— Cognitive Behavioral Therapy

THE
CBT
FLIP CHART
An Evidence-Based Psychoeducational
Tool for Anxiety, Depression, Stress,
Insomnia, PTSD, and More

Seth J. Gillihan, PhD

Copyright © 2021 by Seth J. Gillihan
Published by
PESI Publishing
PESI, Inc.
3839 White Ave
Eau Claire, WI 54703

Cover: Amy Rubenzer

Editing: Jenessa Jackson, PhD
Layout: Amy Rubenzer
ISBN 9781683734291 (print)
ISBN 9781683734314 (ePDF)
ISBN 9781683734703 (KPF)

All rights reserved.

Printed in the United States of America.

pesipublishing.com
 TABLE OF CONTENTS
Section 1: Understanding Think Act Be
What Is CBT?...................................................................................................................... 1
The CBT Model.................................................................................................................. 2
Setting Goals...................................................................................................................... 3
THINK: Cognitive Techniques
Examining Thoughts........................................................................................................... 4
Cognitive Distortions.......................................................................................................... 5
Core Beliefs......................................................................................................................... 6
ACT: Behavioral Techniques
Behavioral Activation Part 1............................................................................................. 7
Behavioral Activation Part 2............................................................................................. 8
Maximizing Follow-Through............................................................................................ 9
Exposure Therapy............................................................................................................. 10
BE: Mindfulness Techniques
What Is Mindfulness?.......................................................................................................11
Benefits of Mindfulness................................................................................................... 12
Mindfulness in Action...................................................................................................... 13
Meditation......................................................................................................................... 14
Being the Observer......................................................................................................... 15
Section 2: Applying Think Act Be
Stress Management Part 1: Recognizing Stress........................................................ 16
Stress Management Part 2: Reducing Stress.............................................................. 17
Depression......................................................................................................................... 18
Worry................................................................................................................................. 19
Procrastination.................................................................................................................. 20
Social Anxiety................................................................................................................... 21
Panic...................................................................................................................................22
Post-Traumatic Stress Disorder (PTSD).........................................................................23
Obsessive-Compulsive Disorder (OCD)....................................................................24
Problematic Anger...........................................................................................................25
Insomnia............................................................................................................................ 26
Maintaining Gains...........................................................................................................27
 WELCOME TO
THE
CBT FLIP CHART
The CBT Flip Chart is an interactive way for therapists to bring mindfulness-
centered cognitive behavioral therapy (CBT) into their sessions.

How To Use the Digital Edition

Each page of this chart has a client-facing version and a therapist-facing
version. The client versions are in color and present the essential ideas
for each topic. You can use the digital markup tools found in your ebook
reading app or telehealth platform to emphasize key points or fill in
client responses. The black-and-white therapist pages provide additional
information to help you confidently guide clients in understanding the
fundamentals of CBT.
To allow you to screenshare the client pages while viewing the therapist
pages on a separate screen or device, an additional copy of the client-
facing material is available for download at www.pesi.com/CBTFlipChart.

The first section of the chart provides an overview of the user-friendly “Think
Act Be” model of mindfulness-centered CBT.
Clients will discover:
• How to deal more effectively with thoughts (Think)
• How to choose actions that lead them toward their goals (Act)
• How to embrace mindful presence and acceptance (Be)
The second section shows how to apply these core CBT techniques to treat
common conditions like depression,
anxiety, and procrastination.
I’ve found mindfulness-centered CBT
to be a life-changing practice, not only
for my clients but also for myself. I wish
you and your clients all the best as you
use The CBT Flip Chart to assist in their
process of healing.
 SECTION 1:
UNDERSTANDING
THINK ACT BE
 WHAT IS CBT?
Training thoughts Practicing actions that Opening to the present
to serve you well match your goals exactly as it is

THINK ACT BE
(COGNITIVE) (BEHAVIORAL) (MINDFULNESS)

Cognitive Behavioral Therapy

(CBT)

Collaborative Skills-Based
Joins the therapist’s
expertise with the client’s Offers new techniques for
intimate knowledge of clients to practice and take
themselves with them after treatment

Goal-Oriented Present-Focused
Clearly defines goals and Emphasizes changing
measures progress so clients present patterns in order
know when they’ve to find relief
reached them

Effective
Based on carefully designed
research studies so you
know it works
 WHAT IS CBT?

THINK ACT BE
(COGNITIVE) (BEHAVIORAL) (MINDFULNESS)

Cognitive Behavioral Therapy

(CBT)

Collaborative Skills-Based

Goal-Oriented Present-Focused

Effective

1
 THE CBT MODEL
At the heart of CBT is an
understanding that thoughts, THOUGHTS The arrows run in both
feelings, and actions are “That dog is directions, showing that each
closely connected. dangerous.” element affects the other two.

FEELINGS ACTIONS
Walk in opposite
Fear direction

Activating Event:
We see a big dog that’s off-leash.

Thoughts Feelings We think the dog is dangerous, so we feel afraid.

We feel afraid, which makes us more likely to believe that the dog is
Feelings Thoughts dangerous.

Thoughts Actions We think the dog is dangerous, so we walk in the opposite direction.

We walk away from the dog, which reinforces our belief that the dog is
Actions Thoughts dangerous—that must be why we’re walking away.

Feelings Actions We feel afraid, so we walk in the opposite direction.

Actions Feelings We walk away from the dog, which leads us to be more afraid of the dog.
 THE CBT MODEL

THOUGHTS

FEELINGS ACTIONS

Activating Event:

Thoughts Feelings

Feelings Thoughts

Thoughts Actions

Actions Thoughts

Feelings Actions

Actions Feelings

2
 SETTING GOALS
In what specific ways will your
life be different after treatment? Effective goals are:
Personal Specific Rightsized Motivating
Will improve your Are easy to measure Are small enough to Help you commit
life in ways that are so you’ll know when be doable but big to changes you’ll
important to you you’ve reached them enough to inspire need to make

Life Domains
Relationships Work/School
• Family • Partner • Productivity • Engagement
• Friends • Enjoyment

Physical Health Spirituality

• Movement • Nutrition • Connection • Meaning • Faith
• Sleep • Passion • Purpose

Daily Tasks Leisure

• Chores • Errands • Self-Care • Fun • Relaxation • Hobbies
• Projects at Home • Recharging

1. Working out three times each week

2. Not working on Sundays

3. Having weekly lunches with a friend

4. Reading for pleasure again

5. Enrolling in a master’s program

 SETTING GOALS
Effective goals are:

Personal Specific Rightsized Motivating

Life Domains
Relationships Work/School

Physical Health Spirituality

Daily Tasks Leisure

1.

2.

3.

4.

5.

3
 THINK
Cognitive Techniques
 EXAMINING THOUGHTS

1. Identify Just labeling a

thought as a thought
Activating Event Thought can provide some
Partner is quiet “He’s mad at me.” distance from it.
at dinner

When something triggers

you emotionally, ask Feeling Action
yourself, “What just went Anxious Extra talkative
through my mind?”
Writing down the thought helps Reactions tend to make sense
you see it more objectively. based on the thought.

2. Evaluate
Is the thought 100% true? What evidence supports it? Is there any evidence
against it?
Usually when he’s quiet he’s just tired.
Keep a light touch with
I don’t know of any reason why he’d be mad. evaluation. We’re not trying to
I often assume that silence = anger. force ourselves to believe that
we’re wrong.

3. Alternative It’s okay if you don’t believe

the alternative. Just recognize
Is there another way of seeing things? that there are different ways of
interpreting this situation.
Maybe my partner is worn out from his day.

How would you feel if you

believed the alternative? How
might a different way of seeing
things change your behavior?

THINK
 EXAMINING THOUGHTS

1. Identify
Activating Event Thought

Feeling Action

2. Evaluate
Is the thought 100% true? What evidence supports it? Is there any evidence
against it?

3. Alternative
Is there another way of seeing things?

4 THINK
 COGNITIVE DISTORTIONS
Our mental filters often cause errors in our thinking:

Catastrophizing Shoulding
Believing a situation is Assuming things ought to be the
much worse than it is way we want them to be

Fortune Telling
Mind Reading
Thinking we can
Believing we know what
predict the future
someone else is thinking

Black-or-White
Thinking Personalization
Thinking something is about
Seeing a situation in us when it isn’t
all-or-nothing terms

Outsourcing Emotional
Happiness Reasoning
Using our feelings as the basis
Believing responsibility for
for how we see reality
our emotional well-being lies
outside ourselves

Discounting Overgeneralization
the Positive Assuming a single outcome
Dismissing evidence that goes applies in every situation
against our negative thoughts

Thought:
My partner thinks I’m an idiot.

Possible Distortion:
Mind reading

THINK
 COGNITIVE DISTORTIONS
Our mental filters often cause errors in our thinking:

Catastrophizing Shoulding

Fortune Telling Mind Reading

Black-or-White
Thinking Personalization

Outsourcing Emotional
Happiness Reasoning

Discounting
the Positive Overgeneralization

Thought:

Possible Distortion:

5 THINK
 CORE BELIEFS
Negative thoughts often have a common theme
that comes from our most deeply held beliefs.

Common core beliefs:

Core beliefs often come • I’m unlovable.
from important experiences that • I’m inadequate.
shape our view of the world, • People can’t be trusted.
other people, and ourselves. • Danger is everywhere.
• There is not enough.
Thought:
I’m lazy
Thought: for not
I never do working Thought:
anything out today.
right. They
Thought:
think I’m Thought:
I’m not as pathetic.
I’m going
smart as he is. to mess
this up.

Specific thoughts When we pay

can strengthen attention to our
the core belief, negative thoughts,
like leaves that we’ll usually find
send nourishment patterns that emerge.
to the roots.

Core beliefs may lie dormant until

high stress or a difficult emotional
experience “activates the roots.”
Core Belief:

I’m inadequate. Our core beliefs are like roots

below the ground. We can
identify them based on the
“leaves” they grow.

THINK
 CORE BELIEFS
Negative thoughts often have a common theme
that comes from our most deeply held beliefs.

Thought:

Thought: Thought:

Thought: Thought:

Core Belief:

6 THINK
 ACT
Behavioral Techniques
 BEHAVIORAL ACTIVATION
Behavioral activation is one of the best-tested and most effective treatments for depression.

Doing enjoyable and important activities helps us

feel energized and engaged, and it relieves depression.
1. Monitor Time Activity
Enjoyment Importance
Daily (0–10) (0–10)
Activities 8–9 a.m. Reading news online 4 4

Start by establishing a baseline for how much

enjoyment and importance are found in each day.
Log daily activities for about 1 week.
Notice opportunities to add rewarding
activities into each day.
Target activities that will be high on
enjoyment, importance, or both.

2. Identify Rewarding Activities 3. Rate Activity Difficulty

Difficulty
Activity
(Easy/Moderate/Hard)
Having lunch with my best friend Moderate

Each activity aligns with your values in Difficulty ratings will help in deciding
a way that will enrich your life. which activities to do first, starting
with more manageable ones.

Continued on next page ACT

 BEHAVIORAL ACTIVATION
Doing enjoyable and important activities helps us
feel energized and engaged, and it relieves depression.

1. Monitor Time Activity

Enjoyment Importance
Daily (0–10) (0–10)
Activities

2. Identify Rewarding Activities 3. Rate Activity Difficulty

Difficulty
Activity
(Easy/Moderate/Hard)

Continued on next page 7 THINK

ACT
BEHAVIORAL ACTIVATION
(continued)

4. Choose Activities to Complete First

Activity
1.
If an activity feels too big to
2. complete, break it into manageable
steps. Then just do the first step.
3.

4. Look for ones that aren’t too difficult and

that you would look forward to doing.
5.

6.

5. Schedule & Complete the Activities

Sat/Sun Mon

Put the activities in your calendar and

set an alarm to remind you.

Tue Wed

Scheduling for a specific day and time

is very helpful for follow-through.

Thu Fri

Begin slowly by planning just 2–3 activities to

start. Then build up gradually over time.

ACT
BEHAVIORAL ACTIVATION
(continued)

4. Choose Activities to Complete First

Activity
1.
2.

3.

4.

5.

6.

5. Schedule & Complete the Activities

Sat/Sun Mon

Tue Wed

Thu Fri

8 THINK
ACT
 MAXIMIZING
FOLLOW-THROUGH
Set yourself up for success with effective strategies for moving
through obstacles. These questions can help guide your planning.

Is it rewarding?
It’s much easier to do activities
that provide some satisfaction.

Is it rightsized?
Tasks that are too big will
feel daunting. Break them
down to get started.

Is it on my calendar?
Planning an activity for a
specific time reinforces our
commitment to doing it.

Are my
thoughts helping?
Address any thoughts that get in the
way, like, “This is a waste of time.”
Am I focused?
Bring your full attention to one
activity at a time so you’re not
overwhelmed by other things.

Am I
accountable?
Accountability to someone
else can help us keep our
promises to ourselves.

ACT
 MAXIMIZING
FOLLOW-THROUGH
Set yourself up for success with effective strategies for moving
through obstacles. These questions can help guide your planning.

Is it rewarding?

Is it
rightsized?

Is it on my
calendar?

Are my thoughts
helping?

Am I
focused?

Am I
accountable?

9 THINK
ACT
 EXPOSURE THERAPY
Activities
range from
easier to more
difficult, like
Confronting what we’re afraid of is
the rungs of a powerful way to reduce excessive fear.
a ladder.

Make a list of ways to face your fears.

Difficulty
Activity
(0–10)

Petting my neighbor’s German shepherd 9

Passing an unknown dog on the sidewalk 7

Walking by a fenced-in dog park 4

Omit activities that are

objectively dangerous (e.g.,
petting a ferocious dog).

Principles of
Effective Exposure

DELIBERATE SUSTAINED
Make the exposures Stay in the situation long
intentional, rather
enough for new learning
than incidental.
to occur.

PROGRESSIVE REPEATED
Do the exposures multiple times,
Start with less challenging exposures which will wear out the fear.
and work your way up.

ACT
 EXPOSURE THERAPY
Confronting what we’re afraid of is
a powerful way to reduce excessive fear.

Make a list of ways to face your fears.

Difficulty
Activity
(0–10)

Principles of
Effective Exposure

DELIBERATE SUSTAINED

PROGRESSIVE REPEATED

10 THINK
ACT
 BE
Mindfulness Techniques
 WHAT IS MINDFULNESS?
The concept is very simple, but
Mindfulness is a research-based way to train the practice often isn’t easy.
the mind and change unhelpful habits.

PRESENT OPEN-HEARTED
FOCUS ACCEPTANCE

At its simplest, to be mindful is to Real presence requires that

be fully present in the moment. we accept reality as it is.

Acceptance doesn’t mean

we like or ignore a situation
that we need to change.
We can accept that it’s
cold, for example, and then
choose to put on a jacket.
We open our awareness
to the current moment
and accept that what’s
happening is happening.

There are two main ways to practice

mindfulness: formal practices and
informal (“in action”) practices.

Formal Mindfulness
Practices in Action
Formal practices tend to be more Informal practices are all about being in
familiar and include activities like our lives more fully. We can bring presence
meditation, yoga, and tai chi. and acceptance to anything we’re doing.

BE
WHAT IS MINDFULNESS?

PRESENT OPEN-HEARTED
FOCUS ACCEPTANCE

Formal Mindfulness
Practices in Action

11 THINK
BE
BENEFITS OF MINDFULNESS

Mindful awareness counteracts our unhelpful habits.

Mindfulness- and acceptance-based practices
are the “third wave” of CBT.
Ruminating about the past

When we’re living in the present, we’re

not focused on the past or the future.

Present Focus Worrying about the future

Counteracts:

Missing life
Focusing on what’s happening
helps us get the most out of life.

Fighting against reality

Most of our suffering comes from
unhelpful resistance to what is.

Open-Hearted Judging ourselves harshly

Acceptance Our tendency is to judge everything as
“good” or “bad” —including ourselves.
Counteracts:
Avoiding discomfort
A willingness to be uncomfortable allows us
to move toward things we care about more
than comfort—like facing our fears
or pursuing our dreams.

BE
BENEFITS OF MINDFULNESS

Mindful awareness counteracts our unhelpful habits.

Ruminating about the past

Present Focus Worrying about the future

Counteracts:

Missing life

Fighting against reality

Open-Hearted
Acceptance Judging ourselves harshly
Counteracts:

Avoiding discomfort

12 THINK
BE
 MINDFULNESS IN ACTION

Any activity is an opportunity to practice being mindful.

Awareness Patience
Settle into the activity, rather than
Notice what’s happening,
rushing to get to the next thing.
both internally and externally:
Let it take the time that it takes.
sights, sounds, smells,
sensations, emotions.

Receptivity Letting Go
Release the urge to cling to “good”
Let yourself receive whatever experiences and reject the “bad” ones.
is happening without labeling it as Keep an open mind.
“good” or “bad.”

Activities to Practice Mindful Presence

1. Doing the dishes
Choose one or two activities to practice each day.
2. Swimming Targeting specific activities makes it easier
to remember to let go of our typical way of
being and enter mindful presence.
3. Hugging my partner

4. Drinking my coffee
Plan to bring awareness, patience,
5. Talking with my son receptivity, and letting go to each activity.

6.

7.
It’s normal to lose focus and slip into mindlessness. Just notice
when that happens and gently come back to the activity
8. without criticizing yourself.

9.

BE
 MINDFULNESS IN ACTION

Any activity is an opportunity to practice being mindful.

Patience
Awareness

Receptivity Letting Go

Activities to Practice Mindful Presence

1.

2.

3.

4.

5.

6.

7.

8.

9.

13 THINK
BE
 MEDITATION

Meditation is a very
simple practice that can As simple as it is,
be guided or unguided. Set an intention the practice can be
challenging.
to focus

Lose focus
Notice where
the mind went Simple Guided Meditation
Sit comfortably and allow your eyes
to close. Begin by feeling your feet
on the floor... and the weight of
your body pressing into your seat...
noticing the breath as you inhale...
and exhale. For the next few
moments, just pay attention to the
sensations of breathing. Whether
at the nose... or the belly... focus on
those sensations. And each time
your attention wanders—and you
notice you’re thinking about other
things—just gently return your
awareness to the breath.

Unhelpful Myths About Meditation

I have to make my thoughts stop. It’s impossible to stop the mind from thinking.

Breath focus is the most common type of meditation,

There’s one right way to meditate.
but there are countless ways to meditate.

I’m bad at meditating. There’s no “good” or “bad” in meditation. It’s all practice and observing.

Meditation is one of an infinite

Meditation is the only way to practice mindfulness. number of ways to practice being
present and accepting.

BE
 MEDITATION

Set an intention
to focus

Notice where Lose focus

the mind went

Unhelpful Myths About Meditation

I have to make my thoughts stop.

There’s one right way to meditate.

I’m bad at meditating.

Meditation is the only way to practice mindfulness.

14 THINK
BE
 BEING THE OBSERVER
With mindful awareness, you are the Observer that witnesses
all of your experience, without being defined by it.

You can bring interest and

Sensations curiosity to physical sensations,
including pain, and simply notice
them without labeling them as
“good” or “bad.”

When we’re an Observer,

we are like a mountain.

Thoughts
Just like a mountain
remains stable in the face
of fleeting changes in
weather or the seasons, we Thoughts become merely products
aren’t defined by fleeting of the mind that may or may not be
changes in sensations, true and don’t have to be acted on.
thoughts, or emotions.

Emotions
You can make space for any
emotions you feel, opening to them
with acceptance and compassion.

Less Greater
Reactivity Choice
Uncomfortable emotions, upsetting Being the Observer gives
thoughts, and even pain cause less us more opportunity
suffering when we can observe to consider and choose
them from a bit of a distance. our response, instead of
reacting automatically.

BE
 BEING THE OBSERVER
With mindful awareness, you are the Observer that witnesses
all of your experience, without being defined by it.

Sensations

Thoughts

Emotions

Less Greater
Reactivity Choice

15 THINK
BE
 SECTION 2:
APPLYING
THINK ACT BE
 STRESS MANAGEMENT
Part 1: Recognizing Stress

Stress is a mental, physical, or emotional demand on our resources. The stress

response involves every aspect of our being: mind, body, behavior, and emotions.

In order to manage
our stress, we need to MIND
be aware of when it’s Cluttered thoughts BODY & BEHAVIOR
affecting us. Tune in to Feeling scattered Muscle tension
the ways you might be Distractibility Poor sleep
responding to stress. Poor concentration Headaches
Memory problems Digestive problems
Overwhelm Drug/alcohol use
Social withdrawal
Keep in mind that stress is
different from anxiety, which
is a fear about what might
happen in the future. Stress
and anxiety often go together, Stress causes the body’s
but not always. alarm systems to turn
on, which release stress-
related hormones like
adrenaline and cortisol.

EMOTIONS
Discouragement
Low enthusiasm
Hopelessness
Agitation
Disconnection Our stress system
Irritability works best in
response to short-
term challenges,
like running
to catch a bus.
Identify the common Longer-term
ways that you tend to stress can start to
respond to stress. wear us down.

Chronic, unmanaged stress can lead to a wide range of problems,

including depression, anxiety, exhaustion, physical illness, and burnout.

STRESS MANAGEMENT
 STRESS MANAGEMENT
Part 1: Recognizing Stress

Stress is a mental, physical, or emotional demand on our resources. The stress

response involves every aspect of our being: mind, body, behavior, and emotions.

BODY & BEHAVIOR

Muscle tension
MIND Poor sleep
Cluttered thoughts Headaches
Feeling scattered Digestive problems
Distractibility Drug/alcohol use
Poor concentration Social withdrawal
Memory problems
Overwhelm

EMOTIONS
Discouragement
Low enthusiasm
Hopelessness
Agitation
Disconnection
Irritability

Chronic, unmanaged stress can lead to a wide range of problems,

including depression, anxiety, exhaustion, physical illness, and burnout.

16 STRESS MANAGEMENT
THINK
 STRESS MANAGEMENT
Part 2: Reducing Stress

Cognitive, behavioral, and mindfulness practices can

address the various components of stress.

Schedule short and

long breaks into your
schedule, ranging from
ACT BE Let go of stress that
comes from worrying
full-length vacations to Periods Present about the future or
mini-breaks throughout of rest focus dwelling on the past.
the workday.

ACT THINK BE
Physical Examining Mindful
movement acceptance
Thoughts
Consistent physical exercise Practice opening
is one of the most reliable to all of your
ways to manage stress. experience, instead
of resisting.
ACT BE
Enjoyable Mind-body
activities exercises
Plan to do things you Examples: yoga,
enjoy every day, and meditation, progressive
protect the time in muscle relaxation, slow
your schedule. breathing, tai chi

Common stress-related
Notice when thoughts:
you need I have to finish this.
to manage I should be doing more.
stress, set an I’m taking too long.
intention to I’m going to fail.
find rest, and I don’t have time to rest.
make a specific
plan to follow.

Effective stress management requires attention, intention, and planning.

STRESS MANAGEMENT
STRESS MANAGEMENT
Part 2: Reducing Stress

Cognitive, behavioral, and mindfulness practices can

address the various components of stress.

ACT BE
Periods Present
of rest focus

ACT THINK BE
Physical Examining Mindful
movement acceptance
Thoughts

ACT BE
Enjoyable Mind-body
activities exercises

Effective stress management requires attention, intention, and planning.

17 STRESS MANAGEMENT
THINK
 DEPRESSION
Depression affects not just our emotions but our
thoughts, energy, appetite, sleep, and interest in doing things.

THINK
Challenge the thoughts
that contribute to depression
Depressed thinking often includes thoughts like:
• There’s no point in trying.
• I’m worthless.
• Things will never get better.
• Nobody cares about me.

ACT
Do activities that
are rewarding

Experiences of pleasure and mastery:

• Activate your reward system
• Boost mood & energy
• Increase motivation for additional activities

BE
Practice mindfulness of
thoughts, feelings, and actions
Mindful awareness helps you to:
• Spot unhelpful thoughts • Accept difficult emotions
• Choose valued activities

For example, challenging our unhelpful thoughts can help us complete activities, doing rewarding activities
can change our way of thinking, and being fully present in our activities makes them more rewarding.

These three elements work together and are mutually reinforcing.

DEPRESSION
 DEPRESSION
Depression affects not just our emotions but our
thoughts, energy, appetite, sleep, and interest in doing things.

THINK
Challenge the thoughts
that contribute to depression

ACT
Do activities that
are rewarding

BE
Practice mindfulness of
thoughts, feelings, and actions

These three elements work together and are mutually reinforcing.

.

18 DEPRESSION
THINK
 WORRY
Worry is the mind’s way of trying to make sure things will work
out okay by anticipating everything that could go wrong.

We tend to think
THINK Worry gives us the feeling that
worry helps us in
some way, as if
we’re “doing something” when
• Challenge thoughts about we can’t completely control an
worrying will prevent
the usefulness of worry bad surprises or help
outcome we care about, like:
us solve problems.
• Release a false sense of • A loved one’s health
But when we look
control • A job interview
more closely at these
• The economy
beliefs, we usually
• Others’ feelings about us
find they aren’t true.

ACT When we worry and nothing

Use the breath
• Take care of what you bad happens, our minds
to quiet the
can control learn that worrying “prevents
nervous system,
• Engage in valued activities harm”—making it more likely
which can
that we’ll keep worrying.
reduce the
tension that
contributes to
worry.

BE Part of open-hearted
acceptance is embracing
• Calm the body the uncertainty in life.
• Focus on the present When we open to not
• Embrace uncertainty knowing the future, we
can stop trying to control
the uncontrollable.

Set an intention to let go of things you can’t control. Focus

instead on doing the best you can with what’s in your power.

WORRY
 WORRY
Worry is the mind’s way of trying to make sure things will work
out okay by anticipating everything that could go wrong.

THINK
• Challenge thoughts about
the usefulness of worry
• Release a false sense
of control

ACT
• Take care of what you
can control
• Engage in valued activities

BE
• Calm the body
• Focus on the present
• Embrace uncertainty

19 WORRY
THINK
 It’s hard to stop

PROCRASTINATION procrastinating.
It helps to have
many tools to
move through it.

Two fears lead us to delay doing a task:

ACT
Use short
work sessions
ACT
Just get
It’s easier to work started
when we know a
Starting a task is
“It’s going to be
break is coming. often less unpleasant
than dreading it.

THINK unpleasant.”
Examine permission-
giving thoughts
ACT
Reward
For example, “I’ll do it yourself
when I feel like it.”
Build in mini-incentives
to boost motivation.

BE
Accept discomfort ACT
Remember that you can do
“I’m going to Break down
tasks
things you don’t feel like doing.
do a bad job.” Make it easier to start
and to do a good job.

THINK
Aim for
imperfection BE BE
Embrace
Find focus
Watch out for thoughts uncertainty
like “What if I mess up?” Bring your full attention
or “It has to be perfect.” Welcome not knowing
to the task.
how it will turn out.

The habit of avoiding pain comes from negative reinforcement, which is the
reward we get when we avoid something we think will be unpleasant.
Avoiding tasks is habit-forming because we avoid imagined pain.
Finding ways to move through procrastination builds healthier habits.
PROCRASTINATION
 PROCRASTINATION

Two fears lead us to delay doing a task:

ACT ACT
Use short Just get
work sessions started

“It’s going to be
unpleasant.”
ACT
THINK Reward
Examine permission- yourself
giving thoughts

ACT
BE Break down
Accept discomfort “I’m going to tasks

do a bad job.”

THINK BE
Aim for Embrace
uncertainty
imperfection
BE
Find focus

Avoiding tasks is habit-forming because we avoid imagined pain.

Finding ways to move through procrastination builds healthier habits.

20 PROCRASTINATION
THINK
 SOCIAL ANXIETY
Social anxiety is common when we’re afraid of embarrassing
ourselves or we fear that other people will think badly of us.

Situations that often

Practice seeing the stories that trigger social anxiety:
THINK the mind creates about what • Being at a party
• Meeting new people
others think of you.
Examine thoughts • Eating with others
Common cognitive distortions
that elicit anxiety • Giving a speech
in social anxiety are mind • Talking in a meeting
reading, personalization, and
catastrophizing.

Gradually approach
ACT more challenging social
situations. Take care
Confront feared social to examine unhelpful
situations via exposure thoughts during exposure.

Social anxiety often leads us

to focus on ourselves and on

BE how we’re coming across to the Work toward embracing the

other person. This self-focus anxiety that sometimes arises
increases anxiety. Direct your in social situations. Allow it to
• Maintain an outward focus
attention instead to the other “come along for the ride,” rather
• Practice accepting discomfort
person and the back-and-forth than treating social anxiety
discussion. as a problem that must be
eliminated.

These three elements work together. For example:

• Doing Exposure with an Outward Focus • Examining Thoughts during Exposure

SOCIAL ANXIETY
 SOCIAL ANXIETY
Social anxiety is common when we’re afraid of embarrassing
ourselves or we fear that other people will think badly of us.

THINK
Examine thoughts
that elicit anxiety

ACT
Confront feared social
situations via exposure

BE
• Maintain an outward focus
• Practice accepting discomfort

21 THINK
SOCIAL ANXIETY
 PANIC
Panic is a runaway fear reaction involving the mind and body. It’s driven by
the sympathetic nervous system: the body’s fight, flight, or freeze response.

BE
Situations often Inhale for a count of 4, and exhale for a count
associated with panic: of 6. The point of breathing is not to make
• Driving on bridges Practice slow, sure you don’t panic but to help you stay in
• Being in crowds relaxed breathing the situation, however you’re feeling.
• Grocery stores
• Movie theaters
• Restaurants BE
• Elevators Open yourself to experiences vs.
trying to avoid panic at all costs
Resistance to panic often makes
THINK panicking more likely, while being
willing to panic can make it less likely.
Examine predictions about
terrible things that will
happen during panic
ACT
Common distortions in panic • Expose yourself to feared bodily
include fortune telling, emotional sensations (e.g., a racing heart)
reasoning, and catastrophizing.
• Expose yourself to feared
situations (e.g., bridges, restaurants)

Use the principles of exposure Remember during

to confront physical sensations the exposures not
that you may try to avoid. to make panic
the enemy. Focus
instead on being
fully in the situation.

Panic is an overwhelming emotional experience, so understandably we often

invest a lot of energy in pushing it away. But as we live a life that’s less centered
around panic, we are actually less likely to experience panic attacks.

Together these techniques can help you do the things

you care about, even when panic is a possibility.

PANIC
 PANIC
Panic is a runaway fear reaction involving the mind and body. It’s driven by
the sympathetic nervous system: the body’s fight, flight, or freeze response.

BE
Practice slow,
relaxed breathing

BE
Open yourself to experiences vs.
trying to avoid panic at all costs
THINK
Examine predictions about
terrible things that will
happen during panic ACT
• Expose yourself to feared bodily
sensations (e.g., a racing heart)
• Expose yourself to feared
situations (e.g., bridges, restaurants)

Together theseTogether
techniques can help
these techniques can helpyou
you dodothethe
thingsthings you care
about,you even when
care about, panic
even when panicisisaa possibility.
possibility.
22 PANIC
 POST-TRAUMATIC STRESS
DISORDER (PTSD)
Trauma is a common experience that can have serious effects
on our thoughts, emotions, behaviors, and physiology.
These four approaches work together
and will overlap in reducing symptoms.
Revisiting is also
called imaginal
exposure. It can
happen by telling ACT BE
the memory to Revisit the Practice slow, Inhale through
someone or by trauma memory the nose for a
writing it down. relaxed breathing count of 4. Exhale
Facing the memory out the mouth
directly makes it for a count of 6.
less terrifying. Repeat for 3–5
minutes.

Intrusive
Reexperiencing
Avoidance
of Trauma Physiological
Reminders
PTSD Symptoms Overarousal

Negative Negative
Mood Thoughts

THINK
ACT Examine beliefs about yourself,
Do exposures to other people, and the world
relatively safe but
avoided situations Common trauma-related Examining trauma-related
beliefs include: beliefs can lead to more
Exposure helps both to reduce fear and • I’m weak. helpful ways of thinking,
avoidance and to boost positive mood • No one can be trusted. leading to a better mood
through behavioral activation. • The world is always in the process.
dangerous.

PTSD
POST-TRAUMATIC STRESS
DISORDER (PTSD)
Trauma is a common experience that can have serious effects
on our thoughts, emotions, behaviors, and physiology.

ACT BE
Revisit the Practice slow,
trauma memory relaxed breathing

Intrusive
Reexperiencing
Avoidance
Physiological
of Trauma PTSD Symptoms Overarousal
Reminders

Negative Negative
Mood Thoughts

ACT THINK
Do exposures to Examine beliefs about yourself,
relatively safe but other people, and the world
avoided situations

23 PTSD
THINK
 OBSESSIVE-COMPULSIVE
DISORDER (OCD)
OCD is maintained by a cycle of intrusive distressing fears (obsessions) and
efforts to neutralize the fears through thoughts or actions (compulsions).
Effective treatment must remove avoidance and prevent compulsions.

Cognitive techniques
OBSESSIONS in OCD focus less on
challenging specific
fears and more on
COMPULSIONS seeing obsessive
THINK thoughts as not being
meaningful.
Examine beliefs about
the significance of
obsessive thoughts
ACT
Do exposures to thoughts
and situations that BE
trigger obsessions Mindfully observe
With practice, it will obsessive thoughts
get easier to approach
the things you fear. ACT Practice watching
obsessions without
Prevent trying to avoid or get
compulsions rid of them.

Crucially, exposure in OCD must

be done without compulsions. That
way, your brain learns that anxiety OBSESSIONS
diminishes on its own and that
compulsions are unnecessary to
prevent harm. COMPULSIONS

Together these approaches interrupt the cycle of OCD.

OCD
 OBSESSIVE-COMPULSIVE
DISORDER (OCD)
OCD is maintained by a cycle of intrusive distressing fears (obsessions) and
efforts to neutralize the fears through thoughts or actions (compulsions).

Effective treatment must remove avoidance and prevent compulsions.

OBSESSIONS

COMPULSIONS
THINK
Examine beliefs about
the significance of
obsessive thoughts
ACT
Do exposures to thoughts
and situations that BE
trigger obsessions Mindfully observe
obsessive thoughts

ACT
Prevent
compulsions

OBSESSIONS

COMPULSIONS

Together these approaches interrupt the cycle of OCD.

24 OCD
THINK
 PROBLEMATIC ANGER
Anger is a hot emotion, which can lead us to express it in ways we regret.
Understanding the process of anger can help us to manage it more effectively.

THINK Activating Event

ACT
Know your triggers Partner’s insensitive
comment Assert yourself
Recognize your Express your needs
high-risk situations before they reach
and avoid them if a boiling point.
possible.

Thoughts
THINK They never ACT
Examine angry respect me Give yourself
assumptions enough time
Common cognitive distortions Being rushed is a
include: shoulding, emotional perfect setup for anger.
reasoning, over-generalization,

Experience
and personalization.

of Anger Physical
Feelings Sensations
Annoyed Tight throat
Hurt Knot in stomach

BE
Expression
Practice mindful
ACT
awareness of anger
of Anger Tend to physical needs
• Recognizing symptoms
• Present focus Yelled at partner
Hunger, fatigue,
• Acceptance of what is Slammed doors temperature, pain
• Calming breath
Stormed out
• Being the Observer

These techniques help us make more intentional choices,

even when we’re experiencing strong anger.

PROBLEMATIC ANGER
 PROBLEMATIC ANGER
Anger is a hot emotion, which can lead us to express it in ways we regret.
Understanding the process of anger can help us to manage it more effectively.

THINK Activating Event

Know your triggers

ACT
Assert yourself

Thoughts

THINK ACT
Examine angry Give yourself
assumptions enough time

Experience
of Anger Physical
Feelings
Sensations

BE Expression
ACT
Practice mindful of Anger Tend to physical needs
awareness of anger

These techniques help us make more intentional choices,

even when we’re experiencing strong anger.

25 PROBLEMATIC ANGER
THINK
 Track sleep data during
treatment, including: what

INSOMNIA
time you get in bed, what time
you get out of bed, how long
it takes to fall asleep, time
awake in the middle of the
night, and final wake-up time.

Insomnia is consistent difficulty falling asleep or staying asleep.

ACT
A consistent sleep schedule trains
Beware of naps (especially longer
your brain and body to expect
and later in the day), which
reduce your drive for sleep.
Keep a consistent wake sleep at the same time each day.
time and bedtime

ACT ACT
Spend the right amount Align light exposure
of time in bed with 24-hour cycle
Match the time you’re in bed Seek sunlight early in the day
with the average amount of and avoid bright light (including
sleep you get per night. blue screens) in the evening.

ACT ACT
Follow good
Build a strong sleep-bed sleep hygiene
association
Avoid caffeine later in the day;
Leave the bedroom if unable exercise consistently; keep the
to sleep so your brain doesn’t bedroom quiet, cool, and dark; and
associate the bed with being don’t use alcohol to fall asleep.
awake and frustrated.

ACT
Wind down before bed
THINK
Question sleep-related Do relaxing activities 30–60
assumptions minutes before bed.

Common examples:

BE BE
• I’m going to be a
wreck tomorrow.
• I need to try harder Release effort Practice acceptance
to get to sleep.
Let go of any sense of doing, Open to not knowing how
and let sleep arrive when it will. your sleep will be each night.

These techniques promote sound sleep and can prevent a

night or two of bad sleep from turning into a chronic problem.

INSOMNIA
 INSOMNIA
Insomnia is consistent difficulty falling asleep or staying asleep.

ACT
Keep a consistent wake
time and bedtime

ACT ACT
Spend the right amount Align light exposure
of time in bed with 24-hour cycle

ACT ACT
Build a strong sleep-bed Follow good
association sleep hygiene

THINK ACT
Question sleep-related Wind down
assumptions before bed

BE BE
Release Practice
effort acceptance

These techniques promote sound sleep and can prevent a

night or two of bad sleep from turning into a chronic problem.

26 INSOMNIA
THINK
 MAINTAINING GAINS
The progress you make in CBT usually lasts over time—especially when you
keep practicing and building on the skills you’ve learned in treatment.
Countless studies show Triggering Situations Know what is likely to
that CBT is effective not
challenge you so you
only in the short term but High stress at work can plan to use the skills
also in the long term for
preventing relapse.
Giving a presentation you’ve practiced.

Identify and practice thought

THINK Helpful Ways of Thinking
patterns that help you deal
with difficult situations.

• I have everything I need to succeed.

• I can do my best and release the rest.
• It’s okay to be imperfect.
ACT BE
Actions That Lead Me Favorite Mindfulness
Toward My Goals Practices
• Break down big projects into smaller tasks • 5-minute seated meditation
in the morning
• Meet with my manager when I get stuck
• Mindful cup of tea
• Exercise before work
• Presence with my partner
Make a habit of doing activities that help Find ways each day to be in the moment with
you build a life you’re excited to live. open-hearted acceptance, whether through
formal practices or mindfulness in action.

Have a plan in case Learning to work

self-therapy is no When to Reach Out for Help with your thoughts,
longer enough and
it’s time to contact
When I get into a habit of avoiding things at work feelings, and
emotions is the work
a therapist. When my anxiety starts to feel unmanageable of a lifetime.

You can take the treatment with you wherever you go,
effectively becoming your own therapist.

MAINTAINING GAINS
 MAINTAINING GAINS
The progress you make in CBT usually lasts over time—especially when you
keep practicing and building on the skills you’ve learned in treatment.
Triggering Situations

THINK Helpful Ways of Thinking

ACT BE
Actions That Lead Me Favorite Mindfulness
Toward My Goals Practices

When to Reach Out for Help

You can take the treatment with you wherever you go,
effectively becoming your own therapist.

27 MAINTAINING GAINS