The Anxiety Plan: 42 Strategies For Worry, Phobias, OCD

and Panic

Dr JEREMY DEAN

Copyright © 2016 by Jeremy Dean

All rights reserved. No part of this eBook may be used or reproduced in any form or by any

means without the prior written permission of the author.

Published by:

Web: http://www.psyblog.co.uk

Twitter: http://twitter.com/psyblog

Facebook: http://www.facebook.com/PsyBlog

eBook edition: September 2016

Introduction ............................................................................................................................... 8

Get the best out of this book ................................................................................................. 9

Part 1: Changing thoughts ....................................................................................................... 10

Escape the vicious circle ...................................................................................................... 10

Exercise 1: Identify vicious circles .................................................................................... 11

Monitor anxious experiences .............................................................................................. 12

Exercise 2: Monitor anxious experiences ........................................................................ 14

Change self-talk .................................................................................................................... 14

Exercise 3: Identify patterns of thought .......................................................................... 15

Catastrophising .................................................................................................................... 15

Exercise 4: Challenge catastrophic thoughts ................................................................... 15

Exercise 5: Follow the logic .............................................................................................. 16

Predicting the future ............................................................................................................ 16

Exercise 6: Accept uncertainty ......................................................................................... 17

Black and white thinking ...................................................................................................... 17

Exercise 7: Put a number on it ......................................................................................... 18

Exercise 8: Shades of gray ................................................................................................ 18

Overgeneralising and discounting the positive ................................................................... 18

Exercise 9: Realistic thinking ............................................................................................ 19

Noticing the negative ........................................................................................................... 19

Exercise 10: Switching attention ...................................................................................... 19

Exercise 11: Identify negative patterns of thinking ......................................................... 20

Acceptance ........................................................................................................................... 20

Exercise 12: The walking meditation ............................................................................... 22

Exercise 13: Mindful mini-break ...................................................................................... 22

Exercise 14: Listen mindfully ............................................................................................ 22

Exercise 15: Experience nature ........................................................................................ 23

Part 2: Changing Behaviours .................................................................................................... 24

Behavioural experiments ..................................................................................................... 24

Exercise 16: Survey .......................................................................................................... 25

Exercise 17: Face a fear .................................................................................................... 25

Exercise 18: Take a small risk ........................................................................................... 26

Get some exercise ................................................................................................................ 27

Part 3: Strategies for specific anxiety issues ............................................................................ 29

Generalised anxiety and worry ............................................................................................ 29

Exercise 19: Try anxiety-provoking activities ................................................................... 30

Exercise 20: The worry period ......................................................................................... 31

Exercise 21: Identify worries ............................................................................................ 32

Exercise 22: Face hypothetical fears ................................................................................ 33

Exercise 23: Problem-solve .............................................................................................. 34

Social Phobia ........................................................................................................................ 36

Exercise 24: Switch focus ................................................................................................. 37

Exercise 25: Monitor thoughts......................................................................................... 38

Exercise 26: Identify safety behaviours ........................................................................... 38

Exercise 27: Survey friends and acquaintances ............................................................... 39

Exercise 28: Push social boundaries ................................................................................ 39

Exercise 29: Acts of kindness ........................................................................................... 40

Specific phobias ................................................................................................................... 41

Exercise 30: Make an exposure plan ............................................................................... 42

Exercise 31: Follow the logic through .............................................................................. 43

Panic ..................................................................................................................................... 45

Exercise 32: Triggers and self-talk .................................................................................... 45

Exercise 33: Refocusing attention.................................................................................... 46

Exercise 34: Avoid safety behaviours .............................................................................. 47

Exercise 35: Induce panicky feelings ................................................................................ 48

Obsessive-compulsive disorder ........................................................................................... 49

Exercise 36: Survey .......................................................................................................... 50

Exercise 37: Not scanning for danger .............................................................................. 51

Exercise 38: Thought experiment .................................................................................... 52

Exercise 39: Reduce responsibility ................................................................................... 52

Exercise 40: Check less, be more confident ..................................................................... 53

Exercise 41: Stop checking ............................................................................................... 53

Exercise 42: Stop avoiding ............................................................................................... 54

Part 4: Keep going ................................................................................................................ 56

About the author

Dr Jeremy Dean is a British psychologist and author. He has a PhD in psychology from University College London. He is the owner and author of the popular website "PsyBlog", which describes scientific research into how the mind works. His last full-length book was "Making Habits, Breaking Habits: How To Make Changes That Stick", and his previous ebook was "Spark: 17 Steps That Will Boost Your Motivation For Anything".

Introduction

Everyone has experienced severe anxiety in their lives at one time or another. Births, deaths, marriages, interviews, public speaking and so on will happen to most people down the line. However, comparing this kind of 'regular' anxiety with chronic conditions is a bit like comparing your local park with the Amazon rainforest: the scale is different. Chronic anxiety can be a very difficult condition to live with: it has the potential to ruin the enjoyment of practically any activity.

The aim of this book is to help you live with anxiety; to regain enjoyment in everyday activities that the condition can make so difficult. The aim is not to be anxiety-free. Almost no one is totally free from anxiety. This book gives you the tools to deal with the inevitable anxieties that come with being human, whatever their cause and scale.

Here you will find dozens of scientifically-proven strategies for dealing with anxiety. Most are derived from a type of long-established technique called 'cognitive-behavioural therapy' (CBT). CBT is now routinely taught to millions of people around the world each year. Although there are few studies mentioned here, CBT has repeatedly been shown to help people improve their lives in countless studies conducted over decades.

I wish you all the best and very much hope the techniques prove useful to you -- have courage!

Dr Jeremy Dean

September 2016

Get the best out of this book

The single best way to get the most out of this book is to do the exercises -- at least some of them. Throughout, there are various prompts to record thoughts and feelings over periods of time. The temptation is to skip these, but please consider doing one or more of them. Avoid relying on memory, because it can trick us.

At the start, the exercises involve thinking about and monitoring your experience. Later on, they are more focused on changing behaviour. Thinking about your experience a little and monitoring it will be of some benefit. For better results, though, actions are the most effective way to teach the mind that fears are easily exaggerated.

The book covers most of the different types of anxiety and is divided into four sections. Parts 1 and 2 contain points that are relevant for many people with different types of anxiety. Part 3 goes through more specific types of anxiety, including social phobia, panic and OCD. Part 4 focuses on problems and troubleshooting.

Even if you know you have a specific type of anxiety, it is best to start at the start. Different types of anxiety share lots of common features. At least some of the tools in the first section will be helpful for most people experiencing anxiety.

Part 1: Changing thoughts

Escape the vicious circle

Anxiety has different meanings to different people and various ways of being experienced. Two people might both consider themselves anxious, but have quite distinct experiences. This book is not about telling you what you already know: how you think and feel. Instead, it is about learning and using a set of tools to understand and change this experience.

To do that, we have to use a relatively clumsy tool: language. Bear in mind that language is not precise: do not take it too seriously. That said, though, we can roughly break down the symptoms of anxiety into four different components:

Physical -- your body has certain reactions to anxiety.

Cognitive -- some thoughts come to the fore in anxiety.

Emotional -- feelings usually accompany anxiety.

Behavioural -- anxiety can make you do, or not do, some things.

Just like the language used to describe them, though, the categories are not precise. In fact, each component feeds through into the others.

Here is an example of the experience of a person with anxiety:

Physically I feel sick to the stomach after visiting a restaurant.

Think that perhaps I have food poisoning.

Feel fearful about future health.

Avoid restaurants in future.

In this example it seems like all the problems are being created by the physical symptoms of feeling sick. But, I could just as easily write this another way:

Visiting a restaurant prompts thoughts about food poisoning.

Physically feel sick to the stomach.

Avoid restaurants.

Feel ashamed for avoiding restaurants with friends.

The point is that everything is interacting with everything else -- thoughts, bodily sensations, feelings and behaviours. It is important to see these four factors as all influencing each other. It means we have more ways to deal with a common aspect of anxiety: the vicious circle. Vicious circles in anxiety occur because all these four aspects of experience link up to cause problems.

Here is another example of someone who is anxious about social occasions:

Although David does not enjoy social occasions, he is at a party. There he meets an acquaintance whose name he cannot remember. When David's wife joins the little group, he

has to introduce the acquaintance. Immediately he is embarrassed and almost paralysed with fear. Before anyone can say anything, he excuses himself to go to the toilet. From there he phones his wife and tells her he is feeling sick and has to go home. He avoids parties even more assiduously in the future.

Anyone reading this calmly can see what David might have done in these circumstances. He could say something like: "I'm terribly sorry but your name has slipped my mind for a moment." At that exact time, though, with the embarrassment and fear affecting his judgement, David does not see this option; he just wants to escape from the situation as quickly as possible and avoid the possibility of it happening ever again.

The reality is that there are a jumble of thoughts (hating social occasions), feelings (embarrassment, fear) and behaviours (avoid all social occasions) all acting together.

This is one example about someone who dislikes social occasions. It does not mean everyone with a social phobia experiences exactly the same thing. Similarly, different types of anxiety have different mixtures of these components and they interact in different ways.

One of the challenges in dealing with anxiety is in identifying some typical patterns that you experience. This can be hard because of the jumble of everyday experience. It can also be hard because anxiety is difficult to face -- it feels better to avoid it rather than analyse it.

The problem with these vicious circles is that they lead to avoidance. People tend to avoid the things that make them feel anxious. Sometimes this is not a problem: all right-thinking people avoid the very edge of cliffs. The problem is when people avoid things which can seriously impact their lives, like social situations, going outside or going to the doctor.

Most different types of anxiety have some common threads. People experiencing anxiety tend to:

Over-estimate the danger in a situation.

Be constantly on the look-out for sources of potential harm.

Do their best to avoid difficult situations, thoughts or emotions.

Use short-term strategies which do not help the problem.

This book describes ways to tackle each of these areas. Since thoughts, feelings, behaviours and bodily sensations all feed into each other, tackling each area has a knock-on effect. By working mainly on thoughts and behaviours, we can break down vicious circles and change your experience.

Exercise 1: Identify vicious circles

Have a think about some of the vicious circles that might be operating for you. Generally speaking, what types of thoughts, feelings, behaviours and situations interact to make you feel anxious? It is perfectly normal if it is not clear to you how your anxiety is maintained. Analysing this is the focus of the next section.

Monitor anxious experiences

One of the difficulties with anxiety is that it is habitual. Habits have a number of useful and some not-so-useful properties. Among their less than useful properties in the context of anxiety are:

Anxieties arise automatically, without our consciously being aware of what has prompted them.

Anxieties arise in response to situations in which we regularly find ourselves.

The reason these two are problems is that anxieties can arise quickly, without a clear trigger. The response to anxiety -- usually to try and avoid the situation -- comes so quick on the heels of the feeling that we find we have responded before even thinking about it.

The key is to think about the interpretation of particular events. When anxiety arises and avoidance feels like the only option, there is no time to look at our interpretation of the situation. Changing the interpretation of an event is one way to reduce the anxiety that it tends to create. But, if the interpretation whips by too quickly in the rush of habit, emotion and the moment, then there is no time to think or adjust it.

That is why one of the most important ways of dealing with anxiety is to monitor it. Monitoring experiences -- by writing them down, for example -- serves a number of useful purposes. Apart from anything else, simply becoming more aware of our own thoughts, feelings and behaviours helps us to understand how our anxiety works. It also helps provide some psychological distance: as though you were examining the inner workings of a complex machine. Finally, monitoring thoughts often helps to interrupt the constant flow of anxieties.

The best way to monitor thoughts related to anxiety is to write them down somewhere. Included below is an example of the sort of simple recording system you can use. It just needs to have six columns, which are:

Date

Situation

Thoughts

Feelings

Behavior

Comments

Example sheet for monitoring anxious experiences

Here are some example answers for someone who is anxious about making a telephone call:

Situation: Preparing to make a phone call.

Thoughts: What if when I start talking, I cannot think what to say? Will I get embarrassed and totally clam up?

Feelings: Impatient, anxious, and ashamed.

Behaviour: Fail to make the call.

Comments: I know I need to speak to her about this issue, but it will be an uncomfortable situation, so maybe it is best avoided.

Ideally, anxious situations, thoughts and feelings should be monitored as they occur. When trying to remember them later, it can be difficult to reconstruct exactly what we were thinking and how we felt. Recording anxious moments throughout the day as they happen, though, can be difficult for many people.

One problem people sometimes have is worrying that others will see them. To get over this, try going somewhere private like the bathroom when you need to write down an anxious experience. On the other hand, people now spend so much time typing into their smartphones, it can probably be passed off as texting.

Another problem people sometimes have is worrying that writing down their anxious thoughts will make bad things more likely to happen or that it will make them feel worse. Facing fears on paper can be just as troubling for some as facing them in real life. Both of these are legitimate concerns, but they can only really be addressed by trying it out and seeing what happens.

Exercise 2: Monitor anxious experiences

Try recording your anxious experiences for a few days. Treat writing down situations, fears, thoughts and feelings like an experiment. Let us try it and see what patterns emerge. The idea of this exercise is to make a start at identifying what is keeping your anxiety going. The notes you make here will also be useful for many different exercises across this book. I refer back to this section a lot, so you will have plenty of reminders to try this exercise.

Change self-talk

In our minds we all have a series of images, words, feelings and so on going through our minds. It is what we call 'thinking'. Different people think in different ways. Most people experience something like a kind of internal monologue, or what psychologists call self-talk. The fractured ideas, jumbles of words and flashes of images that tumble through our minds are what make consciousness so fascinating -- and sometimes so frightening.

Over the years of treating people with anxiety, psychologists have discovered that there are certain patterns of thoughts that are central to anxiety. Spotting, understanding and then challenging these thoughts is one very useful strategy for dealing with persistent anxiety.

These ways of thinking are a series of habits of thought that have been learned over the years. This means they can be unlearned or, better still, replaced with other more helpful thoughts.

Exercise 3: Identify patterns of thought

As you read through the patterns of thought described below, try to see which ones are familiar. It may be useful to refer to the results of the exercise to monitor anxious experiences in the previous section (Exercise 2). Hopefully you will spot some of these patterns in your own thoughts and be able to use the strategies provided to counter them.

Remember that the aim of changing your thoughts is that it will also help to change your feelings and, ultimately, your behaviours.

Catastrophising

Catastrophising is one of the most common patterns of thought that anxious people experience. It is the thought, image or belief that something really bad will happen. For example, you get on an aeroplane and catastrophise about it crashing and burning. Or, you go to a restaurant and catastrophise about being killed by food poisoning. Or, you walk to the shops and catastrophise about having left the cooker on and burning the house to a cinder.

While all of these are extremely unlikely, they are possible, and they can feel very real at the time they are experienced. What catastrophising does very effectively is make you worry. It is jumping to the worst possible conclusions, however unlikely, and seeing the consequences replayed in the most gruesome detail in the mind.

Exercise 4: Challenge catastrophic thoughts

The way to challenge catastrophising is not by denying it or just trying to push it away. The best strategy is to examine it a little more closely.

Here are some questions you can use to challenge catastrophic thinking:

What are the chances that the catastrophic event I fear will really happen?

Is there any real evidence that this will happen?

Were there times in the past when this catastrophic outcome did not occur in similar circumstances?

If I told a close friend about this catastrophic outcome, what would they think of it?

What is an alternative prediction of what might happen?

Weighing up different possibilities, what is most likely to happen?

Usually the result of this questioning is to conclude that the feared catastrophe is not that likely.

Note: It may be that you see a catastrophic image in your mind, rather than experiencing a thought. In this case, the first step is to work out what the image is referring to. Often with an image this will be obvious. Once the catastrophic event is described in words, it is possible to use the questions above to challenge it.

Exercise 5: Follow the logic

A second way to deal with catastrophising that some people find helpful is to follow the logic all the way to the end. The idea is that you examine the catastrophic thoughts step-by-step and see where they lead.

For example, let us say you are contemplating speaking in public. Most people find this an anxiety-provoking experience, so for someone already prone to anxiety, it can provoke all kinds of catastrophic thoughts. What if, you might think, I dry up on stage?

Let us try following the logic through. Say you did dry up on stage, what would be so bad about that? Well, you might answer, everyone in the audience will be uncomfortable. OK, what is so bad about that? Well, I will feel embarrassed. OK, would that be the end of the world? No, it would not, you would just be embarrassed and eventually you would get over it.

The potential problem with following the logic to the end is that your logic may well lead in a different way to the logic above. For example, being embarrassed might well feel like the end of the world and you might conclude that you will never recover from it.

Part of the knack of learning this type of reasoning, then, is in making sure the logic takes you in the right direction: away from anxiety. Remember that catastrophising is the tendency to assume that poor outcomes will be much worse than they really are. So the reasoning should take you towards thinking that the outcome is not as bad as you might imagine. The vast majority of people can cope with quite severe bad events -- I am sure you have coped with some yourself.

Predicting the future

When anxious, people often predict future events that will make them anxious. What if my partner has a car accident on the way home? What if I lose my job? What if...? What if...? It is one of the great abilities of the human mind that it is so adept at generating possible futures. Unfortunately, for those experiencing anxiety, this means there is an infinite number of future possibilities to be nervous about.

At its heart, this relentless visualisation of possible future events is about control -- it is about trying to work out what could happen and what we might do about it. We all want to have some control over what happens in the future. Life being what it is; this is not possible. Unfortunately, we cannot be certain what the future will bring.

Exercise 6: Accept uncertainty

One of the challenges for a person experiencing anxiety, then, is learning to deal with uncertainty. Given that we cannot change the uncontrollable, random nature of the universe, we are better off to accept it. No one is saying that acceptance is easy, but there are different ways and perspectives that can help. These will depend on the exact nature of the anxieties, but here are a few examples of some thought processes.

Worry: "I am worried that this situation that I or a loved one is going into is not safe."

Remind yourself: "Total safety is never guaranteed, it is impossible to prevent something bad from ever happening to myself or to loved ones. People must be able to live their lives with acceptable levels of risk -- otherwise, how are we going to live? Never leave the house again?"

Worry: "I am so anxious that my fears will always be out of control and I will never be able to enjoy life."

Remind yourself: "Everyone has thoughts they cannot control sometimes. I can still face these thoughts and examine them to see what I can learn. Strange or anxious thoughts can be experienced and my life can continue."

The pattern is the same each time. The reminders are about finding ways to accept the uncertainty inherent in life. Accepting that life cannot be lived without danger does not change the risks, but hopefully it means that life can at least be enjoyed with less anxiety.

While it might appear weak, acceptance can be an extremely powerful strategy. It is also a great illustration of how changing your attitude to your own thoughts is useful. If the world cannot change -- and, unfortunately, we cannot get rid of risks -- then we can adjust how we view the world.

Black and white thinking

Along with anxiety comes a tendency to see everything as either right or wrong, good or bad, black or white. The world becomes a kind of simplified Hollywood movie where good battles evil. Except, in the eyes of a person who is anxious, nothing really looks that good (since most things are not perfect) and so everything tends to look very bad.

Exercise 7: Put a number on it

One way you can deal with black and white thinking is by forcing yourself to put a number on it. When thinking about something, try giving it a percentage. Is it really 100% bad? Perhaps it is more accurate to say it is 80% bad or 50% bad? If it still seems 100% bad, then try comparing it to the worst possible event you can think of. Surely this is not as bad as the worst thing you can think of?

Exercise 8: Shades of gray

Another way to think about it is to focus on the shades of gray in between the black and white. For example, say I have the thought that if I make a mistake at work, I will be fired. This is an example of black or white thinking because it assumes that either I have to be perfect, or I will get fired. But, trying to explore alternative gray areas in between these two extremes leads to a different conclusion. What if I do a 'good enough' job -- is it more likely that that will be sufficient to keep my boss happy?

Whether it is using scaling or by thinking about an intermediate alternative, the aim is always to reduce the extreme nature of the thoughts. By thinking about shades of gray, the mind can be encouraged to move away from anxiety and towards more moderate ground.

Overgeneralising and discounting the positive

People who feel anxious have a tendency to discount or ignore things that do not fit with their negative view. For example, when an anxious person receives help from another, the anxiety might make them think: "Oh, she's only helping me out of pity." While this might be partly true, it discounts the fact that someone is trying to offer their help. This is one of the many ways in which anxiety perpetuates itself.

Similarly, people with anxiety have a tendency to ignore their own skills and talents. Strengths and accomplishments are disregarded in favour of weaknesses and problems.

Along with discounting the positive, people experiencing anxiety also often overgeneralise in a way that makes them feel bad about themselves. For example: does being late for an appointment on one occasion mean you are an unreliable person? Does making a small mistake in a report at work mean you are going to be fired? People experiencing anxiety have the tendency to draw very negative conclusions from everyday slip-ups.

Both discounting the positive and overgeneralising have a common thread. It is also not too hard to see the commonalities with black and white thinking. The mind is tending to pick out and emphasise the negative points in any situation.

But the solution is not positive thinking. It is not about replacing one set of unrealistically negative thoughts with an unrealistically positive set. It is not about repeating to yourself "Everything is going to be OK. Everything is fine." Rather, it is about realistic thinking.

Exercise 9: Realistic thinking

If you find yourself discounting the positive, try reminding yourself of a true, realistic, positive aspect of the situation. If you have a certain skill or talent, acknowledge it, avoid belittling it. This is not about showing off or getting successes out of proportion. If you have performed well, reached a goal, however humble or simple, then that is something to recognise. All those small victories soon add up.

It is true that mistakes have to be acknowledged and learned from. They cannot just be ignored and swept under the carpet. By the same token, reading too much into them is also not realistic. Everyone makes mistakes every single day, from big to small, but even the big ones do not usually signal the kind of catastrophe you might be imagining.

Far from being all about positive thinking, the response to anxious thoughts is towards realistic thinking. You are looking for something less than completely black, something less than a total catastrophe, but you are also not white-washing the situation and pretending everything is perfect. Finding that middle ground is sometimes hard in the face of heightened anxiety, but the struggle is worth it.

Noticing the negative

One of the central issues with anxiety is paying attention to the negative. When people experience anxiety, it focuses their attention in a particular way: they are looking for problems. Have you ever noticed that when you are in a bad mood, you tend to notice more things that irritate you? In a restaurant the food seems worse, the waiters seem ruder and the chef looks like he probably spat in the soup. Being anxious is a type of negative mood and so it works in a similar way. Just as misery loves company, so anxiety loves things to be anxious about.

This creates a nasty little vicious circle. Anxiety makes people likely to see problems, which creates more anxiety and...well, you see the problem.

Exercise 10: Switching attention

A way out of this anxiety loop is to practice switching attention. For example, people who are anxious in social situations often find they are focusing on their own thoughts and feelings to the exclusion of all else. Instead, they can try switching their focus to other people. Whether that means by asking questions, or just by observing other people, it helps refocus the attention away from anxiety-provoking thoughts and feelings.

It is an old trick, but it works. It actually has two benefits: one is to help the person feel less anxious. The other is a handy byproduct of focusing on other people: they like it and often respond better, so the social situation improves.

Another example might be someone experiencing panicky feelings. Usually these are linked to paying close attention to bodily sensations like a fast heart-rate, a churning feeling in the stomach or shortness of breath. During this episode the person can try switching their attention to something in the external environment that is interesting. They can then observe what difference this makes to their experience. Most people find that they notice their bodily sensations less when focused on something external. This helps reinforce the idea that these do not signal a health problem.

The same exercise of switching focus can be useful for different types of anxiety. Learning how to switch focus -- and that it is possible while experiencing anxiety -- is something that comes slowly with time.

Exercise 11: Identify negative patterns of thinking

At the start of this section on changing thoughts, there was an exercise that asked you to monitor anxious experiences (Exercise 2). Return to the entries in this diary now and see if you can identify any of the patterns of thinking described above.

To recap, they are:

Catastrophising.

Predicting the future.

Black and white thinking.

Overgeneralising and discounting the positive.

Noticing the negative.

In addition, you can specifically monitor for these thoughts patterns over the next few days, or whatever timescale is practical for you. Use the same form as you did for monitoring anxious experiences in general.

Ask yourself:

Which patterns of thoughts do you use most frequently?

Have I tried the strategies to counter these patterns of thoughts?

What was the result?

Acceptance

Anxiety provokes all sorts of responses in people. Most people -- and especially those who are prone to high levels of anxiety -- want to try and control it in some way. This could be by

rigidly avoiding situations that might provoke it; by using distractions such as TV or drugs; or practicing relaxation techniques.

Avoidance and distraction are really both just avoidance. Relaxation techniques seem like a good idea -- and probably are in general -- but some psychologists think they are not a good response to anxiety in-the-moment. This is because if the technique does not work, then the anxiety can break through again.

An alternative is to practice acceptance. This means learning to accept feelings of anxiety and fear and trying to understand that they are a normal human response. Acceptance is about experiencing anxiety and allowing it to just happen rather than trying to work out strategies to avoid it or be distracted from it.

Now, I have to make a confession here: when I talk about acceptance, what I am really talking about is a sort of meditation, often referred to as mindfulness. There is an ever-growing body of research on the benefits of meditation for conditions like anxiety, depression and physical pain. Studies suggest that meditation can be as effective as medication, and it has no negative side-effects.

The reason for being coy about mentioning the name is that it comes with all sorts of baggage, some of it religious and some of it semi-mystical. Some people expect meditation to produce some kind of magical or altered state of consciousness. For our purposes, though, it is better to think of meditation as simply loving acceptance and nothing more.

Acceptance takes practice because it is not something that comes naturally to people. It is not an approach that seems to make sense: normally when we are in an uncomfortable situation, we do all we can to change it. Nevertheless, acceptance can be powerful, especially when there is no other option.

The basics of accepting thoughts

As the name suggests, acceptance is about avoiding passing judgment on your thoughts. The type of judgments that might pass through an anxious person's mind include "If I think like that, I am a bad person" or "What is the point of trying if it makes me feel like this?" These are just a couple of suggestions, yours are likely quite different. Judgments refer to any of the internal commentary we have on our basic thoughts and feelings. Sometimes people do not even really notice this continuous commentary until they start to focus on it.

The goal, though, is not push these thoughts away. Rather, it is to let them come and go as they will. If your mind wanders while you are trying to concentrate on something specific (and we will come to that in a moment), try to nudge your attention back to its primary aim. The feeling to adopt during all of this is one of self-compassion. People experiencing anxiety are often very harsh on themselves. If possible, try to think in a kindly way about your mind, whatever painful thoughts it is throwing at you.

The idea is to notice, in a detached way, what is happening, but not to get involved with it. This way of thinking often does not come that naturally, so requires some practice.

Like all habitual responses, the best way to become more accepting of various thoughts and feelings is to practice. There is no need to set aside formal time for being self-accepting (although, of course, you can). Any time is a good time to practice. Personally, I squeeze in little bouts of practice when the opportunity arises.

What follow is a series of exercises that are relatively easy to fit into an everyday routine.

Exercise 12: The walking meditation

If you do any period of undisturbed walking during the day — at least ten or fifteen minutes — then you can do a little walking mindfulness meditation. It will be easiest if done somewhere with fewer distractions, but try it anywhere and see what happens.

As when cultivating all forms of mindfulness, it is about focusing the attention. At first, people often concentrate on the sensation of their feet touching the ground. Then you could just as easily focus on your breath, or move the attention around your body, part by part. The key, though, is to develop a sort of relaxed attention. When your mind wanders away, bring it back gently, without judging yourself.

Exercise 13: Mindful mini-break

Checking email or social media has now become, for many, what we do in between other tasks, sometimes as a kind of break. Change this. Instead, drop the electronic device and practice some mindfulness. Turn away from the computer/newspaper/smartphone and sit for a moment noticing the sensations in your mind and body.

How do you feel? What can you hear? Try to be as present in that moment as possible. If your mind wanders off to tasks that you have to complete, or starts working over things that happened yesterday, let these go. Gently bring your focus back to the present. Just be wherever you are for a few moments. Remember: mindfulness is not about trying to make sense of anything; it is about attention to that moment.

Exercise 14: Listen mindfully

Any time that is convenient, try a little mindful listening. We get used to a lot of the sounds that are around us and quickly tune them out. If you live in the city, there might be police sirens, train announcements or people sneezing. In the countryside there could be trees rustling, birds calling or a gate creaking. What can you hear right now?

Alternatively, put on some music and really listen to it for a short period: try to hear the music without thinking about it. Let go of wandering thoughts or what the music reminds you of, or judgements about the music, or what the lyrics mean. Just allow the music to flow over you and for you to flow into the music.

Exercise 15: Experience nature

If your walking mindfulness exercises should happen to take you to a park or green space of some kind, then this is the perfect opportunity for a little more mindfulness. As you stand, sit or walk, try to become more aware of nature around you. See the different types of leaves; hear the bird calls, the wind and the distant rumble of traffic; sense the air moving over your skin and (if there is any) the sun heating your face.

Again, after a few moments, your mind may try to wander where it will. Be kind to yourself: gently nudge your attention back to nature and your surroundings. Many people do this naturally when they are in nature, but do not necessarily label it as a mindfulness exercise. It does not matter what you call it, as long as your attention is focused on the present moment and you let go of passing thoughts.

The benefits of meditation

It might feel that while practicing meditation is an interesting experiment, it is not very practical. However, practicing acceptance of your thoughts, even if they are non-anxious ones, is useful for a number of reasons. Two of the chief benefits people experience are greater emotional and attentional control.

The ebb and flow of emotions through the mind is relaxed by greater acceptance. The fact that people tend to become less emotionally reactive has obvious benefits for those experiencing anxiety. It makes it easier to cope with all the anxiety-provoking events in the world, and in the mind.

Anxiety changes the way attention is focused: it makes us seek out problems. In other words, anxiety makes us look for things to be anxious about. Acceptance or mindfulness gives us a greater feeling of power over where we direct our attention. With practice it becomes easier to change the focus of attention when necessary. This is vital for escaping from vicious circles of anxious attention and anxious reactions.

Finally, after practicing acceptance/mindfulness, people often find they have greater awareness of their body. This can be useful when trying to identify tension in the body and how it is reacting to anxiety-provoking situations.

Part 2: Changing Behaviours

Until now the focus has mostly been on challenging thoughts. Thoughts are not isolated events in the mind: they are closely linked to emotions and behaviours. Changing your thoughts can change how you feel and behave. We can also start with behaviours and these changes can filter through to thoughts and feelings. That is the aim of the next few sections.

Behavioural experiments

One of the effects of anxiety is that it provokes avoidance. When people avoid what makes them anxious, they have no opportunity to discover whether their fears are really justified. Behavioural experiments are a way out of this type of vicious circle.

Imagine a person who is afraid of spiders. It is a widespread fear that many people have. For the majority, a fear of spiders does not provide much of a problem in everyday life, but let us say that a person wants to overcome the fear in any case. One of the first things they might do is to expose themselves to something a little bit spidery and see how they feel. For example, they might look at pictures of spiders. Then they might move on to looking at a real spider…and so on. Psychologists call this graded approach to the feared object or situation 'exposure therapy'.

The same principle can work for anything which provokes anxiety. We can expose ourselves to a small aspect of it and see what happens. Behavioural experiments are a sort of exposure therapy. We expose ourselves to a little bit of the situation, the thought, feeling, or whatever it is, and see what happens.

Here are the steps you take to perform a behavioural experiment:

1. Write down the thought or belief you want to test and how strongly you believe it. Give it a number between 1 and 10, where 10 is the strongest possible belief.

2. Think up a way to test this belief. 3. Predict what will happen if you carry out this test. 4. What are any problems that might occur and any solutions you could use?

Once you have carried out the test, there are three points to consider:

1. Describe what happened when you carried out the experiment. 2. Re-rate the thought or belief on a 1 to 10 scale. 3. Reinterpret the thought or belief in the light of what happened.

This is the bare bones of the behavioural experiment, but it can be used in all sorts of different ways. It works best if tailored to your own specific anxiety and the way you prefer to test it out. Still, here are a few ways it is commonly used to give you some ideas.

The survey

People experiencing repetitive anxious thoughts sometimes like to use a survey to check them against other people's experience. This is a type of behavioural experiment. For example, sometimes people have repetitive thoughts about doing something bad, like jumping in front of a train or suddenly stabbing another person with a knife. This can lead an anxious person to conclude that they are a bad person.

The basic idea of the survey is to ask other people whether they also sometimes have these thoughts. Usually, some will say they do, although they do not act on them and are perfectly nice people.

A similar type of survey could be done by someone who finds social situations intimidating and stressful. Carrying out a survey and discovering that other people also become anxious at social situations can be beneficial. Like the survey of other people's bad thoughts, it helps to underline that these sorts of anxious thoughts are common among different people -- and perfectly normal.

Exercise 16: Survey

Carry out a survey to see if other people's thoughts are in any way similar to your own. Remember to use the steps described above so that you are predicting the outcome before you carry out the survey and then comparing your results with the prediction afterwards. Remember, other people's thoughts may not be as frequent or extreme as yours; what you are looking for is some similarity.

Facing a little fear

Another type of behavioural experiment involves facing the feared object or situation, but only in a small way at first. For example, imagine a person who dislikes social situations. One typical behaviour is to avoid eye contact with other people. The problem here is that it can come across as unfriendly to others -- most people look at each other a fair amount while talking.

The natural experiment for facing a little of the fear, then, is to try holding eye contact with someone a little and see what happens. This does not mean staring into everyone's eyes; rather it means making eye contact a little more frequently and for a little longer. It can be fascinating to see the difference between what people predict they will experience and what actually happens when they do this.

Exercise 17: Face a fear

Try devising an experiment to face a little fear. Choose something that only provokes moderate anxiety in you to start off with. Again, remember to use the steps described above to predict what you think will happen and so on.

There is much more on behavioural experiments for facing fears in Part 3 in the sections devoted to each type of anxiety. For now, try make a start by doing something obvious. If other people make you anxious go towards that; if it is a certain situation, think of a way to approach it; if it is dirt or disorder, work out ways of exposing yourself to these to test your response.

Taking some risks

Risks are normally at the forefront of the minds of people experiencing anxiety. Risks seem to be everywhere and most of them probably feel unacceptable. The consequences may feel too awful to contemplate -- almost, but not quite, because people feeling anxious are already picturing the potential disasters that could follow.

Of course, there is no way to guarantee the absolute safety of ourselves and our loved ones at all times. Unfortunately, it is just not the way the world works. Living with uncertainty is better than being cooped up at home avoiding situations all the time -- although sometimes it may not feel like it.

Since avoidance of risk only perpetuates anxiety, it makes sense that taking some very small risks to test the consequences is a useful exercise. Learning to take risks does not necessarily mean sky-diving, rock-climbing or bungee-jumping -- indeed these things might well not scare you. It could be something as simple as opening the front door and going outside, or picking up the phone to call a friend. The types of risks we are talking about, most people might not consider risky -- but to a person experiencing anxiety, they may well feel very risky.

Exercise 18: Take a small risk

Try choosing a small risk you could take. It should be something which rationally you know is not that risky. However, it should be something that normally makes you anxious about the potential consequences. It might be a social occasion, a telephone call or anything else you have been putting off because it makes you anxious.

Again, remember to use the steps described above to predict what will happen beforehand and then compare that with what does actually happen. It is also key to integrate the results of the experiment with your predictions.

How to use the experiments

The experiments should be more than one-off exercises. Trying more exercises to take more risks and face more fears will help your anxiety. After taking one small risk, for example, you could try a different type of small risk, or even a larger one. Similarly, after facing one fear, you could try a different or greater fear. If you need to, consider referring back to your

thought monitoring to pinpoint the types of situations, thoughts and feelings that make you anxious.

There are further suggestions later in the book for exercises for specific types of anxiety. In general, though, the principle is to keep trying to push the boundaries of your anxiety.

Do not take my word for it...

After reading these behavioural experiments, some people may be planning to carry them out. Others, though, may say to themselves: "OK Doctor, I will take your word for it, let's get on to the next section."

It is very important to recognise, though, that the experiments are all about experience. By experiencing them personally, people learn much more than if they simply take it on trust. There is a big difference between someone telling you that other people find their worries are not as bad as reality and actually finding this out for yourself.

Alternatively, others may be saying, "It is all very well for you to say everything is going to be OK if I test out my anxieties, but I am different to everyone else. My anxieties work in a different way." This is a common response -- and, of course, it may well be true. That is why it is all the more important to carry out the experiment to test it out. What did you expect to happen and what actually happened? How did you think you would feel and how did you actually feel? Maybe you are different to everyone else, but how will you know until you test it?

Also, bear in mind that by its nature anxiety tends to produce avoidant behaviour. Our minds want to come up with reasons why we should avoid the feared thoughts or situations. These reasons are not necessarily wrong, but they can conveniently allow us to continue avoiding the feared object or situation.

Get some exercise

This is a relatively short section compared to some of the others. Do not let its length trick you into thinking this is not an important component of alleviating anxiety. The only reason this section is short is that there is not much to say and you may well have heard it all before.

Exercise has been repeatedly found to help people with anxiety. Even low intensity exercise -- like walking at a leisurely pace -- is beneficial. But, the higher intensity exercise you can manage, the more beneficial it will be psychologically.

A few pointers about exercise:

Try to do things you enjoy and look forward to. For example, if you do not enjoy spin classes, then it is hard to stay motivated.

By the same token, try to avoid things which are purely about exercise and which you cannot get much pleasure out of.

Exercise that is built in to your everyday routine is much better than something that requires a big effort in terms of time or money.

One simple example is to go for a walk at around lunch-time. At the weekend, can you walk to the shop to get a pint of milk? Personally, I find these kinds of errands with some purpose work better than going only for the sake of exercise.

These are some bland suggestions simply because fitting exercise into the day should be a mundane event. You do not necessarily need high-vis jackets, expensive gyms, tight Lycra or any other equipment to do some exercise. Whatever you can manage will help. The more you can do, the more it will help. The more it is integrated into your everyday routine, the more likely you are to do it.

Part 3: Strategies for specific anxiety issues

This section covers strategies tailored for the most common types of anxiety issues. These are:

Generalised anxiety and worry.

Social phobia.

Specific phobias.

Panic.

Obsessive-compulsive disorder (OCD).

Generalised anxiety and worry

Many people's worries are not necessarily specific to a particular situation, object or event. Instead they experience more generalised worries. Some people worry about anything and almost everything: money, health, the economy, the universe -- you name it. These are all perfectly normal -- most people worry about their finances, health and performance from time-to-time -- but it is problematic when the worrying is excessive. Some people find these worries uncontrollable and they can cause tension, tiredness, problems with sleep, and so on. Over time, of course, the worrying wears the body down. Both mind and body are over-stimulated and, slowly but surely, both become exhausted.

People who feel very anxious build up a series of strategies to avoid worrying. Here are some common ones:

Distraction: Any activity can be a distraction from worry: cleaning, running, shopping or playing video games. The problem is, once the activity is finished, the worry starts to creep back in.

Suppression: Trying to push thoughts out of the mind. Unfortunately, this makes them come back stronger.

Avoiding certain situations: keeping the self or others away from situations linked to worries.

Changing thoughts and images: trying to adjust the images or thoughts in the mind to reduce worry.

Although some of these techniques can be useful, one problem is that they all involve avoiding the fears. Avoidance tends to maintain the fears.

The drive to worry is also maintained by various strong psychological forces. Here are a few:

Uncertainty: worriers dislike uncertainty more than other people. Worrying is a way to try and work out what will happen in the future by running scenarios in the mind. Instead, worriers need to find a way to tolerate uncertainty.

Hypothetical problems: worriers need to distinguish 'real' problems from hypothetical ones. Frequently generating hypothetical problems is one of the things that keeps worry going.

Poor problem solving: Worry is maintained by both positive and negative beliefs about worry. Certain beliefs about worry need to be addressed and adjusted. One belief about worry that can be negative is that it is actually solving the problem or working towards a solution. Worriers can feel their worrying is helping them, when it is actually hindering them. Research shows that people who spend a lot of time worrying do not normally solve problems very well.

In the sections below are strategies and exercise to help you deal with persistent worries in constructive ways.

Tolerate uncertainty

Learning to tolerate uncertainty can be difficult for people who experience anxiety. The key is to look for situations which are uncertain and start going towards them, rather than away from them.

For example, uncertainty is generally low sitting at home, but higher when meeting new people. Asking others for confirmation of your decision, or checking and re-checking emails or always ordering the same meals in the same restaurants are all behaviours of a person who finds it hard to tolerate uncertainty. Instead, try the reverse: do not ask for confirmation from others, try a different meal and do not check and re-check an unimportant email before sending it. Even taking an unfamiliar route or going in a random direction for once can be beneficial.

Exercise 19: Try anxiety-provoking activities

Make a list of activities that are uncertain and so make you anxious. You might like to take inspiration from the notes made while monitoring anxious experiences. This can provide some clues as to what worries you might try to face. Give each one a rating as to how anxious it makes you, say from 1 to 10. Then start with the highest number you can face and try it out to see how it feels.

To help your motivation, you might like to list some of the practical advantages of side-stepping these worries. For example, people who have to check and re-check emails before they are sent often get behind with their work. So, worrying less about typos in relatively unimportant communications could help you get ahead at work.

Another example might be eating new foods in different restaurants. The advantage will be in discovering another place to go and a new small pleasure in life.

If the new activity is working, then you will feel anxious, but you will also feel the anxiety wearing off over time. Once you are relatively comfortable with a behaviour that you have rated, say a '4' or a '5', move on up to the next level and tackle a '6' or a '7'.

For each experiment, including this one, remember that it is best to go through the process of predicting what will happen beforehand, then seeing what happens in reality and then comparing the two.

Here is a reminder of the steps:

1. Write down the thought or belief you want to test and how strongly you believe it. Give it a number between 1 and 10, where 10 is the strongest possible belief.

2. Think up a way to test this belief (this is the anxiety-provoking activity you have settled on).

3. Predict what will happen if you carry out this test. 4. What are any problems that might occur and any solutions you could use?

Once you have carried out the test, there are three points to consider:

5. Describe what happened when you carried out the experiment. 6. Re-rate the thought or belief on a 1 to 10 scale. 7. Reinterpret the thought or belief in the light of what happened.

Exercise 20: The worry period

A technique for coping with chronic worrying that some people find useful is the worry period. It involves allocating a particular time during the day in which to do your worrying. Set aside, say, half hour in the evening and get your worrying done then. Any worries experienced during the day should be noted down and worried about later.

Two words of warning: try not to have your worry period too close to bedtime or it will likely disturb your sleep. The second is during your worry period, it is better to focus hard on worrying about one thing at a time. When the mind wanders, gently bring it back to your main worry. Once you have finished worrying about one thing, it is fine to move onto another.

It might seem strange that in a book on reducing anxiety, there is a section encouraging you to worry. The explanation is two-fold. It can help free chronic worriers up for the rest of the day -- they know that the worry-period is waiting for them. Second, the worry period can be a useful time to work on anxiety issues. Remember that facing fears is the way to reduce their effect: this is exactly what you can do in the worry period.

Whether or not you decide to use a specific worry period, indeed whenever you do your worrying, it is important to know the right way and a wrong way to worry...

How to worry

We have already discussed some techniques that people use to avoid worrying, like suppression and distraction. Chronic worries also often learn habits of worrying that are less than useful:

1. Getting too involved with hypothetical worries: involves imagining worries about the future. Projecting yourself further forward to more and more potential tragedies.

2. Racing from one worry to the next without really analysing, 'solving' or 'resolving' each one (if solving or resolving is even possible).

3. Starting to solve a problem, then avoiding it when it feels too difficult to deal with.

Real or hypothetical

The first stage in how to worry is to work out whether you are worrying about a real event or a hypothetical event. Often worries about real events create worries about hypothetical events. For example, say your partner is late home from work and you cannot reach them on their phone. While sitting calmly reading this book, I am sure you can list ten unthreatening, logical explanations which involve your partner returning home unharmed later in the evening (a meeting, traffic, dead battery and so on). But the anxious mind can quickly create a series of scenarios that are a whole lot worse (multiple car pile-up, electrocution, heart attack and so on). These are worries about hypothetical events: things that might conceivably happen, but which have not happened yet.

Exercise 21: Identify worries

Try writing down some worries about real-world events and some about hypothetical events. Be sure you understand the difference, as the psychological approach is different. Remember that hypothetical events have not yet happened, whereas real-world events have happened already.

Hypothetical worrying

Hypothetical events can be extremely anxiety-provoking and tremendously uncomfortable to contemplate. A horrible aspect of hypothetical worries is there is nothing to be done about them -- other than worry, of course.

One of the things that keeps hypothetical worries going is that the fear is not really faced. Tactics people use to keep their distance from their worries include suppression and distraction. It is like in a scary movie, where the director spends most of the film hiding the monster that is slowly devouring the inhabitants of a small American town. Hinting at the monster while keeping it mostly hidden is the key to building up the viewer's fears. The

same is true of our hypothetical fears. What is required is to shine a light on them and see how we react.

Another thing that keeps hypothetical fears going is that sometimes people believe worrying is good. Some might believe worrying is a sign of caring, or that, if they worry enough, they will reach a solution of some kind. Both have some kernel of truth, but not to the extent of the worrying you are probably doing.

Exercise 22: Face hypothetical fears

The way to deal with hypothetical worries is to face up to them. Whether it is in your 'worry period' or at another time, the key is to think through these hypothetical worries carefully without trying to distract yourself, suppress the feelings or avoid them in any way.

Many people's natural response to this instruction is that it seems strange and frightening. Surely thinking more about hypothetical worries will make them stronger? Remember, though, that most people have tried avoiding and suppressing worries and this has not worked: they are still causing fear and discomfort. So, why not try something different?

1. Choose one hypothetical worry that you face (you might like to take one from Exercise 2: monitor anxious experiences).

2. Write about it in some detail. Describe what you see, feel, hear and think. Really get inside the worst part of the worry.

3. As you write, it is likely you will start to feel very anxious and possibly upset. This is normal. Try to sit with this anxiety and fear as you write.

4. When you finish your first draft, go back through to add any details you may have missed out. Try to make it as vivid and anxiety-provoking as possible. Remember, we are moving towards the fear here, not away from it. There is no need to write a 'happy ending' or resolve anything. Just write down your fears and leave it there.

5. Reread what you have written at a later time, sit with the anxiety and fear that you feel while reading.

6. Repeatedly re-read and see how it makes you feel the next day and a week later.

The idea is that -- as with all anxiety -- the feeling gets stronger, peaks, then starts to fall away as you face it. This may take a little time or a lot, but each time you read the hypothetical fear, your feelings towards it will change.

The goal is to see the hypothetical worry for what it is: a fear about something that has not happened. In the long-run, it will be clearer when this hypothetical worry is arising in your mind. It will be easier to understand and know how to deal with the fear. More than anything else, the mind should move towards an awareness that the worries are just thoughts and nothing more.

Once you feel that you are coping well with one of your hypothetical fears, then it is time to move onto the next one and perform the same procedure. You may well notice similarities in the content of other fears. They could have themes of loss, separation or be about

finances or work performance. Learning to tolerate these fears better will help you in the future.

Real problem worrying

From hypothetical fears, we move on to worrying about real problems. Real problems in this context mean events that have actually happened, rather than those that might happen. This section has some simple techniques for how to solve problems. They will not give you the answers, but they can help you problem solve in the right way.

Remember that many real-world problems do not have solutions and often there is nothing to be done about them. Realising that there is nothing to be done is not a solution and may not reduce worrying, but it is nevertheless an important realisation. Acceptance of what cannot be changed or 'fixed' is a better strategy.

Avoidance is the classic response of someone who is anxious. In this case people often worry theoretically, but fail to make any decisions. Another way of avoiding problems is to enlist others to solve them for us. The disadvantage with this is that we do not get the experience and gain the confidence that we need ourselves.

Exercise 23: Problem-solve

Choose a real problem to work on. You might like to start with something mentioned or hinted at when monitoring anxious experiences at the start of the book (Exercise 2).

Try following these pointers to see if they work for you:

1. Tackle the easiest part first: Making a start with the easiest part can help break any procrastination that has built up. Do not mentally go around different problems, focus on this one.

2. Go towards the problem not around or away from it: People experiencing anxiety often come towards a problem, then quickly move away from it because of the unpleasant feelings it evokes. Try to go towards the problem.

3. Use concrete questions: When anxious, people ask themselves questions that begin "what if...?" and "why...?" To solve a problem, it is better to use more concrete questions that start with "how...?", "where...?" and "when...?" Focus on the concrete steps that you are going to take.

4. Think it through enough: Making a decision quickly without really thinking about it is another way to get away from the problem. If you have the tendency to make impulsive decisions, try sitting with the problem for a little longer than usual to really think it through.

5. Don't think it through too much: Instead of an impulsive approach, some people over-analyse. They will look for multiple solutions and even more problems that arise from these seeming solutions. If you have this tendency, then remember that tomorrow's problems are for tomorrow and next week's problems are for next week.

Just focus on making one decision here and now and trust yourself to cross the other bridges when you come to them.

6. Try it and see: People feeling anxious tend to have little confidence in their decisions. They can easily envisage all the ways their decision can backfire. Try thinking of your decision as an experiment to see what happens. Then, if it does not work, you can always try something else. (Bear in mind, though, that not all problems require action: choosing to do nothing is also a decision -- it can be a bold one, depending on the situation.)

7. Set it and forget it: Once the decision is made, try to move on to another problem rather than continuously revisiting the decision that has been made.

Maintenance

Anxiety and worries come and go with the ebb and flow of everyday life. It is quite normal to find that anxieties fade when using the techniques described here, but they return months or years later. Habits of both thought and behaviour can change almost imperceptibly over the years. If that time comes in the future, it is useful to revisit the techniques described here to give yourself a top-up.

Other sections to review

A number of sections from the start of the book will be particularly useful for people with generalised anxiety. Consider reviewing the following for further ideas:

Mindfulness and acceptance are very useful for people experiencing generalised anxiety. Have another look at this section, which is at the end of Part 1 (Exercises 12 to 15).

People with generalised anxiety often find it hard to take risks. Have a look at the section on learning to take risks. This is near the start of Part 2 (Exercise 18).

A strong need for control is often seen in generalised anxiety. Consider the strategies mentioned in the middle of Part 1 (Exercise 6).

Social Phobia

Feeling anxious in social situations is an extremely common experience. Most people feel some kind of anxiety in more stressful social situations. There is meeting new people, giving a presentation, having a job interview -- the list goes on. Interactions with others can easily generate anxiety.

Anxiety can easily lead to the avoidance of social situations. Of course, there is nothing wrong with preferring to be on your own, or with avoiding groups of people if that is what makes you happy. Some people, though, feel that social anxiety is blocking them from getting the things they want: relationships, promotions or just human contact in general.

Although it may not feel this way, your relationships may already be better than you think. People who are socially anxious typically believe they are coming across much worse than they actually are. Studies find that socially anxious people rate their relationships as worse than their friends do. Put the other way around: your friends probably see your relationship as better than you imagine.

Social phobia can manifest itself in different ways. Some people are more fearful of informal events like parties, others of speaking in public. Sometimes it is speaking up for themselves -- being assertive -- that causes socially anxious people problems.

This section is all about how to apply some of the general ideas discussed in the first part of the book to social situations.

Forget yourself

With social anxiety, people tend to focus on themselves too much. It is not just what they are thinking, but also how they are feeling. For someone experiencing social anxiety, the attention seems irrevocably pulled towards their own flushing cheek, churning stomach and trembling hands. Naturally, a focus on the self leads to poor conversation: it is hard to react to a person that we are not paying attention to.

Often the reason people feel they need to concentrate on themselves is to monitor how well they are coming across. Unfortunately, this tends not to work well because it is very difficult to know how we are coming across to others. All it really does is hinder our ability to interact.

Instead of focusing on the self, it is better to focus externally. All of your attention does not have to be focused on the other person, that can also produce an unnatural effect. The best place to start switching attention is in conversations with people you know and trust. While you are talking, try to focus your attention very closely on what they are saying. Then let your attention rest on yourself again. Switching your attention like this should provide quite different experiences. Hopefully, as you switch your focus to the other person, you will notice more about how they feel, what they are really saying and many other subtleties.

Once you are comfortable with switching your attention away from yourself, try a more challenging situation. That might include talking to someone you do not know so well or even casual conversations with people in shops or out in public.

Exercise 24: Switch focus

Choose a social situation in which you can practice switching your focus. Try it out and then choose a more stressful situation in which you can practice switching focus. For example, you might start while interacting with a colleague at work and then move on to a stranger later on. Remember that the aim with switching the attention is to be yourself by forgetting yourself.

Changing self-talk

The things we say to ourselves during anxious moments can provide useful information about what is keeping the anxiety going. Try to tune in to any self-talk that goes through the mind during social situations.

People's self-talk often centres around one of four themes:

1. I am boring: for whatever reason, many people with social anxiety think they are boring. In reality, of course, people have interests in different things. Whether two people are interested in each other depends on the match between them. It is better to find out a little about the other person and see if you are interested in them, rather than worrying about whether they are interested in you.

2. High standards: those feeling socially anxious often put a lot of pressure on themselves. They have high standards for how conversations should go. In reality, of course, real-life conversations are nothing like TV or the movies. If you read a transcript of a normal, everyday conversation, it is pretty obvious how low the standard is! "Uh, so, uh, what, uh, do you reckon on the, um, weather that is...like...we have been having..?" It is not exactly Shakespeare.

3. It is my fault: Poor conversations and poor interactions are happening all the time. Either person in a conversation can get distracted, tired and so on. Despite this, people experiencing social anxiety tend to take all the blame themselves when it goes badly and none of the credit when it goes well. Hopefully, focusing on the other person a little will help to make it clear that it takes two to tango.

4. They can see right through me! People experiencing anxiety sometimes feel others can read them like a book: a very anxious book. Most people have a natural tendency to project their thoughts and feelings on to others. Actually it is hard to read someone's emotions from the outside and most people's anxiety is nowhere near as obvious as they imagine.

Exercise 25: Monitor thoughts

Try the exercise "monitoring anxious experiences" mentioned at the start of the book (Exercise 2). Use it to notice the kinds of self-talk you are using before, during and after social interactions and whether they fall into any of the categories above.

Also, have another look at the section on changing self-talk in Part 1 that comes directly after the example sheet for monitoring anxious experiences. Ask yourself if you are catastrophising, predicting the future and so on. It is very common for people who are socially anxious to catastrophise. If so, use the strategies mentioned earlier to challenge these thoughts. Can you catch yourself catastrophising in the moment, and deal with it effectively?

Safety behaviours

People who are anxious about social situations naturally start to avoid them. Sometimes psychologists call these 'safety behaviours'. They are little tricks that people learn to avoid having to interact. They might include things like leaving social events early or outright refusing invitations, avoiding speaking to someone they find attractive, or keeping quiet in front of others, instead of expressing an opinion.

The problem with safety behaviours is that they encourage avoidance. They also reinforce the idea that the situation is 'dangerous' in some way -- otherwise why else would we need a safety behaviour?

Exercise 26: Identify safety behaviours

When you monitored your anxious experiences, did you notice any safety behaviours? Some typical ones include keeping an eye on the exit or holding things very tightly so as not to shake. Perhaps you also tend to rehearse what you are going to say? Rehearsing can be useful in some situations, but in others it can make conversation stilted. Make a note of these behaviours so they are easier to spot -- then work on reducing them.

Social experiments

To help battle these avoidant tendencies, we can run some simple social experiments. These are about breaking down the fear attached to social anxieties. The idea with the experiments is to be curious about your own and other people's reactions to social anxiety.

The experiments mentioned below are just examples. These do not have to be used unless they are things that make you anxious. Start with something that is a small challenge for you. But do not stop with one experiment. Keep trying new things and compare what happened with any fears you may have had beforehand. It is even better if the experiments

form a progression. For example, making more eye contact might be followed by expressing more of your opinions, which could lead to longer conversations with people that you do not already know so well.

In fact, every social interaction is an opportunity to gather more information about whether any fears you have are well-founded.

For each experiment, remember that it is best to go through the process of predicting what will happen beforehand, then seeing what happens in reality and then comparing the two.

Here is a reminder of the steps:

1. Write down the thought or belief you want to test and how strongly you believe it. Give it a number between 1 and 10, where 10 is the strongest possible belief.

2. Think up a way to test this belief. 3. Predict what will happen if you carry out this test. 4. What are any problems that might occur and any solutions you could use?

Once you have carried out the test, there are three points to consider:

5. Describe what happened when you carried out the experiment. 6. Re-rate the thought or belief on a 1 to 10 scale. 7. Reinterpret the thought or belief in the light of what happened.

While you are following these steps, try to be as objective as you can. People with social anxiety are prone to conduct very harsh 'post-mortems' after social interactions. These usually only serve to make them feel worse about the social interaction. Instead, try to stick to the facts.

Exercise 27: Survey friends and acquaintances

An easy one to start with is the survey. This involves asking a few close friends whether they ever get nervous in social situations. It is such a common experience that most people will have something to share. Try asking people what they are worried about and how they deal with those worries. Try to notice exactly what other people are saying about their fears. Were their fears realistic? How do they compare to any fears you might have? Remember, there are no right or wrong answers here; this is just about gathering information.

Exercise 28: Push social boundaries

The types of experiments that are a good idea to run are those which gently push your boundaries. For example, one option is to try telling other people a bit about what you have been doing when asked "How Are You?" Instead of just saying "fine" and shutting down the conversation, you can test a little more information.

Another mentioned earlier is to practice looking at other people's eyes during conversations. Remember that it is important to compare any fears you might have had about the social encounter to what actually happened.

Exercise 29: Acts of kindness

Another experiment to try involves doing acts of kindness for other people. These can be small things like picking up a neighbour's dry cleaning or running some other small errand for them. The idea is that it provides a way to have a small social interaction with someone you do not know that well.

Maintenance

The aim with using experiments, addressing self-talk and changing attention is to become more comfortable with social situations. Being totally free of anxiety in every social situation, though, is not a realistic goal. The aim is to live the life you want while keeping anxiety at a manageable level.

To maintain your progress, it is important to continue to see social situations as opportunities to test your reactions. It is easy to slip back into old ways. Rather than avoiding people and groups, get in the habit of going towards them from time-to-time. Continue to push yourself and use some of the exercises described in this section, along with those that are relevant and useful to you from Parts 1 and 2.

Other sections to review

A number of sections from the start of the book will be particularly useful for people with social phobia. Consider reviewing the following for further ideas:

People with social phobia often find it hard to take risks. Have a look at the section on learning to take risks. This is near the start of Part 2 (Exercise 18).

Much of the self-talk people with social anxiety use is damaging. Review the section on changing self-talk at the start of Part 1 (Exercises 3 to 5 in particular). Consider what your self-talk reveals about your underlying beliefs. For example, you might believe other people are generally hostile or that it is better to avoid revealing information about yourself. What other core beliefs could be limiting your progress?

Specific phobias

This section addresses what psychologists call 'specific' phobias. These are fears and anxieties linked to particular objects or places: two of the most well-known are arachnophobia and claustrophobia (fear of spiders and enclosed spaces).

Although there are many different types of specific phobias, they usually fall into one of a few categories. These are fear of:

The environment: water, heights, storms and so on.

Animals: snakes, spiders, dogs, insects and other creatures.

A particular type of situation: enclosed spaces like lifts, open space, fear of flying.

Medical and blood: seeing blood, injections, and dental trips.

The experience for people with a specific phobia is to have the feeling that something terrible is going to happen when in the presence of the phobic object or situation. The heart may race, the stomach churn and people often describe feeling as though they are going mad or about to faint -- perhaps even die. As with all highly anxious situations, bodily sensations feed into more anxious thoughts until the situation can be exited.

Naturally this causes people with specific phobias to avoid the feared object or situation. Unfortunately, leaving the situation immediately does not provide any evidence to the person feeling anxious about what actually happens if they stay in the situation. Do the awful predictions come true?

The best treatment for specific phobias is to expose oneself slowly to the phobic object or situation. The key is to stay in the situation long enough to find out that the catastrophic events that might be feared beforehand do not actually occur. This section gives you guidance on how to go about doing that.

For each exercise, remember that it is best to go through the process of predicting what will happen beforehand, then seeing what happens in reality and then comparing the two.

Here is a reminder of the steps:

1. Write down the thought or belief you want to test and how strongly you believe it. Give it a number between 1 and 10, where 10 is the strongest possible belief.

2. Think up a way to test this belief (in this case, it is exposure to the phobic object or situation).

3. Predict what will happen if you carry out this test. 4. What are any problems that might occur and any solutions you could use?

Once you have carried out the test, there are three points to consider:

5. Describe what happened when you carried out the experiment. 6. Re-rate the thought or belief on a 1 to 10 scale. 7. Reinterpret the thought or belief in the light of what happened.

Exercise 30: Make an exposure plan

Only by gaining real-life experience of the feared object or situation can the mind and body learn. That is why the best exercise for overcoming specific phobias is to expose yourself to the feared object or situation.

Most people find a graded exposure to be the least stressful. This means starting out small and working upwards. For example, if flying produces uncontrollable anxiety, it might be worth visiting an airport -- at first without taking a flight. If spiders cause anxiety, then just looking at pictures of them could be a good first step.

Below are further instructions on how to create your own exposure plan. The instructions for this exercise are a little longer than normal, so bear with them. First we have to consider safety behaviours.

Avoiding safety behaviours

While being exposed to the anxiety-provoking situation or object, it is important to avoid any safety behaviours. Safety behaviours are often built up over time to try to reduce anxiety. The reason it is best to avoid safety behaviours is that they work like a crutch. The mind learns that it can cope with situations as long as we do a certain thing. For example, someone afraid of flying might grip the armrests of the plane. We need to learn what the feared situation or object is like without using any crutches or safety behaviours.

Avoiding safety behaviours is hard because they are often highly habitual -- things that are done automatically, without thinking. When you expose yourself to the feared object or situation, try to notice any thoughts or behaviours that might be trying to 'keep you safe'. Make a note of these mentally and do not use them to make you feel better during exposure.

Exposure

It is best to start with a level of exposure that causes you a medium amount of fear and then work from there. For example, here is a progression that could be used for a fear of spiders:

1. Catch a spider in the house with a glass and piece of paper. 2. Touch the spider and watch it run away (not turn and attack, as many imagine). 3. Let the spider walk on your hands. 4. Let the spider walk up the body towards the face. 5. Then repeat with bigger spiders.

Here is another example of the steps that could be used for someone who is fearful of getting injections:

1. Looking at a picture of a needle. 2. Holding a real needle. 3. Giving an injection to a piece of fruit. 4. Going to a doctor to discuss having an injection. 5. Getting the injection.

Whatever your specific fear of a situation or object, the progression should look something like this. At each stage it is important to feel the fear ramping upwards and then allow it to slowly subside. Do not let the third or fourth step put you off, just start with the first step and see how it goes. Once reasonably comfortable (remember, a total absence of anxiety is not likely, especially at first), move on to the next stage.

All these suggestions need to be adjusted for your individual phobia and the amount of fear you experience. Everyone has different levels of anxiety and there are different aspects of any situation or object that provoke anxiety. The important thing is to experiment with your phobia and try to go towards the feared object or situation as much as you can. At the same time, do not expose yourself to too much anxiety or it will put you off trying again.

The main point is to expose yourself to moderate levels of anxiety and see what happens. Usually, people find that their anxiety slowly dissipates with time. This must be experienced, though, first hand -- do not take my word for it.

Self-talk

Try to gather information about what specific fears are keeping the anxiety going. Sometimes these are revealed in the self-talk that flits through the mind during anxious moments. Notice what kinds of thoughts cross your mind during the first few steps of exposing yourself to the feared situation or object.

These are some common thoughts that you may recognise from earlier in the book:

Probability overestimation. This means overestimating the chance that something terrible is going to happen. People who are afraid of heights tend to overestimate the chance they will fall. People who get anxious around spiders overestimate the chance it will bite them. People who are anxious fliers overestimate the chance the plane is going to crash.

Catastrophising. When catastrophising, people assume that if something does go wrong, it will be the very worst thing that can happen. Those afraid of heights are sure they are going to jump to their death, despite being 10 metres away from the edge. Those anxious about spiders think a bite will kill them.

Exercise 31: Follow the logic through

One thing you can do to work on these types of beliefs is follow them through to their logical conclusion. The key is to think through your thoughts and beliefs. Do they seem

reasonable? What would you say to a person who espoused these beliefs? Are your predictions realistic? It may help to glance back at the section on catastrophising in Part 1 (Exercise 4).

Maintenance

If you have managed to start facing the situation or object that provokes anxiety, then well done, but the work is not done. It can be easy to slip back into old habits of avoidance and safety behaviours. That is why, if the previously feared situation or object naturally arises in everyday life, it is a great idea to use it as a learning opportunity. Try to engage with the situation or object as a way to test your levels of anxiety.

Continuing to experience some anxiety is to be expected -- anxiety is a normal part of everyday life. But there is a difference between feeling some anxiety and feeling so anxious you are prevented from leading the life you want. People who experience a lot of anxiety can find it difficult to acknowledge gains they have made. Anxiety can be seen in black-and-white terms. "Either I am anxiety-free, or I am a wreck." Of course, the truth lies somewhere in between.

Other sections to review

A few sections from other parts of the book will be particularly useful for people with phobias. Consider reviewing the following for further ideas:

Acceptance of phobic thoughts can help you deal with the anxieties related to exposure. Practice accepting anxious phobic thoughts (Exercises 12 to 15).

Catastrophising is commonly seen with panic attacks. Review the section in Part 1 for strategies to counter this (Exercise 4).

Black and white thinking contributes to phobic anxiety. Consider trying the exercises for challenging this way of thinking (Exercises 7 and 8).

Panic

What psychologists call 'panic disorder' is a little different from the everyday use of the word panic. When having a panic attack, people experience intense fear, a very strong physical reaction and the sensation of being about to die or losing complete mental control. Physical symptoms include shortness of breath, chest pain, upset stomach, sweating and shaking. That is why many people think they are having a heart attack. Of course, thinking you are having a heart attack contributes to the panic. This is all in the face of very little real danger -- although it feels very different to the person experiencing it.

Often people experiencing a panic attack feel there is a physical problem. This is possible. That is why it is sensible to get checked out by a physician. If they, or perhaps other people, suggest it could be more psychological, then panic attacks are a possibility.

Panic attacks are quite common among people who experience a lot of anxiety. It is estimated that around 1 in 10 people experience at least one panic attack in a year. They may not be frequent, but can be triggered by a situation or object that provokes deep fears. For example, people who are fearful of social situations may have a panic attack at a party. Or, people who are fearful of enclosed spaces might have a panic attack in a lift. People who primarily have a panic disorder, though, can experience panic attacks apparently in response to little more than being afraid of being afraid. It is often the fear of having a panic attack that starts the attack itself.

There is a kind of swirl of thoughts at the heart of panic attacks. One of the first steps in addressing panic attacks is understanding and breaking down what is happening.

Stage 1: The first sign of disaster could be anything small that causes the first twinges of anxiety. It might be an upsetting thought, noticing a fast-beating heart or being in a certain situation.

Stage 2: As the anxiety grows -- usually very rapidly -- the physical symptoms get worse. The heart beats faster, the sweats start, the adrenalin flows. These physical sensations only seem to confirm those first twinges of anxiety: it feels as though it must certainly be a heart-attack or some other catastrophic problem.

Stage 3: Anxious thoughts have now become catastrophic thoughts. Naturally, this leads right back into more anxiety, physical sensations and so on.

In this loop it is clear that there are two things that cannot be changed and one thing that can. It is not possible to eradicate anxiety; almost everyone experiences that from time to time. Physical sensations are also part of our everyday life. Walking up the stairs makes the heart beat faster, lying down and relaxing makes the breathing slow, and so on. The one thing that can be changed is how anxiety and physical sensations are interpreted.

Exercise 32: Triggers and self-talk

Identify what triggers the panic attacks. Often people do this by keeping a diary, or sometimes just by thinking back to recent attacks. Whatever works for you. People often

say it is particular places or situations, sudden feelings of anxiety caused by something else or a sensation in the body.

Identify the catastrophic thoughts that are present before or during your panic attacks. These could be things like "I am going to die," or " I am going to have a panic attack." Consider other explanations for the feelings in your body. Racing hearts are also caused by caffeine, worrying, feeling embarrassed, walking briskly, and more. A racing heart is rarely the symptom of a medical condition.

The same thinking process can be used for any other symptoms. Try to come up with other explanations for sensations that are experienced during a panic attack. Could there be other ways of interpreting how the body is feeling without reaching a catastrophic conclusion?

Exercise 33: Refocusing attention

Paying a lot of attention to something makes it seem worse than it is. Try switching attention during a panic attack to something else in the environment. Look at a friend's face, notice the weather, or simply pay attention to something on the ground. Note the change in your experience as you shift your focus away from your body to things in the environment.

Avoiding safety behaviours

Often people who have had a series of panic attacks feel they were frequently close to disaster during the attack, but just managed to avoid it. Over time, safety behaviours can develop: these help those experiencing panic attacks feel that they are safe. Unfortunately, they can make the symptoms worse.

If you feel like fainting, it makes sense to breathe more deeply. Of course, breathing deeply leads to hyperventilation and dizziness.

If it feels like a heart attack, it makes sense to focus the attention on the heart. Naturally, paying more attention to the heart makes you notice more sensations there.

If it feels like you are going crazy, it makes sense to try and control your thoughts. Unfortunately, trying to control thoughts -- especially when very anxious -- is usually counter-productive and leads to the thoughts getting stronger.

These are just a few examples of the types of safety behaviours people use. Try to spot how you react to the feeling of rising panic. The key point about safety behaviours is that they actually keep the fear going. Apart from contributing to the symptoms, they also provide a kind of false crutch. It might feel like they are helping, but in reality they are not.

Even controlled breathing can turn into a kind of safety behaviour. Controlled breathing is sometimes taught as a way to relax and, indeed, it is a good way to do this under normal circumstances. However, someone experiencing panic attacks can unconsciously learn that

if they control their breathing, that disaster will be avoided. Again, it is important to learn that nothing bad will happen even without controlling the breathing.

One of the most important safety behaviours of all is leaving the situation. This kind of avoidance can ultimately lead to radical lifestyle changes. People can stop having sex or exercising because it raises the heart rate, they can avoid going out or being in confined spaces because it makes them feel anxious. Some typical safety behaviours include always bringing a friend or carrying some drugs to calm down.

The problem with always leaving the situation is that there is no opportunity to see what really happens if you remain in it. The mind needs to gather experience about what actually happens, otherwise it can create imaginary scenarios that may be unrealistic.

All these different types of safety behaviours described here have to go. The mind and body has to learn that even without the safety behaviours, nothing bad is going to happen. It is important to prove these things to yourself. Part of the challenge of dealing with panic attacks is going through them, experiencing them, and finding that your worst fears are not in fact realised.

It may not be possible to instantly dismiss all your safety behaviours, but leaving behind some of the precautions that you tend to use puts you on the road to recovery. Panic attacks will continue to give you strong bodily sensations and considerable anxiety, but the anxiety will lessen once the mind learns that nothing bad happens.

Exercise 34: Avoid safety behaviours

Identify safety behaviours and try not to use them. Safety behaviours could involve making plans in advance or carrying certain objects with you, having people with you or behaviours you perform when you feel an attack is coming. Ultimately, all these need to be left behind. The mind must learn what happens when no safety behaviours are used.

For each experiment, remember that it is best to go through the process of predicting what will happen beforehand, then seeing what happens in reality and then comparing the two.

Here is a reminder of the steps:

1. Write down the thought or belief you want to test and how strongly you believe it. Give it a number between 1 and 10, where 10 is the strongest possible belief.

2. Think up a way to test this belief (in this case, it is avoiding safety behaviours). 3. Predict what will happen if you carry out this test. 4. What are any problems that might occur and any solutions you could use?

Once you have carried out the test, there are three points to consider:

5. Describe what happened when you carried out the experiment. 6. Re-rate the thought or belief on a 1 to 10 scale. 7. Reinterpret the thought or belief in the light of what happened.

Exercise 35: Induce panicky feelings

A useful exercise is exposing yourself to some of the bodily sensations linked to panic attacks. Here are some ways you can induce feelings that are linked to your panic attacks:

Spin around to feel dizzy: make sure you do this somewhere 'unsafe', such as out of the house or in public.

Take some deep breaths until you start to feel lightheaded. Do this in a situation in which you are already a little nervous.

Drink a double espresso and feel your heart racing.

All of these are designed to teach your mind that a racing heart, a dizzy feeling and light-headedness are all normal and do not mean you are going to panic.

As usual, when exposing yourself to feared situations, start with one that produces middling levels of fear and get used to that first. Then, work your way upwards to things that you find more panic-inducing. These should be tailored for your specific fear. The previous chapter on specific phobias has a section called 'exposure' that has examples of these types of graded exposures.

Maintenance

As with other forms of anxiety, those experiencing panic attacks can find they return after a period. This is perfectly natural and not a sign of failure. Rather, it is a sign that life changes and our minds do as well. If panic attacks return, the same procedures described in this chapter should be tried again. Hopefully your familiarity with the exercises will make them easier to perform. What worked before can work again.

Other sections to review

A number of sections from other parts of the book will be particularly useful for people with panic attacks. Consider reviewing the following for further ideas:

Catastrophising is commonly seen with panic attacks. Also review the section in Part 1 for strategies to counter this (Exercise 4).

A strong need for control is sometimes seen with panic attacks. Consider the strategies mentioned in the middle of Part 1 (Exercise 6).

If your panic attacks are in response to certain objects or situations, then consider the strategies described in the previous section on specific phobias (Exercises 30 & 31).

Obsessive-compulsive disorder

Obsessive-compulsive disorder is marked by intrusive thoughts that are typically experienced as repulsive. The 'obsession' in the name refers to an obsession with an anxiety: it could be cleanliness, for example. The 'compulsion' in the name refers to a compulsion to carry out a behaviour that makes the sufferer feel better. Perhaps the most familiar example is people repeatedly washing their hands (a compulsion) to avoid getting a disease (an obsession).

Another way to think about OCD is in terms of safety behaviours. These start as ways of reducing anxiety in the moment. For example, someone scared of an evil thought might shake their head three times to 'wipe it away'. Obsessive-compulsive disorder occurs when the anxieties and associated behaviours to reduce these anxieties become problematic.

It is useful to know that some people are considered to have OCD despite 'only' having obsessions or 'only' having compulsions. Around 70% have both obsessions and compulsions, 20% just obsessions and 10% compulsions alone.

Here are some common obsessions:

Need for orderliness and symmetry.

Fear of dirt or contamination by germs.

Excessive doubt.

Fear of sinful or evil thoughts.

Fear of making a mistake.

Fear of harming another person.

Thinking about acting inappropriately or shouting obscenities.

Here are some typical compulsions:

Getting mentally ‘stuck’ on certain images or thoughts that will not go away.

Repeated hand-washing, showering or bathing.

Repeating particular words or phrases.

Always arranging things in a certain way.

Constant counting during routine tasks, whether mentally or out loud.

Performing tasks a certain number of times.

Always checking things like locks or ovens.

Collecting or hoarding things with no value.

These are just some common obsessions and compulsions, there are many others. Whatever the obsessions and/or compulsions, most people who experience OCD feel that their thoughts make them bad, mad or even dangerous in some way. Part of learning to deal with these thoughts is changing this attitude towards them.

Identify what keeps OCD going

Let us think about what tends to trigger your OCD. If this is already perfectly clear to you, then skip this section. Otherwise, it is important to understand what is keeping it going: then it is easier to put a stop to it. Identify the types of thoughts or images that tend to worry you. It often helps to think of a recent episode of OCD and what triggered it. Consider the thoughts, images or feelings you had.

For example, one person might see an image of a family member being hurt, another might be obsessed with a patch of dirt on the floor. Some responses to these thoughts could be repeating a particular word repeatedly, either out loud or in your head. Another could be cleaning the hands, floor or other places very carefully, despite the fact they were only just cleaned.

One important thing to try and focus on is what comes between the thought and your action. This is the interpretation you put on the image, thought or feeling. What does it mean that you saw an image in your head of a family member being hurt? What does it mean that there is a patch of dirt on the floor? Typically for people experiencing OCD, both mean something catastrophic and extremely worrying. You may even interpret thoughts to mean that something bad is going to happen unless you perform some ritual.

It is these interpretations that are part of what is keeping the OCD going.

Have a think about what beliefs about your anxieties might be keeping your OCD going:

Do you think that worrying more means you care more?

Perhaps you feel responsible for preventing harm?

Maybe you also want to control your own thoughts? This would certainly be understandable given how intrusive and irritating they can be.

Below are a variety of exercises you can use to face the things that are keeping your anxiety going, and other aspects of OCD.

Exercise 36: Survey

People experiencing OCD often experience intrusive thoughts or impulses that they take to be signs of mental disturbance. Actually, research from around the world has shown that 94% of people have experienced unwanted, intrusive thoughts or impulses in the last three months.

Do not take this research at face value. Try asking a few friends or family members whether they have ever had intrusive thoughts which were repulsive to them. See what they say, and how they deal with them. Compare this to your own experience.

Exercise 37: Not scanning for danger

Typically people with OCD spend a lot of time scanning ahead for danger. They are searching both their minds and the environment for problems. One useful exercise is to see what happens when you do not scan ahead for danger.

Remember that it is best to go through the process of predicting what will happen beforehand, then seeing what does actually happen, and then comparing the two. Here is a reminder of the steps:

1. Write down the thought or belief you want to test and how strongly you believe it. In this case it may be something like: if I don't scan ahead for danger, I will have a nasty accident. Give it a number between 1 and 10 where 10 is the strongest possible belief.

2. Think up a way to test this belief (in this case, it involves not scanning ahead for danger).

3. Predict what will happen if you carry out this test. 4. What are any problems that might occur and any solutions you could use?

Once you have carried out the test, there are three points to consider:

5. Describe what happened when you carried out the experiment. 6. Re-rate the thought or belief on a 1 to 10 scale. 7. Reinterpret the thought or belief in the light of what happened.

While you are doing the experiment, try to switch your attention away from scanning for danger to other things in the environment: trees, people, shops, the sky, and so on.

After turning off the scanning for a period, what was the effect? Did what you predicted actually happen, or something else?

Most people with OCD find that when they stop continually scanning for danger, they notice less danger. They also worry less and most of the worrying events they fear do not occur.

Thought-action fusion

Many people with OCD feel that thinking something makes it more likely to happen. It could be something that you might do or something that is going to happen. This is called thought-action fusion. It really means giving too much power to thoughts.

For example, a person imagines their friend falling down in the street and breaking their ankle. They believe that thinking this thought is enough to increase the probability that it will happen. They might even feel that the thought is a kind of premonition. The effect of this type of thinking is to make someone with OCD feel responsible for bad things that happen to others. It is also this responsibility that stops a person with OCD from living life fully: for fear of being responsible for harm to others.

Exercise 38: Thought experiment

The natural way to counter thought-action fusion is to run a simple, but possibly slightly frightening experiment. Try imagining that someone you know will fall over in the street in the next 24 hours and break their ankle. Some people find this instruction immoral, despite the fact that the only thing you are doing is thinking the thought -- you are not tripping them yourself. If you believe that your thoughts alone can affect what happens, then it is understandable that you might find this instruction immoral. Nevertheless, really believing that your thoughts alone cannot affect what happens is a vital step to changing how you think.

Again, go through the process of predicting what will happen beforehand. Monitor how you feel over the next 24 hours. Do you feel anxious about the person? Do you feel responsible yourself? What happens after the 24 hours is over? Did the person break their ankle? If they did not, how does that affect your responsibility for your thoughts?

(If anything does happen to your friend in this period, it is just a coincidence. In this case it is best to try the experiment again.)

After doing the experiment once with a friend, try repeating it for a close loved one. This time, though, make the consequences more serious -- as serious as you can bear. Then see what happens over the next 24 hours.

Exercise 39: Reduce responsibility

People experiencing OCD often feel highly responsible for things that, in reality, they have little control over or influence on. As we saw in the 'thought-action fusion' experiment, people with OCD feel their thoughts can influence the world. Another aspect of this is taking too much responsibility for your actions or potential actions.

For example, let us say a person experiencing OCD is thinking of organising a party. While planning it, they might imagine all the possible events that could go wrong at the party. One friend might drink too much and fall over, another might meet someone and cheat on their partner...the list of possible negative consequences of a party is endless.

As a thought experiment, though, try to apportion responsibility out between people. The organiser of a party is not 100% responsible for everything that happens at that party, are they? What percentage, then, can be attributed to people other than the party organiser? The person who slips over should take some percentage. The maker of their shoes should also take some percentage. The person who dropped their drink and made the floor slippery should also take a fair amount of responsibility. What does that leave you with?

Notice that there is one result of a party that someone experiencing OCD is likely to discount: most people might have a really good time. Why is it that all the responsibility for positive outcomes is not assumed? Why is it you do not think of all the potentially good

things that could happen and take responsibility for those? That is not the aim of the experiment: the aim is to let go of some responsibility for the outcomes, whatever they are. Still, it is worth considering how you can be responsible for all the bad stuff, but not the good stuff.

Exercise 40: Check less, be more confident

This part often makes no sense to people with OCD, but push on with it in any case. Remember, these are all experiments to see what happens. If we do not try the experiments, they have absolutely no chance of giving you any useful evidence. I write this here to try and give you an extra push with this experiment, because if you do a lot of checking, then it can be powerful.

Many people experiencing OCD have various rituals of checking. They will check the oven is off multiple times, that the door is locked and whether their heart is still beating. These checks will often be such that they cause a major interference to ordinary, everyday life. They are also linked to high levels of experienced fear.

The revelation -- which you may or may not believe at this stage -- is that checking actually makes you less sure. Not only that, but a little checking breeds more checking. In fact, checking leads to exactly the opposite result than the one that is being hoped for. We might hope to reduce anxiety and increase certainty by checking, but it does the reverse.

An experiment to test this involves doing a lot of checking one day and checking only once the next day. Then, you compare your confidence from one day to the next. For example, you might choose to check the oven is off the first day for 20 minutes. Then, the next day, you check it just once. Later in both days record how confident you are that the oven is off. Most people have a very clear memory of just checking it once and feel more confident than when they checked it multiple times.

Comparing the effects of checking with not checking will prepare you for the next exercise...

Exercise 41: Stop checking

The second exercise is to stop checking altogether.

Think back to a type of checking that you used to do in the past: an obsession you used to have, but no longer do. If you do not have one that has totally disappeared, then choose one that has reduced in strength. Can you think of the reason that it has reduced in strength? Often it will be because it conflicted with something you wanted to do.

For example: checking the front door was locked and the oven off repeatedly made you late for work, so you reduced the checking or even managed to cut it out so you could make it to work on time. Presumably the house was not burgled or burned down, so the lack of checking did not cause anything bad to happen.

If you were able to reduce or eliminate this type of checking without catastrophic consequences, then it must be possible to do the same with other types of checking.

In this way, past changes to obsessions and compulsions can be used to fuel changes to current obsessions and compulsions.

Choose one compulsive habit and decide to eliminate it for one day. Try to choose something that you feel you can cope with first to give you confidence for future changes. For example, someone with a compulsion to wash their hands frequently might choose not to wash their hands at all for one day. If you compulsively check the oven is off and the door locked, then decide to not check at all for one whole day. If you can manage a few days, then so much the better.

If you are having problems committing yourself to this exercise, remember that while not washing or checking the oven might seem like huge risks to a person who is very anxiety-prone, they are not really that risky.

Once you have completed one day successfully, then try to increase the run to a few days, then a week. The habit should begin to fade without repetition. Notice how you feel now that the habit has lessened.

Do not rest after a single success: move onto another type of checking and start eliminating that as well.

Exercise 42: Stop avoiding

Sometimes an obsession does not manifest itself as checking, but rather as an avoidance. For example, people obsessed with cleanliness often avoid touching door handles. Similarly, people with an obsession about always being correct might avoid unfamiliar situations where they might be shown to be wrong.

When the obsession is about something you are not doing, then, to fight it, you need to start doing it. Those obsessed with cleanliness should start touching as many foreign door handles as they can. Those worried about being wrong should put themselves in new situations where they are likely to be wrong: say, learning a new language or other skill.

Use the same progression as for checking. Start with something simple that you have been avoiding that you can do repeatedly for one day. Then extend your run to a few days. See how the change makes you feel. Do not rest after tackling one type of avoidance. Move straight on to other ways of going towards the things you are trying to avoid.

Here are some examples of other types of activities that may be useful depending on your particular obsessions:

Resist the urge to tidy up: leave the kitchen messy and the bathroom towel on the floor.

People with OCD sometimes hoard things: try throwing some things away.

Think a lot about thoughts that are repugnant to you, rather than trying to avoid them. See how it makes you feel.

Maintenance

Like other forms of anxiety, OCD has a way of creeping back into your life in different ways. Be vigilant for new patterns of avoidance or new compulsions arising from obsessive thoughts. The same types of exercises described above will help with any new obsessions or compulsions that appear.

Other sections to review

A number of sections from the start of the book will be particularly useful for people with OCD. Consider reviewing the following for further ideas:

People with OCD often find it hard to take risks. Have a look at the section on learning to take risks. This is near the start of Part 2 (Exercise 18).

Catastrophising and black-and-white thinking are commonly seen in OCD. Review these sections in Part 1 for strategies to counter this (Exercises 4, 7 & 8).

A strong need for control is seen in OCD. Consider the strategies mentioned in the middle of Part 1 (Exercise 6).

Exercise has repeatedly been found to help people with OCD.

Part 4: Keep going

Whatever type of anxiety you are dealing with, progress will usually be slow. As you try some of the exercises, you will make some headway, then, inevitably, there will be little (or possibly larger) setbacks. It is easy to get discouraged, especially as small improvements in behaviour are easy to miss over time.

A key to any type of change -- whether psychological or physical -- is monitoring progress. Giving yourself feedback about how you are doing will enable you to see if there is a problem that needs to be addressed, or if you can give yourself a pat on the back.

There are many different ways to track your progress as you deal with anxiety. Some people might like to set themselves particular goals which are easy to monitor. For example, for people who are reducing the checking behaviours linked to OCD, these are relatively straightforward to monitor.

Other aspects of anxiety may be more difficult to monitor because they cannot be seen. For example, let us say you are working on reducing the amount of catastrophising you are doing. Like black and white thinking and overgeneralising, these are thoughts which are hard to monitor.

So, my preferred method -- although this is only a suggestion -- is to simply choose some specific behaviour that is important for you to improve and keep tabs on that. For example, someone with social phobia might monitor how often they socialise. Someone experiencing panic might monitor how often they managed to go into a particular panic-inducing situation, without using their safety behaviours. Someone dealing with general anxiety might choose how often they managed to stick to using a specific 'worry period' as their measure of progress. What you choose is down to you and, of course, it can be more than one thing. The important thing is to choose something and keep an eye on it.

If you really cannot use a behaviour, then you will have to use a general rating system for your anxieties. Once a week you could ask yourself how bad your anxieties have been on a scale of 1 to 10. On this scale a 1 is totally normal with no interference with everyday life -- whether social or at work. A 10 would be almost constant distress along with the highest level of avoidance and maximum disruption of life.

Hopefully, tracking will allow you to see your progress. People can see all kinds of different types of progress. Some move forwards steadily, others in fits and starts -- some need to give their program a few tweaks to get it working.

How to deal with common problems

If you are not seeing the progress you would like, or no progress at all, it is time to consider some possible problems. Here are some things to think about:

1. Am I challenging my cognitive distortions?

Recall that people experiencing anxiety often have ways of thinking that are not helping them. These include catastrophising, intolerance to uncertainty and black or white thinking. It is important to challenge these ways of thinking using some of the tools in Part 1.

2. Am I starting to avoid things again?

The classic response for someone experiencing anxiety is avoidance. That could mean avoiding people, places, thoughts or emotions. Have a think about what you might be avoiding and find a way to go towards it. Only by going towards the feared thing can the mind get vital information. Part 2 contains exercises related to taking risks and facing fears that can be useful for this.

3. Have my safety behaviours returned?

People experiencing anxiety often have some specific thoughts or behaviours they use to help them feel safe. Again, the mind has to learn to live without these thoughts or behaviours. Try to identify any safety behaviours and find ways to deal with them. Part 3 contains more on safety behaviours for most types of anxiety. Remember that safety behaviours can bring the fear level down (which is why they are attractive), but the idea is to face the fear without any safety net.

4. Have I tried several different strategies which are adapted to my fears?

There are a lot of different exercises included in this book. If you feel one is not working, then try something different. As many strategies as are included here, it is impossible to cover all the different fears people have. So the chances are you will have to adapt the strategy to your fear. Try to think about any novel ways you can move towards your fears rather than away from them. If you can adapt the ideas in this book to your own situation, it will probably work better for you.

5. Am I lacking motivation?

I have written an ebook on motivation, but here are a couple of pointers:

Self-compassion. People experiencing anxiety can be harsh on themselves. Try to think about the self with kindness and compassion, seeing mistakes or problems in context, without evaluating or judging them. Setbacks will happen, mistakes will be

made -- these things are almost inevitable. People who treat themselves with self-compassion, though, often find their motivation increasing.

Avoid excuses. While being compassionate towards yourself, it is also important to accept if you have not made the effort you wanted. Making excuses makes us feel better, but unfortunately it also kills motivation. Better to accept failure compassionately and then plan to do better.

6. Am I pushing myself?

Progress relies on steadily facing greater fears. For example, someone with OCD might first get used to the idea of touching door handles, then might move on to not washing their hands for an entire day.

Despite the importance of self-compassion, consider if you are really pushing yourself. Try exposing yourself to greater fears and see how it goes. If it really is too much, then you can scale it back. But if you can tolerate it, then you have made some well-deserved progress.

7. How to deal with relapse

The best way to think about relapse is that there is no such thing as relapse. In other words: it is unhelpful to think that all is lost if you experience fear or use your safety behaviours. It is better to accept that the road is long and you have to keep working at it. There will be slips, bumps and mistakes along the way.

If (and when) you find fear is creeping up again, just remember how you have dealt with it before and do it again. Everyone continues to experience fear from time-to-time. The aim is not to totally get rid of fear; the aim is to stop those fears getting in the way of the life you want to lead.

8. Road block?

People's personal circumstances and anxieties differ greatly and it may be that, with other stresses and strains in your life, it is too difficult to follow a self-help guide like this one. If you are not seeing the progress you were hoping for, then it may be better to considering recruiting some extra help. This could be a trusted friend or family member, or it could be a mental health professional. Either way, seeking help is the right thing to do -- no one can provide the support you need unless you ask.