pathology: A meta-analytic review. Psychological Bulletin, 128(5), 825–848. https://doi.org/10.1037/0033-2909.128.5.825 47. Goldschmidt, A. B., Wall, M. M., Zhang, J., Loth, K. A., & Neumark-Sztainer, D. (2016). Overeating and binge eating in emerging adulthood: 10-year stability and risk factors. Developmental Psychology, 52(3), 475–483. https://doi.org/10.1037/dev0000086 48. Meier, S. M., Bulik, C. M., Thornton, L. M., Mattheisen, M., Mortensen, P. B., & Petersen, L. (2015). Diagnosed anxiety disorders and the risk of subsequent anorexia nervosa: A Danish population register study. European Eating Disorders Review, 23(6), 524–530. https://doi.org/10.1002/erv.2402 49. Engel, S. G., Wonderlich, S. A., Crosby, R. D., Mitchell, J. E., Crow, S., Peterson, C. B., Le Grange, D., Simonich, H. K., Cao, L., Lavender, J. M., & Gordon, K. H. (2013). The role of affect in the maintenance of anorexia nervosa: Evidence from a naturalistic assessment of momentary behaviors and emotion. Journal of Abnormal Psychology, 122(3), 709–719. https://doi.org/10.1037/a0034010 50. Berg, K. C., Crosby, R. D., Cao, L., Peterson, C. B., Engel, S. G., Mitchell, J. E., & Wonderlich, S. A. (2013). Facets of negative affect prior to and following binge-only, purge-only, and binge/purge events in women with bulimia nervosa. Journal of Abnormal Psychology, 122(1), 111–118. https://doi.org/10.1037/a0029703 51. Lavender, J. M., De Young, K. P., Wonderlich, S. A., Crosby, R. D., Engel, S. G., Mitchell, J. E., Crow, S. J., Peterson, C. B., & Le Grange, D. (2013). Daily patterns of anxiety in anorexia nervosa: Associations with eating disorder behaviors in the natural environment. Journal of Abnormal Psychology, 122(3), 672–683. https://doi.org/10.1037/a0031823

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52. Wilfley, D. E., MacKenzie, K. R., Welch, R. R., Ayres, V. E., & Weissman, M. M. (2000). Interpersonal psychotherapy for group. Basic Books. 53. Fassino, S., Pierò, A., Gramaglia, C., & Abbate-Daga, G. (2004). Clinical, psychopathological and personality correlates of interoceptive awareness in anorexia nervosa, bulimia nervosa and obesity. Psychopathology, 37(4), 168–174. https://doi.org/10.1159/000079420 54. Brown, T. A., Berner, L. A., Jones, M. D., Reilly, E. E., Cusack, A., Anderson, L. K., Kaye, W. H., & Wierenga, C. E. (2017). Psychometric evaluation and norms for the Multidimensional Assessment of Interoceptive Awareness (MAIA) in a clinical eating disorders sample. European Eating Disorders Review, 25(5), 411–416. https://doi.org/10.1002/erv.2532 55. Khalsa, S. S., Craske, M. G., Li, W., Vangala, S., Strober, M., & Feusner, J. D. (2015). Altered interoceptive awareness in anorexia nervosa: Effects of meal anticipation, consumption and bodily arousal. 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The evidence base for EBP: a moving target The world of psychotherapy research is subject to multiple cultural forces. The editors of the TreatmentsThatWork™ series, along with other serious psychotherapy researchers, have justly emphasized the importance of controlled clinical research, including RCTs, as important sources of data with many potential biases eliminated. Some of the authors of this manual have themselves conducted, and highly value, the importance of, RCTs. There are multiple reasons, however, why the field of psychotherapy research is currently less focused on RCT data as a singularly valid form of clinical information than in previous times. Prominent researchers who have advocated for evidence-​based therapy over many decades have recently achieved wide agreement that it has not proven feasible to conduct individual RCTs for every distinct diagnostic category and particular combination of comorbidities, or to train psychologists on each of the many narrow manualized approaches that follow from RCTs with a limited diagnostic focus (Gallo & Barlow, 2012). The dissemination of these narrowly focused approaches and manuals has in fact been resisted by many clinicians (Tasca et al., 2015). The traditional bench-​to-​bedside paradigm (beginning with an RCT for a single diagnostic category, replicating that finding, testing the protocol in RCTs with increasingly heterogeneous samples, and finally establishing effectiveness in the community setting) has proven to be too slow, expensive, and unwieldy to result in widespread improvements in the service delivered by psychotherapists in the community setting (see, for example, Barlow et al., 2013; Goldfried, 2016; Kazdin et al., 2017). Furthermore, extensive research has demonstrated multiple problems with the assumption that psychiatric diagnostic entities are in fact distinct. There is substantial evidence that similar etiological and maintaining factors are shared among disorders (e.g., Andrews et al., 2009; Harvey et al., 2004; Kendler, 1996; Kessler et al., 2005). Co-​occurring disorders are observed to be typical in both clinical and epidemiological studies, and our existing, diagnostic classification system is observed to have limited reliability and practical utility (e.g., Brown et al., 2001; Kessler et al., 2005). This is the context in which transdiagnostic treatments have been proposed and developed, and they are achieving increasing support

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among researchers and practitioners (e.g., Barlow et al., 2004; Craske, 2012; Newby et al., 2015; Norton & Paulus, 2016). Psychotherapy researchers have increasingly embraced the EBP framework due in part to these factors. EBP recommendations consider multiple sources of data, including RCTs, effectiveness research, naturalistic research, and the experience and reports of clients and clinicians. Researchers’ proposals to conduct RCTs are not as likely to be funded in the recent past and immediate future due to the shifting paradigm regarding these judgments of the impact of such research (Proctor et al., 2011). In fact, many of the most recent RCTs for EDs focus on internet-​ based or guided self-​help approaches (e.g., Jacobi et al., 2017; Strandskov et al., 2017; Wagner et al., 2016; Zerwas et al., 2017), which are less expensive to conduct and cost-​effective to administer but typically are not sufficient for clients with severe symptoms and complex comorbidities. Furthermore, the most recent group of clinical trials for EDs that include a comparison of two in-​person, active, symptom-​focused treatments have generally found that both of the active treatments have substantial, clinically significant effects on symptoms, and they have generally failed to find important statistically significant differences in response between active treatment groups (e.g., Byrne et al., 2017; de Zwaan et al., 2017; Fairburn et al., 2009; Wonderlich et al., 2014; Zipfel et al., 2014). Similarly, the aggregated research comparing a wide range of transdiagnostic symptom-​ focused treatments to protocols based on narrower diagnostic categories has found both the transdiagnostic and the diagnosis-​specific approaches to have similar effects (see Newby et al., 2015). It may be time to conclude that active, symptom-​focused, ED-​specific treatments do work for a large proportion of ED clients, but additional treatment research is specifically needed for the most severe, most nonresponsive treatment groups, including the clients who end up in higher levels of care and those with serious co-​occurring disorders. The research that we have conducted in this area and the publication of this manual are intended to advance this goal. Our effectiveness research with the UT for EDs has a much larger database to demonstrate that it works, with the actual population that it is intended to treat, when delivered by typical clinicians (Ns > 2,000); than is typically amassed from multiple RCTs. From another perspective,

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it is problematic to state that existing evidence-​based ED treatment protocols—​which to date have been tested almost exclusively in RCTs of individual, outpatient, weekly psychotherapy without adjunctive treatment—​have amassed enough evidence to support their application to the population we are describing, with severe symptoms, low motivation, and severe comorbidity being treated in groups daily on a team with adjunctive treaters in residential treatment. As noted, the specific evidence we have collected with EDs concerns the use of the UT in a group format along with adjunctive treatment; however, we know that clinicians who purchase manuals in the community commonly choose to apply the interventions in ways that they deem necessary for their client population or setting. Published treatment manuals must have manageable page limits, and the materials necessary to guide the multidisciplinary treatment program at The Renfrew Center are far longer and more extensive than can be published in one manual intended to guide the psychotherapy portion of treatment. Given these competing considerations, we have debated internally what form the manual should take. We have wondered whether it be better to provide the treatment only as provided in the study, without any guidance for other common uses of the treatment, or to provide guidance based on extensive qualitative research conducted with therapists and clients who have received the UT and the research concerning the UP (which is delivered in both highly structured groups and less structured individual sessions). We have decided to provide guidance for use of the structured UT materials in both group and individual treatment, with notes regarding both residential and outpatient settings, but to be very clear in the introduction about how the research has been conducted to date, including its limitations. This research is described in the text that follows.

Scientific rationale for UT: evidence for a transdiagnostic approach to EDs and comorbidity There is extensive evidence that EDs typically co-​occur with other emotional disorders. For example, in one of the most extensive epidemiological studies (N = 9,282), Hudson et al. (2007) found that the overall incidence of co-​occurring emotional disorders (any other Axis I disorder) 16

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among the sample with EDs was 56.2%, 94.5%, and 78.9% for anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED), respectively, including 42% to 71% co-​occurring mood disorders, 48% to 81% co-​occurring anxiety disorders, and 23% to 37% co-​occurring substance use disorders, which varied across diagnostic ED groups. In a recent replication of these epidemiological findings in a large sample of adolescents (N = 10,123), again the majority of respondents with an ED met criteria for at least one other lifetime DSM-​IV disorder, with 83.5%, 88.0%, and 55.2% of adolescents with BED, BN, and AN, respectively, endorsing one or more comorbid disorders (Swanson et al., 2011). In clinical samples, the incidence of co-​occurring disorders is even higher. For example, in one of the largest and most carefully conducted studies of treatment-​seeking clients with EDs, the incidence of any other Axis I disorder among the sample was 71.0%, including 43.1% co-​ occurring mood disorders, 53.3% co-​occurring anxiety disorders, and 10.1% co-​occurring substance use disorders (Ulfvebrand et al., 2015). The more severe and intensive the treatment setting, the more likely that co-​occurring emotional disorders will characterize the sample. For example, in the residential treatment population at The Renfrew Center, 91.0% had at least one Axis I co-​occurring disorder, and the modal number of co-​occurring diagnoses was two. Major depressive disorder was the most common comorbidity (66.3% of the full sample) and 38.5% of the full sample were diagnosed with at least one anxiety disorder, including substantial numbers with diagnosable posttraumatic stress disorder (27.8% of the full sample), generalized anxiety disorder (14.2%), and obsessive-​compulsive disorder (9.9%). A large proportion of the sample was also diagnosed with anxiety disorder not otherwise specified, which included clients with clinically interfering symptoms of panic disorder, social anxiety, agoraphobia, and specific phobias. In summary, across different EDs, and particularly among clients whose disorders are more severe, a wide range of serious co-​occurring emotional disorders are highly prevalent. There is also extensive evidence that EDs and other emotional disorders share common maintaining mechanisms, reflecting aspects of emotional functioning (Fulton et al., 2012; Wildes et al., 2010). These mechanisms include negative affectivity, difficulties with emotion

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Table 1.2 Treatment Effect Sizes from Admission to 6-​ Month Follow-​ Up Across Years of Treatment Eating Disorder Examination Questionnaire—​Global Score

TAU

UT Year 1

UT Year 2

UT Year 3

UT Year 4

Cohen’s d

.75

.86

.84

.90

.88

N

105

208

298

319

369

Cohen’s d

.40

.47

.49

.72

.62

N

66

198

304

326

372

Cohen’s d

.15

.37

.48

.43

.36

N

64

193

305

325

371

Brief Experiential Avoidance Questionnaire

Anxiety Sensitivity Index

Center for Epidemiological Studies—Depression Scale

Cohen’s d

.71

.89

.67

.85

.72

N

90

200

307

325

374

TAU, treatment as usual, preimplementation. UT, Unified Treatment, postimplementation. Effect sizes are relative to the variable observed, but in treatment studies, effects of around .20 are roughly considered “small,” .30–​.50 are roughly considered “medium,” and above .50 are considered “large” (Cohen, 1988).

awareness, negative appraisals of emotion, maladaptive emotion-​ driven behavior, and emotion avoidance. Extensive research to support these observations is described and cited in Table 1.2, along with brief descriptions of how the UT addresses these aspects of emotional dysregulation. We will summarize some of this research here as well. Clients with EDs show less emotional awareness relative to control groups (Nowakowski et al., 2013) as well as greater avoidance of aversive emotional stimuli (Lavender et al., 2015; Wildes et al., 2010). Individuals with EDs show time-​specific increases and decreases in negative affect before and after ED symptom expression (Engel et al.,

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2013; Goldschmidt et al., 2012; Lavender et al., 2016), suggesting that ED symptoms function as maladaptive efforts to escape from or suppress negative affect. Individuals with EDs also show extreme interoceptive sensitivity (Klabunde et al., 2013; Merwin et al., 2013), a specific dimension of emotional intolerance that also characterizes other emotional disorders such as panic disorder, social anxiety, and obsessive-​compulsive disorder (Boswell et al., 2015).1 EDs and other emotional disorders are also observed to share longitudinal risk factors and may share genetic risk factors as well. In longitudinal studies, depressive symptoms and negative affect have been shown to specifically predict later development of EDs (Ferreiro et al., 2014; Stice et al., 2017). Increased negative affect is a primary characteristic of all mood and anxiety disorders and also a known risk factor for the development of each of the specific mood and anxiety DSM diagnoses (Brown et al., 1998; Zinbarg et al., 2016). Multiple twin studies have found shared genetic vulnerability between EDs and substance use disorders (see Munn‐Chernoff & Baker, 2016). Molecular genetic analyses in EDs have largely been equivocal, but some of the strongest evidence suggests involvement of the serotonergic system in genetic vulnerability to EDs; the serotonergic system is also notably involved in vulnerability to mood and anxiety disorders (Hinney et al., 2010; Rozenblat et al., 2017). Factor analytic models have repeatedly found that ED symptoms share variability with factors reflecting broader dimensions of negative affect characteristic of internalizing disorders (Forbush et al., 2010; Forbush & Watson, 2013; Mitchell et al., 2014). Evidence from a wide range of other research studies additionally supports the suggestion that clients with EDs and co-​occurring disorders would be better served by transdiagnostic treatment that addresses all serious co-​occurring problems, via interventions that address these transdiagnostic mechanisms as well as specific symptoms. Treatment studies show that co-​ occurring disorders are a negative predictor of treatment outcome and a positive predictor of relapse following treatment (see Vall & Wade, 2015, for review and Though the large body of research that supports the importance of these maintaining mechanisms in the development and treatment of other emotional disorders is beyond the scope of this introduction, it has been extensively reviewed in publications concerning the UP (Barlow et al., 2004, 2013, 2017; Farchione et al., 2012). 1

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meta-​analysis). Longitudinal studies show that persistence of ED diagnosis is predicted by the presence of a co-​occurring problem (Keel & Brown, 2010). Clients themselves report seeking treatment not just for their specific EDs but also for the wide range of problems with negative effect that trouble them (Ali et al., 2017; Hudson et al., 2007). As a result of all the research summarized here, a number of recently developed EBPs for EDs (e.g., DBT, Integrative Cognitive-​Affective Therapy [ICAT], Emotion Acceptance Behavior Therapy [EABT]) are based on the rationale that clients with EDs have difficulty with emotion regulation. These treatments incorporate interventions for emotion awareness and emotion acceptance, as well as cognitive and behavioral methods for coping with emotion, as key elements of the treatment approach (Wildes & Marcus, 2011; Wonderlich et al., 2014). However, none of these EBPs intends or purports to address comprehensively all the co-​occurring diagnoses with which a client presents for treatment, but each is rather narrowly focused on one or several ED diagnoses, through interventions that address EDs narrowly and emotion regulation broadly. Furthermore, studies that have attempted a stepped-​care model, in which clients with EDs receive a focused ED treatment first, and a broader treatment subsequently if their symptoms do not remit, have not generally had success (Crow et al., 2013; Tasca et al., 2019). In general, therefore, there is extensive research to support the suggestion that EDs and comorbidity should be addressed transdiagnostically and cohesively.

Evidence supporting the efficacy and effectiveness of the UT The UP There is strong evidence to suggest that the UP is efficacious for treating a range of emotional disorders (Boswell et al., 2016; Ellard et al., 2010; Farchione et al., 2012). This evidence spans open and controlled trials as well as single-​case experimental designs. There is accumulating evidence that the UP can be used to successfully treat individuals with primary diagnoses such as major depressive disorder, bipolar disorder, borderline personality disorder, alcohol use disorder, and posttraumatic 20

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stress disorder (Barlow & Farchione, 2018; Boswell et al., 2014; Ciraulo et al., 2013; Ellard et al., 2012; Sauer-​Zavala et al., 2016). In addition to promising symptom reduction across a range of disorders, there is preliminary evidence to suggest that the UP engages the putative core psychopathological targets of aversive reactions to emotions (Brake et al., 2016; Sauer-​Zavala et al., 2012) and neuroticism (Carl et al., 2014) that are thought to maintain symptoms. A recent large-​ scale RCT compared the UP to diagnosis-​ specific protocols for a range of primary anxiety disorders and comorbid conditions (Barlow et al., 2017). Among the 223 clients, 88 were randomized to receive the UP, 91 to receive a single-​diagnosis protocol (SDP), and 44 to a waitlist control condition. Clients were more likely to complete treatment with the UP than with SDPs (odds ratio, 3.11; 95% confidence interval [CI], 1.44–​6.74). Both the UP (Cohen’s d, −0.93; 95% CI, −1.29 to −0.57) and SDPs (Cohen’s d, −1.08; 95%C I, −1.43 to −0.73) were superior to the waitlist control condition. Reductions in clinical severity rating from baseline to the end of treatment (β, 0.25; 95% CI, −0.26 to 0.75) and from baseline to the 6-​month follow-​up (β, 0.16; 95% CI, −0.39 to 0.70) indicated statistical equivalence between the UP and SDPs. Consequently, the UP’s transdiagnostic approach appears to produce equivalent symptom reduction compared to more targeted single-​disorder approaches for principal anxiety disorder diagnoses.

The UT As described previously, the UT was developed by a collaborative team of clinical supervisors and clinical researchers at The Renfrew Center, a large, private network of ED treatment programs. The Renfrew Center undertook a multiyear, multicomponent effort to improve the overall consistency and quality of its clinical care and clinical research, culminating in the implementation of the UT across 2 residential and 14 partial hospital/​intensive outpatient programs. In 2013, The Renfrew Center clinical leaders chose the UP as a foundational evidence-​based treatment model for possible implementation, based on the factors described earlier in the chapter. Between 2013 and 2016, the organization’s implementation team developed adapted protocols for 21

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each level of care, defined UP-​consistent interventions to be delivered across a multidisciplinary care team (e.g., psychotherapy, nutrition, and nursing), provided training to over 400 clinicians, and implemented the program across sites. Any further reference to the UT in this manual refers to the organization’s systematic, UP-​derived treatment approach for EDs and co-​occurring emotional disorders, and any reference to the UP refers to the common elements therapy developed by Barlow and colleagues. There have been two studies demonstrating the comparative effectiveness of the UT over treatment as usual (TAU) for EDs and comorbidity in the Renfrew residential treatment programs, comprising some of the largest and most carefully conducted comparative research including clients with EDs in residential settings. Both studies utilized a naturalistic pre–​post implementation design, in which the data collected from all residential clients in the year immediately prior to the implementation of the UT were compared to two different samples. Study 1 compared the pre-​implementation sample to data collected from all residential clients in the period immediately following the implementation of the UT. This study has the advantage that the two cohorts of patients were closely adjacent in time. In Study 2 (Thompson-​Brenner et al., in press), the pre-​implementation data were compared to a large sample of patients treated over the five years following the implementation. This study has the advantage of having a much larger sample—​particularly at the 6 month follow-​up time point—​and also provides the opportunity to examine the sustainability of the implementation effect over time (These studies are described in detail in Thompson-​Brenner et al., 2019; and Thompson-​ Brenner et al., 20212). We will here describe the methods and results in some detail as they are an important foundation of the assertion that the UT is a “treatment that works.” Prior to the adaptation and implementation of the UT at the Renfrew residential treatment centers, the TAU had been developed over time by the clinicians within the organization. Group and individual therapy sessions were regularly supervised, but there was no manualized approach.

These articles were published with open access in the journals Psychotherapy Res earch and Frontiers in Psychiatry. The full texts are therefore accessible on the internet. 2

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The clinical leadership defined the treatment as “feminist-​relational,” and clinicians were instructed to support clients’ relational connectedness, self-​empowerment, emotional expression, and self-​directedness, including identification of the relationship between clients’ emotions and their ED symptoms. Though there was a stated clinical value system, the content and approach to group and individual therapy was highly eclectic in practice. Research on residential treatment across the country suggests that this eclectic approach, including components without support from psychotherapy research, is characteristic of the many residential treatment programs (Frisch et al., 2006; Twohig et al., 2016). Following an intensive process of training and implementation for the UT, clinician fidelity to the empirically based, adapted treatment was assessed. An observer-rated fidelity assessment tool for the UT with items addressing the therapists’ adherence to the relevant treatment goals for each session (e.g., “Did the facilitators introduce the 3-component model of emotions?”) as well as competence in delivering high-quality therapy (e.g., rapport, warmth) was utilized. The scale was developed from scales utilized in studies of the UP (Barlow et al., 2011) and revised based on therapist, supervisor, and client feedback. Data were collected by audio recordings of group therapy sessions. A total of 58 groups were independently rated, across all stages of treatment and two residential sites. Across all groups and sites, ratings of the therapist adherence were established on average to be “good,” and therapist competence and group quality were established on average to be “adequate to good.” As time progressed from initial implementation, therapists were observed to become more competent in delivering the therapy, and the overall group quality improved (see Thompson-Brenner et al., 2019). A more recent study of fidelity to the UT group therapy at a single residential site also demonstrated good to excellent fidelity (Oswald, 2021), while a recent random sample of partial hospital program groups delivered in a virtual format demonstrated excellent fidelity as well (Smith et al., in preparation). These results suggest that the initial training the therapists received was successful in establishing adherence to the manualized treatment across both residential centers, and that additional experience, supervision, and training following the implementation successfully improved the competence and adherence to the manualized treatment. 23

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There are two published studies demonstrating the effectiveness of the UT for the full sample of patients receiving residential treatment for EDs. The first closely examined data from N = 616 clients immediately prior to and following the initial implementation (Thompson-Brenner et al., 2019) and the second examined data from N = 2,763 patients treated with the UT across 5 years (Thompson-Brenner et al., 2021). Clients in both studies were a highly heterogeneous group, with high severity of symptoms overall. Client ages ranged from 13 to 75, with an average age of approximately 25 and average body mass index (BMI) of approximately 22 (SD approximately 10). The most common ED diagnosis was anorexia nervosa (AN; approximately 40%), followed by bulimia nervosa (BN; approximately 30%). Of clients diagnosed with AN, approximately two-thirds were restricting subtype and one-third were binge-purge subtype. Over 90% of clients also met criteria for at least one Axis I co-occurring disorder, and the average number of co-occurring diagnoses was two. Major depressive disorder and anxiety disorders were the most common comorbid diagnoses. The pre-implementation and post-implementation treatment groups did not differ significantly on age, admission BMI, number of comorbid diagnoses, race/ethnicity, or baseline scores on outcome measures (see Thompson-Brenner et al., 2019, 2021, for detailed demographics).3 Results from both studies indicated that the UT succeeded in producing a larger effect than treatment-as-usual (TAU) on multiple measures of outcome. In the initial study utilizing a smaller sample size, a larger effect was observed for the UT than TAU on the individual emotion regulation variables that were targeted in the UT, including significantly more improvement in experiential avoidance, anxiety sensitivity, and mindfulness. The UT and the TAU both yielded large effects for the ED and depression outcomes, which were not significantly different between groups in the initial sample (see Thompson-Brenner et al., 2019, for full results and discussion). In the second study, utilizing a larger sample, the significantly larger effect for UT than TAU was observed for depression symptoms as well as experiential avoidance, anxiety sensitivity, and mindfulness. Furthermore, analyses of interaction effects

These articles were published with open access in the journals Psychotherapy Research and Frontiers in Psychiatry. The full text is therefore accessible on the internet. 3

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indicated that clients who entered treatment with a higher level of emotional avoidance showed more improvement in ED symptoms when treated with the UT relative to TAU. Patients with low levels of emotion regulation problems (who also had less severe ED symptoms) showed comparable response in both treatments (Thompson-Brenner et al., 2021). Detailed examinations of effect sizes for all symptom measures suggested that the observed positive effects for the UT relative to the TAU did not diminish over time—as might have been predicted from prior implementation research on “sustainability” in other fields—but instead, the observed effects were comparable in size or even larger across the 5 years following implementation. It is particularly important to note that substantial data have now been collected from patients completing 6-month follow-up analyses, which observe the stability of the effects of treatment after patients have been discharged from the intensive residential treatment intervention and returned to a more typical environment (see Thompson-Brenner et al., 2021). As Table 1.2 shows, among those patients who entered with clinically significant self-reported ED symptomatology, the UT produced effects at the 6-month follow-up in ED global score and in measures of emotional dysfunction that tend to be consistently larger than for the TAU group, and in some cases show increases over time. A subsequent preliminary investigation of the UT has examined whether the proposed transdiagnostic mechanisms of treatment—specifically emotion avoidance and anxiety sensitivity—were related to the primary treatment outcomes of ED and depressive symptoms. According to UT theory, clients who tend to make greater improvement on the UT mechanisms during treatment would become more tolerant of and approach oriented toward emotional discomfort over time, and consequently less reliant on ED behaviors to avoid or suppress emotional experience. Thus, these clients would be expected to have lower ED and comorbid psychopathology symptoms at discharge and may also be better able to maintain these gains by the 6-month follow-up, after they have returned to their less structured home environments. To test whether this is the case, data were analyzed from a larger sample of routinely presenting clients (N = 1,064) at The Renfrew Center’s two residential programs. All clients were admitted after implementation of the UT. The sample characteristics of these clients (i.e., primary ED

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diagnoses, common comorbidities, age, and duration of illness) were similar to those of the samples described earlier in this chapter. Of the full initial sample, 885 clients (83.2%) had sufficient data to be included in at least one of the discharge analyses. Data from 504 (47.3%) clients were available for 6-month follow-up analyses (Thompson-Brenner et al., in preparation). Models once again controlled for relevant covariates (baseline symptom severity, length of stay, treatment site, and number of comorbid diagnoses). Results from admission to discharge indicated that changes in all three UT mechanisms were predictive of ED symptom outcome. Thus, clients who made greater- than- usual improvements in mindfulness, anxiety sensitivity, and experiential avoidance tended to have less severe ED and depression symptoms at discharge. All three UT mechanisms were included in the same prediction model and were found to be independently predictive; thus, they all appeared to be relevant even when considering the effects of the other mechanisms. The joint effect of all mechanisms on ED symptom outcome was large in size. These results further suggest that UT mechanisms appear to play an important role in facilitating ED symptom improvements during residential UT treatment. Results from the analyses of 6-month follow -up outcomes differed. The models for both ED and depressive symptoms revealed no significant predictors of symptom outcomes, aside from a client’s symptom severity at discharge. Although change in the UT mechanisms during treatment did not seem to predict outcome at the 6-month follow-up, there were also no significant effects for other factors that have previously been shown to have relevance to long -term ED treatment outcomes (e.g., comorbidity, illness duration, BMI at discharge; Thompson- Brenner & Westen, 2005; Vall & Wade, 2015). It is likely that there are other unmeasured factors that may explain differences in 6- month follow-up outcome (e.g., intensity and duration of follow-up care, level of social support at home). These patterns and findings are currently under revision, and additional analyses with a larger sample size and more sophisticated statistical analyses are hoped to further explain and extend these results. Several additional studies, using different subsets of the UT treatment data, have also yielded encouraging results. One recent study found that patients with PTSD who were treated with the integrative Renfrew

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UT program did not show poorer response than patients who did not have PTSD (Mitchell et al., 2021), in contrast to prior research from other treatment settings suggesting that patients with PTSD may be at increased risk of premature dropout, reduced rates of improvement, or increased rates of relapse. Another recent study investigating the utility of a weekly routine progress monitoring tool found that it was possible to accurately predict response at discharge (typically 1 to 3 months later) using baseline symptom level and the degree of change between week 1 and week 2 (Espel-Huynh et al., 2021). Subsequent research in this area is investigating how to individualize treatment following week 2 progress monitoring in order to improve outcome for gradually improving and non-responding patients. Finally, during COVID-19 shelter-inplace orders, a virtual partial-hospital and intensive outpatient version of the Renfrew UT was developed and implemented. Initial results suggest that the virtual program is well received and comparably effective to the program delivered in the traditional face-to-face format (Smith et al., in preparation).

Conclusion The UT has been now utilized and studied with clients with severe EDs and co-​occurring disorders arguably more thoroughly than any other manualized treatment in the residential treatment setting. More research is forthcoming regarding the use of the treatment manual in other contexts and with particular subpopulations. We hope that the publication of the manual will facilitate further research and treatment.

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Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-​of-​onset distributions of DSM-​IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 593–​602. Klabunde, M., Acheson, D. T., Boutelle, K. N., Matthews, S. C., & Kaye, W. H. (2013). Interoceptive sensitivity deficits in women recovered from bulimia nervosa. Eating Behaviors, 14(4), 488–​492. Lavender, J. M., Utzinger, L. M., Cao, L., Wonderlich, S. A., Engel, S. G., Mitchell, J. E., & Crosby, R. D. (2016). Reciprocal associations between negative affect, binge eating, and purging in the natural environment in women with bulimia nervosa. Journal of Abnormal Psychology, 125(3), 381–​386. Lavender, J. M., Wonderlich, S. A., Engel, S. G., Gordon, K. H., Kaye, W. H., & Mitchell, J. E. (2015). Dimensions of emotion dysregulation in anorexia nervosa and bulimia nervosa: A conceptual review of the empirical literature. Clinical Psychology Review, 40, 111–​122. Lock, J., Le Grange, D., Agras, W. S., Moye, A., Bryson, S. W., & Jo, B. (2010). Randomized clinical trial comparing family-​based treatment with adolescent-​focused individual therapy for adolescents with anorexia nervosa. Archives of General Psychiatry, 67(10), 1025–​1032. Lowe, M. R., Bunnell, D. W., Neeren, A. M., Chernyak, Y., & Greberman, L. (2011). Evaluating the real-​world effectiveness of cognitive-​behavior therapy efficacy research on eating disorders: A case study from a community-​ based clinical setting. International Journal of Eating Disorders, 44(1), 9–​18. Merwin, R. M., Moskovich, A. A., Wagner, H. R., Ritschel, L. A., Craighead, L. W., & Zucker, N. L. (2013). Emotion regulation difficulties in anorexia nervosa: Relationship to self-​perceived sensory sensitivity. Cognition and Emotion, 27(3), 441–​452. Mitchell, K. S., Wolf, E. J., Reardon, A. F., & Miller, M. W. (2014). Association of eating disorder symptoms with internalizing and externalizing dimensions of psychopathology among men and women. International Journal of Eating Disorders, 47(8), 860–​869. Munn‐Chernoff, M. A., & Baker, J. H. (2016). A primer on the genetics of comorbid eating disorders and substance use disorders. European Eating Disorders Review, 24(2), 91–​100. Murphy, R., Straebler, S., Basden, S., Cooper, Z., & Fairburn, C. G. (2012). Interpersonal psychotherapy for eating disorders. Clinical Psychology & Psychotherapy, 19(2), 150–​158. Newby, J. M., McKinnon, A., Kuyken, W., Gilbody, S., & Dalgleish, T. (2015). Systematic review and meta-​ analysis of transdiagnostic

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psychological treatments for anxiety and depressive disorders in adulthood. Clinical Psychology Review, 40, 91–​110. Norton, P. J., & Paulus, D. J. (2016). Toward a unified treatment for emotional disorders: Update on the science and practice. Behavior Therapy, 47(6), 854–​868. Nowakowski, M. E., McFarlane, T., & Cassin, S. (2013). Alexithymia and eating disorders: A critical review of the literature. Journal of Eating Disorders, 1, 21. Oswald, J. M. (2021). Developing a clinician self-report fidelity measure for a transdiagnostic, evidence-based protocol at a residential eating disorders treatment center (Publication No. AAI28022686). [Doctoral dissertation, University at Albany, State University of New York]. APA PsycInfo®. (2442368404; 2020-58780-248). Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., Griffey, R., & Hensley, M. (2011). Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health and Mental Health Services Research, 38(2), 65–​76. Radloff, L. S. (1977). The CES-​D scale: A self-​report depression scale for research in the general population. Applied Psychological Measurement, 1(3), 385–​401. Rozenblat, V., Ong, D., Fuller-​Tyszkiewicz, M., Akkermann, K., Collier, D., Engels, R. C. M. E., Fernandez-​Aranda, F., Harro, J., Homberg, J. R., Karwautz, A., Kiive, E., Klump, K. L., Larson, C. L., Racine, S. E., Richardson, J., Steiger, H., Stoltenberg, S. F., van Strien, T., Wagner, G., Treasure, J., et al. (2017). A systematic review and secondary data analysis of the interactions between the serotonin transporter 5-​HTTLPR polymorphism and environmental and psychological factors in eating disorders. Journal of Psychiatric Research, 84, 62–​72. Safer, D. L., Robinson, A. H., & Jo, B. (2010). Outcome from a randomized controlled trial of group therapy for binge eating disorder: Comparing dialectical behavior therapy adapted for binge eating to an active comparison group therapy. Behavior Therapy, 41(1), 106–​120. Safer, D. L., Telch, C. F., & Agras, W. S. (2001). Dialectical behavior therapy for bulimia nervosa. American Journal of Psychiatry, 158(4), 632–​634. Sandoz, E., Wilson, K., & DuFrene, T. (2011). Acceptance and Commitment Therapy for eating disorders: A process-​focused guide to treating anorexia and bulimia. New Harbinger Publications. Sauer-Zavala, S., Boswell, J. F., Gallagher, M. W., Bentley, K. H., Ametaj, A., & Barlow, D. H. (2012). The role of negative affectivity and negative reactivity to emotions in predicting outcomes in the unified protocol

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for the transdiagnostic treatment of emotional disorders. Behaviour Research and Therapy, 50(9), 551–557. https://doi.org/10.1016/j. brat.2012.05.005 Sauer-Zavala, S., Cassiello-Robbins, C., Conklin, L. R., Bullis, J. R., Thompson-Hollands, J., & Kennedy, K. A. (2017). Isolating the Unique Effects of the Unified Protocol Treatment Modules Using Single Case Experimental Design. Behavior Modification, 41(2), 286–307. https:// doi.org/10.1177/0145445516673827 Sauer-Zavala, S., Fournier, J. C., Jarvi Steele, S., Woods, B. K., Wang, M., Farchione, T. J., Barlow, D. H. (2020). Does the unified protocol really change neuroticism? Results from a randomized trial. Psychological Medicine. 1–10. https://doi.org/10.1017/ S0033291720000975 Stice, E., Gau, J. M., Rohde, P., & Shaw, H. (2017). Risk factors that predict future onset of each DSM-​5 eating disorder: Predictive specificity in high-​ risk adolescent females. Journal of Abnormal Psychology, 126(1), 38–​51. Strandskov, S. W., Ghaderi, A., Andersson, H., Parmskog, N., Hjort, E., Wärn, A. S., Jannert, M., & Andersson, G. (2017). Effects of tailored and ACT-​influenced internet-​based CBT for eating disorders and the relation between knowledge acquisition and outcome: A randomized controlled trial. Behavior Therapy, 48(5), 624–​637. Swanson, S. A., Crow, S. J., Le Grange, D., Swendsen, J., & Merikangas, K. R. (2011). Prevalence and correlates of eating disorders in adolescents: Results from the National Comorbidity Survey Replication adolescent supplement. Archives of General Psychiatry, 68(7), 714–​723. Tasca, G. A., Koszycki, D., Brugnera, A., Chyurlia, L., Hammond, N., Francis, K., Ritchie, K., Ivanova, I., Proulx, G., Wilson, B., Beaulac, J., Bissada, H., Beasley, E., McQuaid, N., Grenon, R., Fortin-​Langelier, B., Compare, A., & Balfour, L. (2019). Testing a stepped care model for binge-​ eating disorder: A two-​ step randomized controlled trial. Psychological Medicine, 49(4), 598–​606. Tasca, G. A., Sylvestre, J., Balfour, L., Chyurlia, L., Evans, J., Fortin-​ Langelier, B., Francis, K., Gandhi, J., Huehn, L., Hunsley, J., Joyce, A. S., Kinley, J., Koszycki, D., Leszcz, M., Lybanon-​Daigle, V., Mercer, D., Ogrodniczuk, J. S., Presniak, M., Ravitz, P., Ritchie, K., et al. (2015). What clinicians want: Findings from a psychotherapy practice research network survey. Psychotherapy, 52(1), 1–​11. Thompson-​Brenner, H., Boswell, J. F., Espel-​Huynh, H., Brooks, G. E., & Lowe, M. R. (2019). Implementation of transdiagnostic treatment for emotional disorders in residential eating disorder programs: A preliminary pre-​post evaluation. Psychotherapy Research, 29(8), 1045–​1061.

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Thompson-​Brenner, H., Brooks, G. E., Boswell, J. F., Espel-​Huynh, H. M., Dore, R., Franklin, D. R., Gonçalves, A., Smith, M., Ortiz, S., Ice, S., Barlow, D. H., & Lowe, M. R. (2018). Evidence-​based implementation practices applied to the intensive treatment of eating disorders: A research summary and examples from one case. Clinical Psychology: Science and Practice, 25(1), e12221. Thompson-Brenner, H., Singh, S., Garner, T., Brooks, G. E., Smith, M. T., Lowe, M. R., & Boswell, J. F. (2021). The Renfrew Unified Treatment for Eating Disorders and Comorbidity: Long-Term Effects of an Evidence-Based Practice Implementation in Residential Treatment. Frontiers in Psychiatry, 12, 226. Thompson-​Brenner, H., & Westen, D. (2005). A naturalistic study of psychotherapy for bulimia nervosa, part 1: Comorbidity and therapeutic outcome. Journal of Nervous and Mental Disease, 193(9), 573–​584. Twohig, M. P., Bluett, E. J., Cullum, J. L., Mitchell, P., Powers, P. S., Lensegrav-​Benson, T., & Quakenbush-​Roberts, B. (2016). Effectiveness and clinical response rates of a residential eating disorders facility. Eating Disorders, 24(3), 224–​239. Twohig, M. P., Bluett, E. J., Torgesen, J. G., Lensegrav-​Benson, T., & Quakenbush-​ Roberts, B. (2015). Who seeks residential treatment? A report of patient characteristics, pathology, and functioning in females at a residential treatment facility. Eating Disorders, 23(1), 1–​14. Ulfvebrand, S., Birgegård, A., Norring, C., Högdahl, L., & von Hausswolff-​ Juhlin, Y. (2015). Psychiatric comorbidity in women and men with eating disorders: Results from a large clinical database. Psychiatry Research, 230(2), 294–​299. Vall, E., & Wade, T. D. (2015). Predictors of treatment outcome in individuals with eating disorders: A systematic review and meta‐analysis. International Journal of Eating Disorders, 48(7), 946–​971. Wagner, B., Nagl, M., Dölemeyer, R., Klinitzke, G., Steinig, J., Hilbert, A., & Kersting, A. (2016). Randomized controlled trial of an internet-​ based cognitive-​ behavioral treatment program for binge-​ eating disorder. Behavior Therapy, 47(4), 500–​514. Wildes, J. E., & Marcus, M. D. (2011). Development of emotion acceptance behavior therapy for anorexia nervosa: A case series. International Journal of Eating Disorders, 44(5), 421–​427. Wildes, J. E., Ringham, R. M., & Marcus, M. D. (2010). Emotion avoidance in patients with anorexia nervosa: Initial test of a functional model. International Journal of Eating Disorders, 43(5), 398–​404. Wilfley, D. E., MacKenzie, K. R., Welch, R. R., Ayres, V. E., & Weissman, M. M. (2000). Interpersonal psychotherapy for group. Basic Books.

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Wonderlich, S., Peterson, C. B., Crosby, R., Smith, T., Klein, M., Mitchell, J. E., & Crow, S. J. (2014a). A randomized controlled comparison of integrative cognitive-​affective therapy (ICAT) and enhanced cognitive-​ behavioral therapy (CBT-​E) for bulimia nervosa. Psychological Medicine, 44, 543–​553. Wonderlich, S. A., Peterson, C. B., Crosby, R. D., Smith, T., Klein, M., Mitchell, J. E., & Crow, S. J. (2014b). A randomized controlled comparison of integrative cognitive-​affective therapy (ICAT) and enhanced cognitive-​behavioral therapy (CBT-​E) for bulimia nervosa. Psychological Medicine, 44, 543–​553. Yager, J., Devlin, M. J., Halmi, K. A., Herzog, D. B., Mitchell, J. E., Powers, P., & Zerbe, K. J. (2014). Guideline watch (August 2012): Practice guideline for the treatment of patients with eating disorders, 3rd edition. Focus, 12(4), 416–​431. Zerwas, S. C., Watson, H. J., Hofmeier, S. M., Levine, M. D., Hamer, R. M., Crosby, R. D., Runfola, C. D., Peat, C. M., Shapiro, J. R., Zimmer, B., Moessner, M., Kordy, H., Marcus, M. D., & Bulik, C. M. (2017). CBT4BN: A randomized controlled trial of online chat and face-​to-​face group therapy for bulimia nervosa. Psychotherapy and Psychosomatics, 86(1), 47–​53. Zinbarg, R. E., Mineka, S., Bobova, L., Craske, M. G., Vrshek-​Schallhorn, S., Griffith, J. W., Wolitzky-​Taylor, K., Water, A. M., Sumner, J. A., & Anand, D. (2016). Testing a hierarchical model of neuroticism and its cognitive facets: Latent structure and prospective prediction of first onsets of anxiety and unipolar mood disorders during 3 years in late adolescence. Clinical Psychological Science, 4(5), 805–​824. Zipfel, S., Wild, B., Groß, G., Friederich, H.-​C., Teufel, M., Schellberg, D., Giel, K. E., de Zwaan, M., Dinkel, A., Herpetz, S., Burgmer, M., Löwe, B., Tagay, S., von Wietersheim, J., Zeeck, A., Schade-​Brittinger, C., Schauenburg, H., Herzog, W., ANTOP Study Group. (2014). Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in outpatients with anorexia nervosa (ANTOP study): Randomised controlled trial. Lancet, 383(9912), 127–​137.

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CHAPTER 2

How to Use This Manual

We have designed the materials in this manual to be utilized in many settings and modalities (e.g., group or individual treatment), by therapists from various disciplines (e.g., psychologists, counselors, dietitians), and at any frequency of session scheduling, to facilitate use by the broadest range of therapists and clients. Research on implementation suggests that evidence-​based interventions need to be adapted to the particular needs of a clinical population and setting to be maximally effective, and in fact we have had to repeatedly adapt the materials depending on the setting in which we are using the Unified Treatment (UT). In The Renfrew Center’s treatment programs, the UT group sessions are highly structured, as presented in this manual. The psychoeducation is carefully reviewed in each group and then applied to each client personally in the in-​session exercises. Depending on the size of the group and the content of the therapy exercise, the exercises may be conducted with each client individually, with one person as an example and others contributing thoughts and ideas, or with the group broken out into dyads or triads. At higher levels of care, clients progress through phases of the treatment in stages, based on their level of functioning and clinical progress. The UT is utilized in concurrent individual therapy as well, and the individual sessions are personally structured by the clinician and client, based on his or her current clinical needs and stage. As noted in the Introduction, the research on Renfrew’s UT with clients with eating disorders has been conducted primarily in the residential setting. In contrast, the original Unified Protocol (UP) was administered in clinical trials in once-​or twice-​weekly outpatient individual therapy. In outpatient therapy, with high-​functioning clients, it is very useful to have clients read the psychoeducational material in a session/​chapter

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before the session in which this material and associated exercises are reviewed. In the original UP studies, this is how the treatment was administered. Outpatient clients read the psychoeducational materials in the workbook between sessions, and the therapists discussed these materials and conducted exercises and therapeutic interventions, either from the workbook or as summarized in the therapist manual. We have elected—​in The Renfrew Center and in this manual—​to present the materials differently. Clients who are lower functioning, or who are meeting in group daily, are less capable of reading and digesting extensive psychoeducational material between sessions. Therefore, we provide all the psychoeducational material in each session in both the client workbook and therapist manual. In groups, therapists review all the important points in the psychoeducation aloud and engage clients in discussion and personalized application of the material throughout the session. Depending on the membership of the group, or on the nature and habits of the individual client, therapists may decide to do more or less intensive psychoeducation in session. We do recommend that clients read the material for the next session prior to the group, if possible, and we include this reading in the list of weekly homework for this reason. It can be tricky for a therapist to provide and apply the necessary psychoeducation and also be engaging, empathic, authentic, and attuned at the same time! In our research on the UT, summarized in the Introduction to this manual, we found that therapists were able to master the structured aspects of the treatment fairly quickly, and they became more natural, engaging, and otherwise generally competent over time. Despite high adherence and competency ratings demonstrated in the research, the supervisors in our programs agree that additional therapist training is necessary to become expert at conducting the UT sessions. Over time, even the most skilled therapists may also tend to “drift” from the manualized approach. After you have become comfortable with the material and have had time to integrate emotion-​focused relational skills into your work with your clients, we also recommend revisiting the basics of this manual regularly to keep your skills sharp. Perhaps because the group materials were highly structured, and perhaps because they were somewhat academic in their presentation, we

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observed that therapists were utilizing less than their full capacity for interpersonal and general therapeutic skills. At times the therapists seemed more like teachers than like the emotionally engaged, empathic, creative therapists we knew them to be. The Renfrew Center then designed and conducted training in emotion-​focused relational skills to support therapists using the UT to use their general therapeutic skills—​such as empathy, authenticity, and emotional attunement—​so that they would be more effective. Much of the training that The Renfrew Center provides is experiential and interpersonal and would certainly overlap with any good general training that a therapist or counselor has received. However, we want to provide the content of the training here in order to encourage and support therapists using the UT not to make the mistake of becoming too “academic” in their delivery of this particular treatment.

Emotion-​focused relational skills Our method of delivering the UT at The Renfrew Center is informed by research that suggests the importance and primacy of relational connection in human psychological health, and the importance of the therapeutic alliance across all forms of psychotherapy. The extensive research supporting these two statements is beyond the scope of this introduction, but we hope to describe elements of our therapeutic stance and important interpersonal skills to develop and emphasize in therapy using the UT. It is important that therapists using the UT do not respond to the structured and at times didactic nature of the psychoeducation by becoming an “instructor” or even a “lecturer.” Therapists need to maintain an empathic, collaborative, interpersonally connected stance in order to successfully conduct psychotherapy. Individuals with eating disorders have a variety of problems maintaining relational connection in their lives and in the therapeutic process. Without a strong interpersonal connection, it is very difficult to identify emotions, to tolerate emotions, and to make sometimes challenging behavioral changes. Next we summarize some of the general therapeutic skills that we emphasize in the delivery of the treatment.

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Mutuality, authenticity, and empathy We encourage therapists to attempt to minimize the power differential and to collaborate in an authentic therapy process. To support this goal, we suggest that therapists let their “humanness” show. Clinicians may share the impact that a part of a session has had on them or otherwise disclose their experience in the here and now. The goal is not to be completely transparent and spontaneous (of course!) but to allow the client to see that the therapist is emotionally responsive. This stance can involve some vulnerability on the part of the clinician. In order for empathy to fully contribute to healing, the clients must see, know, and feel the therapist’s empathy. It isn’t enough for therapists to privately feel empathic, by sharing some part of their cognitive-​ emotional responsiveness; rather, it is important for therapists to label and demonstrate the emotions that they see and feel, in some way. This provides important information to clients—​information about emotion, information about the relationship, and the general sense that they “matter.” We suggest that when emotions come up, it is important to label them and validate them before providing other responses to them.

Attention to disconnection In the face of troubled emotions and the impulse to avoid, clients may employ “strategies of disconnection,” which may involve withdrawal, anger, or displays of emotional dysregulation. In the therapy room, we might see that the relationship becomes less authentic or emotional, the client appears tired or bored, or, in contrast, the client’s emotions become stronger and dysregulated. It is important to stop and pay attention to these process dynamics when they occur in order to learn about emotion as well as to bring connection and authenticity back to the therapy process. Disconnections occur all the time, but the question is, “What happens next?” Is there responsiveness? If disconnections are noticed, understood, and reworked, this can be a process that yields great growth.

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Clinician self-​awareness This treatment focuses on emotions and experiences that are by definition difficult for clients to tolerate, and clinicians may also have strong reactions to this process. Some may be conscious and relatively easy to attend to, but others may signal the clinician’s own disconnection and avoidance. We suggest that therapists attend to certain cues—​a drop in their own energy, a rise in their own negative affect, or the sense that something just “shifted” in the room. In response to these cues, as the therapist, you might bring your awareness to your own experience, engage in ongoing self-​reflection, and use supervision to gain insight. To be maximally effective, you should keep asking yourself about your own responses to your clients’ problems. It can be useful to ask yourself: What do you expect from the clients? What do you expect from yourself? When your clients or you don’t live up to those expectations, what does that say about you?

Group effectiveness skills The administration of the UT in groups can be a challenging task for the therapist! However, if done well, the group process can be very powerful and moving. Over the years of delivering the UT in groups, we have observed a number of “traps” that therapists commonly fall into. We hope a warning about these traps, and suggestions for how to avoid them, will be helpful: 1. Failing to plan: Before starting group, think through what the intention and the purpose of this group are. What are the goals for the group as a whole and for each activity? What do you want the clients to take away from the group experience? How will you make sure those goals are met? What is the supporting rationale? How does it fit into the big picture of the emotion-​focused program? Then, take some time to visualize it. What will it look like? How will it flow? 2. Skipping the check-​in: When you skip a check-​in time, it does not allow the facilitator and group participants to know “where one is” (feeling, thinking, current moment, emotionally); therefore, the group is not plugged in and connected.

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3. Ignoring disconnection: Therapists commonly fall into the trap of becoming overly focused on group goals, with the participation of a few active clients, while ignoring or not attending to disconnection among other group members. For example, disconnected members of the group may use avoidance strategies such as staring off, doodling, sleeping, or not making eye contact; you may have the feeling like “you lost them” somehow. As noted earlier, take time out to observe the disconnection and try to understand it. It is never too late to pay attention! Try to address disconnection the first time it happens, and then redirect back to disconnection when it inevitably happens again. 4. Going with your own avoidance: Disconnection or negative emotion in the group can be threatening to the therapist. It is avoidant to not address, with transparency, when something doesn’t feel good in the group, when there is an obvious conflict, or when someone is visibly and emotionally moved. Clinicians need to attend to when they are feeling anxious, try to understand why they are anxious, and address their own and others’ emotions as they arise. 5. Playing “the expert” and forgetting your humanity: When ideas are presented as the “expert’s opinion” or as the “right answer,” then the creative reflexivity, attunement, and responsiveness of the group is lost. As we have noted repeatedly, it is important to run the group with your own natural, genuine, comfortable energy. Humor is good! Human is good! 6. Jargon and confusion: It is alienating and impersonal when the therapist’s language includes too many “UT-​isms” or therapy jargon without explicit explanation or acknowledging the attendee’s newness and learning curve. Be clear. Make it explicit. Do not assume people are following you; take their cues. If someone says (verbally or nonverbally), “I’m confused,” take that cue. Slow down and explain it clearly. Perhaps consider using a concrete example, using a visual aid, or asking for another group member to share their understanding of the topic. 7. Failing to attend to the pace and flow: Remember to press “pause” and take a break when energy levels are low. Remember to use micro skills of paraphrasing, summarizing, or reflection before moving on from one activity to the next. It is unfortunate to have a rushed

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closing where there is insufficient time to discuss homework, “where one is at now,” and how the group landed with the members. Think ahead! Bookend the learning! Therapists running UT groups have to wear several hats. You may have to act, at times, like a teacher—​you can stand up, use a whiteboard, and manage the psychoeducational message by underlining and circling words on the board. Your tone at these times may be emphatic. At other times, when wearing a more exploratory therapist hat, your tone may be lower and slower. Make sure to allow for pauses, without filling the space. Make eye contact around the room, and stay seated. While wearing all different hats, however, it is necessary throughout to keep the clients engaged, via questions, empathy, energy, and thoughtful attention to emotion.

Other training resources Because this treatment integrates evidence-​based interventions from multiple approaches to address difficulties with emotion regulation, any given therapist may have more or less experience with the different interventions and approaches included here. We have tried to supply sufficient material, instruction, and structure to support therapists from all disciplines and at different levels of training. However, it may be important to seek out more information or training for certain approaches with which you are less familiar. We have provided a brief list of basic resources here and encourage you to seek out additional training as necessary.

Motivational interviewing Cassin, S., & Geller, J. (2017). Motivational interviewing in the treatment of disordered eating. In H. Arkowitz, W. R. Miller, & S. Rollnick (Eds.), Motivational interviewing in the treatment of psychological problems (2nd ed.). Guilford Press. Miller, W. R., & Rollnick, S. (2012). Motivational interviewing (3rd ed.). Guilford Press.

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Regular eating Fairburn, C. G. (2008). Cognitive behavior therapy and eating disorders. Guilford Press. Wonderlich, S. A., Peterson, C. B., & Smith, T. L. (2015). Integrative cognitive-​ affective therapy for bulimia nervosa: A treatment manual. Guilford Press.

Mindful awareness of emotion Baer, R. A. (Ed.). (2014). Mindfulness-​based treatment approaches: Clinician’s guide to evidence base and applications (2nd ed.). Elsevier Academic Press. Wildes, J. E., & Marcus, M. D. (2011). Development of emotion acceptance behavior therapy for anorexia nervosa: A case series. International Journal of Eating Disorders, 44(5), 421–​427. doi:10.1002/​eat.20826 Wolf, C., Serpa, J. G., & Kornfield, J. (2015). A clinician’s guide to teaching mindfulness. New Harbinger Publications, Inc.

Cognitive therapy Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). Guilford Press. Fairburn, C. G. (2008). Cognitive behavior therapy and eating disorders. Guilford Press. Harvey, A. G., Watkins, E., & Mansell, W. (2004). Cognitive behavioural processes across psychological disorders: A transdiagnostic approach to research and treatment. Oxford University Press.

Exposure therapy Barlow, D. H., Farchione, T. J., Sauer-​Zavala, S., Murray Latin, H., Ellard, K. K., Bullis, J. R., Bentley, K. H., Boettcher, H. T., & Cassiello-​ Robbins, C. (2018). Unified Protocol for Transdiagnostic Treatment of Emotional Disorders: Therapist guide (2nd ed.). Oxford University Press. Delinsky, S. S., & Wilson, G. T. (2006). Mirror exposure for the treatment of body image disturbance. International Journal of Eating Disorders, 39(2), 108–​116. doi:10.1002/​eat.20207

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Ehrenreich-​May, J., Kennedy, S. M., Sherman, J. A., Bilek, E. L., Buzzella, B. A., Bennett, S. M., & Barlow, D. H. (2017). Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents: Therapist guide. Oxford University Press. Steinglass, J. E., Albano, A. M., Simpson, H. B., Wang, Y., Zou, J., Attia, E., & Walsh, B. T. (2014). Confronting fear using exposure and response prevention for anorexia nervosa: A randomized controlled pilot study. International Journal of Eating Disorders, 47(2), 174–​180. doi:10.1002/​ eat.22214 Waller, G., & Mountford, V. A. (2015). Weighing patients within cognitive-​ behavioural therapy for eating disorders: How, when and why. Behaviour Research and Therapy, 70, 1–​10. doi:10.1016/​j.brat.2015.04.004

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CHAPTER 3

Therapist Materials for Preparing for Treatment

Clients should read workbook Chapters 1 to 3 prior to attending the first group session. You may decide to devote more or less time to the goals of providing feedback about the intake assessment, formulating the client’s problems in terms of the Unified Treatment for Eating Disorders and Emotional Disorders (UT) model, and teaching clients the importance and optimal use of the self-​monitoring forms. There may be some cases in which this material needs to be broken into different sessions and other cases where all these goals can be met in a single session (or have been partially met prior to reading Chapters 1 to 3). When conducting a group, it is a good idea to cover some of these goals in individual intake assessment/​formulation sessions prior to starting the group.

Goals Chapter 1 ■ Describe the types of problems this program was designed to address. Describe eating disorders and other co-​occurring problems as ■ “emotional disorders.” Understand that “emotional disorders” are typically characterized ■ by one or more of these issues: Frequent, strong emotions ■ Negative reactions to emotions ■ Attempts to avoid emotions ■ Help clients determine whether their difficulties fit with this ■ program. Gain a basic understanding of the symptoms of different eating ■ disorders.

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■ Gain a basic understanding of emotional issues that commonly co-​occur with eating disorders, such as panic disorder, generalized anxiety disorder, social anxiety disorder, obsessive-​compulsive disorder, posttraumatic stress disorder, major depression, body dysmorphic disorder, borderline personality disorder, substance use disorders, and self-​harm. ■ Help clients gain a basic understanding of how the therapy described in the manual was tested in research, and provide references for further reading on this research.

Chapter 2 ■ Provide an overview of the skills that clients will learn in this treatment, which are depicted in Figure 2.1: Building a Healthy Relationship with Emotions: The Skills of the UT, including: Observing oneself objectively over time ■ Developing personal reasons (motivation) to engage in treatment ■ To “accept” and “approach,” rather than judge and avoid, emo■ tional experience To break emotions into parts (thoughts, physical sensations, and ■ behaviors) To notice and understand how emotional experience plays out ■ over time To develop skills to address each of these parts of emotional ■ experience To put these skills into practice, using exposure therapy ■ Highlight the importance of practicing these skills. ■ Describe how this treatment can be used in combination with other ■ treatments like medication, nutrition counseling, and other forms of therapy. Explain that it possible to combine medication, nutrition coun■ seling, and some other types of therapy (marital counseling, etc.) with this therapy, but members of the treatment team should discuss their plans in advance, as well as this therapy approach in detail, to make sure that there are no conflicting messages in the different approaches.

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■ Determine if now is the right time for a client to begin this program. Appreciate the importance of prioritizing therapy during the in■ itial months of treatment, and review whether there will be any major disruptions anticipated.

Chapter 3 ■ Understand the importance of recordkeeping. Become an objective observer of emotions: ■ Rather than feeling helpless, focus on observing and under■ standing In order to learn new things about emotions that are helpful ■ To counteract mood-​influenced, biased, negative assessment of ■ functioning or progress Some things clients might learn about emotions through record■ keeping: To identify specific triggers for emotional experiences ■ To identify the different parts of emotions ■ To objectively evaluate the effects of their efforts to change ■ Introduce Form 3.1: Eating, Depression, and Anxiety (EDA), and ■ conduct In-​Session Exercise 3.1: EDA. Fill out Form 3.1 and graph the score on Form 3.2: EDA Graph ■ for practice. Review sample completed graphs in Figures 3.1, 3.2, 3.3, and 3.4 ■ to see how completed graphs can illustrate different aspects of treatment progress and lead to more objective and detailed understanding of emotion.

Opening the session If you are running an Individual Session, the opening requires no formality aside from your usual methods. After greeting the client, it is good to get a quick initial sense of their emotional state. If the client is experiencing a notable emotion, consider suggesting that this example may be something to use in the session for a real-​time example of the

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relevant UT material. Try to get to the homework review within a few minutes of opening the session. Group Sessions do benefit from having a formal check-​in. A formal starting ritual is important to help the group members shift from a customary, social state of mind to a therapeutic state of mind. It is very useful to help group members with social anxiety or those who have trouble participating for other reasons to begin speaking right from the beginning of the session. Knowing something about how each group member feels at the beginning of group also helps the therapist to make the session more “alive.” When you conduct in-​session activities, it is very useful to return to examples of emotions that were shared in the group check-​in, to invite individual participants (again, particularly group members who have more trouble taking center stage) to use their own examples of active emotions to discuss in the group. If you are running a Group Session, you might introduce this group with the following check-​in: The way that we start groups is to check in. It’s important to take your emotional temperature at the beginning of the group and get your voice working to check in with yourself and with everyone else about how you are doing. If you can look around and make eye contact with the other members of group, that is good, too, because it helps us to get over the initial awkwardness of being in a group and to make connections with one another. Let’s go around the room and introduce ourselves, because everyone in this group is in their first week here, and say one thing about how we are each feeling. You might also say a few words about what emotional issues you are here to work on, if you feel like it. If you want to just say a sentence about what you are feeling in this moment, that’s great, too. The group check-​in should be brief—​for example, it should take about 5 minutes for a 50-​minute group session and 10 minutes for a 90-​or 120-​minute group session. Based on the number of people in your group, you might make a recommendation about how long the check-​ in should be. For example, if there are six people in the group, you could suggest that each person take about 1 minute. Early in treatment, before clients have developed a sense of how much material there is to

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cover during group time, they may take a little longer or more variable amount of time to speak.

Therapist tips for the “preparing for treatment” session The rationale for the UT There is language in Chapters 1 and 2 that will help you to describe the relationships between emotional disorders and eating disorders and the rationale for using the UT to treat all presenting problems in a unified way. There is also language for describing how emotional disorders include frequent, intense emotions and/​or habitual efforts to avoid or escape emotion. You and your clients can together review this reading and the responses that clients have to these ideas. Many clients with eating disorders may not consider themselves to be the type of person who has frequent and intense emotions, but this does not need to be a problem. It is likely that they are so good at avoiding situations that provoke emotion that they do not experience strong emotion that often. In these cases, the avoidance itself is likely causing problems—​restricting food until it is unhealthy in order to avoid the fear of being fat, for example. There are many ways that clients may identify that their lives are limited or they suffer negative consequences because of actions they take that are avoidant in some way. Here are a number of questions that can help you to explore the role of emotion and the application of the UT model: Regarding frequent/​intense emotions Does it seem like you feel sad/​anxious/​frustrated more than other ■ people? Is it hard for you to stop thinking about things that upset, anger, or ■ embarrass you? Do you consider yourself a worrier? ■ Do you have trouble controlling your temper? ■ Have other people observed that your emotions seem very intense? ■ Does it seem to take you a long time to calm down when you get upset? ■ Does it seem like your feelings in general are intense? ■

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Regarding negative reactions to beliefs about unwanted emotion Do you beat yourself up for feeling certain ways, like giving yourself a ■ hard time for getting upset about something? Do you get frustrated thinking that your emotions are irrational? ■ When you feel nervous, do you often worry it is going to escalate into ■ more and more anxiety? When you start to feel down, do you feel like it’s going to ruin your ■ whole day? Do you sometimes wish you could get rid of negative emotions ■ altogether? Are there parts of your thoughts/​feelings/​symptoms that scare you or ■ scare other people? Do your emotions feel very uncomfortable at times? ■ Regarding avoidant efforts to control or change emotions ■ Do you tend to put off or avoid doing things that make you anxious? Do you tend to avoid situations where you think you’ll be ■ uncomfortable? Do you avoid doing things when you are in a bad mood or ■ feeling down? Do you try not to think about the things that make you upset? ■ Do you sometimes cope with uncomfortable emotions by distracting ■ yourself? Are there things you wish you could do but don’t because you’re ■ concerned about feeling a strong emotion, like anxiety, sadness, or frustration? Do you try to do things to get rid of your negative emotions? ■ Do you try to do things to prevent yourself from feeling certain ■ emotions?

EDA and progress chart exercise Self-​monitoring can be an onerous task that clients may wish to avoid. We have found that it is necessary to take time prior to beginning therapy to fully review the importance and utility of self-​monitoring. The materials in the workbook review many of the important ideas for

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why self-​monitoring is important—​however, the reading itself is somewhat technical and it is much more useful to go over the graphs and do a self-​monitoring and graphing exercise together in one of the early sessions. Here are some questions, in addition to information in the workbook, that are useful to review with the group participants regarding the EDA and progress chart. What is the point of self-​monitoring? ■ ■ ■ ■

Notice the relationships between antecedents and emotional responses. Track the natural ups and downs of your emotional life. Track your overall progress. If your scores are going down (i.e., getting better), it lets you see that and is encouraging. It is actually hard to remember accurately how you scored before. ■ If your scores are going up (i.e., getting worse), tracking helps you reflect on what might be going on and helps you think about how you want to react to that. Is there something that you want to change? Or are these stronger emotions something that you need to pass through without action to make them go away? If some scores are going up and some are going down, it might help you ■ think about how your emotions relate to one another. When you stop using eating disorder behaviors and your eating disorder gets better, do you get more or less depressed? Do these things seem to go together, or are they separate? When you are working on one specific thing—​say, if you worked hard one week on the symptoms of anxiety—​did your anxiety go up or go down? Sometimes the therapy you are doing might make your emotional reactions go up in the short term and then come down in the long term, or sometimes your emotional state might feel immediately better. When clients begin to understand and see the usefulness of tracking, they will begin to feel very enthusiastic about it. They will want to track all of their emotion-​driven behaviors (EDBs), triggers, and emotions alongside the original three parts of the EDA. Some of the extras that people commonly track include self-​injury, urges to drink/​use, anger outbursts, poor body image, and motivation. While their enthusiasm shouldn’t be doused, it is helpful to point out that:

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■ There is no corresponding questionnaire and rating for these items, so you lose some objectivity. Perhaps one EDB line is enough for several co-​occurring symptoms; in ■ other words, do you need to track anger, self-​injury, and urges to use? Many people have found it tremendously useful to annotate the highs ■ and lows on the graph. Adding a simple label can be important because it lets you see how you managed certain triggers in the past and how that affected your mood. It is even better to compare how you handle the same trigger as time passes. Some people will start to notice patterns in emotional experiences; for some ■ reason Fridays are hard, or holidays, or days when a certain event happens.

Closing the session Closing an Individual Session does not require any additional formality beyond preparing the homework, confirming the next session time, and other customary practices. Group Sessions can require additional formality. Try to save 5 or 10 minutes at the end of the session after preparing the homework and confirming the next session time for closing the group. If it is not possible to save the time, it is not as important to formally close the session as it is to open it formally. If you are running a Group Session, and you have time saved, you might close the session as follows: It’s important that you try to complete Forms 3.1 and 3.2 every single day. If you still need some help understanding how to do this, please ask for some help. To close the group, let’s go around the room and say one thing about how we are each feeling. You might also say a few words about what impact this group had on you; did you learn anything new or did you feel surprised or moved by something? Also, if you have a personal goal for the week, that can be good to say aloud.

Homework Many of the forms and worksheets will need to be filled out more than once. We are including one blank copy of every worksheet and form in the client

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workbook (within the corresponding chapter) as well as a blank copy of each in the appendices to this therapist manual. For those items that clients will need more than once, you can provide additional copies for them, or clients can download blank copies themselves from the TreatmentsThatWork™ website at www.oxfordclinicalpsych.com/​UTforEDs. Fill out Form 3.1: Eating, Anxiety, and Depression (EDA). ■ Plot scores on Form 3.2: EDA Graph. ■ Read Chapter 4 and preview the exercises. ■

In-​Session Exercises All in-​session exercises appear in the client workbook within the body of the corresponding chapter. We also include these exercises in this therapist guide, near the end of the corresponding chapter.

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In-​Session Exercise 3.1 EDA

You will need the following items to complete this activity: ■ Form 3.1: Eating, Depression, and Anxiety (EDA). This questionnaire can be found near the end of this chapter. ■ The matching EDA Graph (Form 3.2), which also appears at the end of this chapter ■ Highlighters or colored markers When you are ready, start with Steps 1 and 2 pictured in the process below, but don’t go on to Step 3 just yet:

Step 1: start by filling out the questionnaire based on today

Step 3: plot your ratings on the graph, using different colors for ED, depression, and anxiety

Step 2: calculate your ratings in each section

As you probably noticed, there are sections for eating disorder (ED), depression, and anxiety scores. Each section has a question asking how intense your symptoms are and a question asking how much those symptoms have made it difficult to function. Each score can range from 0 (meaning no symptoms or interference at all) to 8 (meaning the most intense symptoms possible and complete inability to function due to those symptoms). A score of 4 would be midway between those poles. In Step 3, you are going to learn how to graph these scores. You will begin graphing for homework. Figure 3.1 shows an example graph of the first 5 days of someone’s treatment.

8 Scores

6 4

ED

2

Depression

0

Anxiety 1

2 3 4 First 5 days in treatment

Figure 3.1: Learning to Plot Your Scores on the EDA Graph

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What do the scores mean?

Symptom score

Tracking your emotions is the activity of regularly observing your emotions at regular intervals—​it could be every day, every time you have a therapy session, or every week—​and monitoring how they peak and fall and regulate based on many factors, such as your inner experiences, your behavior, and things that happen to you. Imagine that you have graphed the score of your eating disorder symptoms over time, and the graph looks like the simple one shown in Figure 3.2. 7 6 5 4 3 2 1 0

ED

1

2

3 4 Time in treatment

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Figure 3.2: Example ED Graph

A deeper understanding of the EDA Now we are going to look at a little more complicated graph. This is a client’s graph showing all three parts of the EDA tracked over most of the time that this client (who was filling out her EDA daily) was in treatment. In total, she tracked just over 12½ weeks of treatment at multiple levels of care, and we are going to look at two different snapshots of her journey to help us understand the EDA in a deeper way. Figure 3.3 shows her first month of treatment, and Figure 3.4 shows weeks 7 through 10. After about 1 month, this client transitioned from residential to day treatment, and toward the end of the second month she moved to a different state. It is worth noting that after 2 weeks of residential treatment, she was no longer reporting behavioral symptoms, but continued to experience urges at varying intensities. We are going to trace over each of the lines with a different color. This will make the eating disorder, depression, and anxiety lines really pop out while we’re talking about what her scores mean.

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8 7 Scores

6 5 4

ED

3

Depression

2

Anxiety

1 0

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

First month in treatment

Scores

Figure 3.3: Example EDA Graph

8 7 6 5 4 3 2 1 0

ED Depression Anxiety 1 2 3 4 5 6 7 8 9 10111213141516171819202122232425262728 Weeks 7–10 of treatment

Figure 3.4: Example EDA Graph

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MODULE 1

Motivation and Goals

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CHAPTER 4

Therapist Materials for Motivation and Regular Eating

Goals ■ Discuss the importance of motivation. Motivation and treatment engagement are the most important ■ predictors of outcome. Motivation goes up and down, and ambivalence is OK—​it is ac■ tually expected. It is useful to recall a difficult achievement in the past and what ■ kept the client motivated to persist in achieving that goal, using In-​Session Exercise 4.1: Q&A on Achieving Difficult Things. Use In-​Session Exercise 4.2: Decisional Balance Activity and In-​ ■ Session Exercise 4.3: Decisional Balance Exercise to explore: The costs and benefits of changing. ■ The costs and benefits of remaining the same. ■ Use In-​Session Exercise 4.4: Setting Goals Activity to set specific ■ goals the client hopes to achieve during treatment. Some goals will be ED-​related, and some goals will be related to ■ “other issues.” One goal will be regular eating, particularly if clients are in outpa■ tient treatment. Set manageable steps to reach treatment goals, using In-​Session ■ Exercise 4.5: Introduction to “Taking the Necessary Steps.” Include one step for the next period of time before the next ■ session. Introduce Worksheet 4.1: “Taking the Necessary Steps” Homework ■ Sheet.

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■ Introduce Form 4.1: Regular Eating Food Log and Box 4.1: Sample Completed “Taking the Necessary Steps” Worksheet. Decide whether client should complete daily for homework.

Homework review Fill out Form 3.1: Eating, Depression, and Anxiety (EDA). ■ Plot scores on Form 3.2: EDA Graph. ■ Read Chapter 4 and preview the exercises. ■ Recordkeeping may be different depending on the frequency of sessions. The EDA should be completed each time there is a session, which means daily, several times weekly, or weekly, depending on session frequency. In the homework review, you should discuss whether clients are doing the EDA on the correct schedule and plotting the scores on the chart. If clients did not do the recordkeeping this past week, you can ask them to think about what may have kept them from recording their experiences, and ways they might make sure to stick to it. Is there a time of day they can devote 10 minutes to recording? Could they set an alarm? Can they leave forms somewhere that will remind them to complete their recordkeeping, like next to the bed (to remind them to do it at the end of the day) or next to the coffee maker (to remind them to do it at the beginning of the day)? It is crucial to have these records, to help clients feel more in control of their distressing experiences, to be able to observe and understand them, and to objectively track their progress over time. If clients did complete the self-​monitoring, congratulate them for a job well done!

Opening the session If you are running an Individual Session, the opening requires no formality aside from your usual methods. After greeting the client, it is good to get a quick initial sense of their emotional state. If the client is experiencing a notable emotion, consider suggesting that this example may be something to use in the session, for a real-​time example of the

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relevant UT material. Try to get to the homework review within a few minutes of opening the session. Group Sessions do benefit from having a formal check-​in, however. A formal starting ritual is important to help the group members shift from a customary, social state of mind to a therapeutic state of mind. It is very useful to help group members with social anxiety or who have trouble participating for other reasons to begin speaking right from the beginning of the session. Knowing something about how each group member feels at the beginning of group also helps the therapist to make the session more “alive.” When you conduct in-​session activities, it is very useful to return to examples of emotions that were shared in the group check-​in, to invite individual participants (and, again, particularly group members who have more trouble taking center stage) to use their own examples of active emotions to discuss in the group. If you are running a Group Session, you might introduce this group with the following check-​in: Before we begin talking about motivation today, I’d like us to first take a moment to transition from our lives outside of here, and anchor fully into this session today. Take a deep breath in and think for a moment: What brings you here? What do you want to be different about your life outside of here? Change is hard to do, and finding the motivation to make changes is hopefully one of the reasons you’re here. We are going to go around the room, and each person is going to share something about change and motivation. You can say what your level of motivation to change is, you can say how you feel about making a change, or if you like you can share about what is motivating you to be here. The group relational check-​in should be brief—​for example, it should take about 5 minutes for a 50-​minute group session and 10 minutes for a 90-​or 120-​minute group session. Based on the number of people in your group, you might make a recommendation about how long the check-​in should be. For example, if there are six people in the group, you might say something like: Why doesn’t everyone take about a minute or so to share their feelings about change and their motivation to be here.

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Therapist tips for motivation and regular eating The in-​session exercises appear in the client workbook and also later in this chapter, prior to the vignettes.

Talking about motivation in the past First, using In-​Session Exercise 4.1: Q&A on Achieving Difficult Things, clients will identify difficult things they have done in the past and try to remember how they managed to stay motivated. This intervention comes from Motivational Interviewing and is intended to help develop self-​efficacy around changing the habits associated with the ED and other emotional issues.

Group activity about the pros and cons of making changes Second, using In-​Session Exercises 4.2: Decisional Balance Activity and 4.3: Decisional Balance Exercise, clients will do a “decisional balance” exercise, which again comes from the field of motivational interviewing, and is intended to help make ambivalence more conscious, to welcome ambivalence as a topic of conversation, and to address what will truly be motivational obstacles to change and reasons for change.

Thinking about food, eating, and emotion functioning goals Third, using In-​Session Exercise 4.4: Setting Goals Activity, discuss the goal of “regular eating,” which means eating three meals and two or three snacks without eating in between.1 It is important to address motivation and necessary steps to achieving this goal. The example of “regular eating” is intended to show how to develop “necessary steps,” which include filling out the food log.

If a client is in residential treatment or working very closely with a nutritionist, these goals will be addressed as part of the team approach, which is how the manual has been used in research studies. If a client is in outpatient treatment, this goal is even more important and requires more time. 1

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Fourth, clients will address goals and necessary steps in other areas of eating issues and emotional functioning.

Reviewing the goal-​setting example and homework Finally, using In-​Session Exercise 4.5: Introduction to “Taking the Necessary Steps,” clients will review an example of a “taking the necessary steps” form, if there is time, to think about setting goals. Use Box 4.1: Sample Completed “Taking the Necessary Steps” Worksheet for reference.

Ambivalence and judgmental thought Clients often judge themselves for not having enough motivation. In some ways they feel like they should want treatment, or that they should want to get rid of the ED, or that they ought to be more committed to the process. The truth is that motivation fluctuates, and this is normal. In many ways, ambivalence is like its own emotional experience, and therefore we should encourage clients to lean in to that. The more you can normalize the feelings of ambivalence, the better; the more you can validate the judgment, the better. Saying things like “I get why you feel like you ought to be more motivated, because everyone around you is urging you to be . . . but some days are really hard, and it’s tough to find that motivational energy on those days. And yet, here you are today.”

Nothing wrong with low-​balling a goal One of the biggest pitfalls that people make with setting goals is overestimating what they can do in reality. Sometimes it’s aiming too high; sometimes people are so out of touch with what they are capable of; sometimes people are perfectionists and don’t know how to do “normal” and only know how to do “exceptional”; and sometimes past failures are enough to put people off from trying at all. It is actually a skill to learn how to set attainable and realistic goals. When clients are learning to set realistic, concrete goals, sometimes it helps

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to encourage them to “low-​ball it.” Why? First, we want to ensure success the first go-​round. Second, low-​ball goals are easier to set and make concrete, and therefore they are a good way to learn the skill of setting realistic goals.

Clinician’s awareness As a clinician, sometimes your own desires for your clients to recover can present an obstacle in the relationship. For instance, one way that the decisional balance activity can go wrong is when your input is overly coercive or pro-​recovery. Try to meet the clients where they are; even when there are a dozen different reasons on your mind why recovery might be important for a particular person, if that client can only think of two (or one), then that is where they are. When you are able to connect with that reality (perhaps feeling a little uncomfortable but accepting it anyway), then the trust and empathy undoubtedly created in those moments will ultimately help build motivation down the road.

Introducing Form 4.1: Regular Eating Food Log When you introduce Form 4.1: Regular Eating Food Log for homework, note that in addition to setting concrete goals for their behavior for the week, one goal is just to fill out Form 4.1 each day. Achieving regular eating may be a long-​term goal with many concrete steps. One important first goal is just to write down what eating occurs, as close as possible to when it occurs, and to start observing patterns. You might ask clients to reflect on what would be difficult just about writing down the food that they eat—​would binge eating be particularly hard to write down? Or would it be hard to do it without calorie counting? Encourage clients to simply try to record as much as possible without trying to achieve a “diet,” counting calories, or other ways that they may have used self-​monitoring as part of a restrictive diet. There are additional therapist guide materials in the next chapter for reviewing and addressing the regular eating logs in subsequent sessions.

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Closing the session Closing an Individual Session does not require any additional formality beyond preparing the homework, confirming the next session time, and completing other customary practices. Group Sessions can require additional formality. Try to save 5 or 10 minutes at the end of the session after preparing the homework and confirming the next session time for closing the group. If it is not possible to save the time, it is not as important to formally close the session as it is to open it formally. If you are running a Group Session and you have time saved, you might close the session as follows: To close the group, let’s go around the room and say one thing about how we are each feeling. You might also say a few words about what impact this group had on you: Have you learned anything new or do you feel surprised or moved by something? Also, if you have a personal goal for the week, that can be good to say aloud. Therapists do not need to model the closing reflection. However, you might alert everyone to how much time there is left to ensure everyone has a chance to speak. For example, you might say: We have just a few minutes before the end of session, so a brief reflection is welcome. Or, alternatively: We have 15 minutes before the end of the session, so take some time to really reflect on your response to the regular eating material, and share as much or as little as you like. You might include a personal goal for this week as well.

Homework Many of the forms and worksheets will need to be filled out more than once. We are including one blank copy of every worksheet and form in the client workbook (within the corresponding chapter) as well as a blank copy of each in the appendices to this therapist manual. For those items that clients will need more than once, you can provide additional copies for them, or clients

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can download blank copies themselves from the TreatmentsThatWork™ website at www.oxfordclinicalpsych.com/​UTforEDs. Fill out Form 3.1: Eating, Depression, and Anxiety (EDA). ■ Plot scores on Form 3.2: EDA Graph. ■ Fill out Form 4.1: Regular Eating Food Log. You and your thera■ pist should discuss if it is a good idea to fill out Form 4.1 each day. We do recommend using the actual form, which as noted earlier is available to download, particularly if you do not eat regularly or experience binge eating and/​or compensatory behaviors. The form has a column labeled “B?” where you can put a mark in the column if an eating event was a binge episode. It also has a column labeled “CB?” where you can put a mark if you purged by vomiting, used laxatives, or used diuretics as a compensatory behavior. The form should not be used to record calories or measurements, just general descriptions of the food and the amount, along with the other information listed. Review Box 4.1: Sample Completed “Taking the Necessary Steps” ■ Worksheet, and then fill out Worksheet 4.1: “Taking the Necessary Steps” Homework Sheet for yourself. Read Chapter 5 and preview the exercises. ■

In-​session exercises All in-​session exercises appear in the client workbook within the body of the corresponding chapter. We also include these exercises in this therapist guide, near the end of the corresponding chapter.

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In-​Session Exercise 4.1 Q&A on Achieving Difficult Things

Please think of something in the past that you achieved that was really difficult (such as “I completed my undergraduate degree” or “I made the team”). What about that was hard? What helped you to stay motivated? Write your answers to these questions below. Past achievement: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​__​_​_​ What about that was hard? _​_​_​_​_​_​_​_​_​_​_​_​_​_​__________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ What helped you to stay motivated? _​_​_​_​_​_​_​_​_​_​_​__________________​_​_​_​_​_​_​_​_​_​_​_​_​_​

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In-​Session Exercise 4.2 Decisional Balance Activity

Most people at this point in treatment have mixed feelings about their eating disorder, other emotional problems, and pursuing recovery. At times you might feel confused or overwhelmed by these conflicting feelings and give up thinking about them altogether. Thinking through the good reasons to change and the strong reasons NOT to change can help the process feel more manageable. Start by identifying the problem areas—​perhaps based on your diagnostic information, or perhaps just whatever you struggle with—​that you came to treatment for help with. These should be things you would be interested in changing. Examples might be “eating disorder,” “social isolation,” “OCD,” or “body image problems.” Write as few or as many as you like: 1. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ 2. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Others: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​____________________________​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__________________________________​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__________________________________​_​_​_​_​_​_​_​_​_​ For each of these areas, we are going to identify key pros and cons of change. There are blank copies of some of the Chapter 4 worksheets later in this chapter.

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In-​Session Exercise 4.3 Decisional Balance Exercise

People want to change because they don’t want to keep feeling this way, and they don’t want to continue to be limited in their lives. Think about all the ways your symptoms have gotten in the way of living the life you want. Do you have values, goals, or qualities that have been compromised by the eating disorder, depression, or anxiety? If things stay the same, how will things look a year from now? What wouldn’t you like about that? How has your life changed since you became this way—​what would you like to have back? Problem area: _​_​_​_​_​_​_​_​_​_​_​_​_​_____​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Cons/​Costs Why don’t you want to change? Why do you want to stay the same?

Pros/​Benefits Why do you want to change? Why don’t you want to stay the same?

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In-​Session Exercise 4.4 Setting Goals Activity

This worksheet can be difficult. It might feel like the steps necessary to meeting your goal are not manageable, or it is hard to see yourself actually doing some of these things. These are common feelings! As you go through treatment, you will learn skills that will help to make the emotions more manageable, although it is hard to believe this one hundred percent now. Keep in mind that the goal of this section is to come up with specific behaviors that can be completed in a specific timeframe, such as “Eat lunch” as opposed to “Recover from my eating disorder.” Research shows that regular eating is an important part of recovery. Most individuals with eating disorders do not eat regularly—​meaning eating three meals and two or three snacks, or eating roughly every 3 to 4 hours throughout the day. One important goal is regular eating. However, this can be a very difficult goal to achieve! To make it more manageable, one of the goals for each session at the beginning of treatment will be taking steps toward that goal. We will address regular eating first, and set more personalized goals next. One of my goals for early treatment is: Regular eating Making it more concrete Now, we are going to make this goal more concrete. We have set some guidelines, and you can identify what other things you would be doing or not doing. THINGS I WANT TO DO (regular eating): Eating three meals and two or three snacks per day Eating roughly every 3–​4 hours and not eating between these times Eating enough to maintain a healthy weight for my body THINGS I WANT TO STOP DOING (for example, binge eating, grazing, or compensatory behaviors such as purging by vomiting, laxative abuse, or compulsive exercise): ______________________________________________________________________ ______________________________________________________________________

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In-​Session Exercise 4.5 Introduction to “Taking the Necessary Steps”

Next, think about some small steps that you can take toward reaching the specific treatment goal you have recorded earlier in this form. These steps should take anywhere from a few days or a week to achieve. It can be helpful to work backward from your goal to help identify specific steps. Use the behaviors listed earlier in this form to help come up with specific steps. If you are working with a nutritionist/​dietitian, you may be setting goals in those sessions as well. This work can support those goals or add to them. Are there any steps you can be trying to take between now and your next session of therapy? Step 1: Write down my eating, compensatory behaviors, and notes in self-​ monitoring log Step 2: Step 3: Step 4: One personal goal for treatment is: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​____________________________________________​_​_​_​_​_​_​_​_​_​_​​

Making it more concrete What would it look like once you have achieved this goal? What concrete things would you be doing, or not doing? What behaviors would you be engaging in, or not engaging in? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__________________________________​_​_ ______________________________________________________________________ ______________________________________________________________________​

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Case vignettes Case ­vignette 4.1 The following is therapist/​client dialogue where the therapist and client are exploring motivation and ambivalence. These concepts will be explored using a spontaneous cost/​benefit exercise in the vignette, included more formally in the workbook as the Decisional Balance Exercise. The patient is a Latino adolescent cisgender woman diagnosed with Anorexia Nervosa and Generalized Anxiety Disorder. She was recently required to take a medical leave from her senior year of high school due to the decline in her health. C:

I am so frustrated with my parents. They make me come here even when I don’t want to! T: I hear you; it is frustrating to do things we don’t want to do. C: Yeah, they definitely want me to recover more than I do. Some days when I come here, though, it is not so bad, but I just never know what it’s going to be like and I don’t like that. T: Sure, I imagine it is hard to not know what to expect. C: Yes! It makes my heart race and my palms sweat just thinking about it. I am okay with seeing you, though; I just don’t know if I am really ready to change my eating. At least my time with you is helpful. T: I’m glad to hear the sessions are helpful. And there may be days that you don’t want to see me or that you are mad at me, and that’s okay. We will talk about it. I can handle any of your emotions. C: Thanks. T: I want to go back to something you said. It was so very important and insightful. C: Really? What? T: You said that there are some days when you don’t like coming because there is so much unknown and that you still come. You confront that fear, that’s really hard, and you have experience in here now where after confronting that anxiety you get something out of the session. C: Huh, yeah, that’s true. Maybe I don’t really know what I want. T: And that’s okay too! Ambivalence is totally normal. In fact, in the same moment you can want to change and not want to change.

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You may find that it changes from day to day or even moment to moment. Or meal to meal? Exactly! Let’s try something: Can you think of two reasons not to change and also two reasons to change? Well, I don’t want to gain weight, and before I came into treatment my days were very well planned out, so I knew exactly what to expect. I do want to go to college next year, so I know I have to be better to do that. I also want to be able to be just a little spontaneous, like with my friends—​but that scares me. Wow, great job! See? You recognized how you can be both motivated to change and not to change at the same time!

Case ­vignette 4.2 The following is therapist/​client dialogue where the therapist and client are exploring motivation and goal setting. The client is a middle-​aged White woman diagnosed with Binge Eating Disorder and Major Depressive Disorder. She is separated from her partner and lives alone. T:

I would like to spend some time today discussing what treatment will look like. We do this by coming up with a set of goals. This will be a collaboration between me and you so that way we both know what we’re working on. These goals are not static, meaning they can change as treatment progresses, so we can shift the goal if you feel you’ve met it, or if you feel that there is another goal that resonates more as we work together. In our first few sessions, you discussed your depression and your eating disorder, so would it be okay with you to start there? C: Sure. T: Can you say more about your depression? C: I feel so depressed and weighed down all the time and it makes everything hard to do. Even simple things like showering or getting to work or appointments that should be easy for people are really hard for me, and I’m lonely, which just makes everything worse.

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It seems like it is tough to go to work and make your commitments when you feel so weighed down. Is this something you feel comfortable working on with me? I think it may be helpful. Yes, it is. I would like to not call out of work as much and to be able to make it to my appointments on time. OK, great—​those are great start. You also mentioned showering. Is this something that we can add to your goals? Probably. It does help once I’m actually in the shower; it’s just hard getting there. I don’t know if I can do it on my own, though. It seems so hard in the moment. This conversation makes me think of the concept of motivation in goal setting. Whenever we’re goal setting, our motivation also fluctuates. This doesn’t mean the goal is unachievable. Often, it is in the engagement of what you need to do in the moment—​ rather than the motivation for the task—​that helps change, since motivation can fluctuate often and frequently. For example, you may not be particularly motivated to go to work or to shower, and being engaged in the task can still yield the results you want in the long term. I see. I have more motivation to achieve the larger goal of being less depressed, and I use that motivation to get myself to shower even though I really don’t want to. Exactly! And what role does your eating disorder play in all of this? What goal might you have for that? Well, the days I’m most depressed, I usually don’t have an appetite, so whether I make it to work or not, I usually binge later in the afternoon. And that definitely contributes to being more depressed. So what would it look like if we were to make a goal for the treatment of your eating disorder? Hmm. I know we have talked about if I eat more during the day, I won’t be starving later in the day and decrease my binges—​which would be helpful, since I feel so ashamed by my binges. Sure, that can certainly be the case as you nourish yourself more during the day. How do you think we can break that down a bit further? What necessary steps might we include to get to the goal of not binge eating in the afternoons?

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That’s a hard question. I know I often rush and grab for anything in the house. So I would like to be able to slow down and pause to think before I grab something. Slowing down and taking pauses is a great start! How might we do that? Well, we’ve talked about mindfulness and turning off the television, not scrolling through social media, or comparing myself to my married friends, which makes me sad. Right. I’m sure whatever is happening for you while seeing your friends with their families is a trigger as well for binges, would you agree? What do you do then? Completely. Well, I binge and then I completely disengage; I don’t even answer texts from my friends, especially because I’m still ashamed of being alone and being separated. What would it look like if we were to make this even more concrete? Probably answering at least one text from my friends a day, to start, and then maybe an alarm to remind me to eat during the day? Absolutely. That’s a great idea!

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CHAPTER 5

Therapist Materials for Regular Eating

This is a supplementary session that is particularly designed for groups and clients who are not receiving frequent, adjunctive treatment focused directly on eating regularly (such as meetings with a dietitian/​nutrition counselor, residential treatment, or daily food coaching). Some clients also may not require extensive attention to regular eating because they eat very regularly already and have other issues. Nonetheless, it is important to log eating and to monitor and discuss connections between eating, symptoms, and emotions. As the therapist, you should decide whether this session is necessary as a standalone focus for a full session; whether a brief review of these issues can be combined with other sessions (such as the previous one or the next one); or whether there is so much attention in the client’s treatment team to food and eating behaviors that this session is not necessary or not appropriate.

Goals Review homework. ■ Review food logs. Refer to Form 4.1: Regular Eating Food Log. ■ If the client has completed food logs regularly, acknowledge the ■ importance of this effort and encourage the client to continue. If the client did not complete food logs regularly, assess what the ■ obstacles were and how to facilitate food record completion. If the client did no food logs, try to fill in a form together during ■ the session, using the past one or two days from memory, to practice and to help the client appreciate the importance of food records. Take time to note patterns in food logs. ■

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■ Understand and plan regular eating. Introduce In-​Session Exercise 5.1: Personal Regular Eating Calendar. “Regular eating” means eating three meals and two or three snacks ■ per day. Never go more than 4 hours without eating. ■ Take time to plan as many meals and snacks as possible. Not rig■ idly, for the whole week, but always have a plan for the day that allows for eating, and a general idea of what is going to be eaten at that time. Roughly map out what times of day those meals and snacks would ■ occur for the client. Review Figures 5.1 and 5.2 for examples of regular eating schedules. Identify obstacles to regular eating and develop specific plans to ad■ dress obstacles. Introduce Worksheet 5.1: Weekly Obstacle Sheet. Identify strategies to delay automatic compulsive eating between ■ regular eating episodes. Introduce Worksheet 5.2: Activities to Delay Compulsive Eating.

Homework review Fill out Form 3.1: Eating, Depression, and Anxiety (EDA). ■ Plot scores on Form 3.2: EDA Graph. ■ Fill out Form 4.1: Regular Eating Food Log. You and your thera■ pist should discuss if it is a good idea to fill out Form 4.1 each day. We do recommend using the actual form, which as noted is available to download, particularly if you do not eat regularly or experience binge eating and/​or compensatory behaviors. The form has a column labeled “B?” where you can put a mark in the column if an eating event was a binge episode. It also has a column labeled “CB?” where you can put a mark if you purged by vomiting, used laxatives, or used diuretics as a compensatory behavior. The form should not be used to record calories or measurements, just general descriptions of the food and the amount, along with the other information listed. Review Figure 4.1: Sample Completed “Taking the Necessary Steps” ■ Worksheet, and then fill out Worksheet 4.1: “Taking the Necessary Steps” Homework Sheet for yourself. Read Chapter 5 and preview the exercises. ■ 80

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Opening the session If you are running an Individual Session, the opening requires no formality aside from your usual methods. After greeting the client, it is good to get a quick initial sense of their emotional state. If the client is experiencing a notable emotion, consider suggesting that this example may be something to use in the session, for a real-​time example of the relevant UT material. Try to get to the homework review within a few minutes of opening the session. Group Sessions do benefit from having a formal check-​in, however. A formal starting ritual is important to help the group members shift from a customary, social state of mind to a therapeutic state of mind. It is very useful to help group members with social anxiety or those who have trouble participating for other reasons to begin speaking right from the beginning of the session. Knowing something about how each group member feels at the beginning of group also helps the therapist to make the session more “alive.” When you conduct in-​session activities, it is very useful to return to examples of emotions that were shared in the group check-​in, to invite individual participants (again, particularly group members who have more trouble taking center stage) to use their own examples of active emotions to discuss in the group. If you are running a Group Session, you might introduce this group with the following check-​in: Before we begin talking about regular eating today, I’d like us to take a deep breath and think for a moment: How does the phrase “regular eating” sit with you? How does it make you feel? What does it bring to mind? Just take a moment to observe yourself responding to this phrase. We are going to go around the room, and each person is going to share something about that. You can say what you were thinking, you can say how you feel about regular eating, or if you like you can share something else about regular eating that came to mind. Remember that the check-​in exercise is not meant to generate discussion; rather, it is a place for every voice to be heard, in the moment. With groups that include members who have trouble identifying a statement that is appropriate to begin the group—​particularly how long or detailed the statement should be—​it can be helpful for the therapist to

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model the length and type of comment that is appropriate. For example, in this case, a therapist might say: I will start the check-​in. When I think of “regular eating,” I feel a little guilty about my eating habits, but I also feel a sense of hope, like maybe regular eating could give me more energy. Therapist comments can be true reflections of the therapist’s experience and do not have to be universally positive, but they also should not include very personal details or intense, unresolved negative emotion. (Client statements during the check-​in absolutely may include personal details and intense, unresolved negative emotion, of course.) The group relational check-​in should be brief; for example, it should take about 5 minutes for a 50-​minute group session and 10 minutes for a 90-​or 120-​minute group session.

Therapist tips for reviewing food logs and planning regular eating The exercise is intended to help clients become aware of when it is difficult to conduct regular eating and what patterns of behaviors, symptoms, and emotions precede and result from differences in eating behaviors. Both the discussion of the food logs (Form 4.1) and the process of planning regular eating (In-​Session Exercise 5.1: Personal Regular Eating Calendar) should take a long time, and you should help clients attend to fine details and list specific foods and specific strategies to address problems using Worksheet 5.1: Weekly Obstacle Sheet (for example, buying snacks ahead of time and carrying them, or identifying a store clients can run to during work or school to get a specific snack). Encourage clients to take their time with each piece of this process. It is hard to start planning every meal and addressing every obstacle, and being encouraged to really think it through in session is the best way to start being more conscious and attentive. Clients in the regular eating activities tend to say they understand the concept and they will just try to do it without digging into the details of how they will do it. This is the time for digging into the details, both

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the details of what usually happens for the client and the details of how to implement regular eating over the next week. You may feel that your role is overlapping with a dietitian’s role when you do this. In some senses, it is overlapping. Ideally a dietitian will be involved in the treatment team. However, nutrition counseling is often more focused on the content of the food than the regularity of the food. From a psychological standpoint, we know that going for long periods of time without eating creates psychological vulnerability. It is much easier to intervene in a set of behaviors that lead to a symptom early in the chain rather than when the emotion is strongest and the emotion-​ driven behavior is harder to resist. Being able to eat regularly has been shown to provide clients with a foundation on which to do the other hard work involved in therapy. It is also true that clients expect themselves to be able to follow a “diet,” and it can feel like you are assigning them a diet. Try to help them not to see it this way. You are suggesting a pattern of behavior that will interrupt their regular patterns of overlearned symptoms, which will allow you and the client to see when certain emotions and thoughts prevent them from eating in a regular and healthy fashion. Worksheet 5.2: Activities to Delay Compulsive Eating provides some examples of symptom interruption strategies and encourages the clients to come up with their own strategies. A surprisingly large amount of information comes from digging into eating behavior specifically. Often people are not aware of the emotions attached to eating (and to not eating), and this focused and detailed attention to eating can help reveal the emotions that drive the disordered patterns.

Closing the session Closing an Individual Session does not require any additional formality beyond preparing the homework, confirming the next session time, and other customary practices. Group Sessions can require additional formality. Try to save 5 or 10 minutes at the end of the session after preparing the homework and

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confirming the next session time for closing the group. If it is not possible to save the time, it is not as important to formally close the session as it is to open it formally. If you are running a Group Session, and you have time saved, you might close the session as follows: During this session you have probably had a lot of different emotions. Thinking and talking about regular eating can be stressful. To close the session, I’m going to challenge you to dig deep and say one thing that was stressful about this session, and why it was stressful for you. You might also say a few words about what impact this group had on you; did you learn anything new or did you feel surprised or moved by something? Also, if you have a personal goal for the week, that can be good to say aloud. Whatever you’re comfortable sharing is great! Therapists do not need to model the closing reflection. However, you might alert everyone to how much time there is left to ensure everyone has a chance to speak. For example, you might say: We have just a few minutes before the end of session, so a brief reflection is welcome. Or, alternatively: We have 15 minutes before the end of the session. So take some time to really reflect on your response to the regular eating material, and share as much or as little as you like. You might include a personal goal for this week as well.

Homework Many of the forms and worksheets will need to be filled out more than once. We are including one blank copy of every worksheet and form in the client workbook (within the corresponding chapter) as well as a blank copy of each in the appendices to this therapist manual. For those items that clients will need more than once, you can provide additional copies for them, or clients can download blank copies themselves from the TreatmentsThatWork™ website at www.oxfordclinicalpsych.com/​UTforEDs. Fill out Form 3.1: Eating, Depression, and Anxiety (EDA). ■ Plot scores on Form 3.2: EDA Graph. ■

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Fill out Form 4.1: Regular Eating Food Log. ■ Fill out Worksheet 5.1: Weekly Obstacle Sheet and Worksheet 5.2: ■ Activities to Delay Compulsive Eating. Read Chapter 6 and preview the exercises. ■

In-​Session Exercises All in-​session exercises appear in the client workbook within the body of the corresponding chapter. We also include these exercises in this therapist guide, near the end of the corresponding chapter.

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In-​Session Exercise 5.1 Personal Regular Eating Calendar

Meal

Time

Possible Food Items

Breakfast Snack Lunch Snack Dinner Snack

YOU pick what YOU can do in order to keep going. If you eat something that is unplanned, then immediately try to get back on schedule by eating the next meal/​snack, even if you aren’t hungry.

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Case vignettes Case ­vignette 5.1 In the following vignette, the therapist addresses the client’s obstacles to regular eating. This client has been diagnosed with avoidant/​restrictive food intake disorder (ARFID). This client uses non-​binary pronouns. They have a highly limited number of foods they are willing to eat, and they experience a significant amount of emotional discomfort with the physical sensations associated with eating and digestion. T: C: T:

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Tell me about how things have been going with your eating since our last session. What do you mean? I ate things. Yes, I am sure you did. I’m sorry; that was too broad of a question. Let me clarify. Since we are focusing on getting you on a more regular schedule with your eating, can you tell me what times you ate yesterday and what you ate? I don’t remember. I ate some yogurt and later some cereal. OK. Was there anything else you ate? And do you happen to remember what time you ate those things? I don’t remember—​maybe sometime in the afternoon. Yeah, it is hard to remember those sorts of things if you aren’t paying close attention to it. That is actually why we have homework. So for your homework between now and when we meet next week, I want you to use the Personal Regular Eating Calendar that we worked on in session last week and try to follow the calendar. Then you can write down how it went on the Weekly Obstacle Sheet. That way it is easier for you to keep track of and helps me get a better understanding of how things are going. What do I put on the obstacle sheet? This sheet is where you will note if anything got in the way of following the calendar. For example, we have on the calendar we developed last week that you would eat cereal with milk, toast with butter, and some fruit for breakfast and that breakfast should be sometime before 9 a.m. I don’t like most fruit.

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I remember you mentioning that before, so that’s an example of an obstacle. Is there any type of fruit that you would be willing to eat? Remember, right now our focus is on getting you eating regularly and on a schedule; we will tackle harder things like increasing your variety later when you are ready for it. I will eat cut-​up pears that come in those little cups—​you know, the ones that come in a package. Oh yeah, those. That’s a creative solution to the obstacle. The obstacle is that you don’t feel quite ready to try whole fruit like biting into an apple, but a solution would be to have fruit in another way, like the packaged containers of precut pears. So, you would write both the obstacle and solution on the obstacle sheet. Does that seem doable for you? Yeah, I get it. But I am not eating before 9 a.m. I am just not hungry that early, and if I eat when I am not hungry, my stomach is going to churn and I’m going to feel gross and sick. My body is just not used to eating that early. OK, this is another great example of an obstacle. And you are right, it might be hard to eat at a different time than you are used to, especially if it feels uncomfortable in your body. But what we know is that your nutritional needs have to be met, and waiting to eat until later in the day just isn’t going to do that. I know it will be hard, but I think you can do it—​you’ve shown that you’ve done lots of hard things before, and I believe you can do this too.

Case ­vignette 5.2 In the following vignette, the therapist addresses and helps the client brainstorm ways to prevent compulsive eating. The client has been diagnosed with bulimia nervosa, is a recent college graduate, and is studying and preparing to take the LSAT test for admission to law school. They have delayed seeking a higher level of care due to fears that taking a break to seek treatment will derail their career potential. C:

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Prepping for the LSAT is messing with my head and my eating. The pressure is just so intense.

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Yeah, I can imagine this would be a pretty stressful time for you. What we know is that in times of great emotional distress, that’s when it’s pretty tempting to rely on eating disorder behaviors to cope. Tell me more about what is happening with your eating. Well, when I am stressed I just feel like I need all the help I can get to take the edge off—​and, honestly, food seems to do the trick the best. It makes sense that with so much going on that your first inclination is to find a way to quickly cover up that stress and anxiety. I know! It really is so overwhelming. I get so wrapped up in my studying and my worries that I just need a break, so I have some snacks—​well, more than just “some,” I have quite a bit. It just happens automatically, even if I’ve kept to my regular eating schedule and I am not really hungry. It doesn’t really count as a “binge,” I don’t think—​but the behavior happens. Like a habit. Kind of like that, yes. Right, and we all do this. The behaviors that help us feel better or give us relief in the moment become overlearned habits that are difficult to break. This is why we have been working on this regular eating schedule. I know. I just get so caught up in the moment and get so overwhelmed, it’s hard to know what else to do. Absolutely. When we are experiencing our emotions intensely, it can feel like we have to act fast. It might seem like otherwise these feelings will last forever. But one important thing we will emphasize throughout our work together is that emotions always pass. They also often come back again. But if you can break the chain between the thoughts, physical sensations, and behaviors that are part of your emotional disorder, you can develop new flexibility and transform your emotional experience. That sounds really great in theory, but how am I supposed to do that? Well, let’s start by coming up with a list of things you can do that might help you delay acting on the urge to eat when you are not really hungry. These activities don’t take the urge away, but if you allow yourself to experience the urge and the emotions but don’t act on it, you might find that the urge starts to ease up on its

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own, or that you learn something about your ability to tolerate your emotions and not act on less helpful urges. If you have a list handy, then you don’t have to come up with them right when things are at their worst. Okay. what sort of activities do you think work? It is best if you come up with a list that fits for you, with things that are pleasant and easy to do, no matter where you are. A few examples that come to mind are do a mindfulness exercise, read a magazine article, or go outside for a few minutes. Those are OK, I guess. What about playing a game on my phone or listening to part of a podcast? Yes, you’ve got it! Put those down on the list and keep it somewhere you can look at it when you might be in this spot of feeling compelled to eat when you are not hungry.

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MODULE 2

Understanding Emotion

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CHAPTER 6

Therapist Materials for the Natural Function of Emotions

Goals ■ Understand the natural, adaptive, helpful function of different emotions. See Figure 6.1: How We Understand Emotions. Though emotions are not necessarily serving an adaptive or ■ helpful function when someone has an emotional disorder, it is useful to understand that every emotion does have a useful purpose in nature. To see the emotion as potentially useful and natural can make ■ the emotion feel less dangerous. Knowing the function of the emotion can help us understand ■ why we are having certain emotions at certain times. Present important main adaptive functions of each emotion using ■ In-​Session Exercise 6.1: Trying On Emotions. Fear motivates us to escape more quickly than we would have oth■ erwise, to keep us alive. Sadness helps others see that we need help, tells us an important ■ change has happened, and keeps us focused on what is important at that time of transition. Anxiety helps us get ready for something important or threat■ ening, do our best, focus on what is important, and anticipate possible challenges. Anger signals that something is unjust and/​or that we need to take ■ action, and shows that we are serious and strong. Guilt and shame signal that we’ve done something wrong and ■ need to make amends or change. Disgust indicates that we should stay away from something that ■ might make us sick.

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■ Understand and explore the function of internal physical sensations. Illustrate that while sensations may be uncomfortable, they are not dangerous. Introduce Worksheet 6.1: Function of Physical Sensations Homework.

Homework review ■ ■ ■ ■

Fill out Form 3.1: Eating, Depression, and Anxiety (EDA). Plot scores on Form 3.2: EDA Graph. Fill out Form 4.1: Regular Eating Food Log. Fill out Worksheet 5.1: Weekly Obstacle Sheet and Worksheet 5.2: Activities to Delay Compulsive Eating. ■ Read Chapter 6 and preview the exercises.

Opening the session If you are running an Individual Session, the opening requires no formality aside from your usual methods. After greeting the client, it is good to get a quick initial sense of their emotional state. If the client is experiencing a notable emotion, consider suggesting that this example may be something to use in the session, for a real-​time example of the relevant UT material. Try to get to the homework review within a few minutes of opening the session. Group Sessions do benefit from having a formal check-​in, however. A formal starting ritual is important to help the group members shift from a customary, social state of mind to a therapeutic state of mind. It is very useful to help group members with social anxiety or those who have trouble participating for other reasons to begin speaking right from the beginning of the session. Knowing something about how each group member feels at the beginning of group also helps the therapist to make the session more “alive.” When you conduct in-​session activities it is very useful to return to examples of emotions that were shared in the group check-​in, to invite individual participants (again, particularly group members who have more trouble taking

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center stage) to use their own examples of active emotions to discuss in the group. If you are running a Group Session, you might introduce this group with the following check-​in: An important way to start a group is to create connection with one another. Can I ask that everyone take a nice, deep breath and anchor into the moment, look around the room, and make eye contact with your peers. Notice how you are feeling. As we create connection in the group we not only plug into the work we’ll be doing together, but we also build empathy and awareness for ourselves and for each other. When you are in connection with another person, you have awareness of your own emotions and the possible feelings and reactions of others. Let’s check in and focus on the function of an emotion you are feeling now. Remember that the check-​in exercise is not meant to generate discussion; rather, it is a place for every voice to be heard, in the moment. I would like to encourage you to identify the emotion you’re feeling right now and guess how that emotion might be useful. You can use this phrase to help you: “I am feeling _​_​_​_​_​right now, and I think in this moment its purpose is to _​_​_​_​_​.” Now everyone anchor into the present moment and we will go around the room to share just one sentence about an emotion that you’re experiencing, along with its function. With groups that include members who have trouble identifying a statement that is appropriate to begin the group—​particularly how long or detailed the statement should be—​it can be helpful for the therapist to model the length and type of comment that is appropriate. For example, in this case, a therapist might say: I will start the check-​in. I am feeling excited right now, because the “functions of emotion” group is one of my favorites. I think in this moment the purpose is to motivate me to do a good job with the material and share that feeling with you. Therapist comments can be true reflections of the therapist’s experience and do not have to be universally positive, but they also should not include very personal details or intense, unresolved negative emotion. (Client statements during the check-​in absolutely may include personal details and intense, unresolved negative emotion, of course.)

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The group relational check-​in should be brief; for example, it should take about 5 minutes for a 50-​minute group session and 10 minutes for a 90-​or 120-​minute group session.

Therapist tips for natural function of emotions exercise In Chapter 6 of the client workbook, you will see the steps of the functions of emotion exercise, which is basically a structured discussion. Most of the major emotions are listed, and then an example of the emotion being experienced in a potentially functional way is presented. Then the clients can discuss why the emotion would be functional to have in that situation. The point of the discussion is NOT to tell people that their emotions are always “right” and therefore they are not a problem. Clients will often loudly proclaim that their emotions are NOT functional and are in fact the reason they are in therapy, which is true! The idea is to understand that although their emotions may be happening in the wrong situations, too strongly, and driving them to do things that are not healthy currently, every emotion is natural and has a function. This is an important realization for people who believe they should never feel angry, sad, or scared, or for people who feel like the experience of those emotions might be hurting their bodies. We want people to understand that emotions exist not because they are harmful but because they are helpful. To illustrate this point, in the case of every emotion, you can ask the question “What if you never felt this emotion?” In the case of every emotion, it is possible to see how there could be negative repercussions for individual people or for society if an emotion did not exist. Some of the functions of the emotion are listed here and some are described in the client workbook. You and your clients may come up with more interesting and varied points about this, but make sure the basic points get covered as well. This session is primarily composed of In-​Session Exercise 6.1: Trying On Emotions. In this exercise the clients imagine that they are in different scenarios with different emotions and explore the consequences in each case. It is useful to suggest that the session be as “alive” as possible, like

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a workshop or a meeting, in which everyone is exchanging ideas about each emotion. It is useful to get people to really imagine that they are in the scenario—​each one should be read out loud. It is useful in a group to invite everyone to talk, speak up, and share their thoughts on each emotion with each other. Useful questions to ask after each emotion scenario include: What could have happened if you didn’t have that emotion? ■ What is the difference between feeling a “good” amount of that emotion ■ or “too much”? What is a useful way to react to that emotion versus a not-​useful way? ■ Do the physical sensations of this emotion occur in multiple situations? ■ Do they feel different based on the situation? Think outside of the box here; for example, excitement and fear have similar physical sensations, but the emotional states are interpreted differently. Are there other examples? Having fun on a playground versus feeling dizzy in other situations? ■ Feeling sweaty due to exercise versus feeling hot and sweaty due to ■ being flustered? Getting a good old “bear hug” versus being held back by someone? ■ Feeling tingly when an amazing coincidence happens versus feeling ■ tingly when creeped out? It is helpful to start introducing the idea that physical sensations are not immediately threatening and that it is our thoughts about them that are powerful. If the therapy you are conducting includes detailed attention to the food logs and regular eating, save at least 50% of the session for the review of the adaptive function of emotion so that the point is clear, and assign whatever remains as homework, along with continued self-​monitoring of food.

Closing the session Closing an Individual Session does not require any additional formality beyond preparing the homework, confirming the next session time, and other customary practices.

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Group Sessions can require additional formality. Try to save 5 or 10 minutes at the end of the session after preparing the homework and confirming the next session time for closing the group. If it is not possible to save the time, it is not as important to formally close the session as it is to open it formally. If you are running a Group Session and you have time saved, you might close the session as follows: Please share something about this material that was a surprise to you—​a new discovery—​and whether there are any emotions that you find it very difficult to see as ever being adaptive. Therapists do not need to model the closing reflection. However, you might alert everyone to how much time there is left to ensure everyone has a chance to speak. For example, you might say: We have just a few minutes before the end of session, so a brief reflection is welcome. Or, alternatively: We have fifteen minutes before the end of the session. So take some time to really reflect on your response to our discussion of the functions of emotion, our discussion of regular eating, and other aspects of the group, and share as much or as little as you like. You might include a personal goal for this week as well.

Homework Many of the forms and worksheets will need to be filled out more than once. We are including one blank copy of every worksheet and form in the client workbook (within the corresponding chapter) as well as a blank copy of each in the appendices to this therapist manual. For those items that clients will need more than once, you can provide additional copies for them, or clients can download blank copies themselves from the TreatmentsThatWork™ website at www.oxfordclinicalpsych.com/​UTforEDs. Fill out Form 3.1: Eating, Depression, and Anxiety (EDA). ■ Plot scores on Form 3.2: EDA Graph. ■ Fill out Form 4.1: Regular Eating Food Log. ■

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■ Read and complete Worksheet 6.1: Function of Physical Sensations Homework. Read Chapter 7 and preview the exercises. ■

In-​Session Exercises All in-​session exercises appear in the client workbook within the body of the corresponding chapter. We also include these exercises in this therapist guide, near the end of the corresponding chapter.

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In-​Session Exercise 6.1 Trying On Emotions

Fear Fear is crucial to our survival. Sometimes it is important to react quickly to danger with a “fight or flight” response. Imagine you are crossing the street with a friend. Suddenly, a car comes screeching and careening straight toward you. Without thinking, you jump onto the sidewalk and pull your friend to safety away from the oncoming car.

So, how was fear helpful in this situation? ■ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​____________________________​_​_​_​_​_​_​_​_​_​_​ ■ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​ ■ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

Sadness We often neglect to note the very important function of sadness in our lives. It is a signal to us and to others that something important has changed, requiring some time and attention. Imagine you find out that a very close friend or family member or a beloved pet has passed away. You will probably feel intense sadness and a great sense of loss. You feel as if you have no energy and it is hard focus on anything else except on your loss. You might feel like sleeping, crying, or staying home, and possibly talking about the person who you lost with people you love. What could be useful about being sad in this situation? ■ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​____________________________​_​_​_​_​_​_​_​_​_​ ■ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​____________________________​_​_​_​_​_​_​_​_​ ■ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________________​_​_​_​_​_​_​_​_​_​

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Anxiety Anxiety serves a very important function! It is a future-​oriented state; it has to do with getting ready to cope with future events. When we feel anxious, our bodies and minds go into a state of alertness and “preparation” so that we aren’t caught off guard if something bad happens. Imagine that you have a presentation coming up, which is important for your job or grade. You think about it often as the date approaches and you start to feel anxious. You do research on the topic, and you work late to gather all the information you need. You prepare the presentation and practice it several times. You imagine some of the questions people might ask and write down some possible answers. On the day of the presentation, you get up earlier than usual, put on nice clothes, and review the presentation.

How did anxiety help out in this situation? How was it good? ■ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_____________________________​_​_​_​_​_​_​_​ ■ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​____________________________​_​_​_​_​_​_​_​_​ ■ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__​___________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​ Anger Anger is focused on keeping things fair and also on acting to defend your rights, values, and safety. It is the “fight” side of “fight or flight,” or the referee in the game of life. Imagine you discover that the clerk at your local coffee shop has been putting extra charges on your credit card every morning when you go to buy breakfast. You angrily call the store and report the theft to the manager, but the manager says that the clerk has quit and there is no way to get your money back. You demand to speak to the manager’s supervisor, and then demand to have the money returned. You say you will go to the police if they cannot help you. How could anger be helping you here? ■ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​____________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ ■ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​____________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ ■ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​

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Guilt and shame Guilt and shame are similar but different. Some people say that guilt is when you recognize that you have done something specific that is bad, whereas shame is an overall feeling that you are a bad person, possibly because of something that you have done, how you see yourself, or how you think someone sees you. Both guilt and shame actually can be adaptive and helpful. You see there is a voice message on your phone from someone who calls you a lot. You are having a bad day and feel irritated that this person calls so much and often bothers you during busy times. You roll your eyes and delete the message without listening to it. The next day, you realize it was that person’s birthday! You forgot to wish them happy birthday and angrily screened the call—​and you feel instantly guilty. You realize you were about to do that to your current messages as well, and you feel a little ashamed. How could guilt and shame be helping you here? ■ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​____________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ ■ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​____________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ ■ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Guilt is a little bit easier because it helps you know you have done something wrong and you want to fix it. Some examples might be making an apology or admitting you were wrong about something. Guilt has a self-​correcting function or a reconciliatory function. Shame is meant to serve the same function basically—​by noticing there might be something wrong with you-​-​but because shame can make you want to run away, hide, or dissolve into the floorboards, it doesn’t always serve that function! One way to think about it is that feeling guilty, feeling ashamed, and feeling embarrassed are all variations of the same point, which is that you have done something that you feel bad about or think others could judge you for. Without those emotions, you wouldn’t have a signal about how you are supposed to behave in social groups or relationships.

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Disgust Humans are disgusted by things that may have been contagious at some point in evolution—​ things that are dirty or smelly, for example, might have germs. Having repulsion for dirty things can protect us. Imagine that you are entering a public bathroom. As you grab the knob, you realize it is a little wet and really sticky. As you enter the bathroom your shoes are also sticking slightly to the floor. Near the toilet and in the sink you see pooled green liquid, partially dried. You realize the whole bathroom has a very sour smell, and you realize that your sticky hands smell sour, too.

How could disgust be helping you here? ■ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ ■ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________________​_​_​_​_​_​_​_​_​_​_​_​_​ ■ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​

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Case vignette In the following vignette, the therapist is exploring the function of sadness with a client. The client is a 24-​year-​old Middle Eastern, cisgender woman diagnosed with binge eating disorder and major depression. She lives alone and is working her first job after college. Recently the client’s dog, Mo, died. She got Mo when she was 10 years old, right around the time when her parents were separating, and she has been struggling with grieving the loss of her dog. C: T: C: T: C: T:

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I don’t feel like anything is getting better. Hmm, what do you mean by that? Well, I spent all weekend binge eating, sleeping, and watching Netflix. Literally the whole weekend, I didn’t see anybody. That sounds pretty lonely. How are you feeling about the weekend? I’m annoyed. Yeah, I know how you like to be “productive on the weekends” and you have been working on reaching out to friends. What do you think got in the way? All the binge stuff! Yes, and what do you think was going on that led to the binges? It was really nice out this weekend, and typically I would take Mo to the park and we would play with the frisbee. It was the first nice weekend out since he died, and then Sunday my friends were all planning to take their dogs to the baseball game for “Pups in the Park.” There were a lot of reminders about Mo this weekend. What emotions did it bring up for you? I was pretty numb, I think. I mean, I was sad for a minute, but that’s pointless because it’s not going to bring Mo back and I just feel bad. I’d rather find ways not to feel sad, and binge eating, as much as I hate it, seems to work in the moment. Sometimes it’s hard to see the point of emotions, especially if we are feeling bad. One of the important concepts about this model is that all emotions have a function. I imagine that this could be hard to believe right now. Yeah, I don’t see how there is a function to feeling terrible about something I can’t change.

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May I give you an example of a time when I think feeling your sadness served a function? C: Um, sure. T: Last week when your mom didn’t show up to family therapy, how did you feel? C: Sad. T: And do you remember what happened next? C: I think so. You asked me to talk about it and I cried. I said how I really wanted to binge and she let me down. I didn’t like feeling that way. T: Sure, most people don’t like feeling sad or uncomfortable. When you agreed to stay and talk and feel, a couple of things happened. C: Like what? T: Well, you let me in to understand how important your relationship is with your mom. Because you took that risk, our relationship is stronger and you gained support. Maybe also you realized something yourself about how important that relationship was to you. Instead of immediately going to binge, you stayed and allowed yourself to be vulnerable and connected. C: I’ve never really thought about it that way before. T: Right, most of us just don’t like to feel sad, so we put it on the “bad” list and try our best to avoid it. But now that you can see how expressing your sadness to me in session last week was helpful, can you see how it might have a function right now too? C: Umm, maybe if I let myself be sad with you, I could honor how important Mo was to me. T: That seems really important and true. How could you be sad and honor Mo? C: Maybe if I told you about how much I miss him, you would understand how important he was to me, how great he really was. And maybe if I grieve him, maybe eventually I will actually get out of my house and stop feeling like I’m so stuck and alone. T: Wow, that is a lot for you to say. That really resonates with me so strongly. C: I miss Mo. T: I can see that you do; he was very special to you. Can you tell me more?

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CHAPTER 7

Therapist Materials for the Three Parts of Emotions (3-​Component Model)

Goals ■ Understand and describe the three components of emotions. Review Figure 7.1: The Three Parts of an Emotion and Figure 7.2: The 3-​Component Model Example, including: Thoughts, ■ Physical sensations, and ■ Behaviors and urges. ■ Conduct In-​Session Exercise 7.1: The 3-​Component Model, for a ■ recent emotion and practice this skill using Worksheet 7.1: The 3-​ Component Model Homework, including: What thoughts, physical sensations, and behaviors made up the ■ emotion How these three components interacted and unfolded over time ■

Homework review ■ ■ ■ ■

Fill out Form 3.1: Eating, Anxiety, and Depression (EDA). Plot scores on Form 3.2: EDA Graph. Fill out Form 4.1: Regular Eating Food Log. Read and complete Worksheet 6.1: Function of Physical Sensations Homework. ■ Read Chapter 7 and preview the exercises.

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Opening the session If you are running an Individual Session, the opening requires no formality aside from your usual methods. After greeting the client, get a quick initial sense of their emotional state. If the client is experiencing a notable emotional experience, consider suggesting that this example may be something to use in the session, for a real-​time example of the relevant UT material. Try to get to the homework review within a few minutes of opening the session. Group Sessions do benefit from having a formal check-​in, however. A formal starting ritual is important to help the group members shift from a customary, social state of mind to a therapeutic state of mind. It is very useful to help group members with social anxiety or those who have trouble participating for other reasons to begin speaking right from the beginning of the session. Knowing something about how each group member feels at the beginning of group also helps the therapist to make the session more “alive.” When you conduct in-​session activities, it is useful to return to examples of emotions that were shared in the group check-​in, to invite individual participants to use their own examples of active emotions to discuss in the group. If you are running a Group Session, you might introduce this group with the following check-​in: At the beginning and end of group, we work to be connected to our own emotions and to the other people in the group. We hope you will be able to share your experience with others and build empathy for others and yourself. Our check-​in today is meant to help everyone be aware of their current emotional state and acknowledge just one part of it to the group. There may be opportunities to talk about these emotions later in the group, but right now we are just checking in with ourselves and each other. We will take half a minute of silence; look inward and identify what emotions you are feeling right now. Then I will start and we will go around the room, and everyone will name one emotion they are feeling right now, in one word or a few words. It may feel funny not to explain or discuss the emotion now, but we will have many chances to follow up later in the group. With groups that include members who have trouble identifying a statement that is appropriate to begin the group—​particularly how long or

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detailed the statement should be—​it can be helpful for the therapist to model the length and type of comment that is appropriate. For example, in this case, a therapist might say: I will start the check-​in. Right now I am feeling optimistic. Therapist comments can be true reflections of the therapist’s experience and do not have to be universally positive, but also should not include very personal details or intense, unresolved negative emotion. (Client statements during the check-​in absolutely may include personal details and intense, unresolved negative emotion, of course.) The group relational check-​in should be brief—​for example, it should take about 5 minutes for a 50-​minute group session and 10 minutes for a 90-​or 120-​minute group session.

Therapist tips for the 3-​Component Model exercise In group administration of this session, to make the topic of emotions and the 3-​Component Model specifically “come alive,” we suggest that the teaching example be one of the emotions that were shared in the opening exercise. Therefore, it is important to pay careful attention to what is shared during the check-​in. Using the check-​in to support the exercise feels more salient and real than a hypothetical example. In general, it is best to be transparent and identify hypothetical examples and review them in simple terms to convey the idea of the 3-​Component Model in a concrete manner. Then, spend much more time exploring the real example and the details of the 3-​Component Model. The content for this session is well covered in the client workbook materials. The main activity for the group is to cover the three components of emotion—​ thoughts, behaviors/​ urges, and physical sensations—​and help clients to separate their emotions into these parts, including as many details as possible for each part, in order to understand and observe them. In groups, during the psychoeducation component of the session, we have found it helpful to conduct the discussion in a workshop style. “Workshop style” means that everyone is contributing ideas, almost like

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a group discussion, while the therapist writes down everyone’s ideas on a whiteboard or flip chart. For example, we recommend that you draw the elements of Figure 7.2: The 3-​Component Model Example on the board to provide visual cues to the conversation and to help with the examples shared during In-​Session Exercise 7.1: The 3-​Component Model. It helps to have everyone’s brains working together rather than independently. Additionally, having the group process take place makes the concept less threatening. This is a highly recommended form of group facilitation for other chapters and groups as well. With regard to thoughts, clients frequently know that they have thoughts, but they have difficulty putting the thoughts into specific words. Although the thoughts may present themselves more vaguely or abstractly, it is helpful to teach clients to practice identifying thoughts as very simple declarative sentences, such as “If you eat this, you will get fat” or “It’s going to be OK; it’s part of your treatment” or “Those people are thinking mean things about you.” Sometimes we describe this as “What is your brain telling you?” This technique becomes helpful for the frequent process of identifying parts that are parts of emotion and also parts of the development of emotion over time. With regard to physical sensations, clients are often least familiar with thinking about physical sensations as a part of emotion. It can be useful to have a list of suggested, common physical sensations to prompt their thinking. With regard to behaviors, it is useful to think of urges as well as behaviors and also to broaden thinking to a wide range of behaviors. In the client workbook materials we have listed prompts that we have found helpful for identifying behaviors (as well as the other components).

Closing the session Closing an Individual Session does not require any additional formality beyond preparing the homework, confirming the next session time, and other customary practices. Group Sessions can require additional formality. Try to save 5 or 10 minutes at the end of the session after preparing the homework and

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confirming the next session time for closing the group. If it is not possible to save the time, it is not as important to formally close the session as it is to open it formally. If you are running a Group Session, and you have time saved, you might close the session as follows: Please share if you had a reaction of empathizing with a thought, physical sensation, or behavior that someone else shared today. Also, if you have a personal goal for the week, that can be good to say aloud. Therapists do not need to model the closing reflection. However, you might alert everyone to how much time there is left to ensure everyone has a chance to speak. When there is a lot of time left, you might also encourage people to identify a personal goal for the next week.

Homework Many of the forms and worksheets will need to be filled out more than once. We are including one blank copy of every worksheet and form in the client workbook (within the corresponding chapter) as well as a blank copy of each in the appendices to this therapist manual. For those items that clients will need more than once, you can provide additional copies for them, or clients can download blank copies themselves from the TreatmentsThatWork™ website at www.oxfordclinicalpsych.com/​UTforEDs. ■ ■ ■ ■

Fill out Form 3.1: Eating, Anxiety, and Depression (EDA). Plot scores on Form 3.2: EDA Graph. Fill out Form 4.1: Regular Eating Food Log. Review Figure 7.2: The 3-​Component Model Example. Then complete Worksheet 7.1: The 3-​Component Model Homework (please complete the worksheet for two different situations where you noticed heightened emotions or symptoms). ■ Read Chapter 8 and preview the exercises.

In-​Session Exercises All in-​session exercises appear in the client workbook within the body of the corresponding chapter. We also include these exercises in this therapist guide, near the end of the corresponding chapter. 111

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In-​Session Exercise 7.1 The 3-​Component Model

Name the situation here: ​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Then in the corresponding circles below, write your answers to the following questions: 1. Thoughts: What thoughts were you having at that time? What was your brain telling you? Was it telling you anything about yourself? Was it making any predictions about the future? Was it saying something about the emotion itself? Have you been in similar situations? What thoughts came up in that situation? 2. Physical Sensations: What are the physical sensations associated with that emotion? Think about your stomach, head, chest, muscles . . . Think about heaviness, tightness, pain, numbness, tingling . . . What were you feeling in your body? 3. Behaviors/​Urges: In this case, what did you do? What did you do immediately, in the situation? Did you do anything to reduce your discomfort? What didn’t you do? Did you have any other urges that you didn’t act on? What might you have done or felt like doing in other, similar situations?

Behaviors/Urges

Thoughts

Physical Sensations

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Case vignettes Case ­vignette 7.1 In the following vignette, the therapist is teaching the client how break down an emotion into its three component parts. The client is a Black man collegiate athlete. He is diagnosed with anorexia nervosa and engages in excessive exercise. T:

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If you could label the emotion you were feeling yesterday, after your coach made that comment about your performance, what would it be? I don’t know. Maybe tense. Or worried. Or stressed. I can see how you might have felt that way. I know you have very high expectations of yourself when it comes to your sport, so it was hard to hear your coach say that. Yeah. It was terrible. And embarrassing. I just wanted to get out of there so fast. And then it felt like I was just spinning out. It’s just too much. Sometimes our emotions can feel just like that—​“too much.” That is why it is really useful to try to break down our emotions into their three component parts, so it is more manageable for us to understand what is going on when it feels like we are “spinning out.” Writing it out on these three circles helps us visualize it while we are learning the skill. So you mentioned feeling tense, worried, and stressed. When you were feeling that way, what thoughts were running through your mind? That my coach thinks he made a mistake, he should never have given me that scholarship. Wow, it must be hard to think and feel that way. Did you have any other thoughts? That he should be disappointed, I’m a disappointment. My weight is dragging me down and slowing down my time. I’ve got to shed some of this extra weight. I’ve been so lazy letting myself eat like this and get out of shape. OK, so when all those thoughts, which are so harsh and critical of yourself, start to swirl around, what do you notice in your body?

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That I feel so heavy, like I feel this heaviness in my stomach. And I’m antsy and jittery. And all my muscles tighten up, especially in my back and shoulders. And then I just want to run . . . Right, so you are feeling all these things in your body and that just makes you want to run, so that is an urge, right? You see, our thoughts, physical sensations, and behaviors/​urges are all interconnected. One affects the other, and then the other . . . Yeah, so I just want to run, to get out of there, to go to the gym and work off all that extra weight, and then my mind goes to obsessing about my measurements, and my times, and my calories. Yep, that’s a great example of how all those three components are connected and play off one another—​no wonder our emotions feel so intense and overwhelming sometimes. The good news is that the more we understand what is happening, the more we can respond in ways that might be more helpful to us.

Case ­vignette 7.2 This therapist–​client interaction involves targeting the physical sensations component of the 3-​Component Model. The client identifies as a biracial transgender woman, and she has been diagnosed with anorexia nervosa. T:

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Like we talked about last week, the three components of an emotion are thoughts, physical sensations, and behaviors. You can start in any section, as some people are easily able to access their thoughts more so than their physical sensations, and others are very attuned to their physical sensations or behaviors. What component is the most present and obvious for you when you are feeling a strong emotion? I always have so many thoughts in my head, so it’s hard not to notice those. And the behaviors are pretty easy to figure out since I’m either doing something or I’m not. But I don’t really have intense physical sensations most of the time, so I’ll just leave that part blank. Well, just because you don’t notice your physical sensations does not mean they are not there. It seems like you are not very

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sensitive to your physical sensations, but I would bet there have been times when you felt and noticed them. Well, yeah, I notice them when I’m having a panic attack. Like I did right before dinner last night, when I was out with my parents. OK, so let’s talk about your experience with panic, since you mentioned it. Can you walk me through what that experience was like within your body when you were at dinner? Sure. I started by feeling shaky, and then a bunch of different stuff. Where should I begin? That’s a great question. How does it feel to be shaky? Begin at your head, asking yourself a series of questions: “Did I have a headache? Any tension in my jaw? Pressure behind my eyes?” I felt something in my head; I got dizzy, I guess. Then my heart started racing and I was breathing really heavy. Was it hyperventilation? I guess that’s a good word for it; I was definitely hyperventilating. See? You were having physical sensations. It’s likely that you have been out of touch with them. Or you don’t notice them separately from the rest of the experience. Anything else happening in your body when you were at dinner? I remember I had to take my jacket off because I was getting worked up and hot and sweaty. Did you feel anything in your stomach? Nausea? Butterflies? Honestly, not that I’m aware of. That’s okay. Sometimes when we’re retroactively trying to think of a situation and how we felt, it’s hard because we’re no longer in the moment. Knowing this moving forward may help increase awareness the next time you may be at a meal. I encourage you to pay attention to this component, as it is a very important part of our emotional experience. For example, it might be interesting that you stop feeling a sensation—​like before you got to dinner you were feeling hungry, and now that you are at the table you aren’t hungry at all. That is a good example. I can imagine noticing that if I were paying attention as I went along.

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CHAPTER 8

Therapist Materials for Tracking Emotions over Time (the “ARC”)

Goals ■ Learn the steps that unfold over time in emotions. Introduce Form 8.1: The ARC of Emotional Experiences. See Figure 8.1. Antecedent (A) is what comes before that sets up the emotional ■ reaction. Response (R) is the emotional response itself, which has the ■ three components of thoughts, physical sensations, and urges/​ behaviors. Assign Worksheet 8.1: Following Your Thoughts for an expanded exploration into the thoughts component. Assign Worksheet 8.2: Focusing on Your Behaviors for an expanded exploration into the behaviors component. Consequence (C) involves all the positive and negative, short-​ ■ term and long-​term effects of the emotion—​what happened and didn’t happen; what we learned or missed out on learning; and what was reinforced by our actions. Introduce Figure 8.2: An Example of the Emotion–​Behavior–​Consequences Cycle. Practice identifying the ARC of an emotion in an example. ■ Look for patterns in emotional triggers (what causes emotional ■ experiences). Explore short-​and long-​ ■ term consequences of emotional responses. Do a “workshop-​ ■ style” ARC using Figure 8.1: The ARC of Emotional Experiences (Sample).

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Homework review ■ ■ ■ ■

Fill out Form 3.1: Eating, Depression, and Anxiety (EDA). Plot scores on Form 3.2: EDA Graph. Fill out Form 4.1: Regular Eating Food Log. Review Figure 7.2: The 3-​Component Model Example. Then complete Worksheet 7.1: The 3-​Component Model Homework (please complete the worksheet for two different situations where you noticed heightened emotions or symptoms). ■ Read Chapter 8 and preview the exercises.

Opening the session If you are running an Individual Session, the opening requires no formality aside from your usual methods. After greeting the client, get a quick initial sense of their emotional state. If the client is experiencing a notable emotional experience, consider suggesting that this example may be something to use in the session, for a real-​time example of the relevant UT material. Try to get to the homework review within a few minutes of opening the session. Group Sessions do benefit from having a formal check-​in, however. A formal starting ritual is important to help the group members shift from a customary, social state of mind to a therapeutic state of mind. It is very useful to help group members with social anxiety or those who have trouble participating for other reasons to begin speaking right from the beginning of the session. Knowing something about how each group member feels at the beginning of group also helps the therapist to make the session more “alive.” When you conduct in-​session activities, it is useful to return to examples of emotions that were shared in the group check-​in, to invite individual participants to use their own examples of active emotions to discuss in the group. If you are running a Group Session, you might introduce this group with the following check-​in: I ask that everyone take a nice, deep breath and anchor into the moment. Then look around the room and make eye contact with your peers. Notice how this feels. As we create connection in the group we not only plug in 118

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to the work we’ll be doing together, we also build awareness of ourselves and of each other. Think back over the past week and about how the events of the past week have made you feel. Maybe you will think about something significant that happened a few days ago, or maybe the cumulative effect of repeated experiences, or maybe something that just happened before you walked in the door. It doesn’t have to account for everything you are feeling—​just one emotion and the events that you think may have contributed to it. After a minute of thinking, we are going to share our experiences with each other by using this sentence: “Because _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ has happened in the past week, I am feeling _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​.” With groups that include members who have trouble identifying an appropriate statement to begin the group—​particularly how long or detailed the statement should be—​it can be helpful for the therapist to model the length and type of comment. For example, in this case, a therapist might say: I will start the check-​in. Right now I am feeling worried because my cat has been acting a little funny. Therapist comments can be true reflections of the therapist’s experience and do not have to be universally positive, but also should not include very personal details or intense, unresolved negative emotion. (Client statements during the check-​in absolutely may include personal details and intense, unresolved negative emotion, of course.) The group relational check-​in should be brief—​for example, it should take about 5 minutes for a 50-​minute group session and 10 minutes for a 90-​or 120-​minute group session.

Therapist tips for tracking your emotion over time: the ARC exercise The exercise in this session is to fill in an ARC form. See Figure 8.1: The ARC of Emotional Experiences (Sample) in the client workbook materials for a completed example. In a group, each client would fill out their own form (Form 8.1: The ARC of Emotional Experiences is a blank form that can be copied for future use), or pairs of people 119

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can work together. Then the group will discuss together answers to the questions that come up. We suggest you use a recent meal as an example—​however, if a particular client wants to do a different experience, that is fine as well. This exercise can be a very powerful interpersonal experience. In a group, this is particularly true when the exercise is conducted in dyads; however, it works well as a group workshop too. For the dyads, one person is the “listener” and the other is the “storyteller” who will share their experience in as much detail as possible. The listener’s job is to listen and notice the parts of the ARC and then give the storyteller that feedback and reflection. It has been our experience that the listeners take their role very seriously. The responsibility of listening, reflecting, and validating the storyteller’s experience, and then giving them that feedback, not only is an opportunity to review the concepts but also strengthens both participants’ abilities to think flexibly and consider multiple viewpoints in a scenario. The comment we frequently hear is about how this exercise brings people together, helps people learn about each other, and facilitates empathy. In dyads, have people move the chairs to face each other, using eye contact and body position to support their connection. When clients are sitting side by side on a sofa, eye contact may not happen, or they can become distracted with items on their laps, like pens and notepads. The workshop-​style exercise is also powerful because it allows people to learn about the ARC and also learn through interacting with one another as a group, and how we all view situations differently. Both are a good opportunity to facilitate relational connection. The homework in this session is extensive (refer to Form 8.1: The ARC of Emotional Experiences), and learning to do this skill well—​particularly at the same time as food intake is getting more regular, etc.—​can be a lot to juggle. We have also included two additional worksheets (Worksheet 8.1: Following Your Thoughts and Worksheet 8.2: Focusing on Your Behaviors) that may help to broaden clients’ thinking about the kinds of thoughts that are important to consider and the kinds of behaviors that are related to emotions. Therefore it may be necessary to spread the homework over 2 weeks and repeat the material to make sure clients become really good at it. At The Renfrew Center, we use variations of this exercise such as clips from movies or TV shows to allow

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clients to examine someone else’s experience. At times we do the ARC as a group, using one person’s experience, and have other participants in the group volunteer ideas about what they might be feeling in a similar situation, or have other members ask questions from the worksheets to help the volunteer identify different aspects of their experience.

Closing the session Closing an Individual Session does not require any additional formality beyond preparing the homework, confirming the next session time, and other customary practices. Group Sessions can require additional formality. Try to save 5 or 10 minutes at the end of the session after preparing the homework and confirming the next session time for closing the group. If it is not possible to save the time, it is not as important to formally close the session as it is to open it formally. If you are running a Group Session, and you have time saved, you might close the session as follows: Please share if you had a reaction of empathizing with a thought, physical sensation, or behavior that someone else shared today. Therapists do not need to model the closing reflection. However, you might alert everyone to how much time there is left, to ensure everyone has a chance to speak. When there is a lot of time left, you might also encourage people to identify a personal goal for the next week.

Explanation for the client of this session’s homework The homework is to do your own ARC of emotions. You can choose any emotional experience that is current for you. We really want you to focus on this experience vividly, so it’s best if it’s fresh in your mind. Do your ARC just like we did in session together using Form 8.1. Try to do at least one ARC every day. Remember, the point of the ARC is not to reduce your emotion but rather to help you track it and understand how the emotion unfolds. This is a skill worth developing, and it requires practice!

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You also need to complete Worksheet 8.1: Following Your Thoughts. This is an important exercise for your next ARC session and will really help you become aware of how many different types of thoughts might be happening simultaneously in an emotional experience. To complete Worksheet 8.1, you can choose any of the experiences that you completed the ARC for, and follow the prompts to identify as many thoughts as possible. We will be diving into this material in the next session. Next you will need to complete Worksheet 8.2: Focusing on Your Behaviors. This exercise will increase your awareness of your behaviors and help you start identifying what the function of those behaviors might be. Spoiler alert: These behaviors probably help you escape or avoid uncomfortable emotions. What’s nice about this exercise is that you are prompted to explore events in three categories that are quite relevant to individuals with eating disorders: body image, food, and interpersonal situations.

Homework Many of the forms and worksheets will need to be filled out more than once. We are including one blank copy of every worksheet and form in the client workbook (within the corresponding chapter) as well as a blank copy of each in the appendices to this therapist manual. For those items that clients will need more than once, you can provide additional copies for them, or clients can download blank copies themselves from the TreatmentsThatWork™ website at www.oxfordclinicalpsych.com/​UTforEDs. ■ ■ ■ ■

Fill out Form 3.1: Eating, Depression, and Anxiety (EDA). Plot scores on Form 3.2: EDA Graph. Fill out Form 4.1: Regular Eating Food Log. Complete the full Form 8.1: The ARC of Emotional Experiences for: A body image event ■ A food/​eating event ■ An event related to another emotional goal (fill in goal here): ■ _​_​_​_​_​_​_​_​_​_​_​_​____________________________________​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______________​_​_​_​_​_​_​

■ Complete Worksheet 8.1: Following Your Thoughts and Worksheet 8.2: Focusing on Your Behaviors. Read Chapter 9 and preview the exercises. ■ 122

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Case vignettes Case ­vignette 8.1 The following scenario illustrates how the therapist helps the client with tracking emotions and identifying the antecedents to emotional experiences. The client is a 15-​year-​old Black cisgender woman diagnosed with bulimia nervosa. She has been engaging in self-​harm by cutting weekly for the last 2 years. C:

I cut again over the weekend. I don’t know why this keeps happening, but it just does. T: Okay, let’s take a moment and try to explore the antecedent together. C: There wasn’t an antecedent. There never is. Like I said, it just happens because it happens. T: Sometimes it can feel like our emotions come out of nowhere. However, our emotions are usually a reaction to something. This emotional reaction could be intensified because of the experiences we’ve had in our past or even our fears about the future. C: That’s not how it works for me. It’s like the next thing I know, I have cut myself or I’ve binged and purged. T: I’m picking up on maybe some skepticism and frustration. Is that accurate? C: Yeah, I would like to know what’s causing it, but I don’t think there is anything. It’s just what I’ve always done. T: Would you be willing to explore this some more together? Let’s approach this with a curious mind. C: Okay. T: For now, let’s just skip the antecedent part of the ARC since we already know that’s hard and move on to the response. Can you share with me any thoughts you were having right before you self-​ harmed this weekend? C: Yeah, that’s easy. I was thinking I hate my body. I’m never going to get better. I can’t believe I just ate dinner. I hope my parents will leave soon so I can purge. T: You had some powerful thoughts. C: Yeah, but they are always there. Sometimes they are louder than other times, I guess. 123

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T: C:

T: C:

T:

What had happened earlier in the day? That was the day that I went and watched my soccer team play and I wasn’t allowed to play. I felt like such a loser. Then after all that, I had to come home and eat dinner. It’s so unfair! I think you just identified your antecedents for that emotional experience. Even though that same situation is going to happen again, and I basically feel the same way all the time, it can still be an antecedent? Sure. In fact, often our triggers or antecedents come up over and over again. This process of completing an ARC allows you to “press pause” so you can become aware of your emotional response to the antecedent and then decide how you want to handle it while thinking about short-​and long-​term consequences. This process might not make you feel better in the moment, but it can help you take more control over how you respond with your behaviors.

Case ­vignette 8.2 The following vignette illustrates a therapist working with a client to understand the short-​term and long-​term consequences of her behaviors of binge eating and substance use. The client is a cisgender woman in her 40s, is married with children, and has been diagnosed with binge eating disorder and alcohol use disorder. C:

T: C:

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I can get behind the antecedents and understand how they impact my response, like how I think and how I feel and what I do, but I just write the same things over and over again for my consequences. I guess I don’t know how else to fill it out. Can you elaborate on those consequences? Well, I usually write “feel guilty” for short term and “recovery” for long term. But those feel wrong and inauthentic, and they don’t help me really because it feels like I’m just writing it down because I don’t know what else to write. I guess I sometimes don’t see how I can change my behavior when I feel relief in the short

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T:

C: T:

C:

T:

C: T: C: T:

C:

term. In those moments I would do almost anything to feel some relief. Absolutely. That good feeling you get when you can avoid or prevent a bad feeling is very powerful, which is why the behavior is so hard to unlearn. To make this a bit more concrete for the both of us, can you walk me through an example? Well, I want to stop binge eating and drinking. But both really provide comfort and relief for me better than anything else has. That feeling of relief is absolutely a short-​term consequence that keeps the desire to use behaviors going. It makes sense—​we don’t want to be uncomfortable and we want to take the discomfort away! So we try to do anything we can to reduce this discomfort, and for you it’s binge eating, drinking, or leaving the situation entirely. This is what we call negative reinforcement and learned behaviors, when you take something away that feels painful and then feel you better. How might binge eating, drinking, and leaving the situation affect you after the relief dissipates? What are the long-​term consequences of using those behaviors? Well, I feel an incredible amount of shame, for one. Another thing is that when I am doing those things, I cannot be truly present with my family. Food or alcohol will continue to take up so much of my brain space. I have so many other things to think about, but those things trump everything else. You most definitely do have other things to attend to, and I’m so glad you’re aware of that. Our goal is to have thoughts of food and substances take up less space in your brain. That will occur with new learned behaviors. Have you ever had the urge to binge, but didn’t? Yes. Not too many times, but yes, I have, when I’ve been with my family and couldn’t. And what was that like, in the short term? Awful. I was irritable, and I remember planning a way to make it happen because I felt so out of place with my family. Right, so sitting with the urge and the emotion that came from wanting to binge—​but not doing it—​resulted in increased anxiety, irritability. Anything else? I was also much more quiet and reserved and not “me.”

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It sounds like you were pretty uncomfortable to sit with the emotion instead of doing the things you have learned to do to escape from the emotion—​temporarily, at least. This is so common! Our bodies react to thoughts and feelings and try to move us away from perceived danger. If you have been led to believe that your emotions are dangerous, of course you want to dampen them, suppress them, try to make them go away. And it works—​in the short-​term, at least. What occurs in the long term when you sit with your emotions and don’t use behaviors that you have learned? Well, I’ll have it as evidence that I survived. The feelings did pass after a while. And while I still feel nervous around hunger and may still feel pretty awful about myself, I am able to trust a bit more that the emotion isn’t dangerous, which I guess counts for something.

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MODULE 3

Mindful Emotion Awareness

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CHAPTER 9

Therapist Materials for Mindful Emotion Awareness

Goals ■ Understand the concepts involved in mindfulness. See Figure 9.1: What Is Mindfulness? Awareness of two types of emotion, primary (Figure 9.2: Diagram ■ of a Primary Emotion) and secondary (Figure 9.3: Diagram of a Secondary Emotion) Awareness that is focused on the present, not focused on the past ■ or future Awareness that is accepting of emotion rather than judgmental ■ Complete In-​Session Exercise 9.1: Awareness of Primary Emotions ■ and Secondary Emotions. Introduce Figure 9.4: Primary and Secondary Emotions Worksheet to illustrate key concepts and provide examples. Assign Worksheet 9.2: Primary and Secondary Emotions Homework to practice. Box 9.1: Primary and Secondary Emotions Homework Activity will provide helpful examples and instructions for this homework. Complete In-​Session Exercise 9.2: Guided Mindfulness to notice ■ physical sensations and to try to anchor in the present moment. Complete In-​ ■ Session Exercise 9.3: Focusing on Nonjudgmental Emotion Awareness to particularly focus on the self-​judgments that emerge. Assign Worksheet 9.3: Present-​Focused Awareness Exercise I—​Mindful Walking for homework. Take notes on Worksheet 9.1: Nonjudgmental Present-​ ■ Focused Emotion Awareness regarding experiences in In-​Session Exercises 9.2 and 9.3.

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Homework review ■ ■ ■ ■

Fill out Form 3.1: Eating, Depression, and Anxiety (EDA). Plot scores on Form 3.2: EDA Graph. Fill out Form 4.1: Regular Eating Food Log. Complete the full Form 8.1: The ARC of Emotional Experiences for: A body image event ■ A food/​eating event ■ An event related to another emotional goal (fill in goal here): ■ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______________​_​_​_​_​_​_​_​ ■ Complete Worksheet 8.1: Following Your Thoughts and Worksheet 8.2: Focusing on Your Behaviors. Read Chapter 9 and preview the exercises. ■ There was quite a bit of homework for the ARC session, and if the material needs detailed review and extended focus for another week, you should make that judgment.

Opening the session If you are running an Individual Session, the opening requires no formality aside from your usual methods. After greeting the client, get a quick initial sense of their emotional state. If the client is experiencing a notable emotional experience, consider suggesting that this example may be something to use in the session, for a real-​time example of the relevant UT material. Try to get to the homework review within a few minutes of opening the session. Group Sessions do benefit from having a formal check-​in, however. A formal starting ritual is important to help the group members shift from a customary, social state of mind to a therapeutic state of mind. It is very useful to help group members with social anxiety or those who have trouble participating for other reasons to begin speaking right from the beginning of the session. Knowing something about how each group member feels at the beginning of group also helps the therapist to make the session more “alive.” When you conduct in-​session activities, it is useful to return to examples of emotions that were shared in the group

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check-​in, to invite individual participants to use their own examples of active emotions to discuss in the group. If you are running a Group Session, you might introduce this group with the following check-​in: I ask that everyone take a nice, deep breath and anchor into the moment, look around the room, and make eye contact with your peers. Notice how this feels. Now close your eyes and try to identify the emotion you are feeling right now. This check-​in exercise is not meant to generate discussion at this point in the session; rather, it is a place to notice and briefly share your authentic experience. Since this group is about emotion awareness, or mindfulness, we are going to focus on that today. I am going to read the quote by Jon Kabat-​Zinn, printed in your workbook: “It’s not a matter of letting go—​you would if you could. Instead of ‘Let it go,’ we should probably say, ‘Let it be.’ ” Can everyone anchor into your emotion? What emotion are you feeling right now that you are going to “let be”? As we go around the room, please tell us what emotion you’re experiencing and how you feel about “letting it be.” With groups that include members who have trouble identifying an appropriate statement to begin the group—​particularly how long or detailed the statement should be—​it can be helpful for the therapist to model the length and type of comment. For example, in this case, a therapist might say: I will start the check-​in. Right now I am feeling a little nervous about a doctor’s appointment, and I am trying to just “let that be.” Therapist comments can be true reflections of the therapist’s experience and do not have to be universally positive, but also should not include very personal details or intense, unresolved negative emotion. (Client statements during the check-​in absolutely may include personal details and intense, unresolved negative emotion, of course.) The group relational check-​in should be brief—​for example, it should take about 5 minutes for a 50-​minute group session and 10 minutes for a 90-​or 120-​minute group session.

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Therapist tips for mindful awareness of emotion exercise In the client workbook materials, there are detailed concepts to review, including the importance of nonjudgmental, present-​ focused, purposeful awareness. Figure 9.1: What Is Mindfulness? provides a visual representation of the most important key points: 1. The concepts of primary and secondary emotions are reviewed. In-​ Session Exercise 9.1 helps identify common secondary emotions and alternative adaptive reactions, and there is a summary sheet in the homework section. There is also a homework exercise (Worksheet 9.2) to identify common secondary emotions and potential problems with these common reactions. 2. In-​Session Exercise 9.2 is a guided exercise for present-​focused awareness, which is for you to read and the clients to participate in. 3. For homework there is a present-​ focused awareness activity (Worksheet 9.3), which needs daily attention for the following week, as well as an option to try mindful walking instead of sitting and breathing. This is a lot of material to cover in one session! It can easily be divided into several sessions. If so, the homework might include just the material on primary and secondary emotions following the first session, and then the practice of awareness might follow in the next. People put a lot of pressure on themselves to do mindfulness “correctly” and will experience a lot of judgmental thoughts about how “well” they are executing the tasks. People also misunderstand what the goals are, thinking that having a peaceful, calm, “Zen-​like” moment is an indication of good mindfulness. As often as possible, remind clients that mindfulness is about noticing, being aware of, and accepting whatever comes up, not having no emotions or having only positive emotions. Being judgmental of ourselves for how we are doing mindfulness is a good example of a secondary emotion! People have a lot of preconceived notions about mindfulness, such as “I’m not into this stuff” or “It frustrates me” or “I can’t do it” and so on. We have found that the mindful walk is a great way to introduce mindfulness concepts in a different, innovative, and nonthreatening way.

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Consider the mindful walk as an alternative to the guided mindfulness exercise if anyone is struggling with the traditional approach. The primary and secondary emotion concept is tricky to grasp. We recommend taking extra time to review many salient examples. We have found that clients who really understand this concept tend to do better with flexible thinking and behavioral change in this model.

Closing the session Closing an Individual Session does not require any additional formality beyond preparing the homework, confirming the next session time, and other customary practices. Group Sessions can require additional formality. Try to save 5 or 10 minutes at the end of the session after preparing the homework and confirming the next session time for closing the group. If it is not possible to save the time, it is not as important to formally close the session as it is to open it formally. If you are running a Group Session, and you have time saved, you might close the session as follows: Please share if you had a reaction of empathizing with a thought, physical sensation, or behavior that someone else shared today. Therapists do not need to model the closing reflection. However, you might alert everyone to how much time there is left, to ensure everyone has a chance to speak. When there is a lot of time left, you might also encourage people to identify a personal goal for the next week.

Homework Many of the forms and worksheets will need to be filled out more than once. We are including one blank copy of every worksheet and form in the client workbook (within the corresponding chapter) as well as a blank copy of each in the appendices to this therapist manual. For those items that clients will need more than once, you can provide additional copies for them, or clients can download blank copies themselves from the TreatmentsThatWork™ website at www.oxfordclinicalpsych.com/​UTforEDs.

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■ ■ ■ ■ ■

Fill out Form 3.1: Eating, Depression, and Anxiety (EDA). Plot scores on Form 3.2: EDA Graph. Fill out Form 4.1: Regular Eating Food Log. Complete Form 8.1: The ARC of Emotional Experiences. You are going to practice nonjudgmental, present-​focused awareness this week, daily, for homework. Choose one situation, per day, for the next week where you can practice present-​ focused awareness. It can be just sitting quietly, doing a mindful walk (as described in Worksheet 9.3: Present-​Focused Awareness Exercise I—​ Mindful Walking), listening to a song, washing the dishes, or any other 5-​minute period of time during the day. Use Worksheet 9.1: Nonjudgmental Present-​Focused Emotion Awareness, and record one entry per night. ■ You are going to be generating examples of secondary emotions and exploring the effect of these reactions. Please review Figure 9.4 and Box 9.1 on your own to help you better understand this concept, and then complete Worksheet 9.2. Your therapist will guide you through the two practice examples on the figures and explain the worksheet instructions carefully. Do a daily mindfulness practice: Sit and breathe, or do a mindful ■ walk, and then complete Worksheet 9.1: Nonjudgmental Present-​ Focused Emotion Awareness. ■ Read Chapter 10 and preview the exercises.

In-​Session Exercises All in-​session exercises appear in the client workbook within the body of the corresponding chapter. We also include these exercises in this therapist guide, near the end of the corresponding chapter.

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In-​Session Exercise 9.1 Awareness of Primary Emotions and Secondary Emotions

There are six emotional states listed below; these are situations that many of us may identify with. The main point of this activity is to explore different ways to respond to emotional states, including our usual secondary (judgmental) reactions, and also helpful and adaptive ways:   I’m having a really hard time at the moment and I feel very sad, so I: ■ Usual secondary reactions? _​_​_​_​_​_​_​_​_​_​___________​_​​ ■ Adaptive reactions? ​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​_​_​_​​

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  I’m going to see my weight today and I’m so afraid of what the number will be, so I: ■ Usual secondary reactions? ​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ ■ Adaptive reactions?​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

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  I was really angry at my friend, so I: ■ Usual secondary reactions? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ ■ Adaptive reactions? ​_​_​_​_​_​_​_​___​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

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 Now I feel so guilty about how I treated my friend, so I: ■ Usual secondary reactions? _____​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ ■ Adaptive reactions? ________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

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Something really wonderful just happened to me and I’m overjoyed, so I: ■ Usual secondary reactions? ​_​_​__​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ ■ Adaptive reactions? ​_​__​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

My plans were canceled last minute, and I feel lonely, so I: ■ Usual secondary reactions? ___​_​_​_​_​__​_​_​_​_​_​_​_​_​_​_​_​_​_​​ ■ Adaptive reactions? ​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

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I’m chilling out at home alone, feeling quite bored, so I: ■ Usual secondary reactions? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ ■ Adaptive reactions? _______​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

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In-​Session Exercise 9.2 Guided Mindfulness It’s not a matter of letting go – you would if you could. Instead of “Let it go,” we should probably say “Let it be.” – Jon Kabat–Zinn

Now that you have fully explored possible secondary reactions, we want you to start practicing paying close attention to your experience. It is important to get used to what it feels like to observe your experience as it is occurring in the present moment. To help you learn this skill, let’s practice anchoring yourself to the present by noticing at least one thing going on around you. We are going to be using Worksheet 9.1: Nonjudgmental Present-​ Focused Emotion Awareness (located later in this chapter) for homework.

First, let’s focus on physical sensations. Close your eyes and for a moment now, turn your attention to yourself in the room. Picture the room—​imagine what the room looks like, what is in the room, where the furniture is laid out. Now picture yourself sitting inside the room and exactly where you are. Notice how it feels to be sitting in the chair. Begin to observe how your body feels and any sensations that are there. Notice any physical reactions you are having. Pause for a moment, and just allow yourself to observe your physical sensations. What physical sensations did you notice? Jot these things down on Worksheet 9.2. Next, let’s focus on the present moment. To anchor yourself in the present, one very useful cue is the breath. Pairing a deep breath with a shift in attention onto something tangible occurring in the present moment (such as listening to the sounds around you) can condition the breath to serve as a powerful cue to remind you to focus on the present moment. However, breath here is not intended to be a distraction or relaxation technique. Rather, breath here serves as a reminder to focus on what is going on at this moment. Now, let’s try using breath as a way to anchor ourselves. Slowly bring your attention to your own breathing. Notice yourself breathing in and breathing out. Focus on your breathing as it is happening right now, in this moment, using your breath to help anchor yourself to the present moment. Focus on the sensation of your breath entering your body, then leaving your body. Your breath is always with you, and your breathing is always happening in the here and now. Use your breath to remind you to pay attention and observe what is happening right now. Pause for a moment, and just allow yourself to notice your breath. What did you notice?

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In-​Session Exercise 9.3 Focusing on Nonjudgmental Emotion Awareness

The goal of this exercise is not to think about the meaning of what you notice, nor is it to try to understand your reaction to it. The goal is to let go of judgments about your experience and to just practice being an observer of your own experience or reactions. In this sense, there is no “right” or “wrong” way, just getting more used to observing how your thoughts, physical sensations, and behaviors unfold and influence each other. Remember, you are practicing becoming a curious observer of your experience, rather than approaching your experience as a judge and jury like you might be used to doing. This is a new perspective, and it takes time to get comfortable with it. Let’s try some more exercises together, using Worksheet 9.1: Nonjudgmental Present-​Focused Emotion Awareness to continue taking notes. As you stay focused on your breath, bring your attention inward toward your own thoughts. Notice how your thoughts are constantly changing. Sometimes you think one way, sometimes you think another. Some thoughts just pass by, others may distract you, and some of them may be hard to let go of. Simply notice what you’re thinking. If you notice yourself getting caught up in or carried away by a thought, just acknowledge it, without judgment, and gently try to bring your attention back to observing your thoughts as they occur. Allow yourself to watch your thoughts for a few moments—​and as you do, notice how they come and go. What did you notice? As you take note of these thoughts, start to shift and explore how you’re feeling. Emotions, just like thoughts, are constantly changing. Sometimes you feel love and sometimes hatred, sometimes calm and then tense, joyful and then sorrowful, happy and then sad. Sometimes emotions come in waves, sometimes they linger; sometimes they are brought on by certain thoughts, other times they seem to come out of nowhere. Simply acknowledge how you’re feeling in this very moment. Allow yourself to observe your emotions, without judgment. Notice how they ebb and flow. Pause for a moment, and just allow yourself to observe your emotions. What did you notice? Continuing to use your breath to anchor you, begin to take note of your entire experience—​how your body feels, what you are thinking, what emotions you are experiencing. If you notice that you are trying to change your experience in some way, take note of that, and gently guide yourself back to your experience. Notice whatever you’re experiencing in this very moment. 137

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What did you notice? Using your breath to anchor you, allow your awareness to shift so you can take in what’s going on around you. Notice the temperature of the room. Notice any sounds occurring outside the room. Notice any sounds occurring inside the room. What did you notice? And, when you are ready, start to bring yourself back into the room. Picture yourself sitting in this room, picture the way the room looks, how it is laid out. When you are ready, come back into the room and open your eyes. As you can see by this example, doing this exercise the first time around may feel a little strange, or you may feel like you are not doing it right. Remember that the goal of this exercise is not to do it perfectly; rather, the goal is to begin to learn how to observe and be aware of your own experience, to understand how the whole process unfolds for you. This will help you to begin to see where your emotional experiences might be changing from something adaptive and helpful to something maladaptive and unhelpful.

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Case vignettes Case ­vignette 9.1 The following vignette illustrates a therapist working with a client to understand the primary and secondary emotions of her behaviors of binge eating. The client identifies as a cisgender Latina. She is divorced, single, and in her mid-​50s. She has been diagnosed with binge eating disorder and major depressive disorder. T: C: T: C:

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You seem pretty tense. What is going on? I guess you could say I’m tense, but really it’s because I’m angry. What happened that led you to feel this way? I had a doctor’s appointment earlier today and my doctor is a straight-​up jerk. He reviewed my labs, weights, and vitals and then he asked me how I was doing with my meal plan from my dietitian. I told him I was working on flexibility and that I had started allowing myself to have dessert when I really wanted it. And then that jerk just stared at me and condescendingly said I should “be more careful” with my choices. I have been working so hard in therapy to not hate myself and hate my body, and then this guy comes in and tells me I’m a terrible, disgusting person for having dessert once in a while. Oh, wow, no wonder you are experiencing some strong emotions. I am so sorry you had that experience, and I am so glad you told me about it. I was so angry I just couldn’t deal with it! When I left his office, I stopped at two fast-​food places and ate everything I wanted—​ Taco Bell and ice cream—​on the way here. Obviously my doctor is right, and I can’t make good choices, so why bother trying? Right now you are feeling really strong emotions, understandably. Let’s take a breath, and take a moment to anchor in the present. You mentioned and expressed a lot of anger, but I am wondering if there are any other emotions underneath the anger. Remember when we talked about primary and secondary emotions? Kind of. But honestly I find it pretty confusing. A lot of people find this a little confusing, but I think it might be useful to really understand what you were feeling earlier, and what you are feeling right now. Can you put yourself back in 139

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that moment? So, when your doctor made that comment, I know you felt very angry. Understandably. Was there anything else you might have been feeling? Like a fat loser. Ouch. That must feel pretty bad. Yeah. It feels terrible [tearful]. I just feel so down on myself and so hurt. His words and his judgment really hurt. Oh, yes, it makes a lot of sense that you might feel sad or hurt. It also makes sense that you might feel angry. [Crying a minute, then stopping.] Okay, so all of those emotions are primary, then? What is the difference between primary and secondary emotions? Our primary emotions are our first, most instinctive response to the situation as it is actually happening. It sounds like you felt both hurt and really angry in the situation as it was happening. I am actually looking at the binge eating part of the story as maybe a sign of a secondary emotion. I am guessing that you might have started to judge those emotions. Maybe you felt like you didn’t want to feel so hurt or angry, or you felt like it was hopeless to express those feelings, so you tried to get relief by binge eating. That might be true, but what does it matter if I label them as primary or secondary emotions? I am just going to feel it all anyway. Do you remember the moment in between when you were hurt and angry and when you decided to go binge eat? You said that what the doctor said made you feel “like a fat loser.” Yeah, I felt like it was my fault, I did this to myself, I deserve this abuse. I shouldn’t be mad or surprised because it’s reality, and it’s my fault anyway. It seemed like it was obvious and true that I’m a loser. Those sound like extremely painful judgments of yourself and of your emotions. I certainly understand how hard it would be to bear that. If maybe the next time you had a little bit more distance—​if you felt like, I know this feeling, this is the judgment that I make of myself when someone hurts me with their ignorance or disrespect. Maybe if you recognized it as a secondary reaction rather than just reality, you would have a moment to consider options about what you wanted to do about it. [Pause] I could write a letter to the doctor.

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Yes! You could provide that misguided doctor with some much-​ needed education! [Laughing] And then I could find a new doctor.

Case ­vignette 9.2 In this therapist–​client dialogue the therapist explains mindfulness and guides the client through psychoeducation on mindful emotion awareness followed by a mindfulness exercise. The client identifies as a black woman lesbian and has been diagnosed with anorexia nervosa and generalized anxiety disorder. C:

I’m not very good at mindfulness. Being in the here and now is not relaxing to me at all. My here and now is pretty awful and makes me even more anxious. So I just don’t do it. T: That’s actually extremely common. Most people don’t think they are good at mindfulness because they think it is supposed to be relaxing. Mindfulness is not the same as a relaxation technique, and it is not meant to distract from the moment we’re in right now. Rather, mindfulness is being aware of our present, even if the here and now is distressing and makes us want to run away. We can keep ourselves in the moment by using an “anchor” to keep in the present. Usually people use their breath, and you can also anchor with the five senses. C: What do you mean? T: You can keep paying attention to the feeling of your breath, or you can refocus by attending to sounds or feelings on your skin each time you notice that your mind has wandered. If we keep anchoring ourselves back in the here and now, with our breath or senses, we can reorient on what we are feeling emotionally, and try to be accepting rather than judgmental. Is it okay to try an exercise today? C: Sure. T: To begin, do you mind telling me what is consuming your thoughts right now, if anything? C: The fact that going home every day after work is stressful. Home always has been to some degree, but I received a text from my partner who is annoyed that I’ve been isolating, so we’ve been 141

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fighting. As you know. Now she wants to talk. I’m unhappy with her, but if we break up, I don’t know what I’d do. I also feel guilty because I’m not doing enough to improve this relationship. I’m supposed to be a role model for my younger siblings and I’m just a waste. Wow, that makes sense you’re feeling stressed. I’m also noticing a lot of judgment in your thoughts, based on what you said. While I do have questions I’d love to ask about the whole situation, the goal today is to implement present-​focused and nonjudgmental emotion awareness, especially in the face of everything happening. What this means is that although the present moment is distressing, it’s important to label the thoughts you are having as potential distractions away from the present moment, and try not to follow the train of thoughts. How could that be possible to not go with the train of thought? I don’t understand. My thoughts just race. It’s a hard concept! I understand that. It takes practice, but we’ll practice together. We have so many thoughts a day that it seems unnatural not to go with them. What I will ask you to do, though, is to notice these thoughts, label them as part of the emotion, recognize them as a potential distraction, and come back to an anchor—​that’s mindfulness. The anchor in this situation is going to be your breath. Would you say your thoughts are future-​oriented, thinking about the conversation with your partner later today, the future of your relationship, et cetera? Hmmm, yes, I can’t stop thinking about that conversation. It’s making me anxious. I just know she wants to break up with me. And what do you think will happen if you continue to think about it and ruminate on it? I don’t know—​get more anxious? Exactly. You are here for the next half-​hour and your thoughts are making you anxious, so you might as well try the experience of being as present and mindful as possible, even if it isn’t exactly comfortable. Notice the pull to think about the future, or the pull to judge yourself, and re-​anchor in the present. Are you willing to practice with me? Sure. I guess.

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I know it can feel odd, and not appealing if you think it doesn’t work. However, let’s start practicing. Let’s start by taking a few deep breaths in and out. Do you want to close your eyes, or keep them open and focused on a spot right in front of you? I’m going to close my eyes. Great. Please bring your attention to your breath, specifically counting your breath. As you breathe in, count to yourself—​ one, two. Hold your breath in your chest counting—​three, four. Breathe out—​five, six. Hold on the exhale—​seven, eight. So it is inhale for two, hold for two, exhale for two, hold for two. I want you to continue breathing, counting silently to yourself for the next few minutes, and I will let us know when the exercise is over. [Several minutes pass.] And now, slowly, bring your attention back into the room. What was that like for you? I have to be honest: I was pretty distracted, like I expected. But your instructions did help me remember to breathe, and that brought me back a number of times. Where did your thoughts bring you? That I’ll end up living back with my parents. I really feel like my relationship won’t last. I don’t have enough money to live by myself and my parents have told me that they don’t accept my “life choices.” While all of the worries listed might come true, I am going to ask you to sit with me in this moment. How does it feel if we focus in on the here and now with me and you in this room together? When I am more present, I feel less anxious. But I know that if I’m in the here and now during the stressful conversation with my girlfriend later, I’ll feel even more anxious and shameful. That might be true. The later thought, for right now, though, is going to be labeled as a distraction. Because that isn’t happening right now. I guess not. Were you able to bring your awareness back and anchor in the present with your breath? I was, at times, because you reminded me. That’s why we’ll practice this, until it becomes more natural.

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CHAPTER 10

Therapist Materials for Mood Induction

Goals ■ Review the principles of the natural course of emotions using Figure 10.1: The Natural Course of Emotion: There are three components of emotion (thoughts, physical ■ sensations, behaviors/​urges) that unfold over time. If we escape or avoid, we never learn that emotions pass on their ■ own, and we end up reinforcing that emotions are scary and dangerous. Secondary emotions often lead to escaping or avoiding. ■ If we stay with the primary emotion and do not react by escaping ■ or avoiding, we can learn new things about the emotion, and it can pass on its own. Learn how mood induction is intended to help promote new toler■ ance of emotion. Do In-​ ■ Session Exercise 10.1: Mood Induction Using Audio/​ Visual Media two times. Materials needed: Recordings of “Happy,” “The Star-​Spangled ■ Banner,” “Taps,” or alternatives; video screen if a group, cellphone if individual. Plan mood induction exercises for home using Form 10.1: Mood ■ Induction Recording.

Homework review Fill out Form 3.1: Eating, Depression, and Anxiety (EDA). ■ Plot scores on Form 3.2: EDA Graph. ■

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Fill out Form 4.1: Regular Eating Food Log. ■ Complete Form 8.1: The ARC of Emotional Experiences. ■ You are going to practice nonjudgmental, present-​focused aware■ ness this week, daily, for homework. Choose one situation, per day, for the next week where you can practice present-​ focused awareness. It can be just sitting quietly, doing a mindful walk (as described in Worksheet 9.3: Present-​Focused Awareness Exercise I—​ Mindful Walking), listening to a song, washing the dishes, or any other 5-​minute period of time during the day. Use Worksheet 9.1: Nonjudgmental Present-​Focused Emotion Awareness and record one entry per night. You are going to be generating examples of secondary emotions and ■ exploring the effect of these reactions. Please review Figure 9.4 and Box 9.1 on your own to help you better understand this concept, and then complete Worksheet 9.2. Your therapist will guide you through the two practice examples on the figures and explain the worksheet instructions carefully. Do a daily mindfulness practice: Sit and breathe, or do a mindful ■ walk, and then complete Worksheet 9.1. Read Chapter 10 and preview the exercises. ■

Opening the session If you are running an Individual Session, the opening requires no formality aside from your usual methods. After greeting the client, get a quick initial sense of their emotional state. If the client is experiencing a notable emotional experience, consider suggesting that this example may be something to use in the session, for a real-​time example of the relevant UT material. Try to get to the homework review within a few minutes of opening the session. Group Sessions do benefit from having a formal check-​in, however. A formal starting ritual is important to help the group members shift from a customary, social state of mind to a therapeutic state of mind. It is very useful to help group members with social anxiety or those who have trouble participating for other reasons to begin speaking right from the beginning of the session. Knowing something about how each group member feels at the beginning of group also helps the therapist to make 146

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the session more “alive.” When you conduct in-​session activities, it is useful to return to examples of emotions that were shared in the group check-​in, to invite individual participants to use their own examples of active emotions to discuss in the group. If you are running a Group Session, you might introduce this group with the following check-​in: To begin the group, we try to bring ourselves into the present moment and into connection with one another. I ask that everyone take a nice, deep breath and anchor into the moment, look around the room, and make eye contact with your peers. Notice how this feels. Now close your eyes and try to identify the emotion you are feeling right now. This check-​in exercise is not meant to generate discussion; rather, it is a place to notice and briefly share your authentic experience. Since this group is about deliberately noticing how it feels to have an emotion, let’s think of that today. Let’s go around the room and share one or two emotions that you are feeling right now. It can be useful for the therapist to start the check-​in. See prior chapters of the therapist guide for suggestions and examples regarding therapist disclosures. The check-​in should be brief—​about 5 minutes for a 50-​minute group session and 10 minutes for a 90-​or 120-​minute group session.

Therapist tips for mood induction exercise Prior to doing the exercise, review the principles of present-​focused, nonjudgmental awareness. The goal of mood induction is to practice this new learning using stimuli that will prompt some emotions. Selecting an appropriate stimulus is an important job. It is also important to have it ready to play before the session. In a group, the stimulus should be played on a device with adequately loud volume and/​or an adequately large screen, while in an individual session, cellphones can easily be used. When group members or individual clients have a lot of anticipatory anxiety, it can be preferable to use music as the stimulus and to start with something that typically provokes a pleasant emotion. Three good selections for an initial

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introduction of the mood induction exercise are listed in the bulleted list in this section. In the session, as noted in the client workbook materials, you can use three tried-​and-​true songs that reliably prompt some emotion in most people, if they really try to stay with their emotion. You can also use alternative songs or stimuli that you judge to be moderately intense and generally well known. If you would like to use the audio clips that we have selected as typically appropriate for an in-​session introduction to mood exposure, make sure you have them ready to play for the session. We suggest these three because they often do produce emotions but often not extremely intense emotions, as a first example for in-​session exposure. Over time, more intense stimuli can be introduced. If clients agree they are ready to try something more intense, they might select a personally relevant song or movie scene. Three suggestions for the first introduction of mood exposure exercises are as follows: ■ Pharrell Williams singing “Happy” The context of this song is that it comes from a pivotal mo■ ment in Despicable Me 2’s storyline, and Williams wanted to recreate that feeling with the music video. Gru, the lead character who’s no longer a villain, has fallen in love and feels so much joy that he literally dances through the streets. Williams explains, “That kind of happiness is so infectious; you can’t help but smile.” If this does not make clients feel happy or upbeat, perhaps it ■ makes them feel a different emotion. Ask them to try thinking about why their reaction is what it is. Whitney Houston singing “The Star-​Spangled Banner” ■ The context of this recording is that Whitney Houston sang this ■ version soon after the 9/​11 terrorist attacks on the World Trade Center. People often feel inspired, sad, or excited when they hear this song ■ (or a mix of emotions). Some people feel emotions about 9/​11 or about the military. However, there is no “right” reaction. Ask clients what they feel, and why their reaction is what it is. “Taps” by the Army National Guard ■ 148

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■ The context of “Taps” is that it is a song played to say goodnight at the end of the day, or to say goodbye to a person who has died. If the emotion does not feel very strong to clients, perhaps listen ■ to it a second time and ask them to think about someone or something that they have lost. This song often makes people feel sad or peaceful. However, there ■ is no “right” reaction. Ask clients what they feel, and why their reaction is what it is. Clips from television shows and movies that provoke emotions are also extremely good stimuli. The therapist should take time to preview the clip to plan the length and intensity of the stimulus. Dramatic television shows (for example, This Is Us) and children’s movies (such as The Lion King) have many excellent scenes, about 3 minutes in length. Following each exercise, take time to discuss what everyone noticed and filled out in Form 10.1: Mood Induction Recording. It is extremely helpful for therapists to share some of their own reactions to a stimulus because mood induction is not a familiar practice for most people. You can model the activity of sharing authentically about your response to a music clip, as well as being brave enough to share any secondary reactions that may have been elicited. In our experience, this sharing is moving, it helps to build relationships, and it is normalizing in terms of being OK with experiencing strong emotions and being a little vulnerable in the moment. This is a highly recommended tip! It is also helpful to use film clips or photography as mood induction stimuli. For example, just listening to “Taps” can be challenging for some; what would it be like to listen to “Taps” and also look at a photograph of Arlington Cemetery? Or to watch a video of a solider playing “Taps” in uniform at the cemetery? We can layer stimuli to make the experience evocative in different ways, but you should judge the appropriate intensity of stimulation based on the participants in the group. If a participant is feeling no emotion, it is important to focus on whether there is avoidance going on. In both the cases of feeling no emotion or feeling “too much” emotion, it can be useful to repeat the same stimulus twice to see how the experience changes after talking about avoidance, the emotion itself, judgments of emotion, and secondary emotions.

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It can be important to point out that having a secondary reaction may not happen! There are cases where a client does not experience a secondary reaction in response to the stimulus and is able to stick with the primary emotion. This is great—​but in our experience, this can create confusion because sometimes clients believe that they should be having a secondary reaction. Be sure to discuss that just having the primary one is OK, too. It may also be important to distinguish multiple primary reactions versus primary and corresponding secondary reactions. This is a very common mistake that clients make. Clients sometimes think that if there is more than one emotion associated with a stimulus, then the first one is the primary reaction and the rest are the secondary reactions. This isn’t correct; remember, the idea of a secondary reaction is a very specific concept. For instance, it’s quite possible that the national anthem could make a person feel more than one emotion (e.g., pride, calmness, belonging, nostalgia, and determination), which are all examples of different primary emotions in response to a single stimulus. You should clarify the difference and remind clients that different emotions can happen simultaneously. Clients sometimes worry about how mood induction will feel. Sometimes you will see them trying to escape doing a mood induction. You can expect that sometimes clients may comment or complain that they have seen a clip before, or that they’ve seen it “too many times” before, or that they don’t think the mood induction will work on them, or that they should not do it or don’t want to do it. Therapists should see this unfolding event as an emotional reaction in and of itself; just the idea of watching the clip has induced a powerful emotional reaction! See if you can work with that, showing clients that they are, in that moment, working through some kind of anxiety. We want to build self-​ efficacy and the idea that a person can actually “lean in” to uncomfortable emotions and cope with them. When this kind of event is handled well, you will be able to get clients to not only explore and explain their anxiety and reluctance but also get them to agree to participate in the planned mood induction. Following both exercises and discussion, take time to plan what will be chosen for mood induction for homework. It should be something that will prompt a strong emotion that one would usually want to escape or avoid.

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Closing the session Closing an Individual Session does not require any additional formality beyond preparing the homework, confirming the next session time, and other customary practices. Group Sessions can require additional formality. Try to save 5 or 10 minutes at the end of the session after preparing the homework and confirming the next session time for closing the group. If it is not possible to save the time, it is not as important to formally close the session as it is to open it formally. If you are running a Group Session, and you have time saved, you might close the session as follows: Let’s go around the room and say one thing about how we are each feeling as we end the group, or a few words about what impact this group had on you. Therapists do not need to model the closing reflection. However, you might alert everyone to how much time there is left, to ensure everyone has a chance to speak. When there is a lot of time left, you might also encourage people to identify a personal goal for the next week.

Explanation for the client of this session’s homework Here is how you might explain this session’s homework: Your job for homework is to do your own mood induction. Please feel free to repeat the exercise as many times as you like, each time monitoring any changes in your emotions. You should know what you are going to do before you leave today. Write down your idea, and brainstorm with the group leader if you need help accessing some material. Suggestion 1 Group Redux: If you liked the format of the group today, think of songs or scenes from movies or shows that make you feel a particular way. 1._​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​______________​_​_​_​_​_​_​_​_​ 2._​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​______________​_​_​_​_​_​_​_​ 3._​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​______________​_​_​_​_​_​_​_​

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Suggestion 2 Imaginal: You could spend time writing down a story of something that happened to you that made you feel a particular, strong emotion that you might try to avoid or escape. Your story could usefully be about food, eating, or body image, although it doesn’t have to be, and it should be something that you can remember in good detail, particularly how you felt at that time. Try to remember a story that will make you feel a little uncomfortable so that you can become aware of these feelings and begin to tolerate them. You are going to use this piece of writing as your mood induction. Use Form 10.1: Mood Induction Recording to observe your emotions after you’ve written and read through your story.

Homework Many of the forms and worksheets will need to be filled out more than once. We are including one blank copy of every worksheet and form in the client workbook (within the corresponding chapter) as well as a blank copy of each in the appendices to this therapist manual. For those items that clients will need more than once, you can provide additional copies for them, or clients can download blank copies themselves from the TreatmentsThatWork™ website at www.oxfordclinicalpsych.com/​UTforEDs. ■ ■ ■ ■ ■ ■ ■

Fill out Form 3.1: Eating, Depression, and Anxiety (EDA). Plot scores on Form 3.2: EDA Graph. Fill out Form 4.1: Regular Eating Food Log. Complete Form 8.1: The ARC of Emotional Experiences. Mood Induction Homework (suggestion 1 or 2). Fill out Form 10.1: Mood Induction Recording. Read Chapter 11 and preview the exercises.

In-​Session Exercises All in-​session exercises appear in the client workbook within the body of the corresponding chapter. We also include these exercises in this therapist guide, near the end of the corresponding chapter.

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In-​Session Exercise 10.1 Mood Induction Using Audio/​Visual Media

Our in-​session exercise is to try to feel some emotions deliberately by listening to some recordings of songs. We are going to start deliberately observing what we do when we actually have these more difficult emotions. We are going to practice doing general exercises in session so that we can then plan what to do that would be more specific to you and your emotions at home. Please turn to Form 10.1: Mood Induction Recording at the end of this chapter. Notice what we are going to do, what boxes you are going to be filling in after the experiential part of the exercise is over. The goal is to notice the thoughts, physical sensations, and behaviors/​urges that come up during an emotional experience. Now, take a look back at Figure 9.4: Primary and Secondary Emotions Worksheet and review the concepts there. It’s possible that you will try a mood induction exercise and not have a secondary emotion. Once these two forms make sense to you, you can put them aside. Remember, the point of these exercises is for you to let an emotional experience happen, and to notice what that experience is, be it primary or secondary. The experience might be that you don’t have very much of a reaction at all, and you will notice that. You might notice that you are afraid of the reaction and that you try pushing it away. The experience might be that you have a strong reaction, like feeling very tearful, angry, or guilty. Of course, as in any session, you have choices about what you want to do with that emotion. The suggestion here is to try to have the emotion without judging it, to allow it to exist, to observe it, and to notice what happens with your thoughts, physical feelings, and behaviors. Try to remember that it is not dangerous to have emotions, but you may have been treating them as dangerous for a long time. For this in-​session exercise we have music that pretty reliably induces some emotions, of some kinds, in most people. There is no particular emotion that you should feel, and you may not feel that much. The goal is to see what you feel, let your emotion become as strong as you can without resisting it, notice if you have secondary emotions that take you away from the primary emotion, and discuss the experience afterward. It is a practice exercise for being able to plan this for yourself here and at home. We will do a few of them, so that hopefully one will resonate with you.

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■ Pharrell Williams singing “Happy” ■ The context of this song is that it comes from a moment in Despicable Me 2 when the lead character has fallen in love. ■ Whitney Houston singing “The Star-​Spangled Banner” ■ The context of this recording is that Whitney Houston sang this version soon after the 9/​11 terrorist attacks on the World Trade Center. ■ “Taps” by the Army National Guard ■ The context of “Taps” is that it is a song played to say goodnight at the end of the day, or to say goodbye to a person who has died.

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Case vignettes Case ­vignette 10.1 The following vignette is a therapist/​client dialogue introducing mood induction. The client is a single 18-​year-​old cisgender Asian American woman who is a freshman at a local university. She is currently in her second semester and has been diagnosed with anorexia nervosa. At this point in therapy, she is engaged and compliant with her meal plan, and weight restoration is progressing along with work of the UT. T:

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From our recent sessions and the homework you’ve been completing, it seems like you’re getting the hang of labeling your emotions and trying to incorporate reappraisals and shifting your perspective to include multiple different possibilities. So, today, we’re going to be talking about experiencing emotions while actually experiencing them right here in session. The point of the exercise we’ll be doing today is to observe differences in your level of comfort or discomfort with different emotions, and to start to notice what you do to escape from those emotions, and how it is possible to bring yourself back. Are there any emotions that you’ve learned thus far that are more uncomfortable for you? Sadness and anger. Recently I’ve been feeling embarrassed and ashamed, and I try to avoid feeling that way. Those can be tough emotions to sit with, absolutely, and the point of the next exercise is to observe differences in our level of comfort or discomfort with different emotions, and to start to notice what we do to escape from those emotions, and how it is possible to bring yourself back. If you don’t judge the emotion, and you don’t try to escape from it or suppress it or make it go away, then it will come down by itself. Often judgments on the emotion can bring up what we call secondary emotions, and it’s important to know when we are acting on a primary or secondary emotion. You already have acquired some skills for anchoring yourself in the present, which means to try to remain in the present moment, instead of—​ for example—​ remembering something bad that happened in the past or imagining something bad that could happen in the future, or even just planning or thinking or 155

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distracting yourself in other ways from the present moment. Are there avoidance strategies that you realize you rely on? We want to experience the full emotion, without using anything to keep the emotion away or go away quickly. I usually make mental to-​do lists, or shake my leg—​that’ll be something you’ll be able to notice! I also play with my nails and twirl my hair. Usually, though, I’ll think about something else. Or, if I’m home and not in a place where I’m talking to someone, I’ll keep myself extremely busy. OK, so maybe you rely more heavily on cognitive avoidance, and that will be more difficult for me to look out for while you experience emotions. It’ll be important for you to be aware in situations of the tendency to avoid by thinking about something else—​whether that is a mental to-​do list, or thinking about the past or the future. Our exercise for today is to try to feel some emotions deliberately here in session, by listening to music, watching videos, or imagining things. And we are going to start deliberately observing what we do when we actually have these more difficult emotions. We’ll be using Form 10.1: Mood Induction Recording. Notice what we are going to do and what boxes you are going to be filling in after the experiential part of the exercise is over. We will be yet again noticing thoughts, feelings/​physical sensations, and behaviors or impulses—​what we want to do in reaction to the emotion. Try not to write during the mood induction, only afterwards to record your experience. Instead, try to notice at what parts you feel that you want to avoid or dampen—​and if you notice yourself avoiding, just bring yourself back to the present and watching the clip. Hard. But I get it. What are we watching? A short clip from a popular TV show. Before I tell you about the clip we’ll be watching, I want to share the point of this all. These exercises are for you to have an emotional experience and to notice what that experience is. The experience might be that you don’t have very much of a reaction at all, and you will notice that. You might notice that you are afraid of the reaction, and so that is part of pushing it away. The experience might be that you have a strong reaction. Of course, you have choices about what you

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want to do with that emotion. And the suggestion here is to try to have the emotion without judging it; to allow it to exist; and to notice your thoughts, physical feelings, and behaviors. I want to simply remind you that it is not dangerous to have emotions, but you may have been treating them as dangerous for a long time. So if you’re willing, let me know if this comes up for you and I hope we can talk about it. We will start with one mood induction, and if we have time, we can do more than one. [Therapist plays 5-​minute clip from a television show where one person is expressing frustration and anger at a group of friends.] T:

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Okay. please take a few minutes to record your experience, your thoughts, what it felt like physically, and behaviors you had in the moment. [Therapist allows the client several minutes to write.] What did you notice in your thoughts? Surprisingly, this annoyed me. I wrote down that I felt annoyed; he shouldn’t be yelling at his friends. It also reminded me of the way that my roommate is. She expresses anger and I never do. For the past year, I’ve been living with her and she gets angry at everything. It’s weird to me. So you noticed that your mind was relating what you were seeing to what you have experienced with your roommate. How did the expression of the person in the clip make you feel physically? Well, I don’t know. I kind of got this flutter in my stomach and my heart rate increased a bit. Did you notice any efforts in trying to make it go away? Have you felt like this before? With my roommate. I feel really uncomfortable with her. She gets angry, and then I feel angry that she’s angry, which makes me never want to go into my room. I even noticed I wanted to cry during this today, but I didn’t and I really wanted to turn the TV off to stop watching it. If we were to backtrack for a moment, into primary and secondary emotions, what emotions were you feeling and what stopped you from expressing by crying? I didn’t want to be crying because of a show. I think I felt sad for him and then angry that he was yelling.

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So initially, from the clip, you felt sad. And then he started to yell, and you felt angry. Or did you feel angry because you were noticing that it was upsetting you? I think in this case, I was feeling both anger and sadness and then angry for being sad. Which is a really interesting point. Sometimes we have emotions about emotions—​and the emotions are the same! It’s why we do this exercise, to notice the thoughts we have that elicit a judgmental reaction and to create a pause and increase awareness. I think being more comfortable with anger may be something we can try to do for homework. Think about what’s available to you that would put you in this particular mood. You could listen to a piece of music, or watch a film clip, remember something that happened to you that made you feel a particular way, use a piece of art you made, perhaps look at photos. Try to do things that may be a little uncomfortable so that you can become aware of these feelings and begin to tolerate them.

Case ­vignette 10.2 This vignette illustrates the therapist engaging the client in a mood induction exercise. The client is a 32-​year-​old White cisgender woman diagnosed with bulimia nervosa and substance use disorder. At this point in therapy, she has been refraining from drinking and her binge eating episodes are somewhat reduced. Her feelings in general have become more intense, a phenomenon that she has been interested in observing and learning from. The therapist and client just viewed a video clip of a woman being surprised by her boyfriend with a marriage proposal. The client has historically struggled with relationships and this year has been a bridesmaid in several weddings. C: T: C:

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Now I just feel worse about myself! Thanks. Tell me more. Well, you know how much I want to find my person and be married. This clip just reinforced how that is never going to happen for me. I am pathetic and unlovable. I have gone dateless to seven weddings this year, five of which I have been in. I’m an archetype in a bad romantic comedy.

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Seeing your friends getting married has been really hard. Can you tell me more about your physical sensations along with urges and behaviors that came up when you were watching this clip? C: Okay. I felt my heart race, tension in my head, and my eyes started to water at the beginning, but I focused on something else because I didn’t want to cry. It felt similar to when I have been at the weddings and get this pit in my stomach, which is usually when I start drinking. I had the urge to look the other way and even to make a joke about it. My behaviors were watching and holding my breath. T: And what emotions did this bring up for you? C: Shame and embarrassment. I mean, who on earth is single at 32 years of age? I’m so pathetic. T: I want to keep going with this emotion if you are up for it. C: Sure. T: Do you remember when we talked about primary and secondary emotions? C: Yes. T: I wonder if you are feeling both primary and secondary emotions in response to watching this clip. C: What do you mean? T: Let’s take your emotions of shame and embarrassment for example. One clue to you that it could be a secondary emotion is if there is a pattern of leading to EDBs in these types of examples. This is because secondary emotions tend to be more action oriented. We may feel like we are more able to do something about them. C: Well, I did say it felt like when I drink at weddings and usually end up binge eating and purging too. T: Yes, that was a clue for me, too. Secondary emotions also tend to include judgmental thoughts because the emotion itself is a judgment of the primary emotion. C: I had a lot of judgmental thoughts. I usually do. Why is it important to know if and what the primary emotion is? T: Good question! The primary emotion gives us information about the present. If you can remember back to earlier sessions when we talked about the function of emotions, that primary emotion is showing up to tell us something. The secondary emotion shuts

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it down, though, and interrupts the natural course of emotion. Another helpful trick is to ask ourselves if there is anything else that could possibly be going on. Hmmm. Well, I did try to shut down my tears before I even let any out. I think underneath the shame and embarrassment is sadness. But I don’t like to feel the sadness because I don’t feel like I can do anything about it. That’s a great connection you made. When we jump to secondary emotions it’s often because we feel like we can do something with the emotion, let’s say drink or binge and purge. While it may feel like it is helping in the short term, we know that in the long term it continues to create this cycle we find ourselves trapped in. Well, yeah, then I feel shameful and embarrassed about using my EDBs. My hope through this mood induction is to show you that if you stick with the primary emotion—​in this case, allow yourself to feel sad—​maybe the emotion will peak and naturally decrease on its own without having to do anything at all. Shall we watch the clip again and give it a shot?

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MODULE 4

Cognitive Flexibility

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CHAPTER 11

Therapist Materials for Automatic Thoughts and Thinking Traps

Goals ■ Understand automatic thoughts, which are fast, subjective interpretations of the world. Automatic thoughts influence and are influenced by emotion. ■ There can be more than one interpretation of a situation. ■ Cognitive flexibility means being able to consider various ■ interpretations. Conduct In-​Session Exercise 11.1: Flexibility with Appraisals, in■ cluding the Interpretations Activity Worksheet that follows the stimulus. Observe “automatic” interpretation of the image. ■ Consider personal factors that might contribute to this ■ interpretation. Generate alternative interpretations of the image. ■ Understand how “thinking traps” influence thoughts to produce ■ negative emotion. Jumping to conclusions, or probability overestimation ■ Thinking the worst, or catastrophizing ■ Develop greater flexibility in our thoughts by learning to iden■ tify thinking traps and to generate alternative appraisals (a skill we call cognitive reappraisal) using a recent ARC, as well as In-​Session Exercise 11.2: Cognitive Flexibility Exercise, Worksheet 11.1: Cognitive Reappraisal Strategies, and Worksheet 11.2: Re-​evaluating Automatic Appraisals. Assign Worksheet 11.3: Obsessive Thoughts, to be read and filled ■ out for homework.

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Homework review ■ ■ ■ ■ ■ ■ ■

Fill out Form 3.1: Eating, Anxiety, and Depression (EDA). Plot scores on Form 3.2: EDA Graph. Fill out Form 4.1: Regular Eating Food Log. Complete Form 8.1: The ARC of Emotional Experiences. Mood Induction Homework (suggestion 1 or 2). Fill out Form 10.1: Mood Induction Recording. Read Chapter 11 and preview the exercises.

Opening the session If you are running an Individual Session, the opening requires no formality aside from your usual methods. After greeting the client, get a quick initial sense of their emotional state. If the client is experiencing a notable emotional experience, consider suggesting that this example may be something to use in the session, for a real-​time example of the relevant UT material. Try to get to the homework review within a few minutes of opening the session. Group Sessions do benefit from having a formal check-​in, however. A formal starting ritual is important to help the group members shift from a customary, social state of mind to a therapeutic state of mind. It is very useful to help group members with social anxiety or those who have trouble participating for other reasons to begin speaking right from the beginning of the session. Knowing something about how each group member feels at the beginning of group also helps the therapist to make the session more “alive.” When you conduct in-​session activities, it is useful to return to examples of emotions that were shared in the group check-​in, to invite individual participants to use their own examples of active emotions to discuss in the group. If you are running a Group Session, you might introduce this group with the following check-​in: We like to start our group by making sure everyone’s voice is working, and is heard, and by helping us make authentic connections to our own

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experience and each other. Take a breath, try to connect to yourself, and also look around the room. This series of groups has been about thoughts. Let’s go around the room and each share one thought you had about being in the group today, and one reason why you might have had that particular thought at this time. It can be useful for the therapist to start the check-​in. See prior chapters of the therapist guide for suggestions and examples regarding therapist disclosures. The check-​in should be brief—​about 5 minutes for a 50-​ minute group session and 10 minutes for a 90-​or 120-​minute group session.

Therapist tips for automatic thoughts and thinking traps exercises Psychoeducation on cognition This session introduces and develops the idea that (1) thoughts are subjective and (2) thoughts are influenced by and influence our emotions. In the session we introduce the goal of developing “flexibility” in thoughts so that we are not trapped in rigid patterns of negative emotions. The main exercise for developing flexibility here is to look at an ambiguous image and discuss different interpretations (“appraisals”) of what might be happening in the image. There are no right or wrong interpretations. The goal is to be able to see that interpretations are subjective, to reflect on why we might see things a certain way, and to develop flexibility to consider different ways of seeing things. If your clients are having trouble coming up with a personally relevant example of an emotional state influencing their interpretations of a situation, present the following scenario: You are walking through a mall and you see an old friend you haven’t seen in a while. You wave to this person, but she does not wave back. If your thought is, “She just ignored me!” how would this interpretation

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make you feel? Probably sad, embarrassed, or lonely. But if your thought is, “She must not have seen me”? Then probably neutral. Keep in mind that those two thoughts and feeling states would also likely drive different behaviors. If clients think, “She ignored me,” they would probably just walk away, or even try to hide from this friend. If, on the other hand, clients think, “She didn’t see me,” they might go seek her out. If clients do the latter, they might then find out that this friend is happy to see them, or perhaps was distracted by something going on in her own life. Then for the client, some chronic negative automatic thoughts (people don’t like me, people are mad at me) and possibly even core beliefs (I am unlovable, I will always be rejected and lonely) would be challenged. If your client is having trouble coming up with a personally relevant example of how emotions also affect interpretations, consider the “running into an old friend” example again. Imagine that right before running into the old friend, the client had a binge eating episode or had received really bad news—​like doing poorly on a test, or being let go from their job. While feeling this way, how would the client be likely to interpret the friend not waving back? Probably in a more negative way. But if the client had just had a great morning or received some very good news, how would feeling joyful affect their interpretation of the person not waving back? Probably in a more neutral way.

Ambiguous picture exercise For the ambiguous picture exercise (In-​Session Exercise 11.1: Flexibility with Appraisals), first present the ambiguous picture to your client(s). After about 10 seconds, put the picture away and ask for the initial interpretation of what is happening in the scene. After identifying the initial (or automatic) interpretation, consider asking your client to try to name the specific aspects of the picture (such as a particular object, posture, or facial expression) that may have led them to this automatic interpretation. Consider asking whether a past memory or experience, or current emotion or experiences, may have influenced their initial interpretation. Once you have spent some time discussing the first interpretation, return the image to your client and ask them to try generating alternative interpretations about what might be happening.

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Here are some useful questions to ask following the administration of the ambiguous picture stimulus: What was your first interpretation? ■ What was it that influenced you to see it that way, do you think? ■ Things particularly about the picture? ■ Things (mood, current situation, experience) that you bring to the ■ picture? If you were a person in the story, and this were the case, how would ■ you feel? What would you do in response? If the alternatives suggested by other people were true, how would the ■ character react differently? What emotions did you experience as you considered different ■ appraisals? How do you think this activity relates to real life? ■ How hard or easy was it to take in different kinds of alternative ■ appraisals? During the ambiguous picture exercise, encourage clients to generate as many alternative interpretations as possible, even if some seem less plausible. Some clients have trouble with this. You may validate that the pictures do pull for certain interpretations, or that it can be difficult to do this at first, but with practice it gets easier and may become “second nature.” You may also note that there is no right answer and that the purpose of the exercise is not to change interpretations so that they are “better,” or to get the “right” one. Rather, the purpose is to show that despite the speed with which we generate initial interpretations, other interpretations are possible. The main points to emphasize are that: ■ We come up with initial interpretations very fast, sometimes without conscious awareness. We tend to do this by focusing on particular parts and ignoring ■ other parts. Once we have an initial interpretation, it can be difficult to step back ■ and see other possibilities. This is particularly difficult if we are having an intense emotion. ■ However, there are always other possible interpretations of a given ■ situation.

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You may also use the exercise to illustrate the points from the psychoeducation about how certain moods or recent experiences can strongly affect how people interpret situations.

Thinking traps Research has shown that people with emotional disorders tend to latch onto negative, pessimistic interpretations. Noting how certain interpretations are pessimistic, catastrophic, or negative may set the stage for the conversation about thinking traps. We have simplified the common “cognitive errors” exercise into two basic thinking traps, jumping to conclusions (which can include probability overestimation as well as mind reading) and thinking the worst (which is also known as catastrophic thinking). We find that focusing on these two traps helps to focus patients on developing cognitive flexibility rather than getting really focused on what kind of cognitive error they are displaying. It isn’t necessary for it to be one particular kind; it can be a combination. It is common for clients to blame themselves for their automatic thoughts and thinking traps. This can create a barrier to generating flexibility in thinking because the more they blame themselves, the more negative affect they experience in response to the thoughts and, in turn, the more negative thoughts they have. It is important to help clients practice being aware of automatic thoughts in a nonjudgmental way, noticing the thought and allowing it to pass through their mind (consistent with practicing mindful emotion awareness) rather than holding onto it as the only way of considering the situation and running with that interpretation. The point is to be aware of the thinking trap and consider it within the context of the emotion being experienced, not as the only truth, but as one way of thinking about the situation. It is not necessary to categorize a particular automatic thought as one type of thinking trap or another—​some thoughts and thinking traps are a combination of catastrophizing and jumping to conclusions, and it’s very difficult to figure out exactly which thinking trap is at play. Neither

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one feels quite right, or both feel equally right. That is fine! They do not have to be completely separated; this is just an exercise to help clients label their experience and practice observation. It is important to emphasize that the purpose of this cognitive flexibility skill is not to eliminate all negative thoughts, nor is it to “punish” clients for having negative interpretations. Cognitive flexibility is useful for helping the client gain some perspective on thoughts so that negative, automatic thoughts do not further feed the problematic emotional response cycle. Thinking more flexibly about and during emotional situations is also a helpful way to facilitate later emotion exposures by allowing for different assessments of the emotions when they are experienced. Helping clients to realistically assess automatic interpretations will provide some motivation for them when faced with completing a difficult emotion exposure. We have also found it useful to encourage clients to work toward increased flexibility in their thoughts about emotions themselves. Many of our clients tend to have negative, judgmental, and/​or catastrophic interpretations of the experience of emotion. Thoughts like “feeling anxious is terrible” or “I can’t handle feeling this way” are very common. To assist the client in considering alternatives, you might ask them to reflect on how emotions can be adaptive and functional, as was discussed in Chapter 6 (for instance, “anxiety can help me prepare for important things” or “being sad after a loss is normal—​feeling this way now will help me move on later”). You should at least begin In-​Session Exercise 11.2: Cognitive Flexibility Exercise to prepare for the homework. Clients will finish the rest of the activity for homework. It is useful to complete one full example of reappraising a thought to refer to for homework. For this part of the activity you will need: Form 8.1: The ARC of Emotional Experiences ■ A pen or pencil ■ Worksheet 11.2: Re-​evaluating Automatic Appraisals ■ First, fill out the ARC form for a recent intense emotional experience. Next, using the two descriptions of common thinking traps, see if the client can find a good example of probability overestimation and/​or

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catastrophizing that fits into the ARC. It is not crucial to identify the exact right type of thinking trap for the thought on the ARC; rather, the purpose is to begin to recognize rigid thinking in order to practice increasing flexibility.

Different methods for In-​Session Exercise 11.1: Flexibility with Appraisals in a group Running this session is pretty straightforward in individual therapy—​it simply involves going through the exercises as described above. It can be useful in a group, however, to make it slightly more interactive and engaging. We have found a few different engaging ways to run the reappraisal exercise in groups.

Suggestion 1: Reappraisal workshop As a group, get everyone to “workshop” a couple of ideas together. Workshop-​style discussion means that everyone is contributing ideas, so it’s important that everyone participates in some way: One person shares their first interpretation. ■ Compare people’s reactions and interpretations of that and en■ courage flexibility. Generate reappraisals as a group. ■ What is it like being flexible about each other’s interpretations? How ■ does it feel?

Suggestion 2: Practicing flexibility Go around the group, and have each person share their interpretation of the picture. Everyone will notice that some interpretations have similarities and differences; we are all unique in the way we see things. You might say: As we go from person to person, and as you are listening to each appraisal, I want you to be very aware of how other people’s appraisals impact you.

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In other words, what is it like to consider an interpretation that’s different from your own? Think about the following points and feel free to share your experience and thoughts with the group: ■ What emotions did you experience as you considered different appraisals? If another person’s appraisal seemed like it could be believable, how did ■ you notice yourself responding to that (in other words, what did you think to yourself )? If another person’s appraisal seemed like it could not possibly be believ■ able, how did you notice yourself responding to that (in other words, what did you think to yourself )? How do you think this activity relates to real life? ■

Suggestion 3: Practicing interpersonal flexibility in dyads Working with a partner, each person writes down their automatic appraisals and shares them with their partner. Then each person will try to make two reappraisals for their partner and write these down. You could ask: ■ Are you willing to take in any new interpretations about the picture and accept them alongside your initial interpretation? What is it like to practice being cognitively flexible? ■

Closing the session Closing an Individual Session does not require any additional formality beyond preparing the homework, confirming the next session time, and other customary practices. Group Sessions can require additional formality. Try to save 5 or 10 minutes at the end of the session after preparing the homework and confirming the next session time for closing the group. If it is not possible to save the time, it is not as important to formally close the session as it is to open it formally. If you do have time saved, you might close the session as follows:

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Let’s go around the room and say one thing about how we are each feeling as we end the group, or a few words about what impact this group had on you. Therapists do not need to model the closing reflection. However, you might alert everyone to how much time there is left, to ensure everyone has a chance to speak. When there is a lot of time left, you might also encourage people to identify a personal goal for the next week.

Homework Many of the forms and worksheets will need to be filled out more than once. We are including one blank copy of every worksheet and form in the client workbook (within the corresponding chapter) as well as a blank copy of each in the appendices to this therapist manual. For those items that clients will need more than once, you can provide additional copies for them, or clients can download blank copies themselves from the TreatmentsThatWork™ website at www.oxfordclinicalpsych.com/​UTforEDs. ■ ■ ■ ■ ■ ■ ■ ■

Fill out Form 3.1: Eating, Anxiety, and Depression (EDA). Plot scores on Form 3.2: EDA Graph. Fill out Form 4.1: Regular Eating Food Log. Complete Form 8.1: The ARC of Emotional Experiences. Read and complete Worksheet 11.1: Cognitive Reappraisal Strategies. Finish filling out Worksheet 11.2: Re-​evaluating Automatic Appraisals. Read and complete Worksheet 11.3: Obsessive Thoughts. Read Chapter 12 and preview the exercises.

In-​Session Exercises All in-​session exercises appear in the client workbook within the body of the corresponding chapter. We also include these exercises in this therapist guide, near the end of the corresponding chapter.

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In-​Session Exercise 11.1 Flexibility with Appraisals

Here’s an exercise to help illustrate the ideas that appraisals are subjective and that they are influenced by emotions, situations, and experience. Take a moment to look at the picture on the next page. Think about what might be happening in the picture, and then fill out the Interpretations Activity Worksheet.

Used with permission from Oxford University Press

Interpretations Activity Worksheet Remember, there are no “right answers,” even if some of the appraisals might seem right. What were your automatic interpretations about the picture? (These are the first things that jumped into your mind about what’s happening in the picture.) _​__​ _​ _​ _​ _​ _​ _​ _​ _​ _​ _​ _​ _​ _​ _​ _​ _​ _​ _​ ___​ _​ _​ _​ _​ _​ _​ _​ _​ _​ _​ _​ _​ _​ _​ _​ _​ _​ _​ _​ _​ _​ _​ _​ _​ _​ _​ _​ _​ ___________________ _______________________________________________________________________ 173

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_______________________________________________________________________ _______________________________________________________________________ What factors contributed to your automatic interpretations (e.g., past experiences, memories, specific aspects you focused on in the picture, etc.)? _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Generate some alternative interpretations about what the picture might mean (come up with at least three alternatives). If your first, automatic interpretation was a negative one, see if you can come up with a positive interpretation. If your first, automatic interpretation was positive, see if you can come up with a negative interpretation. Practice being flexible with your interpretations. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________

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In-​Session Exercise 11.2: Cognitive Flexibility Exercise

This part of the exercise will get you started. You will have to finish the rest of the activity for homework, and review it in the next session. For this part of the exercise you will need: ■ Form 8.1: The ARC of Emotional Experiences ■ A pen or pencil ■ Worksheet 11.2: Re-​evaluating Automatic Appraisals, found later in this chapter First, fill out the ARC form for a recent intense emotional experience. Next, using the two descriptions of common thinking traps, see if you can find a good example of probability overestimation and/​or catastrophizing that fits into the ARC. Remember, it’s not crucial that you identify the exact right type of thinking trap for the thought on your ARC; rather, the purpose is to begin to recognize when you are falling into these rigid ways of appraising situations, so that you take the next step in treatment: increasing flexibility in your thinking. Next, put your ARC side by side with Worksheet 11.2: Re-​evaluating Automatic Appraisals. Then take your example from your ARC and write it in the appraisals column, along with the antecedent (what happened before the emotion), the emotion(s), and the thinking trap. Then stop. If there is time left in this current session, let’s get started working together to reappraise these automatic appraisals using Worksheet 11.2.

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Case vignettes Case ­vignette 11.1 This vignette illustrates the therapist helping the client practice cognitive flexibility after falling into a thinking trap. The patient is a 60-​year-​old White cisgender woman diagnosed with binge eating disorder and generalized anxiety disorder. C: T: C:

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I’ve decided I’m canceling my plans for Mother’s Day. Oh? You mentioned you were so excited about that last week. What happened? I don’t want to be a burden to my daughter; she’s got enough on her plate. So if I cancel our Mother’s Day plans, she can have the day to herself and at least she won’t resent me. Let’s back up. Did your daughter say that she was too busy and wasn’t able to get together for Mother’s Day? Well, no, she didn’t say that. I just know that it will be a burden on her, and I don’t want to be a burden. So it seems like you are falling into a thinking trap here and jumping to the conclusion or making an assumption that your daughter doesn’t want to spend Mother’s Day with you. Maybe, but it’s probably true. Well, it might be true, and lots of other things could also be true, too. What are some other possibilities? She might already have something planned for us on Mother’s Day. That is a possibility. She might be disappointed if I cancel and think I don’t want to be around her. That is also a possibility. She might be busy but still want to see me on Mother’s Day. Yes, you just came up with three other possibilities of how to interpret the situation. You are getting the hang of this flexibility thing. It is not important to determine which possibility is right or wrong, as many things could be true at the same time. It is important for us to remember that our thoughts are automatic, subjective, and often pretty judgmental. So when we notice we

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are falling into a thinking trap, practicing flexible thinking is the best way to get out of that trap. C: I know you told me that there are names for these things, these traps. Which one would you call this? T: Okay, let’s think about it. One of them is called catastrophizing, or thinking the worst. Do you think your automatic thought was a catastrophe? C: It was the worst of the ones that we came up with, but it wasn’t exactly a catastrophe. It is just a little depressing. T: I agree; I think catastrophizing might sound like, “If I don’t cancel Mother’s Day, it is going to be the straw that breaks the camel’s back, and my daughter is going to lose it completely and probably move to Oregon, and I will never see my grandchildren and I’ll die alone.” C: [Smiling] I can’t say I’ve never had those thoughts, but I wasn’t quite there this time. T: Good for you! Okay, the other trap is jumping to conclusions, when you assume that you know what is going to happen or what someone else is thinking. C: That sounds right! I was jumping to conclusions. I’ll try to remember that; I think I do that quite a lot.

Case ­vignette 11.2 In this case vignette, the therapist helps the client identify when he is falling into the thinking trap of catastrophizing. The patient is a 25-​year-​ old White cisgender man who has been diagnosed with bulimia nervosa and generalized anxiety disorder. He is an athlete who swam at an elite university. He had hopes of going to the Olympics, but they were “ruined” after he suffered a bad fall during a family ski vacation the winter of his senior year. He now works as a recruiter for an executive placement agency and recently was written up after missing an important meeting with a client. C:

I’m freaking out. I’m not sleeping because I am up all night worrying that I am going to be fired from my job. I’m going into work exhausted, and I am sure my work performance is suffering. It’s inevitable; I screwed up, and now it’s all over.

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I am hearing you that you are freaking out and worried that you will lose your job. I can see your legs shaking and hear your voice getting louder and faster. I would like to explore this fear some more with you. Before we do that, I’m wondering if you would be open to building more awareness by anchoring in the moment. C: I’ll try. T: Okay, great. Let’s try going through the three components of an emotion. Talk me through your thoughts, physical sensations, and urges and behaviors. And let’s go ahead and put both feet on the floor to really try and feel the ground beneath us. I’ll join you. C: So, my thoughts are kind of all over the place. I am thinking: I’m going to lose my job, and no one will ever hire me again. My girlfriend will leave me. I won’t be able to pay rent without a job. I’ll have to move in with my parents. This is as good as life is going to get. I screwed everything up. Physical sensations-​wise, sweaty, shaky limbs, difficulty breathing, headache, and dizzy. As far as urges and behavior, I have the urge to scream, binge, check my work email, and text my girlfriend. In terms of behaviors, I am talking to you, shaking my legs a little, and I think my talking has slowed a little. T: Nice work. I want to point out to you that not only are you talking to me, but you are talking about a difficult emotion. C: Yeah. I hate feeling so anxious. T: So it doesn’t feel good to feel anxious? C: No! T: I didn’t think so, and yet you are tolerating it. One of the things we know about people with emotional disorders is that they experience emotions more intensely and more frequently. On top of that they often believe if they let the emotion hit its peak, something bad will happen and they won’t be able to cope. C: I can relate to that A LOT! T: And yet look at what you just did. You experienced your anxiety in the moment, and while it hasn’t come all the way down, I want to point out that nothing bad happened and you were able to cope. C: Yeah, I guess. T: Can you think of another time when you thought the worst was going to happen?

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Of course. I think about it all the time. When I had to quit swimming and give up my dream, I didn’t think I was going to find purpose in anything else. I got really depressed, and I didn’t think I was going to get out of it. That’s when the eating disorder and anxiety were at their worst. I was hopeful when I found my job that there would be something else I am good at. I think that’s why this freaks me out so much. Now that I don’t have my job, I am ruined again. T: You don’t have your job? C: I mean, that’s what I think is going to happen. T: That feels like the worst thing that could happen right now? C: Absolutely, the worst! T: And it also feels like it is definitely going to happen, or already has happened? C: I can see that it hasn’t happened yet, but yes, it seems like the most likely outcome, a really definite possibility. T: That sounds like a pretty terrible combination of ideas. We talked last time about automatic thoughts. And you did a great job earlier identifying what those thoughts are. I think you are ready to take it to the next step. Our automatic thoughts can get us stuck in what we call a “thinking trap” where it is hard to see any other option. Thinking traps intensify emotions, which drive behaviors. Now, we know that we can have any thought or any emotion and still not act on behaviors; however, it is helpful to create reappraisals to exist alongside our automatic thoughts. C: I do feel trapped sometimes in my thoughts. T: [Nodding] So, I want to help you create a little bit of wiggle room. Once you recognize the automatic appraisal, we are going to label the thinking trap. We tend to focus on two main types: overgeneralization, also known as jumping to conclusions, and catastrophizing. Catastrophizing is assuming the worst possible thing is going to happen and fearing that we won’t be able to cope with it. In these situations, it’s helpful to more accurately assess our ability to cope, which is much greater than we initially think. C: My thought that I am going to be fired is the catastrophizing one. It does feel like the worst thing, and I am not sure I will be able to cope if it happens.

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I would agree with you that it’s catastrophizing. It really seems to take you down a spiral of thinking. But I did notice some flexibility there even in that last sentence. C: You did? T: Yes. You said, “I am not sure I will be able to cope.” Earlier when we started you sounded firm about your belief. By going from “I know” to “I am not sure,” you are already practicing flexibility. C: Cool!

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CHAPTER 12

Therapist Materials for Core Beliefs

Goals ■ Understand how negative automatic thoughts are related to negative core beliefs. Our negative core beliefs are the roots from which different types ■ of related automatic thoughts grow. Understand where core beliefs come from, illustrating this with ■ Figure 12.1: How Core Beliefs Form: Repeated similar experiences, and ■ Powerful single experiences. ■ Identify core beliefs with the Downward Arrow technique, using ■ In-​Session Exercise 12.1: The Downward Arrow and Form 12.1: Downward Arrow.

Homework review ■ ■ ■ ■ ■ ■ ■ ■

Fill out Form 3.1: Eating, Anxiety, and Depression (EDA). Plot scores on Form 3.2: EDA Graph. Fill out Form 4.1: Regular Eating Food Log. Complete Form 8.1: The ARC of Emotional Experiences. Read and complete Worksheet 11.1: Cognitive Reappraisal Strategies. Finish filling out Worksheet 11.2: Re-​evaluating Automatic Appraisals. Read and complete Worksheet 11.3: Obsessive Thoughts. Read Chapter 12 and preview the exercises.

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Opening the session If you are running an Individual Session, the opening requires no formality aside from your usual methods. After greeting the client, get a quick initial sense of their emotional state. If the client is experiencing a notable emotional experience, consider suggesting that this example may be something to use in the session, for a real-​time example of the relevant UT material. Try to get to the homework review within a few minutes of opening the session. Group Sessions do benefit from having a formal check-​in, however. A formal starting ritual is important to help the group members shift from a customary, social state of mind to a therapeutic state of mind. It is very useful to help group members with social anxiety or those who have trouble participating for other reasons to begin speaking right from the beginning of the session. Knowing something about how each group member feels at the beginning of group also helps the therapist to make the session more “alive.” When you conduct in-​session activities, it is useful to return to examples of emotions that were shared in the group check-​in, to invite individual participants to use their own examples of active emotions to discuss in the group. If you are running a Group Session, you might introduce this group with the following check-​in: We like to start the group by getting everyone’s voice heard, and making authentic connections to ourselves and to one another. Take a breath and look around the room, and be aware of your thoughts and your emotions. Instead of sharing where you are emotionally, I invite you to be bold and share an automatic thought about one of the following two topics: An automatic thought right now about your body image. ■ An automatic thought you had this morning about your breakfast. ■

You can use these sentences as an example: “My automatic body image appraisal is: Everyone can see these pants make my thighs look huge.” ■ “My automatic thought about my breakfast was: It was good until I added the peanut butter, and that was bad.” ■

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We’re not going to reappraise these interpretations as a group, but for yourself, please be aware of how your thoughts impact your emotion in this moment. The check-​in should be brief—​about 5 minutes for a 50-​minute group session and 10 minutes for a 90-​or 120-​minute group session.

Therapist tips for the downward arrow technique The biggest mistake that clinicians make in practicing the downward arrow technique is one that makes complete sense: As mental health care professionals, we are united in our common interest of helping others, and doing the downward arrow doesn’t always feel like help! When this technique is used, it exposes sad, distressing, and often morbid material. We have observed, however, that often this distress is felt most intensely by the clinician, as these are thoughts the clients live with every day. You may feel really bad about the exercise and may have an instinct to reassure the client, or fix the distress, or make the client feel better, but this is not the next step and you should try to resist that temptation. It is not uncommon to have concerns about facilitating this exercise. Fears may arise regarding how the client will respond to the emotional experience that is evoked by identifying a core belief. You may fear, such as “What if they self-​harm?” or “What if this drives them to symptom use or other treatment-​interfering behaviors?” and “How am I supposed to do this with a client, knowing that I won’t see them again for 2 days?” It is helpful to remember that client core beliefs are nothing new. These are messages the client has received consistently over time, reinforced by impactful experiences. The client has already been exposed to this core belief, just never before in this context. Although arriving at a core belief and saying it out loud is an emotionally evocative experience, it’s a necessary part of the client’s work. It is also an opportunity for the therapist to “hear” the client and empathize with the client’s experience. In this exercise you can expect to share powerful moments with your clients in which they are staring face to face at some of their worst fears and most punishing thoughts. It is important to let them have those moments, almost without interruption, and know that just your being there—​as

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witness—​is important and therapeutic. It is important to give space to feel the power of the emotion, to acknowledge the pain they may have, and to validate the experiences that have formed this deep belief about who they are. When the client arrives at a core belief, your clinical instinct may be to help the client reappraise this core belief, but reappraising isn’t yet the next step. The next step is to help the client understand how this belief came to exist and to explore how this belief impacts the way they see the world. The task is one of awareness. The client is tasked with noticing when they make appraisals that are ultimately an outgrowth of their core beliefs. With repeated practice and exploration, trends and patterns in the client’s thinking style emerge. By practicing mindfulness in a given situation, paired with skills of reappraisal, the client is primed to take in more and more. They are able to attend to aspects and details of a situation that they may have otherwise been prone to ignore. This is so important because it is often these details that disconfirm an initial appraisal and/​or lead to more adaptive and reality-​based reappraisals. Over time, the client builds a repertoire of experiences that allow for new core beliefs to form, making their original core beliefs less valid. This process takes time, but the end result is a more authentic and sustainable shift in thinking that also shifts the other related components of their emotional experience in a given situation. Remember that our thoughts, physical sensations, and behaviors/​urges are all connected to each other. When one component shifts, it impacts the other two components as well. This results in new patterns of behavioral responding and new consequences or outcomes, and ultimately, new learning occurs. After really taking the time to listen, to empathize, and to make space for powerful emotions, it may be nice to commend people for being brave enough to look at these core beliefs and to share them. In terms of identifying core negative beliefs, it is useful to have some ideas to present to clients, who might get stuck. Some highly relevant, very common core negative beliefs are listed next. Familiarize yourself with these, so that you can quickly identify where clients’ fears could be headed.

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Common negative core beliefs ■ I am worthless, I am a failure, I am defective, I am weak, I am not enough, I am not smart, I am not attractive. I will become ill and/​or die. ■ I will go crazy, be hospitalized, be homeless, kill myself, lose control, ■ hurt someone else. I am unlovable, I will always be rejected, I will always be abandoned, ■ I don’t deserve love, I can’t bear to be loved, I will end up alone. I am evil. ■ If I am assertive or angry, I will be punished. ■ I don’t deserve to be happy, I don’t deserve to be successful, I ruin the ■ good things in my life. I am going to end up like my parents (or other negative models). ■ The world is dangerous, unpredictable, uncaring, out of control. ■

Closing the session Closing an Individual Session does not require any additional formality beyond preparing the homework, confirming the next session time, and other customary practices. Group Sessions can require additional formality. Try to save 5 or 10 minutes at the end of the session after preparing the homework and confirming the next session time for closing the group. If it is not possible to save the time, it is not as important to formally close the session as it is to open it formally. If you are running a Group Session, and you have time saved, you might close the session as follows: Let’s go around the room and say one thing about how we are each feeling as we end the group, or a few words about what impact this group had on you. Therapists do not need to model the closing reflection. However, you might alert everyone to how much time there is left, to ensure everyone has a chance to speak. When there is a lot of time left, you might also encourage people to identify a personal goal for the next week.

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Homework Many of the forms and worksheets will need to be filled out more than once. We are including one blank copy of every worksheet and form in the client workbook (within the corresponding chapter) as well as a blank copy of each in the appendices to this therapist manual. For those items that clients will need more than once, you can provide additional copies for them, or clients can download blank copies themselves from the TreatmentsThatWork™ website at www.oxfordclinicalpsych.com/​UTforEDs. ■ ■ ■ ■ ■

Fill out Form 3.1: Eating, Anxiety, and Depression (EDA). Plot scores on Form 3.2: EDA Graph. Fill out Form 4.1: Regular Eating Food Log. Complete Form 8.1: The ARC of Emotional Experiences. Before the next session, try to complete one Form 12.1: Downward Arrow each day for different emotions and automatic thoughts that come up. ■ Read Chapter 13 and preview the exercises.

In-​Session Exercises All in-​session exercises appear in the client workbook within the body of the corresponding chapter. We also include these exercises in this therapist guide, near the end of the corresponding chapter.

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In-​Session Exercise 12.1 The Downward Arrow

We’re going to spend the remaining time today doing the downward arrow. The downward arrow technique is both an emotional exposure and an awareness tool. The function of this tool is to bring about insight and facilitate new learning, which may not be a feel-​good experience at first. In fact, if it brings up strong emotion, you are probably identifying important core beliefs. Turn to Form 12.1: Downward Arrow at the end of this chapter. We take a surface-​level thought, or appraisal, and ask ourselves a question: “And so what if this were true?” This helps us understand why the thought is important and meaningful to us, and it provides us with a new thought to explore, to which we can ask: “What would happen next?” or “If this were true, what would it mean about me?” In so doing, we get to an underlying thought or belief, and we explore this thought the same way. As we repeat this process, we “follow the arrow down” and deepen the intensity of the emotional experience with every layer. We eventually arrive at a core belief.

Rolling with the content As you can see, there are several questions from which we can choose to pull in the service of exploring the thought. Remember, the goal is to uncover a more personally relevant and emotionally evocative thought. The follow-​up question that is used each time may be different, based on what the content of the thought is and what makes the most sense. For example: ■ ■ ■ ■ ■

If this were true, what would it mean about me? Why does this matter to me? What would happen if this were true? What would happen next? What does this mean about how people would perceive me?

There are common automatic thoughts that reflect different core beliefs. You can choose one listed here to work on with the downward arrow, or come up with your own automatic (negative or anxious) thoughts from the past week. Use the questions above to get to your core beliefs using Form 12.1: Downward Arrow. Common automatic thoughts (create your own variation!) are as follows: ■ If I eat _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​, I am going to _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ (get fat, binge eat, etc.).

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■ If I _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​, I am going to be uncomfortable and embarrass myself. ■ If I _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​, then _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ is going to judge me. You may be wondering, “What now?!” when you get to the core belief. Perhaps you even thought, “Well, that made me feel worse!” If you thought similar thoughts, then you’re on the right track—​we can’t work through these feelings until we get to them!

First, just sit with it for a minute. Let yourself identify what feelings it brings up. Think a little about where you think that core belief might have come from. To start exercising flexible thinking, see if any of these approaches might help when you run up against a core belief: ■ “I’m doing it again! This is an automatic thought based on past things in my life.” ■ “Yes, it might feel that way, that’s how it has been for me in my life, but that doesn’t mean I’m certain to fail.” ■ “This is my core belief I carry with me that’s based on my past, not this current experience/​challenge.” ■ “This is a thinking trap! I am underestimating my ability to cope with the situation. Let me see if I can find a reappraisal in this moment.”

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Case vignettes Case ­vignette 12.1 The following therapist/​client dialogue includes an exploration of the core beliefs that are underneath an automatic thought. This client is a Black transgender woman and they use they/​them pronouns. They have been diagnosed with major depressive disorder and anorexia nervosa, and the client has recently experienced a break-​up with their partner. In this session, the therapist has asked the client to voice some of the core negative thoughts that have been bothering them since the breakup. This dialogue is meant to illustrate some of the ways that therapists address clients’ skepticism that core beliefs, which are the result of experience, can be changed. C: T: C:

T:

C: T:

I’ll never be able to keep a relationship, and I’ll be alone and miserable forever. Can you say more about this? I’m just too complicated. I have been broken up with three times, and I am just so different than others, people can’t handle me and they shouldn’t have to. I know we’ve talked about how certain thoughts we have feel like they have more power than other thoughts. And this isn’t a “flaw” or something that you can control or change per se; however, I think it’s important to cover why you might experience these thoughts. Where do you think this idea that you’ll “never be able to keep a relationship” came from? It came from the fact that I was just broken up with, again. It makes sense, right? That if a situation happens repeatedly, then we draw a conclusion from it. If X plus Y equals Z over and over again, we may automatically learn that if X happens, it means Z. In your case, if you’ve been broken up with multiple times, and it has made you sad, the conclusion of “I’ll never keep a relationship” or “I’ll be alone forever” or “I’ll keep being miserable” seems more and more possible. However, we also dismiss that other possibilities may exist, because our core beliefs drive the way we look at situations, filtering out other possibilities. Core beliefs can happen from repeated events, like with what you’re unfortunately going through currently, and they can form from one single event that has a lot of meaning. For example, if your 189

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partner cheated on you or really betrayed you in some horrible way, a core belief might form from that because it was so impactful, even if it hasn’t happened repeatedly. We all have core beliefs, and it’s important that we acknowledge they came from somewhere and also open ourselves up to other possibilities by practicing cognitive flexibility. How do I do that? And what if I don’t believe the other possibilities—​wouldn’t that be lying to myself? Asking yourself, “What else is possible?” can help. And you’ll likely not believe the other thoughts. It’s okay. It makes sense because that’s not how you view it yet, and it might not resonate since that lens of looking at situations is new. Just by holding the other possibility, however, it decreases the intensity of the negative core belief. You may find yourself holding multiple beliefs at the same time, even if one is negative and one is more positive. And that is okay because hopefully you can begin to build some evidence for the other, more positive belief, and while the negative core belief might not go away immediately, it’ll hopefully start to become less and less powerful. We are going to have to go at it from a lot of different angles.

Case ­vignette 12.2 The following vignette illustrates the therapist engaging in the downward arrow exercise with the client to uncover what core beliefs might be contributing to her automatic thoughts that she cannot speak in group. This client is a 21-​year-​old White woman diagnosed with other specified feeding and eating disorder (OSFED) and social anxiety. It has been recommended for the client to participate in supportive group therapy for her eating disorder, but she has been hesitant to actively participate and leaves the group anytime the group facilitator addresses her. C: T: C: T:

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I’ll go to the group, but I’m not sharing anything. Can you tell me more about why you won’t share anything? I feel like there is something more here than that you just don’t want to. I don’t know what to say. So you think you won’t have anything to say. If that were true, what would that mean about you?

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Well, if I talk, people will think I am stupid. So if you say something, you think people will judge it and think you aren’t very smart. If that were true, what would it mean about you? C: That no one will want to be around me. T: So if people think you aren’t smart, they will not want to be around you. If that were true, what would it mean about you? What would happen next? C: No one will want to be around me. No one will ever love me but my parents, and one day they will die and I will be all alone. T: Wow, that is a really difficult core belief you have been walking around with. No wonder the thought of talking in group seems so difficult when it is tied to this long-​held belief and fear of being alone. I’m really glad that you were able to share that with me. C: [Crying] So what am I supposed to do about it? T: Well, for now, I think that saying it out loud, and sharing it with me, is a big step. I want to honor how sad and scary that belief must be. I hope that not being alone with this belief is an important first step.

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MODULE 5

Behavioral Flexibility

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CHAPTER 13

Therapist Materials for Countering Avoidant Behaviors

Goals ■ Understand how suppression of thoughts and emotions can be counterproductive. Suppression or attempted avoidance may control things some■ what in the short term but rarely works in the long term, and it increases the intensity of emotion when we encounter a similar situation in the future. Do In-​Session Exercise 13.1: Demonstration of Emotion Avoidance ■ to demonstrate the paradoxical effect of suppression. Learn how habitual avoidance of emotion gives us negative messages ■ about our capabilities and robs us of the chance to learn that the emotion is tolerable and will pass on its own without our efforts to avoid or escape. Identify the three different types of avoidance by completing ■ Worksheet 13.1: List of Emotion Avoidance Strategies, which are further explained in Table 13.1: Example of a List of Emotion Avoidance Strategies: Overt and subtle behavioral avoidance ■ Cognitive avoidance ■ Safety signals ■ Review Worksheet 13.2: Reducing Avoidance, which is assigned ■ for homework, and learn how to do the opposite of our avoidance strategies. Develop a willingness to lean into emotions, or approach them, ■ and thereby learn new lessons about emotion, situations, and ourselves.

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Homework review ■ ■ ■ ■ ■

Fill out Form 3.1: Eating, Anxiety, and Depression (EDA). Plot scores on Form 3.2: EDA Graph. Fill out Form 4.1: Regular Eating Food Log. Complete Form 8.1: The ARC of Emotional Experiences. Before the next session, try to complete one Form 12.1: Downward Arrow each day for different emotions and automatic thoughts that come up. ■ Read Chapter 13 and preview the exercises.

Opening the session If you are running an Individual Session, the opening requires no formality aside from your usual methods. After greeting the client, get a quick initial sense of their emotional state. If the client is experiencing a notable emotional experience, consider suggesting that this example may be something to use in the session, for a real-​time example of the relevant UT material. Try to get to the homework review within a few minutes of opening the session. Group Sessions do benefit from having a formal check-​in, however. A formal starting ritual is important to help the group members shift from a customary, social state of mind to a therapeutic state of mind. It is very useful to help group members with social anxiety or those who have trouble participating for other reasons to begin speaking right from the beginning of the session. Knowing something about how each group member feels at the beginning of group also helps the therapist to make the session more “alive.” When you conduct in-​session activities, it is useful to return to examples of emotions that were shared in the group check-​in, to invite individual participants to use their own examples of active emotions to discuss in the group. If you are running a Group Session, you might introduce this group with the following check-​in: At the beginning of the group each week, we take time to create connections to our experience and to one another. Since this group is about avoidance

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of emotional experience, let’s each briefly describe how we are feeling right now and then try to identify one part of how you are feeling that you are trying to push away, avoid, or ignore but that keeps coming back, right now or these days in general. It can be useful for the therapist to start the check-​in. See prior chapters of the therapist guide for suggestions and examples regarding therapist disclosures. The check-​in should be brief—​about 5 minutes for a 50-​minute group session and 10 minutes for a 90-​or 120-​minute group session.

Therapist tips for countering avoidant behavior The countering avoidant and emotion-​driven behavior sessions are extremely important, and working through the homework and material may take additional sessions. It is crucial to take time to work through the homework on avoidance and the homework on emotion-​driven behaviors—​there is quite a bit of both—​so if it is necessary to add sessions for the same material, feel free to do so. Over the next two sessions and review of the homework, you and your clients are going to identify avoidance behaviors and come up with strategies to practice the opposite of avoidance, and you are going to identify emotion-​driven behaviors (EDBs) and come up with strategies to practice the opposite of those EDBs. It may take additional sessions to grasp all of these concepts, to identify important avoidance behaviors and EDBs, and to get in the rhythm of practicing “opposite actions.” In the countering avoidant behavior session, the first task is to come up with reasons why suppression might not work. Reasons are listed in the client workbook materials, and you also might ask the group to generate their ideas and their own examples. After conducting the emotion avoidance exercise, here are some questions you might ask: ■ How successful (or unsuccessful) were you at not thinking about the frog?

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■ If you did successfully think about other things without going back to the frog at all, how long do you think you could sustain that—​in other words, how long could you truly not think about the frog? How frequent and intense were your thoughts when you tried not to ■ think about the frog as compared to when you allowed yourself to think about it? Did you think about other things and occasionally “check” to see if the ■ frog was still there? Is there anything that you have been trying not to think about that keeps ■ pushing itself back into your mind? Perhaps a recent troubling experience, something coming up in the future, something that is upsetting you about yourself? How well is it working to try not to think about it? After introducing the idea of subtle behavioral avoidance, cognitive avoidance, and safety signals, ask clients for their own examples. Useful questions to ask about their examples include: ■ When might it be helpful to use that strategy of avoidance, and when might it be problematic? How would you know when it had become problematic? ■ During the psychoeducation component of the session, where clients are learning about the three less obvious categories of avoidance, we have found it helpful to do this section in workshop style. In a group, “workshop style” means that everyone is contributing ideas, almost like a group discussion, while the therapist writes down everyone’s ideas on a whiteboard or flip chart. In individual sessions, both the client and therapist can contribute ideas while the therapist writes them down. Identifying avoidance is a challenging task at first because people aren’t always aware of their avoidance strategies, so it helps to have everyone’s brains working together rather than independently. In a group, the shared process can make the concept less threatening. We have watched patients experience tremendous catharsis in these moments, when they get to own or name their avoidances out loud and connect with one another on shared behaviors. To contribute a layer of relational connection, you may decide to own some of your avoidance strategies, demonstrating humanness and vulnerability. These can be rich, rewarding learning moments. This is a highly recommended facilitation strategy!

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This strategy actually helps clients get started on part of their homework; they can use Worksheet 13.1: List of Emotion Avoidance Strategies during this discussion to write down as many ideas as possible and add some of their own unique ideas later on. Additionally, we recommend incorporating Worksheet 13.2: Reducing Avoidance into the group discussion because it is such an important starting point. Because clients need to understand very clearly what the homework entails, you can review the worksheets and figures and then get started by thinking of one example together. If time permits, clients can be challenged to choose an avoidance strategy that they can target while still in the session, such as leg shaking, fidgeting, or eye contact. Sometimes clients find it difficult to tell when a behavior is adaptive and when it is interfering. In these cases, it is a good idea to work collaboratively to define what constitutes adaptive versus nonadaptive behaviors, taking into consideration clients’ expectations of their own behavior, the specific context in which the behavior occurs, and particularly the consequences with which it is associated. It can be useful to put the behavior into a 3-​Component Model or ARC to see how it may or may not be the part of a negative cycle. As a rule, behaviors are less adaptive when they have very negative repercussions in the moment and/​or contribute to maintaining distress in long-​term cycles. Helping clients understand that emotional behaviors are learned and reinforced over time can lend insight into why they might continue to engage in such behaviors despite their negative consequences. To cultivate a nonjudgmental stance, it is helpful to think about how avoidance is immediately reinforced (or was over time in the past). Some clients can find the distinctions between different types of emotional behaviors (avoidance versus EDB, subtle versus overt behavioral avoidance, etc.) confusing. These categories are meant to provide a heuristic to help examine behaviors that may contribute to emotional disorders, but there is no need to get hung up on subtle distinctions. Certain behaviors may actually fit in multiple categories. Instead help clients focus on the function (i.e., to get away from strong emotions) and the role of the behaviors in maintaining emotional disorders, and then work toward implementing “opposite actions.” The concept of opposite action is introduced in the homework for Chapter 13, Countering

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Avoidant Behavior, and should be previewed before the end of the session. The homework concerning opposite action for avoidant behavior will then be reviewed at the beginning of Chapter 14, Countering EDBs, and the practice of opposite action for EDBs will be included in the homework for that session. Some clients have difficulty recognizing a behavior as avoidant or emotion-​driven because it seems like a “personal preference” or like “normal behavior.” For example, someone might state they prefer to sleep with their second-​floor windows locked, or that this is “normal,” though it also serves the function of avoiding anxiety about a burglary. With regard to food and eating, clients may state it is “normal” to remove all the fat from meat before cooking it, or that it is “healthy” not to eat dessert. You may work with the client to respectfully consider that these preferences may reflect an underlying fear of internal or external stimuli. Though we commonly state that emotional behaviors make individuals feel better in the short term, some clients will find this description inconsistent with their experience, claiming that their emotional behaviors only make them feel worse in both the short and long term. In these cases, the emotional behavior might be the “lesser of two evils.” While the emotional behavior does not feel good, it feels “less bad” than if the client were to resist engaging in it altogether. For example, worry can be very unpleasant while it is occurring and also interfering in the short term. However, it can also feel like problem solving, and someone might be avoiding feeling guilty or anxious for “ignoring” the topic of concern. So even though the worry is unpleasant, it would feel even worse not to do it. Sometimes clients experience difficulty thinking of opposite actions. When this issue arises, encourage them to think of the most extreme opposite action possible and then scale it back to a behavior that is feasible and that they are willing to do. For example, someone might be scared of offending other people and typically avoids disagreeing on any point. An extreme example might be to insult everything that someone says. A more doable example would be to disagree with someone politely. It can be particularly difficult to think of opposite actions to worry and rumination when those behaviors are used as subtle forms of avoidance. For these behaviors, we recommend the use of mindful emotion

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awareness as the opposite action. Present-​focused awareness is inherently inconsistent with ruminations about the past or worries about the future. Another potential opposite action can be problem solving—​ making a concrete list of steps to address the problem and then following through on them step by step.

Closing the session Closing an Individual Session does not require any additional formality beyond preparing the homework, confirming the next session time, and other customary practices. Group Sessions can require additional formality. Try to save 5 or 10 minutes at the end of the session after preparing the homework and confirming the next session time for closing the group. If it is not possible to save the time, it is not as important to formally close the session as it is to open it formally. If you are running a Group Session, and you have time saved, you might close the session as follows: Let’s go around the room and say one thing about how we are each feeling as we end the group, or a few words about what impact this group had on you. Therapists do not need to model the closing reflection. However, you might alert everyone to how much time there is left, to ensure everyone has a chance to speak. When there is a lot of time left, you might also encourage people to identify a personal goal for the next week.

Explanation for the client of this session’s homework You might explain the homework like this: The homework is to identify some avoidance strategies that you engage in and choose some that you are going to try to stop doing. It is even more helpful and informative to try to do the opposite of avoidance. In each case, the “opposite action” is going to depend on what the avoidance behavior is. We should take a look at Worksheet 13.2: Reducing Avoidance and Form 13.1: Reducing Avoidance Practice Chart in the session to

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make sure it makes sense to you. You have to remember that when you first stop doing them, you may feel an upsurge in anxiety because you have come to depend on these things. But as you persist, you will find that the anxiety associated with the issue overall will start to come down.

Homework Many of the forms and worksheets will need to be filled out more than once. We are including one blank copy of every worksheet and form in the client workbook (within the corresponding chapter) as well as a blank copy of each in the appendices to this therapist manual. For those items that clients will need more than once, you can provide additional copies for them, or clients can download blank copies themselves from the TreatmentsThatWork™ website at www.oxfordclinicalpsych.com/​UTforEDs. ■ ■ ■ ■ ■

Fill out Form 3.1: Eating, Anxiety, and Depression (EDA). Plot scores on Form 3.2: EDA Graph. Fill out Form 4.1: Regular Eating Food Log. Complete Form 8.1: The ARC of Emotional Experiences. Review Table 13.1: Example of a List of Emotion Avoidance Strategies, and then fill out Worksheet 13.1: List of Emotion Avoidance Strategies. ■ Complete Worksheet 13.2: Reducing Avoidance. Complete Form 13.1: Reducing Avoidance Practice Chart. ■ ■ Read Chapter 14 and preview the exercises.

In-​Session Exercises All in-​session exercises appear in the client workbook within the body of the corresponding chapter. We also include these exercises in this therapist guide, near the end of the corresponding chapter.

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In-​Session Exercise 13.1 Demonstration of Emotion Avoidance

We’re going to do a quick experiment that will help you understand the concept of emotion avoidance, and to see how emotion avoidance strategies work (and don’t work!). Focus on the picture of the frog, and really take in the details of this picture for a few moments. Now close your eyes and follow these instructions, which your therapist will read aloud: For about 1 minute, try to think about the frog. Don’t think about anything else except the frog. [A minute passes.] Open your eyes. How successful were you in thinking about this creature? Okay, now close your eyes again for another minute and think about anything you want to, but absolutely do not think about the frog. [A minute passes.] Open your eyes. What did you notice?

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Case vignettes Case ­vignette 13.1 This vignette illustrates how the therapist will assist the client in identifying commonly used avoidance strategies. The client is a first-​generation Indian American cisgender woman in her mid-​30s and has been diagnosed with bulimia nervosa and posttraumatic stress disorder. She has been a caretaker in all her relationships and has a pattern of non-​mutual romantic relationships. T:

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I was thinking today we would focus more on the concept of emotion avoidance and how you might see avoidance playing out in your life. Okay. I am not entirely sure what you mean. Sure, I will clarify. We’ve talked before about how all of us as humans want to avoid feeling bad. However, often the ways in which we avoid ironically set us up for the exact opposite of what we wanted, and it can become habitual. I think I am following. Would it be like when I was in college and I would avoid doing my homework and studying and then feel even more overwhelmed at the end of the semester when I would have to cram? Yes! That’s a great example. In the short term, you would be pushing the stress aside, but then down the road it came back even stronger. Yeah, and you would think I would have learned my lesson, but I would do the same thing the next semester. We are human, and powerful habits can become hard to change. Therefore, we must intentionally do something different, but we will come back to that. Let’s continue by reviewing your goals for yourself; they can be short-​term or long-​term goals. I want to stop binge eating and purging. I want to get married and have kids, but I guess I should find a way to be in a healthier relationship. I would like to be more social—​I just worry something bad will happen, but I also hate being alone. Now to explore this concept more, can you pick one of those goals? Sure. How about being in a healthy, mutual relationship? That is really important to me, but it’s really scary to take the risks

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to get there. I always freak out no matter what is going on. For example, if Kabir doesn’t text me back or call, I end up freaking out that he is ignoring me, so I just keep calling and texting and then I can’t handle it, so I end up binge eating and purging. That is some great insight! I am also remembering how you have shared in the past that you do things so that he doesn’t break up with you. Yeah, so I will always do stuff for him like run his errands, do his laundry, pay for things, and let him pick what sort of thing we will do on dates. Don’t get me wrong, I think it is good to do nice things for the person you are dating, but it would be nice if it was a bit more . . . mutual. Everything feels so surface and like I am doing all the work. It’s like I keep doing it—​and do more and more of it—​because I feel like it’s not enough, and then I will lose him or he will get mad at me. So would you say you have been doing these things in an attempt to avoid or prevent dealing with the anxiety of possibly being alone? Yeah, I think what started out as normal “new relationship” behaviors have become avoidant behaviors. One of the things we know about avoidant behaviors is that avoiding leads to us experiencing our world in a much smaller way. Our fears take over, and then we try to do things faster than we can feel in an effort to avoid potentially feeling bad. Unfortunately, this also gets in the way of us expanding our world, feeling good, and learning to tolerate when we don’t feel good. Everything you are saying makes sense and I see it within myself. I get trapped in a cycle and I keep on spinning and it even reinforces my core underlying feeling—​or belief, I guess—​that I am not good enough and will always be alone. But I am really scared of doing anything different. I am scared he will break up with me and I will be alone. I don’t even know where I would start. I really appreciate your honesty and your vulnerability. I want to offer an alternative appraisal, and that is that you have already started the work.

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How’s that? You know what it is that you are stuck in, and you can see that it is counterproductive. Now we talk about taking these avoidant behaviors that you identified and coming up with alternative actions to counter them. This can be hard, and I believe you can do it. We want to make sure that we are not replacing one avoidant behavior with another. We want to think about how we can take steps to approach the feared emotion. Thinking about the behaviors you shared earlier, where are you willing to start approaching the emotion and doing the opposite of avoidance? This is all going to be hard, but I am willing to try. When I don’t offer my opinion about what to do or where we should go eat, I think I am trying to avoid feeling rejected. I think that if I suggest something that he doesn’t want to do, then he will think I am weird or that we don’t belong together. What would be an alternative to not giving your opinion and would allow you to experience whatever emotions come up? We are getting together tonight for dinner and a movie at my place. I am not ready to choose both things. Plus, it’s not just in the moment that I worry about it, it’s during the movie or the meal I am wondering what he is thinking and if he is enjoying himself. I will try choosing the movie to counter my avoidance. Whoa, just saying that makes me anxious! I would imagine it does since you are not used to doing that! So that means it’s a great first step. It may not seem like a big change from the outside, but it is a significant step for you, emotionally. May I suggest that you do an ARC prior to telling him your movie choice and another one halfway through the movie? I want to make sure we are not only changing behaviors but also feeling the emotions. Yes, I can do that.

Case ­vignette 13.2 The following is a case vignette where the therapist helps the client identify safety signals she has been using to avoid experiencing her emotions. The client is a married white trans woman in her late 40s, using she/​her/​hers

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pronouns. She has been diagnosed with anorexia nervosa and obsessive-​compulsive disorder. C:

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I’ve noticed that I don’t nap as much anymore to avoid feeling stressed, but I struggle with not having my husband around when I go to the grocery store, or if I’m stressed, I usually call him and rely on him to help me when my thoughts are racing. I’ve worked really hard on noticing what I’ve been doing to distract from my emotions. That’s great. I know taking a nap was something you did to avoid thinking about everything you had to do and was also something you did to avoid feeling hunger. Can you say more about your reliance on your husband? Well, I guess maybe it’s more reliance on my cellphone. Can both be safety signals? I feel like I can’t leave the house without my cellphone or without being in contact with my husband. Yes, both people and inanimate objects, like cellphones, can be safety signals. One way to check if someone or something is a safety signal is to try to be without it or without them, if it’s a living being, and see if there’s distress. You corrected yourself before and said that you believe that it’s more your reliance on your cellphone. Do you bring your cellphone everywhere with you? Even to the bathroom! Which is weird for me and embarrassing to say, but it’s true. I don’t do that when he’s in the house, but if he’s not home or I’m at work or out with coworkers, I bring the cellphone with me. Is this only with your husband? I think it’s probably with others, too, but I only really notice how stressed I get when it involves him. Okay, what would be an opposite, or alternative, action you can do regarding your safety signals? Remember, we are focusing on doing something different in our actions. What can you do to let go of the safety signal, to begin to experience the emotions that come up—​maybe difficult emotions—​and build tolerance without relying on them? Umm, I’m not sure. Let’s brainstorm together. Let’s start with your cellphone, as this is a bit more concrete, and in the process it may clarify further for us if your husband is also a safety signal. Would you start by leaving 207

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your cellphone in your room when your husband is at work? It can be for a half day or a full day. Up to you. I can try for a half day. It’ll increase my anxiety, that’s for sure. It probably will. You bring your cellphone with you—​or have your husband with you—​ everywhere for an understandable reason, because you don’t want your anxiety to increase and are trying to avoid feeling that way. Trying this out slowly will help you build tolerance, so that way having your cellphone with you is a preference and not a need, and we can see what comes up emotionally not being in contact with your husband. This sounds scary. What if something goes wrong? What if he gets into a car accident? Something might go wrong; and something might not. How often have things gone awry when you have had your cellphone? Or have been with your husband? Not often, but that doesn’t mean that it won’t in the future. Completely true! The purpose of countering safety signals is because it is being used as an emotion avoidance strategy—​something to do to avoid that feeling of anxiety you stated. It’ll allow you to experience the emotion, and while it has an important function, it may not be serving you in the way you want it to and further increasing your avoidance of something that may be helpful to sift through in your healing process. That being said, I do want you to try it, and you get to set your limit. What might be possible? Yeah, I think I can try not having my cellphone while my husband is at work, at least for half a day.

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CHAPTER 14

Therapist Materials for Countering Emotion-​ Driven Behaviors

Goals ■ Understand and identify emotion-​driven behaviors (EDBs) intended to escape from emotion. Refer to Figure 14.1: Examples of EDBs. Identify when and how these EDBs can become problematic. Utilize ■ Figure 14.2: Problems with Eating and Dieting Strategies to Manage Emotions. When we use EDBs exclusively for many emotions, regardless of ■ their source When they become a self-​perpetuating cycle ■ When they interfere with the opportunity to learn other healthy ■ coping methods When the EDBs have negative physical consequences ■ Prepare for homework to substitute opposite actions in place of ■ problematic EDBs. Read and complete Worksheet 14.1: Identifying Your EDBs ■ Writing Exercise. Read and begin Worksheet 14.2: Identifying Your EDBs and ■ Opposite Actions and Worksheet 14.3: EDB Reading and Reflection. Assign Form 14.1: Changing Your EDBs for homework. ■

Homework review Fill out Form 3.1: Eating, Anxiety, and Depression (EDA). ■ Plot scores on Form 3.2: EDA Graph. ■ Fill out Form 4.1: Regular Eating Food Log. ■

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Complete Form 8.1: The ARC of Emotional Experiences. ■ Review Table 13.1: Example of a List of Emotion Avoidance ■ Strategies, and then fill out Worksheet 13.1: List of Emotion Avoidance Strategies. Complete Worksheet 13.2: Reducing Avoidance. ■ Complete Form 13.1: Reducing Avoidance Practice Chart. ■ Read Chapter 14 and preview the exercises. ■

Opening the session If you are running an Individual Session, the opening requires no formality aside from your usual methods. After greeting the client, get a quick initial sense of their emotional state. If the client is experiencing a notable emotional experience, consider suggesting that this example may be something to use in the session, for a real-​time example of the relevant UT material. Try to get to the homework review within a few minutes of opening the session. Group Sessions do benefit from having a formal check-​in, however. A formal starting ritual is important to help the group members shift from a customary, social state of mind to a therapeutic state of mind. It is very useful to help group members with social anxiety or those who have trouble participating for other reasons to begin speaking right from the beginning of the session. Knowing something about how each group member feels at the beginning of group also helps the therapist to make the session more “alive.” When you conduct in-​session activities, it is useful to return to examples of emotions that were shared in the group check-​in, to invite individual participants to use their own examples of active emotions to discuss in the group. If you are running a Group Session, you might introduce this group with the following check-​in: At the beginning of the group each week, we take time to create connections to our experience and to one another. Since we will be looking at emotion-​driven behaviors in our group today, our check-​in will have that theme, too. Close your eyes for a moment and let’s think about symptoms. I want you to think about the last time you used an ED symptom like

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purging, bingeing, restricting, or exercising. What are you noticing about the experience of thinking about it? I want you to think about what emotion was driving that behavior. If it helps you, think about what you think the antecedent was and then try to identify what emotion was driving your behavior. I’ll invite each of you to share just one or two sentences about your experience. You can use this phrase to help you: “The last time I binged I was definitely feeling angry. I think I often binge when I’m anxious as well.” As you share, notice how it feels to share this and to hear others do the same with you. It can be useful for the therapist to start the check-​in. See prior chapters of the therapist guide for suggestions and examples regarding therapist disclosures. The check-​in should be brief—​about 5 minutes for a 50-​ minute group session and 10 minutes for a 90-​or 120-​minute group session.

Therapist tips for countering emotion-​driven behaviors The avoidance and emotion-​driven behavior (EDB) sessions are extremely important, and working through the homework and material may take additional sessions. It is crucial to take time to work through the homework on avoidance and the homework on EDBs—​there is quite a bit for both—​so if it is necessary to add sessions for the same material, or postpone the interoceptive session, feel free to do so. The next session—​interoceptive exposure—​takes a lot of time as well, so do not start on the interoceptive exercises until it feels like avoidance and EDBs have been fully addressed. After introducing the psychoeducation about EDBs that are intended to escape from the emotion, and reviewing the specific emotions listed, ask clients to come up with their own examples. There are quite a few opportunities in this session to use mild imaginal exposures; for instance, asking a client to recall, in as much detail as possible, their last symptom episode, or the last time they used other EDBs. The purpose of these exercises is to get in touch with urges, in order to examine the types of behaviors that happen in response to strong

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emotions, as well as the antecedents, the consequences, and the way that moment felt to that client. This kind of insight-​building exercise is extremely important therapeutic work for the clients to be doing; it leads to understanding the cycles of emotion and behavior. It is important to talk about how evocative imaginal exposure can be and to validate the challenge of the task. As we have pointed out in other sessions, there are rich and rewarding therapeutic moments to be shared when clients have the courage to say out loud what they typically keep inside. It is particularly important for you to self-​monitor here; it can be awkward or uncomfortable to witness these very personal accounts. Try to remember that your being there and your nonjudgmental support in those moments are relationship-​building moments. It is important to practice having these feelings in therapy, so that clients can start to deal with them in new ways with your help. Even though these moments might feel difficult to tolerate or even counterproductive, it’s important that both client and therapist try to lean in and trust in the process—​that when we stick with an uncomfortable emotion for long enough, we end up learning something new. Part of the goal of this session (as with the last session) is to come up with opposite actions. But don’t skip so quickly to opposite actions that you avoid or escape from the emotion that people are experiencing in the moment. Other useful questions to bring the material alive in reference to eating disorders include: ■ What about emotion-​driven behaviors in response to disgust, sadness, anger, guilt, or other feelings that come up specifically about your body image? Which emotions do you think are the ones that drive you the most to en■ gage in restriction, in binge eating, or in other eating disorder symptoms? Are the emotions that drive you to engage in those EDBs mostly about ■ your body, or are they sometimes about totally unrelated things? What different EDBs do you have to primary versus secondary emotions? ■ When are EDBs adaptive versus problematic? How would you know if ■ they were a problem? Think about a time when you engaged in behaviors that are symptoms ■ of your eating disorder. Try to choose a time that you would consider a

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serious symptom episode. Can you briefly identify the antecedent and the emotion that was driving the episode? What emotions, behaviors, and urges are triggered now? ■ Think about a time when you did something and there was a big consequence. Perhaps it was something that really hurt you and/​or something that you really regretted doing afterwards. Can you briefly identify the antecedent and the emotion that was driving the episode? What emotions, behaviors, and urges are triggered now? When was the last time you remember trying to make something really ■ perfect? Why do you think you wanted it to be perfect so badly? What were some of the outcomes of your efforts at perfection? How about a time that you had to let go of something before it seemed perfect? What were some of the various short-​and long-​term outcomes in that situation? ■ What would be some possible opposite actions for the situations we discussed today?

Closing the session Closing an Individual Session does not require any additional formality beyond preparing the homework, confirming the next session time, and other customary practices. Group Sessions can require additional formality. Try to save 5 or 10 minutes at the end of the session after preparing the homework and confirming the next session time for closing the group. If it is not possible to save the time, it is not as important to formally close the session as it is to open it formally. If you are running a Group Session, and you have time saved, you might close the session as follows: To close the group, let’s go around the room and say one thing about how we are each feeling. You might also say a few words about what impact this group had on you: Did you learn anything new, or did you feel surprised or moved by something? Also, if you have a personal goal for the week, that can be good to say aloud. Therapists do not need to model the closing reflection. However, you might alert everyone to how much time there is left, to ensure everyone

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has a chance to speak. When there is a lot of time left, you might also encourage people to identify a personal goal for the next week.

Explanation for the client of this session’s homework You can explain the homework in this way: Today for homework you have an EDB writing exercise, as well as two EDB forms to fill out, in addition to your usual EDAs. The instructions are clearly written on each homework assignment; however, we are going to go through the instructions before we leave today, so that you have an opportunity to clear up any questions that you may have. Take some time to add ideas about key EDBs and useful opposite actions in Worksheets 14.1: Identifying Your EDBs Writing Exercise and 14.2: Identifying Your EDBs and Opposite Actions. You can write about them at more length for homework, but take some time in session to discuss whether you are on the right track. You will also be completing Worksheet 14.3: EDB Reading and Reflection.

Homework Many of the forms and worksheets will need to be filled out more than once. We are including one blank copy of every worksheet and form in the client workbook (within the corresponding chapter) as well as a blank copy of each in the appendices to this therapist manual. For those items that clients will need more than once, you can provide additional copies for them, or clients can download blank copies themselves from the TreatmentsThatWork™ website at www.oxfordclinicalpsych.com/​UTforEDs. ■ Fill out Form 3.1: Daily Eating Disorder, Anxiety, and Depression (EDA). Plot scores on Form 3.2: EDA Graph. ■ Fill out Form 4.1: Regular Eating Food Log. ■ Complete Form 8.1: The ARC of Emotional Experiences. ■ Complete Worksheet 14.1: Identifying Your EDBs Writing Exercise. ■ Complete Worksheet 14.2: Identifying Your EDBs and Opposite ■ Actions.

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Complete Form 14.1: Changing Your EDBs. ■ Complete Worksheet 14.3: EDB Reading and Reflection. ■ Read Chapter 15 and preview the exercises. ■

Case vignettes Case ­vignette 14.1 The following vignette illustrates the therapist assisting the client to identify emotion-​driven behaviors (EDBs). The client is a 49-​year-​old White cisgender man who has been diagnosed with binge eating disorder and substance use disorder. At this point in treatment, he has been able to implement regular eating and mindful awareness of emotion, which is helping with binge eating. However, he recently separated from his wife and is moving into an apartment after learning that his wife has been having an affair. These stressors have been accompanied by increases in binge eating and drinking episodes. C:

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I can’t believe this is where I am at in my life. I am forty nine years old and just signed a lease on a tiny apartment. I’m a bachelor again, starting over from scratch. I can see how difficult this is for you right now in this moment; it has got to be really hard. Can you try to identify some of the emotions that are coming up? I would imagine there are a few. Well, that’s easy. I feel anger, a lot of anger, maybe even rage. Sure, that makes sense: This is a pretty difficult and complicated time. I wonder if you are feeling any other emotions in addition to the anger? Well, the anger is the most obvious. But I guess if I were really honest with myself, I would say that I am confused, surprised, hurt, and kind of scared. You’ve identified quite a number of different emotions. Good work. I don’t think it’s hard to identify the emotions; I think I identify them too much! They overtake me. Yes, emotion can seem really intense sometimes.

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Yes, it’s too much, and I would literally do anything to feel a different way. What are some things that you do? What do you mean? Well, you said that you would do anything to feel a different way, and I suspect that you’ve been trying. Last time we talked about things that you do to try to avoid your emotions. I remember that you shared that lately you have had urges to work late, binge on television, and carry around a flask of whiskey in your trunk “just in case.” Yeah, and I have been working on noticing when I am using some of the avoidant behaviors. I know that working late is avoidant, and I am trying to leave closer to a reasonable time. That’s great. In addition to avoidant behaviors, we also engage in emotion-​driven behaviors, or EDBs. The function of these behaviors is a little bit different than avoidance behaviors because with EDBs you have already started feeling the emotion and you use these behaviors to make the emotion go away or decrease in intensity. Does it work? Well, let’s explore it together and see. You shared feeling a lot of anger. When you feel really angry, what do you tend to do, or even what you may have the urge to do but can’t right now because you are in a therapy session? Today I got some papers in the mail from my wife’s lawyer, and if I wasn’t here, I would probably be at the bar drinking a lot. And then when I got home I would probably eat whatever I could find and probably order a lot more food too. Okay, so let’s keep going with that. What happens to your anger when you drink and/​or binge? Well, I kind of forget about it for a little while. I get either drunk from alcohol or what I call “drunk from food,” sometimes both, and then I pass out. And what happens when you wake up? Sometimes I physically feel awful. Lately, though, it hasn’t been as bad physically because I’ll just stay in bed and sleep until I’m feeling better—​sometimes it takes a while to get up, though. At

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that point I am usually pretty late for work and have a ton of messages from my boss. How do you feel when you listen to those messages? I get angry with myself and embarrassed. And really anxious. Work is important to me and it’s not like me to miss work. People know I’m going through a lot, but still, I feel horrible. Right, so when your behavior is at odds with your values and then you get angry with yourself, what happens next? Honestly, lately, once I’m in that cycle, I may drive through fast food on my way to work, and binge, or I call out sick and just keep drinking. It’s pretty messed up, I know. It’s an understandable cycle. You said earlier you would do whatever you needed to, so as not to feel these emotions. We can see that now with these emotion-​driven behaviors you are describing. What I am also hearing from you, though, is that you only get temporary relief and then these behaviors put you in a situation that is really inconsistent with your values and has bigger long-​ term consequences.

Case ­vignette 14.2 In the following vignette, the therapist assists the client identifying alternative behaviors to engaging in EDBs. The patient is a 25-​year-​old Latina cisgender woman. She is diagnosed with anorexia nervosa and obsessive-​ compulsive disorder. She has been using restriction and some perfectionistic rituals to manage emotions since a recent job loss. C:

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I don’t know how I can stop with the rituals. I just feel so out of control and I’m in so much pain. I know that if I start down the road of cleaning, I’m going to at least have a clean house. And when I’m not restricting my food, I feel so much—​too much. Of course. You feel the relief you get from engaging in the behavior and believe that you won’t be able to handle your emotions if don’t use that behavior. While it’s effective in the short term, it leads to problematic long-​term consequences. This is likely the reason for you sitting across from me, right? So true!

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Cleaning rituals and restriction are strategies you have developed to decrease the intensity of your emotions. What emotions are difficult for you to experience without self-​harming or ritualizing? Sadness, happiness, anger, you name it. Pretty much all of them. I would rather be numb, because anything else is just too much for me. I’m glad you brought up happiness, because that can be an uncomfortable emotion for a lot of us, even though that’s not what people typically talk about when they are referring to discomfort. We call these strategies to decrease those emotions emotion-​ driven behaviors or EDBs. EDBs are behaviors that you have learned to use in response to emotions that bring up extreme discomfort, likely because of thoughts that you were having about the situations at hand. Behaviors are part of the emotions, and they are just one component of them, as you know. Can you talk to me about a situation when you went overboard with rituals? I usually feel really agitated. When I lost my job, I had all of these thoughts about myself as a failure, and I was pretty upset because recovery-​wise, I was doing better, all things considered. I was making my appointments, not acting on urges to wash, and trying to add variety to my meals. And then you lost your job. Yeah, and then, I don’t know, all of these emotions came at me at once and it felt overwhelming and I didn’t know what to do. And I felt like I couldn’t stand the idea that I was also going to get sick, or get someone else sick, at the same time. Did washing and restriction help? For a little. When I was restricting, I felt just a tiny bit more successful and in control, I think. Sometimes it is just a way of turning everything else off. If I’m really lost in a cleaning or washing ritual, I’m not thinking for that period of time. Clearly not helpful in the big picture, though. I know I shouldn’t do it. I felt some relief, but I felt guilty and pretty ashamed for using the behavior. I just don’t know what else to do in those moments. I know, and it’s likely that it truly feels that the emotion will last forever. Except that I’m now going to rock your world when I say that emotions don’t last forever, even if they feel like they do. In fact, self-​harming, or any behavior that is maladaptive, or

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unhelpful, decreases the emotion for a little, but then the emotion comes back, oftentimes more intensely, which leads to an even stronger urge to use an EDB. If you were to consider using an opposite action strategy instead of self-​harm or eating disorder behaviors, one that actually approaches the emotion instead of avoids it, what would that look like? I could just not do it. But, I don’t know, it seems to keep coming back again. Well, not doing it is technically the opposite of doing it. But if just “not doing it” was that easy, it probably would have worked already. So is there something else you can do while “not doing it” that might be an alternative or opposite action—​literally like the opposite of doing it? I could talk about my urges with someone but not act on them. Would that be opposite? Yes! Do you think you’re aware of the emotion you’re trying to move away from when you want to self-​harm or use other EDBs? No, I definitely try everything I can to not think about it. Sometimes I don’t even know what I am feeling and other times I know, but I just distract myself from it. So, then, talking about it with someone, admitting to feeling like a failure, or being sad, or frustrated, or worried you will get sick—​ being really aware of it—​would definitely be an opposite action. I would also recommend an ARC to increase emotion awareness in that moment. Even when you don’t exactly know how you are feeling, the ARC helps by “pressing pause” and allows you to explore the emotion. It also provides helpful information around short-​ term and long-​ term consequences before they happen, which can lead you to healthier outcomes, even if it is really hard or even a little terrible in the short term. I can do that. So what is literally the opposite of cleaning, or the opposite of restricting? I guess messing something up. Or eating. Are there any moments when you might have those urges to clean or restrict and you could literally do the opposite?

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I’m not sure I’m ready to, like, spit in someone’s food. But if I go into the bathroom and I’m tempted to wash, like, excessively, I might be able to mess up my hair or something. That’s an awesome idea! You could give yourself the windblown look. And you would kind of be spitting in the face of the washing impulse. I think that might work a lot better than just not doing it. And when I am really stressed or down on myself, I’m not sure I would be up for, like, a run to the donut store. But I could definitely decide to have a sit-​down, healthy meal, and take care of myself instead of depriving myself. That sounds really awesome. I think you are really good at this. Let’s take a look at your workbook and write these ideas down so you can build on them for homework.

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MODULE 6

Confronting Physical Sensations

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CHAPTER 15

Therapist Materials for Interoceptive Exposures

Goals ■ Understand the importance of learning to tolerate physical sensations of emotion. Identify automatic thoughts that accompany physical sensations ■ of emotion. Practice exercises that stimulate sensations associated with negative ■ emotions. Conduct In-​Session Exercise 15.1: Physical Sensation Induction, ■ which involves hyperventilation and breathing through a thin straw (must have straw). Be able to identify thoughts, physical sensations, and urges/​ ■ behaviors that client experiences during the exercise. Figure 15.1: Example of 3-​Component Emotional Response ■ to Interoceptive Exercise provides an example of what clients might experience during an interoceptive exercise. Fill out Form 15.1: In-​Session Physical Sensation Induction after ■ each repetition. Understand the importance of repeated practice using Form 15.2: ■ Repeated Practice: Hyperventilation and Thin Straw and Form 15.3: Repeated Practice. Consider other exercises that might be personally relevant to client’s ■ physical sensations using Form 15.4: “More Personally Relevant Practice!” Homework. Plan to practice interoceptive exercises daily. ■ Review homework from the prior two sessions (concerning oppo■ site action to reduce avoidance and EDBs), and plan to continue substituting opposite action to avoidance and EDBs over the next week in addition to practicing interoceptive exercises.

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Introductory instructions This material should be spread over two sessions, unless it seems clear that there is no important role of physical sensations after the first session, which is unusual. This material is tricky to juggle because the first part of each session involves practicing the interoceptive exercises, and the second part of each session involves reviewing the homework for reducing avoidance and practicing alternative actions to EDBs. We put the homework review at the end of these sessions for two reasons. First, people often become anxious about the interoceptive exercises, and it is important to do them early in the session so as not to increase anticipatory anxiety. Second, given the large amount of homework (ongoing homework for avoidance and EDBs, homework to practice interoceptive exercises), it is good to go over the prior practice and the future planning together at one time. In the first session, clients practice only the hyperventilation and breathing through a thin straw. For homework, they review and consider additional personally relevant interoceptive exercises. In the second session, clients should practice the personally relevant interoceptive exercises that they identified, or else be encouraged to practice some for the first time with your assistance. Therapist note The homework from the avoidance and EDB sessions is very important. However, we are not going to take the time at the beginning of our interoceptive exposure session to review it, because talking and waiting can increase anxiety. Instead, we will review the homework at the end of the session and plan for the next session.

Opening the session If you are running an Individual Session, the opening requires no formality aside from your usual methods. After greeting the client, get a quick initial sense of the client’s emotional state. Then you can explain that unlike other sessions, you will be reviewing the homework at the end rather than the beginning because you want to get to the interoceptive practices as soon as possible.

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Group Sessions do benefit from having a formal check-​in, however. A formal starting ritual is important to help the group members shift from a customary, social state of mind to a therapeutic state of mind. It is very useful to help group members with social anxiety or those who have trouble participating for other reasons to begin speaking right from the beginning of the session. Knowing something about how each group member feels at the beginning of group also helps the therapist to make the session more “alive.” When you conduct in-​session activities it is very useful to return to examples of emotions that were shared in the group check-​in, to invite individual participants (and, again, particularly group members who have more trouble taking center stage) to use their own examples of active emotions to discuss in the group. If you are running a Group Session, introduce the session as follows: We are going to take just a minute to create connection to the group this week. We will be doing homework review at the end of group, because this group is focused on interoceptive exposure, and we don’t want to delay our practice of hyperventilation and breathing through a thin straw for too long. Let’s go around the group and everyone try to share one emotion they are having, and one physical sensation, if possible, that may be associated with that emotion. Try to keep this check-​in to a few minutes at most.

Therapist tips for interoceptive exposures Always do the interoceptive exercises with the client. You want to model several different things. First, you want to demonstrate the full effort of doing the exercise thoroughly, to provoke strong physical sensations in yourself. Second, you want to model the potential for having a nonthreatening experience of physical sensations. Third, you want to normalize the challenge of this exercise. You can disclose the physical discomfort you experience during interoceptive exercises alongside your acceptance of these sensations. It is really important that you be very familiar with the interoceptive exercise and can move through the process smoothly to maximize its effectiveness. We have noted that when clinicians spend too much time

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explaining or talking, checking notes, or hesitating, the potency of this exercise is lost. Avoidance and EDBs are bound to emerge through the course of this session. We have found that it is best to calmly identify when this is occurring and remind clients to stick with discomfort and try to push one step at a time past their comfort zone. Remember that for some clients, the intensity of the physical sensations, the fear of the physical sensations, and even fear of panic are normal parts of the process. Their fear may prevent them from participating, entering the room, staying in the room, making eye contact, and speaking. You can validate all of these reactions, and encourage them to keep pressing forward one step at a time. You should reassure clients that this is the work and is part of the challenge, physical sensations are just physical sensations, whatever they are able to do is great (even if not the full period of time), and they definitely cannot “fail” these exercises. Furthermore, if these physical sensations are intense and threatening and resemble the experience of having strong emotion, that is actually a good sign for therapy: It means that practicing these exercises may really help clients overcome their emotional disorders. The overall therapist message in this session promotes self-​efficacy, as in “You can do this” or “You are stronger than you think you are.” We highly recommend that you are well read about the many different interoceptive exercises that exist for different problems. Clients find it difficult to imagine interoceptive exercises, so suggesting an informed and well-​thought-​out strategy to them will help a great deal. Clinicians need to do some reading, research, and creative thinking ahead of the session to come up with creative ways to induce physical sensations that are salient to the clients’ most feared situations and emotions. Here are some useful questions for in-​session exercises: ■ Following the hyperventilation, what did you notice? Physical sensations, thoughts, avoidance, or EDBs? Was it easier or harder, more or less intense than you thought it would be? ■ Following the breathing through a thin straw, what did you notice? ■ Physical sensations, thoughts, avoidance, or EDBs? Was it easier or harder, more or less intense than you thought it would be? ■ Did these feelings remind you of a real situation that you’ve been through? ■

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Closing the session Closing an Individual Session does not require any additional formality beyond preparing the homework, confirming the next session time, and other customary practices. Group Sessions can require additional formality. Try to save 5 or 10 minutes at the end of the session after preparing the homework and confirming the next session time for closing the group. If it is not possible to save the time, it is not as important to formally close the session as it is to open it formally. If you are running a Group Session, and you have time saved, you might close the session as follows: Let’s go around the room and say one thing about how we are each feeling as we end the group, or a few words about what impact this group had on you. Therapists do not need to model the closing reflection. However, you might alert everyone to how much time there is left, to ensure everyone has a chance to speak. When there is a lot of time left, you might also encourage people to identify a personal goal for the next week.

Explanation for the client of this session’s homework You might explain the homework by saying something like this: Over the next week, you should practice interoceptive exercises for at least 5 minutes to a half-​hour every day. If you were not able to induce sensations at a level of 4 or 5, practice getting those sensations higher by doing the activity more intensely and for longer. If you were able to get them that high, and had some distress or similarity above a 2, then practice them each night to see it is possible to get the intensity higher but the distress level lower (or lower faster) through repeated practice. Make a plan for how to integrate this best into your schedule. And as noted in the “Review of avoidance and EBD homework” section, this week you are also going to plan ways that you can reduce both avoidance and EDBs—​keeping up or extending these practices. Before you go home, go over the homework for “more personally relevant interoceptive exercises” with your therapist. If there are ones that you think you should try out together first, take time to go over those. 227

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Homework Many of the forms and worksheets will need to be filled out more than once. We are including one blank copy of every worksheet and form in the client workbook (within the corresponding chapter) as well as a blank copy of each in the appendices to this therapist manual. For those items that clients will need more than once, you can provide additional copies for them, or clients can download blank copies themselves from the TreatmentsThatWork™ website at www.oxfordclinicalpsych.com/​UTforEDs. ■ Fill out Form 3.1: Daily Eating Disorder, Anxiety, and Depression (EDA). Plot scores on Form 3.2: EDA Graph. ■ Fill out Form 4.1: Regular Eating Food Log. ■ Complete Form 8.1: The ARC of Emotional Experiences. ■ Practice interoceptive exercises daily and complete Form 15.2: ■ Repeated Practice: Hyperventilation and Thin Straw. Record these exercises using Form 15.3: Repeated Practice. ■ Complete Form 15.4: “More Personally Relevant Practice!” ■ Homework. Complete Form 14.1: Changing Your EDBs. ■ Complete Form 13.1: Reducing Avoidance Practice Chart. ■ Read Chapter 16 and preview the exercises. ■

Review of avoidance and EDB homework You will notice that we are reviewing the homework from the past two sessions. It is important to keep practicing opposite action to replace both avoidance and EDBs. After reviewing the homework concerning EDBs from the last session, you and your client(s) should look over the homework from the prior session as well and plan ways that your client(s) can reduce both avoidance and EDBs—​keeping up or extending these practices—​over the next week. ■ Fill out Form 3.1: Daily Eating Disorder, Anxiety, and Depression (EDA). Plot scores on Form 3.2: EDA Graph. ■ Fill out Form 4.1: Regular Eating Food Log. ■

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Complete Form 8.1: The ARC of Emotional Experiences. ■ Complete Worksheet 14.1: Identifying Your EDBs Writing Exercise. ■ Complete Worksheet 14.2: Identifying Your EDBs and Opposite ■ Actions. Complete Form 14.1: Changing Your EDBs. ■ Complete Worksheet 14.3: EDB Reading and Reflection. ■ Read Chapter 15 (not necessary to review again). ■

In-​Session Exercises All in-​session exercises appear in the client workbook within the body of the corresponding chapter. We also include these exercises in this therapist guide, near the end of the corresponding chapter.

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In-​Session Exercise 15.1 Physical Sensation Induction

In order to understand how physical sensations are contributing to uncomfortable emotional experiences, we should first understand what a physical sensation feels like, apart from any interpretations of what it might mean. The more you can allow yourself to get used to feeling these sensations within a neutral context, the easier it will be to break the association with these sensations as something threatening or signaling danger. ■ Try engaging in these exercises once a day, every day. ■ During the exercises, try to pay close attention to how you feel physically as well as any emotions or thoughts you might have during the exercise. ■ To get the most benefit from these exercises, it is important to repeat them at least two or three times in a row each time. You may notice the first time they feel really bad, the second time maybe not quite as bad, and by the third time they might become much easier. Even if it takes longer and requires more repetitions, you will likely find after several repetitions that you have become more and more used to the physical sensations, and in turn they have become less and less uncomfortable. You will practice them at home as well as in sessions. There are different types of interoceptive exercises that will give you different sensations, and over time you should try many of these. However, everyone should start and become experienced with two initial exercises. We are going to read about them first, and then try them together. 1. Hyperventilation: For approximately 60 seconds, take rapid, deep breaths through your mouth, using a lot of force, as if you were blowing up a balloon. This exercise is likely to produce lightheadedness, dizziness, tingling, and feelings of unreality. 2. Breathe through a thin straw: For approximately 120 seconds, breathe through a thin straw while blocking air from your nose. This exercise will elicit sensations consistent with difficulty breathing and restricted air flow. It may induce anxiety early on, so it is important to continue the exercise for at least 1 or 2 minutes to let the early anxiety subside. Figure 15.1: Example of 3-​ Component Emotional Response to Interoceptive Exercise provides an example of what you might experience during an interoceptive exercise.

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Physical Sensations Tingling all over body Headache, dizziness Slight nausea Racing heart Hot and clammy

Behaviors/Urges Eyes shut tightly I want to lie down Urge to pace Urge to leave group Urge to lie or make an excuse as to why I can't continue

Thoughts “I feel out of control” “I don’t like it at all” “I feel like I need my Dad or someone to take me out of this situation” “I'm going to have a panic attack”

Figure 15.1: Example of 3-​Component Emotional Response to Interoceptive Exercise When you do the exercises, consider the following advice: Connect: In general, just take a moment to connect with your experience, noticing any emotions, thoughts, or behaviors (particularly avoidance) triggered by the experience. Wait until the symptoms have mostly subsided before trying the next exercise. When you are done, pick the exercises that produced the most distress for you. Put a star next to each one, because you will need to repeat those exercises the most times. Practice mindfulness: Even if you are not distressed by the physical sensations, some people find it helpful to use this experience as an opportunity to practice nonjudgmental awareness. Remember, physical sensations (similar to those produced by these exercises) are one of the three components of emotions, so becoming more aware of them can be helpful regardless of whether they elicit distress or are accompanied by other emotions. It is worth noting that some people don’t experience much distress when completing these exercises, while other people may find them more difficult. If you did not experience distress

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during these exercises, it is worth considering a number of possible reasons why. Let’s look at four possible reasons: 1. These exercises may not bring up sensations that are consistent with what you naturally experience during strong emotions. Thinking about your own symptoms, you can develop exercises to elicit physical sensations that you currently find distressing. For homework, there will also be the opportunity to try out different activities that may be more personally relevant. As long as it’s safe to do, you can also be creative. 2. You may have stopped the exercises before experiencing significant sensations, possibly in anticipation that the sensations would be distressing or would become too intense. If you believe you may have stopped the exercises too early, try again. This time, try to continue with the exercises for the full amount of time recommended, or even for longer. 3. You may not experience distress when completing these exercises in an environment that you consider “safe” such as in this group, or when accompanied by a person who conveys a sense of safety, such as a close friend or spouse. In this case, you should consider taking the exercises out of the “safe” environment, or try doing them alone. 4. You might not be afraid of the sensations because you know they were produced by the exercises rather than occurring in response to a distressing situation or accompanied by strong emotion. For some people, it’s also more distressing to have these sensations occur out of the blue or in situations in which they didn’t expect them to occur. Of course, you will not be able to recreate this situation, but you may still benefit from working with these exercises to help you become more comfortable with the sensations, whenever they may occur. Be sure to engage in each exercise fully and try to produce at least moderate symptom intensity each time. Try not to avoid by engaging in the exercises half-​heartedly or by tiptoeing through them. Rather, approach the exercises without hesitation and challenge yourself to elicit the physical sensations. By fully eliciting the physical sensations, you will provide yourself with an opportunity to learn that the symptoms are not dangerous and that they will return to normal on their own after a short period of time. Please fill out Form 15.1: In-​Session Physical Sensation Induction after each repetition. (This form is available later in this chapter.) You want to strive for an intensity level for the physical sensations of at least a 4 or 5. It is usually possible to induce physical sensations at this level if you do these activities intensively enough, no matter whether they are your normal sensations or not. Once you have sensations at this level, you can accurately assess your distress when you feel them and their similarity to what you experience when you are having “negative” emotional experiences. 232

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Case vignette In the following vignette, the therapist is assisting the client with understanding how the interoceptive exercises could mimic the physical sensations she experiences during panic attacks. She is a single Black cisgender woman in her 30s. She is in a high-​stress career and is diagnosed with anorexia nervosa and panic disorder. C:

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I try to avoid all things that increase my heart rate and feeling dizzy; it makes me feel like I’m experiencing a panic attack and I can’t handle that feeling. So, while I really don’t want to do this, I know you’ll probably recommend that I do an exercise that increases my heart rate. Seems inhumane! Ha, I know it seems like that. And I know that your world has become very, very small because of the avoidance of an increased heart rate. What exercises have we done in here, or one that might mimic that physical sensation without actually being in the situation that creates panic for you? The breathing through that stirrer straw usually creates lightheadedness and shortness of breath. It’s hard for me to get through the 2 minutes. When you said it’s hard to get through the 2 minutes, does that mean you’ve gotten through it before? Yes. I know the feeling goes away. I avoid doing it; it just feels so similar to when I actually have a panic attack. The more that you do this, the more and more you will build tolerance and you will, hopefully, no longer feel distressed by it. This takes a lot of practice in between sessions, though. It’s not designed to eliminate the sensations, of course. However, we want to lessen the distress that you feel about the sensations themselves. Are there any other ways we can mimic the increased heart rate? No clue—​I avoid feeling that way! So, I don’t really like to entertain the idea of making myself feel that way. That’s just it! Our interpretations of our physical sensations can increase them. What about hyperventilation? Since you are cleared by your medical team/​dietitian for exercise, we can incorporate some jumping up and down or running in place to increase your heart rate. In the meantime, do you think 233

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hyperventilation would be something that could mimic the increased heart rate feeling? I think so. What else do you feel, maybe in combination with your increased heart rate? Sometimes combining interoceptive exercises is worth considering. Um, there’s this feeling—​I can’t really explain it—​but like I need to take a deep breath. Do you know what I mean? It’s like something is sitting on my chest. Ah, yes! Almost like a heavy chest/​hard-​to-​breathe feeling. Exactly. Maybe something on my chest? What about heavy textbooks? Oh, gosh, yes. That would be so awful. And you’ll tell me I should do it, won’t you? [smiling] Probably [smiling] . . . but I also want to make sure you understand why I would recommend you do this. It’s not suffering for the sake of suffering. The goal is for you to build tolerance, not to make the distress go away. It is perfectly okay to not enjoy the feeling of not being able to breathe! And I want you to not avoid situations because of how you’re interpreting the physical sensations, like I mentioned before. And I know I’m repeating myself here, but it is important to reiterate that the physical sensations themselves are not dangerous; it’s our interpretations of them that can make them feel that way, and if we can build tolerance, then you may not fear them as much when they come! Exciting, right? Right . . . fine. I’ll try it this week. It would be nice to not fear those body feelings. I’m sure it would. I’m proud of you.

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MODULE 7

Emotion Exposures

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CHAPTER 16

Therapist Materials for Skills for Emotion Exposures

Goals ■ Understand what an emotion exposure is by reviewing Figure 16.1: Conducting an Emotion Exposure. Planned introduction of a stimulus to provoke habitually avoided ■ emotions to reduce avoidance and promote new learning. Can be any emotion. ■ Can be situational or imaginal, in the therapy office or elsewhere. ■ Plan exposures for emotions associated with eating disorder and ■ other emotional issues that involve avoidance. Begin filling in a personal emotion exposure hierarchy. ■ In-​ ■ Session Exercise 16.1: Developing a Fear and Avoidance Hierarchy. View Figure 16.2: Fear and Avoidance Hierarchy—​Example and ■ Figure 16.3: Common Emotion Exposures. Understand that exposures can be developed for other emotional ■ disorders demonstrated in Figure 16.4: Common Co-​occurring Emotional Disorders for Emotion Exposure Hierarchy. View Box 16.2: Hierarchy Examples Sheet. ■ Start Form 16.1: Fear and Avoidance Hierarchy. ■ Identify principles of planning an emotion exposure during In-​ ■ Session Exercise 16.2: Exposure Video. Learn how to record before and after exposures by reviewing Form ■ 16.2: Record of Emotion Exposure and Box 16.1: Record of Emotion Exposure Practice—​Mock Example. Learn what happens when you fully engage in exposures by reviewing ■ Figure 16.5: Four Effects of Emotion Exposure. Understand good skills for conducting emotion exposures. ■

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Plan the right level of challenge. ■ Consider expectancies beforehand. ■ Remove avoidance during the exposure. ■ Stay in the situation long enough to learn something useful. ■ Repeat, repeat, repeat! ■ Review Figure 16.6: Classic Graph of Repeated Exposures for ■ Anxiety. ■ Emphasize importance of watching exposure videos! Ensure client has access to videos.

Review of interoceptive exposure homework ■ Fill out Form 3.1: Daily Eating Disorder, Anxiety, and Depression (EDA). Plot scores on Form 3.2: EDA Graph. ■ Fill out Form 4.1: Regular Eating Food Log. ■ Complete Form 8.1: The ARC of Emotional Experiences. ■ Practice interoceptive exercises daily and complete Form 15.2: ■ Repeated Practice: Hyperventilation and Thin Straw. Record these exercises using Form 15.3: Repeated Practice. ■ Complete Form 15.4: “More Personally Relevant Practice!” ■ Homework. Complete Form 14.1: Changing Your EDBs. ■ Complete Form 13.1: Reducing Avoidance Practice Chart. ■ Read Chapter 16 and preview the exercises. ■

Review of avoidance and EDB homework ■ Fill out Form 3.1: Daily Eating Disorder, Anxiety, and Depression (EDA). Plot scores on Form 3.2: EDA Graph. ■ Fill out Form 4.1: Regular Eating Food Log. ■ Complete Form 8.1: The ARC of Emotional Experiences. ■ Complete Worksheet 14.1: Identifying Your EDBs Writing Exercise. ■

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■ Complete Worksheet 14.2: Identifying Your EDBs and Opposite Actions. Complete Form 14.1: Changing Your EDBs. ■ Complete Worksheet 14.3: EDB Reading and Reflection. ■ Read Chapter 15 (not necessary to review again). ■

Opening the session If you are running an Individual Session, the opening requires no formality aside from your usual methods. After greeting the client, get a quick initial sense of their emotional state. If the client is experiencing a notable emotional experience, consider suggesting that this example may be something to use in the session, for a real-​time example of the relevant UT material. Try to get to the homework review within a few minutes of opening the session. Group Sessions do benefit from having a formal check-​in, however. A formal starting ritual is important to help the group members shift from a customary, social state of mind to a therapeutic state of mind, to make sure everyone is participating from the beginning of the group, and to give the therapist a sense of what emotional issues are active. If you are running a Group Session, you might introduce this group with the following check-​in: At the beginning of group we take a few minutes for everyone’s voice to be heard, and to make a connection to ourselves and one another. We are talking today about emotion exposures. I would like for everyone to share one way they are feeling about this important chapter of therapy.

Therapist tips for emotion exposure Many therapists and counselors who are familiar with the other parts of this manual are least familiar with the concept of emotion exposures. We have provided extensive instruction for conducting emotion exposure in the client workbook materials, and therapists using the UT should fully absorb and consider these principles and watch all of the recommended

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videos that are listed in client workbook Chapter 16 (and available on the TreatmentsThatWork™ website at www.oxfordclinicalpsych.com/​ UTforEDs) before teaching these principles to clients and conducting emotion exposures. This particular session involves going over all the principles, starting to work on the hierarchy, and watching one example video in order for clients to get in their minds how to do exposure correctly. For homework, clients then work on their hierarchy more extensively and commit to doing one exposure at least two times before the next session. This is a crucial session to launch the exposure portion of therapy. Everything that clients have learned so far has prepared them for this, the most powerful part of the therapeutic process. Following this session, the goals of the remaining sessions are the same as these goals: ■ ■ ■ ■ ■

To review prior exposures To review their hierarchy To plan new exposures To conduct new exposures To commit to additional exposures for homework.

Some clients want to jump in and do very challenging and powerful exposures before they are ready. It is better to start with exposures that are rated around a 4 so that clients can practice all the principles of good exposure practice before they move to more challenging things. It can be difficult to plan certain activities to last long enough. For example, for a client who is nervous about making a telephone call, it is possible that the call will be ended before they’ve had time to adjust to the situation. It is necessary to be creative in thinking about how to make sure the exposure can be extended or repeated multiple times in one session to allow the necessary amount of time to pass. Sometimes it turns out that the emotion doesn’t start to reduce or become more tolerable within the amount of time that is allotted before the end of the session, or clients don’t find a way through their avoidance until near the end of the session. This is awkward for the therapist but just part of the learning process. It is a good idea to set goals that are really achievable and reasonable. It is not a good goal to plan to “go to a 240

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party and have a good time.” It is a reasonable goal to “go to a party, talk to two people, and stay there for half an hour.” We cannot control—​and often do not correctly anticipate—​what we will feel or whether a social situation works out “well.” It also cannot be a goal to avoid having a panic attack. Panic attacks happen, and although they can feel like a failure to the client and therapist, it is crucial not to treat panic attacks like unbearable events or failures. You and the client will ride it out together and will try to observe that it was survivable, and something was learned from it. It can also be challenging to come up with ideas for starting with seemingly small challenges, particularly for things that people rate at the highest possible subjective units of distress (SUD) level (or above!). It is totally reasonable to start with sitting with a pastry in front of you, on a plate, and smelling and touching it, if it is too challenging to start with eating it. For specific phobias and obsessive-​compulsive fears, it is possible to start with pictures of things—​for example, just the word “bug,” then a picture of a bug, then a fake bug, then a real one. There are books and movies about everything, and there are pictures and videos of everything under the sun on the internet. Therapist exposure planning often involves searching online for content that would be appropriate, because it is hard and possibly counterproductive to send clients willy-​ nilly through the internet on searches themselves. The final sessions are then under the control of the client and therapist. Each week, for as long as necessary, you and your clients will plan exposures, conduct exposures, and move as high up the hierarchy as possible. It isn’t necessary to do every single thing that is planned—​ sometimes people put things on the hierarchy that can’t reasonably be completed. However, get as high on the hierarchy as possible, through courage, persistence, and creativity.

Closing the session Closing an Individual Session does not require any additional formality beyond preparing the homework, confirming the next session time, and other customary practices.

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Group Sessions can require additional formality. Try to save 5 or 10 minutes at the end of the session after preparing the homework and confirming the next session time for closing the group. If it is not possible to save the time, it is not as important to formally close the session as it is to open it formally. If you are running a Group Session, and you have time saved, you might close the session as follows: To close the group, let’s go around the room and say one thing about how we are each feeling. You might also say a few words about what impact this group had on you: Did you learn anything new, or did you feel surprised or moved by something? Also, if you have a personal goal for the week, that can be good to say aloud.

Explanation for the client of this session’s homework You can explain the homework by saying something like this: In the remaining weeks of this treatment, you will focus on conducting exposures both in session and out of session. Session time will be devoted to planning and conducting emotion exposures as well as reviewing exposures that you have done out of session.

Homework Many of the forms and worksheets will need to be filled out more than once. We are including one blank copy of every worksheet and form in the client workbook (within the corresponding chapter) as well as a blank copy of each in the appendices to this therapist manual. For those items that clients will need more than once, you can provide additional copies for them, or clients can download blank copies themselves from the TreatmentsThatWork™ website at www.oxfordclinicalpsych.com/​UTforEDs. ■ Fill out Form 3.1: Daily Eating Disorder, Anxiety, and Depression (EDA). Plot scores on Form 3.2: EDA Graph. ■ Fill out Form 4.1: Regular Eating Food Log. ■ Complete Form 8.1: The ARC of Emotional Experiences. ■ One emotion exposure: _​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ ■ 242

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Complete Form 16.2: Record of Emotion Exposure. ■ Repeat same exposure at least twice! ■ ■ Continue filling in Form 16.1: Fear and Avoidance Hierarchy; if needed, review Figure 16.2: Fear and Avoidance Hierarchy—​ Example and Box 16.2: Hierarchy Examples Sheet. Watch videos of emotion exposures. ■

In-​Session Exercises All in-​session exercises appear in the client workbook within the body of the corresponding chapter. We also include these exercises in this therapist guide, near the end of the corresponding chapter.

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In-​Session Exercise 16.1 Developing a Fear and Avoidance Hierarchy

A big factor in the success of treatment lies in your practice of emotion exposures. You should aim to do exposure activities every day. An important skill is being able to plan the right kind of exposure. The next step is to create your own exposure hierarchy—​a list of your feared and avoided situations, consisting of various activities (situational and/​or imaginal) that will elicit the uncomfortable and distressing emotions that you typically avoid. Our exercise for today is to start making that list. Just to get us started, we are going to brainstorm a list of avoided and feared situations. Don’t worry too much about SUD scores or categories, or difficulty ratings. Just focus on generating a lot of different exposure ideas. Your list can be really messy because we are going to copy it over later to your Hierarchy Form. For this activity you will need Box 16.2: Hierarchy Examples Sheet and Form 16.1: Fear and Avoidance Hierarchy, both located later in this chapter. It can be an “imaginal” exposure just to fill out the top of the hierarchy. For the things that would cause you the most discomfort (for example, eating a full meal of pasta without exercising afterward, singing a song in front of strangers, touching a toilet and then not washing your hands all day), just naming and writing down these things is work enough right now. Down at the bottom of the form, you should include things that you would avoid and would cause you discomfort but that you can possibly imagine actually doing. Once you have done some of the things at the bottom, it will seem more possible to do the things in the middle. Once you have done the things in the middle, it will seem more possible to do the things at the top. You do not have to be ready to do all these things right now! Emotion exposures can be designed around any situation that evokes uncomfortable emotions for you, allowing you to practice emotion regulation skills you have learned (such as nonjudgmental, present-​focused awareness; identifying and challenging automatic appraisals; countering emotion avoidance and EDBs; and tolerating physical sensations). When designing exposures, it is important to consider that uncomfortable emotions can be negative or positive. If there are pleasurable emotions you avoid, think how to include those in your hierarchy. This part of treatment can be hard for people at first. But remember, you have learned so much from treatment that will help you tolerate and learn from emotional situations. It is in this final stage of the treatment that all that learning really pays off! At this point, try to write down at least five on your hierarchy sheet, dealing with different areas of your issues (food, body image, other issues). Try to come up with ones that would be more and less difficult to actually do.

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In-​Session Exercise 16.2 Exposure Video

We are going to watch some short videos of people doing exposures according to the principles that we have described here. We provide links to other good videos as well (on the TreatmentsThatWork™ website at www.oxfordclinicalpsych.com/​UTforEDs) so you can watch them later. While we are watching, see if you can notice the planning principles that we’ve covered today, for discussion after we watch. ■ ■ ■ ■ ■

Coffee exposure Flying exposure Messy finger-​food exposure Elevator exposure Social exposure

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Case vignettes Case ­vignette 16.1 The following vignette illustrates the therapist working with the client to design a situational exposure based on the client’s idiographic exposure hierarchy. The patient is an Asian American cisgender woman and is a sophomore in college. She has been diagnosed with anorexia nervosa and obsessive-​compulsive disorder. T:

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So, we’ve been working on some exposures for a few weeks now. It’s probably a good time to review what you’ve done and the progress you’ve made and think about the next steps. You have been working on eating in the dining hall at school, which was a big deal because you hadn’t done that since the beginning of your freshman year. Tell me how that’s been going and what you have been noticing. Umm, the first time was obviously the hardest. Before I did it that first time, I was pretty sure I was only going to do it for the sake of completing the exposure and then never do it again—​but I’ve actually eaten in the dining hall for breakfast every day this week! I completed the Emotion Exposure form before and after like you asked. I am still anxious about going, but it’s definitely easier than when I started. Tell me more about that and what you have observed with your SUDS. My SUDS are always high before I walk in, increasing when I’m actually walking into the dining room and when I am eating. It drops a little once I am picking out my food. And overall, the score is down from the first time I did it to today. I am starting to see what you meant about repetition being important. Right. The more we do something and experience the emotion with it, the more we are able to build tolerance to the emotion. I bet you have also learned some things about the situation or about yourself or about how the experience goes that are helpful to know. Do you have some thoughts about why you think your SUDS are lower when you are picking out your food versus coming in and eating it? Umm, yeah. Probably because when I am walking in, my thoughts are racing and my chest is pounding, and I actually

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start to think about leaving and not doing it at all. I don’t know who I am going to run into and what others might be thinking about me. I guess it’s the same when I sit down to eat. I think it probably drops when I am picking out my breakfast because I am still choosing the same thing every day. I haven’t had any variety. I really like fresh fruit, granola, and yogurt and it just feels safer and cleaner. Sounds like you are on to something! What do you notice happening to your body when you are selecting your breakfast? I can actually feel the tightness in my shoulders release and my breath becomes freer, like less constricted. I don’t think I would have noticed that if I wasn’t trying to be aware of it and filling out the forms like you asked. Yes! That’s great! The forms can be helpful. How about any avoidant behaviors that you may have been engaging in? So, I noticed on the first day that I had brought my water bottle with me—​you know, the one I used to bring everywhere without even thinking. So, I made sure not to bring it the following days. I went by myself each day, and I expect that it will be harder when I eat around others. Yes, I remember this from our planning session. You had decided to start by going first thing in the morning when the dining hall opened and fewer people were there. Right, and I kept to that. I went at 7 a.m. when it was empty, and the food was the freshest. Most people come around 8 or 8:30. That’s helpful information to have. I’m so impressed. You are doing a really, really awesome job. What we will do next is design the exposure again, while adding increased levels of difficulty. You are totally able to do it! Remember, we don’t want to make it the hardest all at once, and we don’t want to keep it too easy. Building emotional tolerance is like building a muscle. That makes sense. I think I am ready for the next step, but I am also anxious about it. Absolutely! And you’ve gotten good at holding two things at the same time. With exposures, as you know, we want to push ourselves a little past where we are comfortable. What do you think we could add to or change in your existing exposure to accomplish this? Definitely going later, like 7:45 a.m., and my roommate said she would go with me. I will continue not to bring my water bottle. 247

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OK. How are you feeling about this so far? I feel all right. Pretty comfortable actually. I have anxiety about being around more people but not so much about being around my roommate because I’ve eaten other meals and snacks with her. I’m wondering if you would be willing to push that comfort a little bit more. Umm, what did you have in mind? What about trying to incorporate some variety with your breakfast choices? Oh, yeah. I can try to do that, at least two times. I do want to be able to be more spontaneous. I’m starting to feel more nervous now thinking about it, but I know I can tolerate my nerves. Yes! You can tolerate your emotions, even when they are more intense than we would like. One of the things I love about this model is that is prepares us to do hard things. I’m really psyched for you and the progress you are making.

Case ­vignette 16.2 In the following vignette the therapist is working with a client on designing an emotion exposure with food she typically binges. The client is a Latina cisgender woman in her late 50s who is diagnosed with binge eating disorder. C:

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I know I’ll binge. I have never eaten Thai food, especially takeout, without it turning into a total binge. I’ve done it countless times over the past 30 years. That’s a lot of evidence. I think your worries are valid. You don’t have any recent evidence that you have eaten Thai food without it turning into a binge. And before we just do this, there is a distinction between exposure and unfair challenge. An unfair challenge would be us ordering you Thai food and being like, “OK, bye. Let’s see what happens!” This will be different. We are going to make a really careful plan that you are committed to succeeding at. We are going to thoughtfully fill out an Emotion Exposure Form before you even start, so we can really lay out your expectancies and identify automatic thoughts, like the ones you just stated, as well as rate your anticipatory distress before the meal. We will come up with alternative

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appraisals and we will talk it out. We will also discuss any efforts you might use to avoid the emotion or to lessen the intensity. C: Sounds like a blast . . . T: [Smiling] Umm, would we put humor under avoidance strategies you might use? C: [Smiling] Sorry, yes, I’m just feeling really anxious about this. T: That makes sense! This is hard. The point of this exposure is not to do this without any fear. This has been something we have discussed for a while now because it is so uncomfortable for you. We want to do this for a couple of reasons. First, so that way you can test and hopefully disconfirm some of the feared outcomes like, “I will binge, it’s inevitable.” And then we will consider other possibilities, like it might turn out that you don’t binge and it worked out better than expected. The whole reason we do this is because we want you to build tolerance to your emotions without avoiding them. It is likely that you avoid other situations that make you feel this way, so by doing this, you are building tolerance not to just this isolated situation, but to all situations that may feel like this. C: That sounds nice. To be able to eat with friends without being overcome with fear. It seems so far away. T: It does sound like a nice thing, doesn’t it? We want you to build awareness around the avoidance strategies you might use because you fear that you won’t be able to handle the emotion, or that it’ll just keep getting worse. And we want to build awareness around what you do because of those thoughts (maybe binge or maybe avoid?). Chances are that if you stay with the emotion without avoiding it, it’ll eventually diminish on its own. C: OK. I’m in. So, I order the food and then what? T: Awesome! Right. You will order the meal that you think you might like and will satisfy your hunger and nutritional needs. Let’s back up one step, and decide together if it is a good level of challenge to know what you plan to order first, or if it is a good level of challenge to have to order when you get there. C: Oh, I didn’t think about that. I’m just so used to going in there and ordering in a kind of a haze. Maybe for the first time it would be good to know what I am going to order in advance?

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Great. Let’s look at the menu at the end of the session. So you will order what you planned, and once it arrives, you’ll eat it until you decide that you are finished. The purpose of this is to increase awareness—​being present on purpose, with purpose and nonjudgmentally. So as you are going through this process, I want you to anchor in the present and notice your thoughts, physical sensations, and behaviors and urges. At the end you should assess where your distress is using the SUDS, and if it was better, worse, or the same as you expected. You might notice efforts to avoid, or thoughts increasing—​make a note of that. That’s all useful information for how to make future exposures more successful when you do this again.

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Relapse Prevention

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CHAPTER 17

Therapist Materials for Continuing Progress into the Future

Goals Review the important takeaway messages of this program. ■ Learn a quick method to apply skills when taking action in the fu■ ture. Review Figure 17.1: Emotion Skills Action Plan. The three-​point check, on thoughts, physical sensations, and ■ behaviors/​urges, is a good set of cues to apply cognitive reappraisal and present-​focused, mindful awareness and to reverse avoidance or EDBs that may be increasing the intensity or prolonging certain emotions. Evaluate client progress. Complete Worksheet 17.1: Progress ■ Evaluation. Revisit client treatment goals by looking back at completed ■ Form 3.2: EDA Graph and completed Worksheet 4.1: “Taking the Necessary Steps” Homework Plan from the beginning of treatment. Develop a practice plan using Worksheet 17.2: Practice Plan. ■ ■ Review Table 17.1: Example Practice Plan.

Homework review ■ ■ ■ ■

Fill out Form 3.1: Eating, Depression, and Anxiety (EDA). Plot scores on Form 3.2: EDA Graph. Fill out Form 4.1: Regular Eating Food Log. Complete Form 8.1: The ARC of Emotional Experiences.

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■ One emotion exposure: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Complete Form 16.2: Record of Emotion Exposure. ■ Repeat same exposure at least twice! ■ Continue filling in Form 16.1: Fear and Avoidance Hierarchy; if ■ needed, review Figure 16.2: Fear and Avoidance Hierarchy—​ Example and Box 16.2: Hierarchy Examples Sheet. Watch videos of emotion exposures. ■

Opening the session If you are running an Individual Session, you might start by acknowledging that it is the last therapy session. Take more time than usual to get a sense of the client’s emotional state. If the client’s emotions seem intense, they may require time during the session to address. The last Group Sessions may also benefit from a slightly longer check-​ in. If you are running a Group Session, you might introduce this group with the following check-​in: Today is our last group session, and members of the group may be feeling a lot of different emotions—​or not—​about the end of the group. Any way that you are feeling is okay. Today we will be talking about the progress that we have made, and planning to continue that progress outside of therapy in the future. Let’s take a moment to look around the room. Close your eyes, if you like, and take a deep breath. Then let’s go around the room and share how we are feeling in this moment. It is helpful to allow slightly more time to discuss how people are feeling about ending the group. It is important to normalize anxiety and sadness about the therapy ending. Some therapists frame the end of therapy as an exposure in itself, as removing therapy/​the therapist may be removing the last safety signal. It is normal to feel anxious about removing a safety signal, but that does not mean that clients’ fears/​thoughts about the future (e.g., that they will relapse) will come true. It is also normal to feel sad about losing an important relationship or set of relationships.

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Therapist tips for continuing progress into the future The main point of this session is to review key concepts from this treatment program and to help clients prepare for what comes next.1 Clients will review strategies to help strengthen the skills they have been practicing. Here are the important takeaways from this program to review: ■ All emotions, even the ones that feel negative or uncomfortable, are providing us with information that can motivate us to take action in helpful ways. Staying present in the moment and taking a nonjudgmental view ■ of our emotions can help to prevent emotions from increasing in intensity. The way we think about a situation influences how we feel, and how ■ we feel affects the way we interpret a situation. Although avoiding uncomfortable emotion experiences can work ■ well in the short term, it isn’t an effective long-​term coping strategy. It is useful to create new, updated goals. It can be useful to ask: ■ Are your goals specific and concrete enough for you to easily measure your progress? Are your goals manageable and realistic? The purpose of goals is to mo■ tivate you, and if you set goals that are unrealistic, you could end up feeling defeated. Is the ability to achieve your goals within your control, or is the outcome ■ dependent on reasons beyond your control? For example, if you set a goal to go on two job interviews next month, there are many reasons outside your control why that may not be achievable. However, if your goal is to submit two job applications, it is much more under your control! In this session it is helpful to remind clients of the following messages, which are addressed more thoroughly in the client workbook. Though they may have read the chapter prior to the meeting, it is important to

The material in this chapter is largely reprinted from the UP manual, Barlow et al., 2018. 1

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review these messages in your own words and explore how clients react to them. ■ Improvements continue into the future. Clients may be feeling excited about their improvements, or disappointed about not achieving the type of changes they hoped for. Remember that the goal of completing this treatment program is to teach clients the skills for responding to their emotions in a more helpful way. Although it is very common for people to feel that they have made some noticeable progress in addressing their symptoms, there is often still room for improvement following this short-​term treatment. This is because it takes time after learning the skills to see the full effect. Studies on this treatment have shown that clients continue to see additional improvements in their symptoms for up to a full year after completing it. Lean in. Leaning in and feeling our feelings while integrating our ■ emotion awareness skills leads to this ongoing and sustainable change versus short-​term crisis management. With the former, clients are building emotional tolerance and becoming their own emotional expert. Keep up the momentum. Clients may understandably find themselves ■ looking forward to taking a break. However, consider Newton’s first law of motion—​an object at rest stays at rest and an object in motion stays in motion. In other words, it is much easier to maintain all of the positive momentum that clients have worked so hard to accumulate over these past months than it is to get back on track after taking a break. Be your own coach. It is important that clients take ownership over ■ their continued progress. Many people find it helpful to schedule time to review their progress and revise their practice plan on a weekly basis. We recommend blocking out this time on their calendar, the same way they would for a doctor’s appointment or a work meeting. Check in with yourself regularly. It is often said that the best offense is ■ a strong defense, and the same is true when it comes to monitoring one’s own symptoms. Many people wait until their symptoms start to disrupt their lives again before they make time to address them. However, if clients establish the routine of checking in with themselves each week, they will be able to notice any changes in their 256

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symptoms before they get out of hand. For example, if a client notices that they are starting to avoid situations that trigger intense emotions, they can proactively address this using their practice plan. ■ Anticipate and plan for possible challenging events. It can also be helpful for clients to consider whether there are any upcoming situations that may be particularly challenging for them. They can anticipate some of the negative automatic thoughts that are likely to arise and the urges that they have to engage in emotion-​driven behaviors. For example, big social events like weddings and reunions often cause people with a history of eating disorders to want to restrict and to notice negative automatic thoughts about what people will think about them. There are certain times of the year—​like final examinations, or the end of the budgetary year, or the holidays—​that bring up certain feelings. Clients can try to generate more flexible interpretations for their automatic thoughts and create preemptive plans for alternative actions for urges to engage in EDBs ahead of time. Ups and downs are normal. Regardless of the gains clients have made ■ in treatment, it is very likely that they will experience intense or uncomfortable emotions at times in the future! Emotional ups and downs are part of everyday life. Clients may notice that when they are under stress, their symptoms tend to flare up. Sometimes, however, it may seem like their symptoms flare up when there hasn’t been any increase in stress, which can be distressing. These fluctuations in symptoms are natural and normal—​they do not necessarily mean someone has relapsed. Responding to an increase in symptoms with criticism and judgment will only intensify the symptoms. It is very easy to start jumping to conclusions and thinking the worst when symptoms flare up. Clients may find themselves thinking that treatment failed or they will never be able to cope with intense emotions. Mindful emotion awareness and cognitive flexibility skills can be very helpful at these moments. ■ Remember the power of an exposure. When clients complete an exposure, they are not just showing themselves they can do that hard thing; they are also showing themselves that they can tolerate the emotion behind doing something with a specific level of distress. This means that not only can they do that hard thing, but they can also do other hard things that have caused them the same level of distress. The higher we go on our exposure hierarchy, the more

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emotional competency we build, so things that used to feel really overwhelming before no longer cause the same level of distress. And this, of course, comes from—​you guessed it—​repetition. ■ Be patient and persistent. It takes time and effort to change the way we respond to our emotions, and it is hard work. Remind clients that they didn’t develop these unhelpful ways of coping with intense emotions overnight, and it is unrealistic to expect they will be completely eliminated in a few months. However, with consistent practice, clients will be able to replace unhelpful coping strategies with more useful ones, and change the way they respond to their emotions. The end of treatment is just the beginning for clients to make more substantial changes in their lives.

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Appendix A List of Forms

Form 3.1: Eating, Depression, and Anxiety (EDA)  260 Form 3.2: EDA Graph  262 Form 4.1: Regular Eating Food Log  263 Form 8.1: The ARC of Emotional Experiences  264 Form 10.1: Mood Induction Recording  265 Form 12.1: Downward Arrow  266 Form 13.1: Reducing Avoidance Practice Chart  267 Form 14.1: Changing Your EDBs  268 Form 15.1: In-​Session Physical Sensation Induction  269 Form 15.2: Repeated Practice: Hyperventilation and Thin Straw  270 Form 15.3: Repeated Practice  275 Form 15.4: “More Personally Relevant Practice!” Homework  276 Form 16.1: Fear and Avoidance Hierarchy  278 Form 16.2: Record of Emotion Exposure  279

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Form 3.1 Eating, Depression, and Anxiety (EDA)

1. In the past day, how intense or severe were your urges to engage in eating disorder (ED) symptoms ? 0 = None: ED urges absent or barely noticeable. 1 = Mild: ED urges at a low level. It was possible to not engage in ED symptoms. 2 = Moderate: ED urges were distressing at times. I had ED symptoms at points during the day. 3 = Severe: ED urges were intense much of the time. I had ED symptoms during most of the day. 4 = Extreme: ED urges were overwhelming. I thought about little else outside of ED symptoms. 2. In the past day, how much did your ED interfere with your ability to do things you needed to do? 0 = None: No interference from my ED symptoms. 1 = Mild: My ED has caused some interference. Things are harder, but I am getting them done. 2 = Moderate: My ED definitely interferes. I’m not doing all the things I would normally do. 3 = Severe: My ability to function has seriously suffered due to my ED. 4 = Extreme: My ED has become incapacitating. I am unable to complete important tasks. SUM OF #1 + #2:

Plot this number as a circle on your graph.

3. In the past day, when you have felt depressed, how intense or severe was your depression? 0 = Little or None: Depression was absent or barely noticeable. 1 = Mild: Depression was at a low level. 2 = Moderate: Depression was intense at times. 3 = Severe: Depression was intense much of the time. 4 = Extreme: Depression was overwhelming. 4. In the past day, how much did depression interfere with your ability to do things you needed to do? 0 = None: No interference from depression. 260

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1 = Mild: Depression has caused some interference. Things are harder, but I am getting them done. 2 = Moderate: Depression definitely interfering. I’m not doing all the things I would normally do. 3 = Severe: My ability to function has seriously suffered due to my depression. 4 = Extreme: My depression has become incapacitating. I am unable to complete important tasks. SUM OF #3 + #4

Plot this number as a square on your graph.

5. In the past day, when you have felt anxious, how intense or severe was your anxiety? 0 = None: Anxiety was absent or barely noticeable. 1 = Mild: Anxiety was at a low. It was possible to relax when I tried. 2 = Moderate: Anxiety was distressing at times. It was hard to relax or concentrate, but I could do it. 3 = Severe: Anxiety was intense much of the time. It was very difficult to relax or focus. 4 = Extreme: Anxiety was overwhelming. It was impossible to relax at all. 6. In the past day, how much did your anxiety interfere with your ability to do things you needed to do? 0 = None: No interference from anxiety. 1 = Mild: My depression has caused some interference. Things are hard, but I’m getting them done. 2 = Moderate: My anxiety definitely interferes. I’m not doing all the things I would normally do. 3 = Severe: My ability to function has seriously suffered due to my anxiety. 4 = Extreme: My anxiety has become incapacitating. I am unable to complete important tasks. SUM OF #5 + #6

Plot this number as a triangle on your graph.

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Score

0

1

2

3

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5

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8

1

2

3

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5 ED

6

Depression

10 Anxiety

7 8 9 Days/Weeks

Form 3.2 EDA Graph

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Form 4.1 Regular Eating Food Log

This is a format for keeping a food log. You should fill out one for each day. Although your mind may have habits, it is important not to record calories, and record this information as close to “real-​time” as possible, with the goal of eventually eating three meals and two or three snacks a day. Your nutrition team may have other goals and techniques as well; please share this form with them. Put a check in the “B” column if you experienced loss of control over eating (a binge episode) while eating. Put a check in the “CB” column if you utilized a compensatory behavior (for example, purging, driven exercise, or fasting as a compensatory behavior) after the eating event.

Time

Foods

Place

B?

CB?

Emotions, Thoughts, Physical Sensations

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Short-​term:

Long-​term:

Immediate:

Earlier:

EMOTIONAL EVENT:

Long-​term:

Behaviors & Urges

Earlier:

Physical Sensations

Consequences (what happened next?)

Short-​term:

Thoughts

Responses

Immediate:

EMOTIONAL EVENT:

Date/​ Time

Antecedents (situation & triggers)

Form 8.1 The ARC of Emotional Experiences

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Stimuli (Images, Video, Music) Emotions:

Thoughts

Physical Sensations

Behaviors and Impulses

Emotions:

Thoughts

Physical Sensations

Behaviors and Impulses

Thoughts

Physical Sensations

Behaviors and Impulses

Emotion:

Thoughts

Physical Sensations

Behaviors and Impulses

Intensity (0–​10)

Secondary Emotional Responses

Emotion:

Primary Emotional Response Intensity (0–​10)

Use this form to record what you noticed. Rate the intensity of your emotion 0 to 8, with 0 = not at all, 4 = moderately, 8 = extremely.

Form 10.1 Mood Induction Recording

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Form 12.1 Downward Arrow Automatic Appraisal: ____________________________________________________________

If this were true, what would it mean about me? Why does this matter to me? What would happen if this were true? What would happen next? Underlying Appraisal: ___________________________________________________________

If this were true, what would it mean about me? Why does this matter to me? What would happen if this were true? What would happen next? Underlying Appraisal: ___________________________________________________________

If this were true, what would it mean about me? Why does this matter to me? What would happen if this were true? What would happen next? Underlying Appraisal: _____________________________________________________________

If this were true, what would it mean about me? Why does this matter to me? What would happen if this were true? What would happen next? Underlying Appraisal:_____________________________________________________________

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Form 13.1 Reducing Avoidance Practice Chart Record the times that you tried to do the opposite of your avoidance and how it went. (The first row is filled out as an example.)

Avoidance Strategy

Opposite Action

Reaction and Experience

Being quiet in class or hardly ever speaking up

Making a comment as soon as possible after class started in a louder voice. Making several comments over group.

The first time I talked in a particular class I felt my heart pounding and I sounded really loud. But by the end I felt actually much more comfortab le and plugged in than ever before.

267

Emotion

Sadness, guilt, worthlessness. Anger as a secondary emotion.

Situation/​trigger

Ex-​husband

Diet, exercise, co mplaining

EDB Writing in journal or talking to friend about sadness

Opposite action

Possibly learning something new or getting a new perspective. Actually dealing with sadness instead of making myself more sad and lonely by being underweight.

Positive consequence of opposite action

This worksheet is to help you generate ideas about how to engage in opposite action, rather than your customary EDBs, in response to common triggers. Articulating the possible positive consequences of the opposite action may increase your motivation to change your EDBs.

Form 14.1 Changing Your EDBs

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Form 15.1 In-​Session Physical Sensation Induction Please complete each of the exercises (as described) below. Be sure to engage in each exercise fully, and try to produce at least moderate symptom intensity. After the exercise, please make a note of:

1 . The physical symptoms you experienced 2. The intensity of the symptoms (0–​8 scale; 0 = no intensity, 8 = extreme intensity) 3. The level of distress you experienced during the task (0–​8 scale; 0 = no distress, 8 = extreme distress) 4. The degree of similarity to your naturally occurring symptoms (0–​8 scale; 0 = not at all similar, 8 = extremely similar) Try engaging in a set of exercises once a day. During the exercises, try to pay close attention to how you feel physically as well as any emotions or thoughts you might have during the exercise. To get the most benefit from these exercises, it is important to repeat them at least two or three times in a row each time you do them, and to make them intense. Over time you will see your reaction to them change with repetition and learning.

Procedure Hyperventilation (60 seconds)

Experience (3-​Point Check)

Intensity (0–​8)

Distress (0–​8)

Similarity (0–​8)

1.  Physical sensations

2. Thoughts

3.  Avoidance/​EDBs

Breathe through a thin straw (60 seconds)

1.  Physical sensations

2. Thoughts

3.  Avoidance/​EDBs

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Form 15.2 Repeated Practice: Hyperventilation and Thin Straw

Please complete each of the exercises (as described) below. Be sure to engage in each exercise fully, and try to produce at least moderate symptom intensity. After the exercise, please note: 1 . The physical symptoms you experienced 2. The intensity of the symptoms (0–​8 scale; 0 = no intensity, 8 = extreme intensity) 3. The level of distress you experienced during the task (0–​8 scale; 0 = no distress, 8 = extreme distress) 4. The degree of similarity to your naturally occurring symptoms (0–​8 scale; 0 = not at all similar, 8 = extremely similar) Practice one set of exercises once a day. Try to pay close attention to how you feel physically as well as any emotions or thoughts you might have during the exercise. To get the most benefit from these exercises, it is important to repeat them at least two or three times in a row each time you do them, and to make them as intense as possible. Day 1

Procedure Hyperventilation 1 (_​_​seconds)  Hyperventilation 2 (_​_​ seconds) Hyperventilation 3 (_​_​ seconds) Breathe through thin straw 1 (_​_​ seconds) Breathe through thin straw 2 (_​_​ seconds) Breathe through thin straw 3 (_​_​ seconds)

Notes on 3-​Point Check

Intensity (0–​8)

Distress (0–​8)

Similarity (0–​8)

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Day 2

Procedure

Notes on 3-​Point Check

Intensity (0–​8)

Distress (0–​8)

Similarity (0–​8)

Hyperventilation 1 (_​_​seconds)  Hyperventilation 2 (_​_​ seconds) Hyperventilation 3 (_​_​ seconds) Breathe through thin straw 1 (_​_​ seconds) Breathe through thin straw 2 (_​_​ seconds) Breathe through thin straw 3 (_​_​ seconds)

271

27

Day 3

Procedure Hyperventilation 1 (_​_​seconds)  Hyperventilation 2 (_​_​ seconds) Hyperventilation 3 (_​_​ seconds) Breathe through thin straw 1 (_​_​ seconds) Breathe through thin straw 2 (_​_​ seconds) Breathe through thin straw 3 (_​_​ seconds)

272

Notes on 3-​Point Check

Intensity (0–​8)

Distress (0–​8)

Similarity (0–​8)

 273

Day 4

Procedure

Notes on 3-​Point Check

Intensity (0–​8)

Distress (0–​8)

Similarity (0–​8)

Hyperventilation 1 (_​_​seconds)  Hyperventilation 2 (_​_​ seconds) Hyperventilation 3 (_​_​ seconds) Breathe through thin straw 1 (_​_​ seconds) Breathe through thin straw 2 (_​_​ seconds) Breathe through thin straw 3 (_​_​ seconds)

273

274

Day 5

Procedure Hyperventilation 1 (_​_​seconds)  Hyperventilation 2 (_​_​ seconds) Hyperventilation 3 (_​_​ seconds) Breathe through thin straw 1 (_​_​ seconds) Breathe through thin straw 2 (_​_​ seconds) Breathe through thin straw 3 (_​_​ seconds)

274

Notes on 3-​Point Check

Intensity (0–​8)

Distress (0–​8)

Similarity (0–​8)

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Form 15.3 Repeated Practice Complete one for each day, as many interoceptive exercises as are relevant for you.

Notes on 3-​Point Check

Intensity (0–​8)

Distress (0–​8)

Similarity (0–​8)

First repetition

1.

1.

1.

1.

Second repetition

2.

2.

2.

2.

Third repetition

3.

3.

3.

3.

First repetition

1.

1.

1.

1.

Second repetition

2.

2.

2.

2.

Third repetition

3.

3.

3.

3.

First repetition

1.

1.

1.

1.

Second repetition

2.

2.

2.

2.

Third repetition

3.

3.

3.

3.

First repetition

1.

1.

1.

1.

Second repetition

2.

2.

2.

2.

Third repetition

3.

3.

3.

3.

Procedure _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

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Form 15.4 “More Personally Relevant Practice!” Homework

The homework for interoceptive sessions, in addition to repeated practice of the exercises in the session itself, is to try to identify other, more personally relevant interoceptive exercises that might help you develop new experiences of the physical sensations involved in your own emotional issues. As you go down this list, you can check off whether you have particular physical sensations associated with emotions. If you do, or if you think you might, then it is a good idea to do a little practice of the interoceptive exercises suggested or to adapt them creatively to be more like your own physical sensations. We will practice these in the next session. If you need to bring something to the session to practice, please do so.

Physical Sensation

Check If Relevant for You

Interoceptive Exercise Ideas

Body image and eating Nausea

Spinning in a circle with eyes closed for 1 minute (running or in spinning chair)

Fullness, bloating, gastric functions

Gulping water, pushing belly area muscles out

Constriction, general tactile discomfort

Wearing tight clothing, tight belt, pushing belly-​area muscles out

Hunger, salivation, disgust, gastric functions

Smelling and/​or tasting particular foods, holding food in your mouth

Feeling body fat, skin, muscles “jiggle”

Bouncing up and down, wiggling body

Sensation of others (or self ) touching body

Sitting near someone/​close proximity

Feeling of body weight sinking into seat

Sitting on very soft surface (pillows, soft mattress, bean bag chair)

Intense awareness of skin and body parts

Wearing damp clothing

Feeling body/​legs/​buttocks “spread” out

Sitting on hard, flat surface

Relevant to anxiety and worry Muscle tension, fatigue

Deliberately tensing parts of body, muscles

Dizziness, derealization

Staring into mirror or at your hand (try with bright lights on, stare hard without blinking), staring at a blank wall, staring at a dot, staring at a light and then trying to read

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Brightness or aching sensation in eyes, dizziness

Rolling eyes around deliberately for 30 seconds, then looking straight ahead

Temperature, feelings of overheating

Wearing heavy coat, layers, in bright sunshine or next to heater; drinking 1 spoon of Tabasco sauce; drinking 1 glass of hot water

Claustrophobic sensation of “not enough air”

Sitting with pillowcase over your head

Claustrophobic sensation of not being able to move, get out

Lying tightly wrapped in a blanket, like you would swaddle a baby

Head rush

Lying down for a minute or having head between legs, then sitting or standing up quickly

Nausea, lurching stomach

Spinning in chair that spins, swinging in a swing, jumping down from a height, spinning while wearing someone else’s prescription eyeglasses, spinning in a chair with eyes closed

Blushing

Heating face by rubbing skin, standing in front of something hot, putting warm water on face

Sweating

Physically exercising in hot clothing, putting water on normally sweaty areas (armpits, face, back, chest)

Trembling

Exercising specific body parts that tremble (arms in push-​ups or by holding in an extended “T” position, legs in squats, hands by squeezing)

Relevant to depression Heaviness, weight in certain areas

Putting books or weights on those areas and either lying or moving around

Feeling of being slowed down

Walking slowly, watching slow-​motion video

Being tired

Lying with eyes closed in the dark but staying awake

Lump in throat

Swallowing multiple times in succession

Prickling eyes, teary eyes

Wetting eyes with water, rubbing eyes

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Form 16.1 Fear and Avoidance Hierarchy Describe situations you are currently avoiding in order to prevent uncomfortable emotions from occurring, starting with the worst or most distressing situation. Rate the degree to which you avoid each of the situations you describe, and the degree of distress they cause. Do Not Avoid

Hesitate to Enter But Rarely Avoid

0

1

No Distress

2 Slight Distress

Description

1 WORST 2 3 4 5 6 7 8 9 10 11 12 13 14 15

278

Sometimes Avoid 3

4 Definite Distress

Usually Avoid 5

6

Always Avoid 7

Strong Distress

8 Extreme Distress

Avoid

Distress

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Form 16.2 Record of Emotion Exposure Exposure Task: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_________________________________​ Prior to the task: Anticipatory Distress (0–​8): _​_​_​____​_​_​_​ Thoughts, Feelings, and Behaviors you noticed before the task: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__________________________________​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__________________________________​ Re-​evaluate your automatic appraisals about the task: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__________________________________​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__________________________________​_​_​_​_​ After completing the task: Thoughts, Feelings, and Behaviors you noticed during the task: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________________________​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__________________________________​_​_​_​_​_​_​_​_​_​ Number of minutes you did the task: _​_​_​_​_​_​____​ Maximum distress during the task (0–​8): _​_​_​_​_​_​____​ Distress at the end of the task (0–​8): _​_​_​__​ ​_​____​ Any attempts to avoid your emotions (distraction, safety signals, etc.)? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__________________________________​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__________________________________​_​_​_​_​_​_​_​ What did you learn? Did your feared outcomes occur? Were you able to cope? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__________________________________​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__________________________________​_​_​_​_​_​_​_​_​

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Appendix B List of Worksheets

Worksheet 4.1: “Taking the Necessary Steps” Homework Sheet  282 Worksheet 5.1: Weekly Obstacle Sheet  284 Worksheet 5.2: Activities to Delay Compulsive Eating  285 Worksheet 6.1: Function of Physical Sensations Homework  286 Worksheet 7.1: The 3-​Component Model Homework  293 Worksheet 8.1: Following Your Thoughts  295 Worksheet 8.2: Focusing on Your Behaviors  297 Worksheet 9.1: Nonjudgmental Present-​Focused Emotion Awareness  298 Worksheet 9.2: Primary and Secondary Emotions Homework  299 Worksheet 9.3: Present-​Focused Awareness Exercise I—​Mindful Walking  302 Worksheet 11.1: Cognitive Reappraisal Strategies  303 Worksheet 11.2: Re-​evaluating Automatic Appraisals  304 Worksheet 11.3: Obsessive Thoughts  305 Worksheet 13.1: List of Emotion Avoidance Strategies  307 Worksheet 13.2: Reducing Avoidance  308 Worksheet 14.1: Identifying Your EDBs Writing Exercise  309 Worksheet 14.2: Identifying Your EDBs and Opposite Actions  312 Worksheet 14.3: EDB Reading and Reflection  313 Worksheet 17.1: Progress Evaluation  316 Worksheet 17.2: Practice Plan  319 281

28

Worksheet 4.1 “Taking the Necessary Steps” Homework Sheet

This worksheet can be difficult. It might feel like the steps necessary to meeting your goal are not manageable, or it may be hard to see yourself actually doing some of these things. These are common feelings! When completing this worksheet, ask yourself whether the steps you are writing down are specific behaviors that can be completed in a limited time period, not whether you believe you are capable of completing them currently. As you go through treatment, you will learn skills that will be helpful and will ultimately make the emotions begin to feel more manageable, although it is hard to believe this 100 percent now. Keep in mind that the goal of this section is to come up with specific behaviors that can be completed in a specific timeframe, such as “Eat my whole lunch,” as opposed to “Recover from my eating disorder.” One goal for treatment is: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_____________​_​_​_​_​_​_​ Making it more concrete Now, let’s take a moment to make this goal more concrete. What would it look like once you have achieved this goal? What things would you be doing, or not doing? What behaviors would you be engaging in? What behaviors would you not be engaging in? Try to be as concrete as possible here. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​​​_​_​_​_​_​_​_​_​_​_​_​ Taking the necessary steps Next, think about some small steps that you can take toward reaching the specific treatment goal you have recorded earlier in this form. These steps should take anywhere from a few days or a week up to a month to achieve, but there is a line to think about whether there is anything you can do in the next 24 hours to take a step along this path. It can be helpful to work backward from your goal to help identify specific steps. Use the behaviors listed earlier in this form to help come up with specific steps. Are there any steps you can be trying to take between now and your next session of therapy? Step 1:_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Step 2:_​_​_​_​_​_​_​_​_​_​_​_​_​__________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ 282

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Step 3:_​_​_​_​_​_​_​_​_​_​_​_​_​___________________________​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Step 4:_​_​_​_​_​_​_​_​_​_​_​_​_​__________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Another goal for treatment is: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

Making it more concrete Take a moment to make this goal more concrete. What would it look like once you have achieved this goal? What things would you be doing, or not doing? What behaviors would you be engaging in or not engaging in? Again, being as concrete as possible here, try to list specific behaviors. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________​​

Taking the necessary steps Next, think about some small manageable steps that you can take towards reaching the specific treatment goals you’ve listed earlier in this form. These steps should take anywhere from a few days or a week up to a month to achieve. What steps will you need to take? It can be helpful to work backward from your goal to help identify specific steps you will need to take to get there. Use the behaviors you listed earlier in this form to help come up with your steps to achieving your treatment goal. Are there any steps you can be trying to take in the next 24 hours? Step 1:_​_​_​_​_​_​_​_​_​_​_​_​_​___________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Step 2:_​_​_​_​_​_​_​_​_​_​_​_​_​___________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Step 3:_​_​_​_​_​_​_​_​_​_​_​_​_​___________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Step 4:_​_​_​_​_​_​_​_​_​_​_​_​_​___________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ 283

Obstacle? Y /​N If Y, what? Solution?

Obstacle? Y /​N If Y, what? Solution?

Obstacle? Y /​N If Y, what? Solution?

Obstacle? Y /​N If Y, what? Solution?

Obstacle? Y /​N If Y, what? Solution?

Obstacle? Y /​N If Y, what? Solution?

Breakfast

Snack

Lunch

Snack

Dinner

Snack

Tomorrow_​_​_​_​_​_​_​_​_​_​_​

Obstacle? Y /​N If Y, what? Solution?

Obstacle? Y /​N If Y, what? Solution?

Obstacle? Y /​N If Y, what? Solution?

Obstacle? Y /​N If Y, what? Solution?

Obstacle? Y /​N If Y, what? Solution?

Obstacle? Y /​N If Y, what? Solution?

_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

Obstacle? Y /​N If Y, what? Solution?

Obstacle? Y /​N If Y, what? Solution?

Obstacle? Y /​N If Y, what? Solution?

Obstacle? Y /​N If Y, what? Solution?

Obstacle? Y /​N If Y, what? Solution?

Obstacle? Y /​N If Y, what? Solution?

_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

Obstacle? Y /​N If Y, what? Solution?

Obstacle? Y /​N If Y, what? Solution?

Obstacle? Y /​N If Y, what? Solution?

Obstacle? Y /​N If Y, what? Solution?

Obstacle? Y /​N If Y, what? Solution?

Obstacle? Y /​N If Y, what? Solution?

_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

Obstacle? Y /​N If Y, what? Solution?

Obstacle? Y /​N If Y, what? Solution?

Obstacle? Y /​N If Y, what? Solution?

Obstacle? Y /​N If Y, what? Solution?

Obstacle? Y /​N If Y, what? Solution?

Obstacle? Y /​N If Y, what? Solution?

_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

List the days of the week between now and your next session across the top of the chart. Then make notes about possible obstacles to regular eating, and solutions.

Worksheet 5.1 Weekly Obstacle Sheet

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Worksheet 5.2 Activities to Delay Compulsive Eating

In order to stop automatic chains of behavior and to take time to reflect on your emotions, it is good to have some immediate ideas of alternative activities right at hand. You might want to post your list somewhere (in your phone, on the wall) where you can see it to remind you when your mind is consumed with acting on your impulses. If you are able to take some time to delay acting on the urge, you may notice that the urge changes or that you learn something about what you were feeling and thinking in the moment (to write in your food log!). Alternative activities should be pleasant and easy to do in the moment. They should basically help you to tolerate your emotions and urges without punishing yourself for your emotions and urges. Examples: Walking

Listening to music

Taking a shower

Meditating

Writing in a journal or food log

Calling someone

Internet shopping

Watching a show

Reading a book

Walking to buy a magazine

Lighting a candle

Playing Jenga

Listening to a podcast

Being outside

Solo games like Sudoku

Everyone’s list is going to be personal and different. Try to generate 5 to 10 personal, specific things (for example, “Walking to the library and back while listening to my favorite album” or “Calling my mom and just talking about how the day went” or “Reading my novel”). Write your list here: 1.   6. 2.   7. 3.   8. 4.   9. 5. 10.

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Worksheet 6.1 Function of Physical Sensations Homework

The physical component of emotions in our bodies can be functional when the emotion is functional. We don’t always understand why our bodies feel the way they do, which can be confusing or unpleasant, particularly when the emotion itself seems to be happening at the wrong time or too intensely. When we have strong emotional reactions, we often have a sympathetic nervous system response. When the sympathetic nervous system kicks into “fight or flight” mode, there is a chain of reactions from the release of hormones like adrenaline. In order to be the best at fighting or the fastest at running away, oxygen and energy need to be distributed around your body quickly. These hormones cause the following to happen: Your heart beats faster. ■ Blood goes to your muscles. ■ Muscles tense in readiness for activity. ■ Air passages dilate and your breathing speeds up. ■ Digestion slows down as energy is diverted for other needs. ■ Other side effects of these processes can be: Palpitations and chest pains ■ Sweating ■ Dizziness ■ Dry mouth ■ Trembling ■ Tingling ■ Muscle tension and stomach cramps ■ Feeling faint and sometimes feelings of unreality ■ Nausea and stomach pain ■ Urge to urinate ■ Tightness in the throat and difficulty swallowing ■ These particular physical reactions are most characteristic of feeling frightened, anxious, angry, and excited. As noted earlier, they are side effects of being ready to fight or flee.

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Sadness has its own physiological picture: Crying ■ Heaviness ■ Fatigue ■ Headache ■ Stomachache ■ Researchers think that crying when we are sad is adaptive because it signals to others that we are need help. Think of the function of crying for an infant and caregiver—​how else would the caregiver know something is needed? In adulthood, people cry when they are in extreme physical or emotional pain, again signaling to others—​and to themselves—​their helplessness and need for assistance. Some of the physical ways we feel when we are sad or anxious, such as restlessness, are a side effect of our desire to escape from these situations. Over time, we can become anxious and angry about being sad, or sad about being anxious, and these two emotions get intertwined. Some of the physical experiences of sadness are side effects of crying, such as swollen eyes, headaches, or runny nose. Others are side effects that come from the process of recognizing that something very significant has occurred—​either the immediate shock to the system, the onset of crying, or the effort to hold that back. It is important to understand that these reactions are normal and are functional for your body in certain situations. They are natural and not dangerous. Though your emotions and the physical component of your emotions may not be helping you right now, it is important to understand and accept the natural and normal functions of your own physical reactions to all emotions. For homework, please identify several intense physical reactions that you have to emotional situations, and see if you can explain how these reactions could be natural and functional, as well as how they may feel dysfunctional or upsetting. Here are two examples:

Example 1 A strong physical sensation with an emotion: Sometimes when I am talking to a stranger, my stomach growls really loudly. It happens a lot when I really want someone to like me. How does this physical sensation feel dysfunctional? I hate it! I am sooooo embarrassed and I worry that the new person is going to think I am crazy. If I want someone to like me, why does my body make me seem like a freak?

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How could this physical sensation actually be a normal and natural part of an emotion? I am nervous and excited, so I guess that’s my sympathetic nervous system. My stomach must be reacting by having muscle tension and slowing down digestive processes. Is there anything that could even be functional about having that emotion? It is probably a good thing I am excited about this person because otherwise, who cares? Why even try to form a relationship with them? It also could be a good thing to be nervous because it makes me be careful and attentive as I am learning about this new situation. How do I want to think about the physical reaction from now on? It doesn’t help to obsess about it because it just makes me more nervous. There’s nothing wrong with me—​I’m not sick or disgusting; I’m just excited. I try to remind myself that the other person could be nervous and excited too, and the noises will go away eventually. If they care so much about my stomach growling they probably aren’t that nice anyway.

Example 2 A strong physical sensation with an emotion: Every time I go into the dining hall my stomach feels really weird and bad—​sometimes I feel nauseous, and sometimes I have pains in my stomach. I have pains after I eat, too. How does this physical sensation feel dysfunctional? I’m supposed to be eating! So feeling sick is totally counterproductive. Also it makes me feel like there might be something wrong with the food, the food could be bad for me, maybe it will make me sick, or something else that is bad will happen if I try to eat it. How could this physical sensation actually be a normal and natural part of an emotion? It is normal to have weird feelings in your stomach when you are anxious. That’s again the muscle tension and the blood leaving the digestive system. Is there anything that could even be functional about having that emotion? I get anxious about food because I am afraid it is going to make me fat, and then it is normal for my stomach to have that reaction. If someone was trying to feed me

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something that really was going to hurt me, it would be good to be anxious and be able to run away. Though that isn’t a very likely scenario outside of Game of Thrones or a detective novel. How do I want to think about the physical reaction from now on? I want to remember that my stomach hurting is my anxiety misfiring because I have been treating food like it is dangerous. It is not a signal that I am sick or that the food is going to be bad for me. It should go away over time if I lean into it.

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Your turn Now it’s your turn to apply your own experiences. Can you think of two different examples and complete the exercise? Use the examples above to help you.

Your first example A strong physical sensation with an emotion: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ How does this physical sensation feel dysfunctional? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​​_​_​_​_​_​_​_​_​_​_​_​_​ How could this physical sensation actually be a normal and natural part of an emotional reaction? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Is there anything that could even be functional about having that emotion? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

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_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ How do I want to think about the physical reaction from now on? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

Your second example A strong physical sensation with an emotion: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ How does this physical sensation feel dysfunctional? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ How could this physical sensation actually be a normal and natural part of an emotional reaction? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

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Is there anything that could even be functional about having that emotion? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ How do I want to think about the physical reaction from now on? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

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Behaviors/Urges

Situation: ____________________________

Names of emotions: ____________________________ Thoughts

Worksheet 7.1 The 3-​Component Model Homework

Physical Sensations

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Behaviors/Urges

Situation: ____________________________

Names of emotions: ____________________________ Thoughts

Physical Sensations

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Worksheet 8.1 Following Your Thoughts

The situation: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_____________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ 1. What were your foremost thoughts about the situation? ______________________________________________________________________ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ 2. What thoughts did you have about anyone else who was involved? ______________________________________________________________________ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ 3. What thoughts did you have about the emotion itself? ______________________________________________________________________ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ 4. What thoughts did you have specifically about the physical sensations? ______________________________________________________________________ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ 5. What thoughts did you have about your ability to handle the emotion? ______________________________________________________________________ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ 6. What thoughts did you have that were judgments of the emotion? ______________________________________________________________________ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ 7. What thoughts did you have about yourself as a person? ______________________________________________________________________ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ 8. What thoughts did you have about similar situations that happened in the past? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_ ______________________________________________________________________​

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9. What thoughts did you have that were predictions about the future? ______________________________________________________________________ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ 10. Did you have thoughts about what you should do? ______________________________________________________________________ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

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Worksheet 8.2 Focusing on Your Behaviors

You are going to record events in three categories: emotions about body image, food, and interpersonal events. List as many behaviors as you can. A “behavior” can be to do nothing, as well as to do something—​like “stay in the room” or “sit with it” rather than leaving or reacting in another way. Then try to rate that behavior as to how avoidant it was on a scale from 0 to 8, where 0 = not at all avoidant, fully leaning-​in, doing nothing except allowing for the experience of emotion, or doing something that represents going “toward” emotion; and 8 = highly avoidant, with a highly emotionally driven and urgent effort to escape from the emotion and situation. The goal is to help raise your awareness of your behaviors, so don’t worry too much about whether you get the rating “exactly right.” 0

1

2

3

4

5

6

7

8

Not avoidant       Compromise        Highly escapist/​ avoidant

Emotional Events

Actual Behaviors You Used

Escape/​Avoidance Rating

Body Image Emotional Event

Food-​Related Emotional Event

_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​-​Related Emotional Event

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Day 6

Day 5

Day 4

Day 3

Day 2

Day 1

In Session

Describing what you noticed: What physical sensations (such as hearing, smelling, seeing, and feeling) did you notice? Did any emotions arise for you? What else did you notice?

How much did you stay in the present? 0–​10 (0 = completely lost in past or future; 10 = totally in the here and now)

How much did you accept your experiences? 0–​10 (0 = all judging; 10 = totally accepting)

You can choose to sit and breathe for this exercise, or try the mindful walk described in Worksheet 9.3. Anchor yourself to the present by anchoring yourself to your breath. Then you can be creative about what you want to intentionally focus on. This can be a sound you hear, something you see, or something you can physically feel (like your chair, or a breeze, or a sound). The two goals are to try to be here and now (not in the future or past) and to notice when you are judging and redirect to nonjudgmental awareness. When you are finished, fill out the entry in the worksheet.

Worksheet 9.1 Nonjudgmental Present-​Focused Emotion Awareness

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Worksheet 9.2 Primary and Secondary Emotions Homework

Think of some recent situations in which you felt the primary emotional state that is listed for each example. How did you judge or evaluate this experience in some way, which resulted in a secondary emotional response? Also describe some of the problems with each secondary reaction: Feeling sad (primary) _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ What is the secondary reaction in this situation? _​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ What are some of the problems with this reaction? _​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Feeling nervous (primary) _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ What is the secondary reaction in this situation? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ What are some of the problems with this reaction? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Feeling guilty (primary)_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​____________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

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What is the secondary reaction in this situation? _​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ What are some of the problems with this reaction? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Feeling joyful (primary) _​_​_​_​_​_​_​_​_​_____________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ What is the secondary reaction in this situation? _​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ What are some of the problems with this reaction? _​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Feeling bored (primary) ____________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ What is the secondary reaction in this situation? _​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ What are some of the problems with this reaction? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

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Feeling angry (primary) _____________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ What is the secondary reaction in this situation? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ What are some of the problems with this reaction? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

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Worksheet 9.3 Present-​Focused Awareness Exercise I—​Mindful Walking

If you find it hard to sit and breathe as a mindfulness activity, you might try mindful walking. Choose a short path

• Chose a strip of floor, about 5–10 paces long. You are going to use this strip to walk back and forth along during the 5 minutes of mindful walking.

Prepare your feet

• You can chose to have bare feet, or keep your socks or shoes on—whatever will help you to focus and stay present.

Stay silent

• It’s ideal to stay silent and really focus all of your attention on the task.

Do the mindful walk

• Walk slowly and intentionally, focusing on the bottoms of your feet. Use the physical sensations in your feet as an anchor to the present moment. Notice any emotion that arises.

Practice anchoring into the present moment

• As you’re walking practice doing your 3-point check, and tune into the emotion that arises for you in response to the activity.

I’m paying attention on purpose.

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■ Notice the physical sensations of walking, the shifting of the weight, the pressure on your feet, the temperature of the floor, how your muscles work together to make a step possible. Notice your thoughts and keep refocusing on thinking about the activity. You may ■ notice that you are distracted, you may notice a judgmental thought, you may notice yourself “thinking about thinking.” Try not to judge; just do your best to refocus. Notice your behaviors or urges and any particular emotions that you feel. ■ I’m paying attention with purpose.

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As you walk, try to focus your attention on one or more sensations that you would normally take for granted, such as your breath coming in and out of your body and the movement of your feet and legs or their contact with the ground or floor. What do I do if my mind wanders? That’s OK; it’s perfectly natural. When you notice your mind wandering, simply use the breath or the physical sensations of the feet to anchor into the activity once again.

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How do I walk? Try to find a walk that feels natural, and not something exaggerated or stylized that will end up distracting you. You can do whatever feels most comfortable and natural with your hands and arms.

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Worksheet 11.1 Cognitive Reappraisal Strategies

Countering probability overestimation: learning to re-​evaluate jumping to conclusions The first cognitive reappraisal skill is countering probability overestimation, or learning how to re-​evaluate jumping to conclusions. After identifying the automatic appraisal, the next step is to realistically examine the probability of that outcome actually happening. Essentially, you want to look for evidence from the past or present to test how likely it is that your belief/​fear will actually come true. Use these questions when you notice yourself falling into a thinking trap: 1. Do I know for certain that _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ will happen? 2. Am I 100% sure these awful consequences will occur? 3. What evidence do I have for this fear or belief? 4. What happened in the past in this type of situation? 5. Do I have a crystal ball? How can I be sure that I know the answer? 6. Could there be any other explanations? 7. How much does it feel like _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ will happen? 8. What is the true likelihood that _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ will happen? 9. Is my negative prediction driven by the intense emotions I’m experiencing? 10. Is _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ really so important or consequential?

Decatastrophizing: learning to re-​evaluate thinking the worst The second cognitive reappraisal skill is decatastrophizing, or learning to re-​evaluate thinking the worst. Once you have identified the core automatic appraisal, the next step is to realistically examine the evidence based on how you have coped in the past if something similar has occurred. 1 . What is the worst that could happen? How bad is that? 2. Has _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ ever happened in the past? a. If yes, how did you cope with it? How did you handle it? b. If no, how do you think you’d cope with it or handle it now? 3. If it did happen—​so what? 4. Even if _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ happens, can you live through it? 5. Is _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ really so terrible?

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SITUATION/​TRIGGER

AUTOMATIC APPRAISAL(s)

EMOTION(s)

IDENTIFY THINKING TRAP

Worksheet 11.2 Re-​evaluating Automatic Appraisals GENERATE ALTERNATIVE APPRAISALS

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Worksheet 11.3 Obsessive Thoughts

Evaluating obsessive, intrusive, nonsensical thoughts Sometimes people have thoughts that seem to just come into their mind and don’t make sense. This is quite common and happens to most people. Whereas most people are able to let these sorts of “strange” thoughts go, maybe by telling themselves, “That was weird!” and then forgetting about them, others might get “stuck” in the thoughts. For some, the thoughts are intrusive and distressing, and they can’t seem to block them out of their mind. For example, someone might be bothered by an intrusive thought that she will harm someone she loves or that she might do something terrible. These types of intrusive thoughts are also experienced as “automatic,” but they are a little different from what we have been discussing so far. The types of thoughts we are discussing here do not make sense and can be very difficult to challenge. The reality is that the obsessive, intrusive, nonsensical thought is not what needs to be reappraised. Instead, what needs to be evaluated is our interpretation of what having this thought might mean. If you are having these types of thoughts, ask yourself, “How does having this thought make me feel? What do I think having this thought means?” The interpretation a person has about intrusive, nonsensical thoughts is what makes these thoughts distressing to one person and not to another. One person might have horrible intrusive thoughts and be able to “shake them off” as having no real meaning about who that person is or what that person might do. Others, however, can have the same thought and interpret the thought as meaning something terrible about themselves or as something they will inevitably act on. Some common interpretations that can be very distressing—​but can be shown not to be true—​are “These thoughts mean I am crazy,” “These thoughts mean I am evil,” or “These thoughts mean I will do something destructive to myself or someone I love.” It is the interpretation of what these thoughts mean that is the source of distress, and it is here that the strategies discussed in this chapter should be used. If you are having these types of intrusive thoughts, see if you can identify your automatic appraisals about these intrusive thoughts, and see if you can generate some alternative appraisals using the skills discussed earlier.

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If you have obsessional thoughts, make a note of them, take it to your therapist, and try to identify what the meaning is that you make of the fact that you have these thoughts. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________​

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Worksheet 13.1 List of Emotion Avoidance Strategies

The purpose of this list is to begin to identify some of the subtle ways that you may attempt to avoid uncomfortable emotions. We often use subtle avoidance strategies when we have to go into situations that we would rather completely avoid. Examples include when people are eating, interacting with other people, and talking about things that upset them. In the Subtle Behavioral Avoidance column, list subtle avoidance behaviors that you do. In the Cognitive Avoidance Strategies column, list mental techniques of avoidance, such as distracting yourself or tuning out. Finally, in the Safety Signals column, list anything that you carry with you or on you to ward off bad feelings. Subtle Behavioral Avoidance

Cognitive Avoidance Strategies

Safety Signals

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Worksheet 13.2 Reducing Avoidance

One of the most important things you can do to advance your treatment is to choose to reduce avoidance. Most people can identify some avoidance that is habitual but that they could try to change if they think about it, mentally prepare themselves, and try hard to address when the situation comes along. Choose a few of the avoidance strategies you identified in Worksheet 13.1, and identify how you could do the opposite. The most benefit comes from deliberately trying to do the opposite of avoiding, which is leaning into emotion, or approaching it, rather than avoiding it or trying to dampen it down. For example, if you often speak quietly, you might decide that when you are feeling nervous in sessions you are going to talk in a particularly loud and clear voice. Or if you notice that you often chat a lot through a meal to distract yourself, you can decide that you are going to be very quiet and focus on the experience of the food. Other examples: Avoidance strategy: Opposite action: Avoidance strategy: Opposite action: Avoidance strategy: Opposite action:

Being really agreeable with people when you’re nervous Disagreeing with one thing somebody says in a conversation Not looking at yourself when you’re naked Make sure to look at every part of yourself in the shower, for a while Taking small bites and chewing a long time Taking large bites and chewing only until it’s possible to swallow

On this page, identify three avoidance strategies you can try to reduce, and the opposite action to try instead. (1) First avoidance strategy you are going to try to reduce: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Opposite action to this avoidance strategy: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ (2) Second avoidance strategy you are going to try to reduce: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Opposite action to this avoidance strategy: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ (3) Third avoidance strategy you are going to try to reduce: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Opposite action to this avoidance strategy: _​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

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Worksheet 14.1 Identifying Your EDBs Writing Exercise

Instructions To some extent, all of our behaviors are emotion-​driven. When we think about what we should do next, our emotions help tell us whether our behavior will likely have a good or bad overall outcome. However, we aren’t interested in examining all of our behaviors. We specifically want to take a look at emotion-​driven behaviors that are problems for us—​that are a part of our main emotional problems—​and that seem to be a way of escaping an emotion we don’t want to have. To help identify these EDBs, you might think about the following questions: ✠ ✠ ✠ ✠

What are your main emotional problems in life? What do you do as a part of these emotional problems that could be considered an EDB? Are there particular things that you do that are unhealthy? How could these unhealthy behaviors be driven by the desire to escape from or reduce particular emotions?

You are going to write about your own EDBs on the next page. You can read through this example to help you craft your own narrative:

Example My main emotional problems are my eating disorder and my panic disorder. I also have a lot of pain associated with my divorce. As a part of my eating disorder, I exercise and restrict food because I am afraid of becoming fat. When I am feeling fat, or feeling threatened, I restrict food. I know when I am feeling stressed, I also eat less. I don’t like feeling out of control, and I don’t like feeling insecure, and I don’t like feeling sad. Exercising and dieting helped me feel more in control, confident, and op timistic at one time. As part of my panic disorder, I get really afraid of having panic attacks. When I start to feel panicky, I try to escape from any enclosed spaces or crowds. Running away is a big part of that. Sometimes I notice that I ask people for different kinds of help or r eassurance because I’m afraid I’m going to have a panic attack, or I am sick, or that people can tell I am panicky and are judging me. So I might ask people if it is OK if I leave, or if it feels like my heart is beating really hard, if they think that could be a heart attack, or if they can see my hand shaking, and do they think that is crazy.

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I think that EDBs contributed to my divorce in a lot of ways. I really didn’t want to give up my eating disorder because that seemed overwhelming, so I pushed my husband away and got angry when he noticed what was going on. When I started to feel guilty about what I was doing with my husband, somehow that drove me to do it even more. It is really complicated. The divorce itself made me feel sad, guilty, angry, worthless—​so many different bad things. I have been using my eating disorder to try make these emotions go away. I also avoid thinking about or talking about the divorce itself, or how it really makes me feel.

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Identifying Your EDBs Writing Exercise—​Your Turn _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________​

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Worksheet 14.2 Identifying Your EDBs and Opposite Actions

Recent, frequent, and problematic EDBs and possible opposite actions The next part of the homework is to make a list of key EDBs that are parts of your emotional problems, and list some ideas for how you can do alternative opposite actions. Remember, there can be a lot of problems with EDBs—​they can become automatic, they don’t usually work, they teach you that you can’t deal with your emotions, they teach you that emotions are dangerous, they tend to make the emotions stronger over time, and so on. Even if it isn’t clear what the direct positive result would be of turning them around, if you know that they are a part of your emotional issues, then it is probably a good idea to try to reverse them. The first row is filled out as an example. EDBs What is the action? What is the emotional situation? Dieting or exercising after I have talked to my ex-husband. Raging at him. Ignoring how sad I really feel.

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Opposite Action Talking to a friend or writing in my journal about how I feel when I talk to him. Trying not to focus too much on my anger (which may be a secondary reaction) but really the sad or guilty feelings underneath. Making sure I eat a good meal, and don’t exercise in response to these feelings. Giving myself some time to feel sad.

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Worksheet 14.3 EDB Reading and Reflection

Thinking about learned responses Understanding what comes before our emotions are triggered (the antecedents, the A in ARC) helps us to better understand our emotions and our emotional responses (R). It is also important to understand the consequences (C) of our responses to emotional experiences, and in particular our emotion-​driven behaviors or EDBs. We are designed to learn from our experiences. The only way for us to know what is good and what is bad is through our experiences, and our emotions help to guide us in making this distinction. If we want to ensure our survival, we should move toward things that are good for us and away from things that are bad. More often than not, it is our emotions that are telling us what is good and what is bad. If you think about it, this serves a very adaptive purpose in nature. For example, if a rabbit in the forest comes across a fox lurking in the bushes near its favorite watering hole, the intense emotion of fear the rabbit experiences helps the rabbit to learn that it should stay away from this potentially life-​threatening situation in the future. The rabbit learns very quickly from this experience of fear that in order to ensure its survival, it should probably avoid this area and would be better off finding itself a new watering hole. This type of learning takes place in nature all the time and just goes to show that even if we don’t necessarily like fear, fear definitely has its place and is a very adaptive emotion. This type of learning from uncomfortable emotions is not only for animals in the wild. It is something people share and has been passed down through evolution. As humans, we too are designed to learn quickly from our experiences. For example, if you are cooking on a stove and accidentally grab a pot handle that is very hot, you experience pain and immediately pull your hand away. When you reach for a pot handle the next time, you may stop yourself and grab a potholder instead in order to avoid the unpleasant experience of being burned again. You have learned that in order to avoid pain, you should think twice before grabbing something on the stove. What’s more, we are also designed to quickly apply what we have learned not only to the immediate situation but to other similar situations as well. You may be thinking, this is great, but what does this have to do with my symptoms? The important thing to understand here is that we have the ability to quickly learn and alter our behavior in response to unpleasant emotional experiences. For the most part, this is adaptive, but this might not always be the case. What about giving in to the EDB of escape by leaving a crowded event every time we feel panicky, even if being at the event itself is important to us? What about altering our behavior to avoid the possibility of an unpleasant experience like contracting germs on a train by refusing to take public transportation? Or

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how about altering our behavior to avoid the unpleasant emotion of embarrassment by avoiding all social gatherings? Sometimes we interpret our emotions as guiding us away from a threatening situation that might not even be an actual threat, and our responses in turn become maladaptive (unhelpful) instead of adaptive (helpful). Part of the aim of this program is to help you make the distinction between what is a real threat and what is a perceived threat, allowing you to better understand when and how emotions should guide you. We will discuss all of this in more detail in upcoming chapters, but for now, the important thing to begin paying attention to is how we learn from our emotional experiences. When we experience strong emotions, they leave lasting impressions. What triggers our emotions, and what happens when we have them, stays with us and influences how we experience similar situations in the future. As humans, we also learn to repeat things that make us feel good and to avoid things that make us feel bad. However, as humans we also have the gift of reasoning and foresight; therefore, we also may learn to do certain things in order to keep ourselves from potentially feeling bad. For example, if spicy foods give you heartburn, you may avoid spicy foods. Similarly, if large social gatherings make you uncomfortable, you may avoid going to large social gatherings. If you don’t want to wait in long lines at the supermarket, you may do your shopping late at night or during a weekday afternoon or online instead. If you are trying to write an essay and you don’t want to face the possibility that you can’t think of what to say, you may clean the house or watch TV rather than start to write. Similarly, if you don’t want to experience a panic attack, you may walk to work instead of riding the train. In addition to learning to avoid strong emotions, engaging in the behavior the strong emotion is driving us to do (the EDB), such as running when afraid even if there is nothing to be afraid of, forces us to learn some inappropriate, damaging responses because engaging in the EDB does serve to relieve the emotion. Thus, engaging in an EDB, even if it is for just a short time, relieves the emotion and helps us avoid feeling worse. For example, we might avoid making eye contact during conversations, or quickly exit a crowded area when feeling panicky, or stay in bed all day when feeling down. Over time, however, we learn to do this same EDB over and over again in an attempt to relieve the emotion and the possibility of feeling worse. The problem is that repeatedly doing these EDBs can result in a vicious cycle in which the EDBs become automatic, counterproductive, and inconsistent with the actual situation. Because these EDBs relieve uncomfortable emotions in the short term, we may think they are useful for us. However, they may actually be interfering in important ways with our ability to live our lives. These learned strategies for coping with intense emotions, such as avoiding situations that trigger emotions, represent the “Cs” or consequences phase of the ARC model. By avoiding these strong and intense feelings, we never have the chance to find out what these emotions might really be telling us or to see that these emotions will pass.

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Thus, by avoiding intense emotions, we may actually be depriving ourselves of important, valued aspects of our lives. Can you think of something you have learned to do to avoid experiencing something bad? What was the experience that influenced you? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________​ What about something you have learned to do to experience something good? What was the experience that influenced you in this case? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​________________________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________​

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Worksheet 17.1 Progress Evaluation

Mindful emotion awareness What are some specific improvements you’ve noticed in your ability to stay present in the moment instead of getting caught up in the past or worrying about the future? What are some specific improvements you’ve noticed in your ability to nonjudgmentally observe your emotions and your reactions to them? In what ways have you found this skill helpful? ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Where do you see room for continued improvement? Are there situations where you find it more difficult to stay in the present moment or not to judge your emotional experiences? What can you do to address these challenges? ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________

Cognitive flexibility What are some specific improvements you’ve noticed in your ability to be more flexible in the way you think about situations? Are you jumping to conclusions or blowing things out of proportion less often? How has this skill been useful? ______________________________________________________________________ ______________________________________________________________________ 316

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______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Where do you see room for continued improvement? Are there situations where you find it more difficult to be flexible in your thinking and stay out of thinking traps? What can you do to address these challenges? ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________

Confronting physical sensations What are some specific improvements you’ve noticed in your ability to respond to the physical sensations that are associated with your intense emotions? Are you doing activities that you previously avoided due to uncomfortable physical sensations? How has this skill been useful? ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Where do you see room for continued improvement? Are there certain physical sensations that you still find highly distressing? What can you do to address these challenges? ______________________________________________________________________ ______________________________________________________________________

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______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________

Countering emotional avoidance What are some specific improvements you’ve noticed in your ability to identify your unhelpful—​ avoidance or emotion-​ driven—​ behaviors and replace them with alternative actions? How has this skill been useful? ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Where do you see room for continued improvement? Are there situations where you find it more difficult replace avoidance and emotion-​driven behavior with alternative actions? What can you do to address these challenges? ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________

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How can you hold yourself accountable to your practice plan?

What is your specific practice plan for this skill?

How will practicing this skill help you achieve your long-​term goals?

Mindful Emotion Awareness Cognitive Flexibility

Confronting Physical Sensations

Countering Avoidance and Emotion-​Driven Behaviors

Use this form to generate a plan for continuing to practice these skills after you have completed this program.

Worksheet 17.2 Practice Plan

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