Student Workbook

Welcome to Anxiety Toolbox, a fast-paced, three-session seminar intended to help increase your understanding and knowledge about anxiety.  The goal is to provide you with some skills to recognize and manage symptoms you may be experiencing.  We hope you find it helpful.

The goal of this seminar is to provide you with life-long tools you can use while facing anxiety-triggering situations.  Remember, this intervention is not intended to “get rid of” your anxiety.  While occasionally unpleasant, some anxiety can actually be a helpful and motivating emotion.  Our hope is that these three sessions provide you with a jumping board from which to integrate skills into your daily life in the service of reducing anxiety. 

By the end of this course, you will have received a lot of information and at times it may feel overwhelming.  Remember that like any skill (e.g., learning to ride a bike), the skills you will learn in Anxiety Toolbox take time and practice to master.  At times, you may encounter obstacles and/or find it difficult to integrate these skills into your daily life.  That’s okay, it’s how change works, and as with all change, it’s important to practice as much as you can, even after encountering setbacks.  

Think of your practice of these skills as a form of “mental health hygiene.” At the outset, it may seem tedious and you may question why you need to practice these skills so often.  Think of it like dental hygiene—you brush your teeth multiple times a day to prevent the buildup of plaque and ultimately to prevent cavities.  Similar to brushing your teeth, daily practice prevents a buildup of anxiety and stress over time.  The more you practice and use these skills as part of your daily routine, the less tedious they may seem because they simply become a regular part of daily life. 

Should you wish to focus more in depth on any of your anxiety related concerns, you may debrief with a therapist following completion of Anxiety Toolbox to discuss options. 

If at any time you feel that you need additional support, please let your Anxiety Toolbox leader know or contact USF CAPS at (415) 422-6352.  You may also find additional resources online at usfca.edu/counseling

What is Anxiety Toolbox?

Anxiety Toolbox is a fast-paced three-session seminar specifically designed to help people who struggle with a variety of anxiety-related concerns (e.g., panic attacks, Generalized Anxiety, test anxiety).    The goal of this seminar is to provide education on anxiety and to teach coping skills for managing anxiety symptoms.

Why does Anxiety Toolbox use a 3-session model?

Teaching Anxiety Toolbox over the course of 3 sessions allows you sufficient time to learn the concepts with time to practice between sessions.  Keeping it to three 50-minute sessions allows you to find time in your busy schedule to learn these skills.

What if I need more than 3 weeks to learn the model?

You are not alone.  The skills taught in Anxiety Toolbox are difficult and take time to build.   For this reason, we offer a follow up anxiety group intended to provide further support for practicing these skills. 

What if I don’t feel comfortable in groups?

Many people feel a little anxious about participating in a group.  Anxiety Toolbox is structured and curriculum-driven, like an academic class.   You are not required to speak to the entire group if you do not feel comfortable doing so.  The facilitators respect each participant’s right to share only what they are comfortable sharing and never require you to share sensitive or potentially embarrassing information about yourself.

What if I have an urgent need to see a counselor during Anxiety Toolbox?

Simply let the facilitator or Counseling Services’ front desk staff know and they will facilitate you getting the help you need. 

Why do I have to do homework?

The focus of this workshop is on building skills to cope with anxiety; in order to achieve that goal, regular practice is essential.  The more you practice, the more you may find you get out of this workshop.   The assignments are for you and only you, in the service of your own personal growth.  You will not be required to provide your responses at any time during this workshop; however, it’s important to bring your responses as you may be asked to look back on or elaborate on a prior assignment during the workshop. 

What if I didn’t do my homework?

We encourage you to come to group regardless of whether or not you were able to complete the homework assignment.   If you forget your workbook, we can provide you a new one.  We can also assist you in working on examples when the homework is reviewed. 

(A person is confronted with an anxiety-producing situation which leads to an uncomfortable sense of worry and agitation.)

(The anxiety-producing situation is avoided, and the person receives a feeling of relief. However, next time the anxiety will be worse.)

Common Anxiety symptoms

1. Get regular. Go to bed and get up at more or less the same time every day, even on weekends and days off!
2. Get up & try again. Go to sleep only when tired. If you haven’t been able to fall asleep after 30 minutes, get up and do something calming (not stimulating) until you feel sleepy, then return to bed and try again.
3. Avoid caffeine & nicotine. Avoid consuming any caffeine (coffee, tea, soda, chocolate) or nicotine (cigarettes) for at least 4-6 hours before going to bed. These act as stimulants and interfere with falling asleep
4. Avoid alcohol. Avoid alcohol for at least 4-6 hours before bed because it interrupts the quality of sleep.
5. Bed is for sleeping. Do not t to use your bed for anything other than sleeping and sex, so that your body comes to associate bed with sleep.
6. Electronics Curfew. Don’t use back-lit electronics 60 minutes prior to bed, as the artificial light prevents hormones and neurons that promote sleep.
7. The right space. Make your bed and bedroom quiet and comfortable for sleeping. An eye mask and earplugs may help block out light and noise. 
8. No naps. Avoid taking naps during the day. If you can’t make it through the day without a nap, make sure it is for less than an hour and before 3pm.
9. Sleep rituals. Develop rituals to remind your body that it is time to sleep, like relaxing stretches or breathing exercises for 15 minutes before bed.
10. No clock-watching. Checking the clock during the night can wake you up and reinforces negative thoughts such as “Oh no, look how late it is, I’ll never get to sleep.”
11. Keep daytime routine the same. Even if you have a bad night sleep it is important that you try to keep your daytime activities the same as you had planned. That is, don’t avoid activities because you feel tired. This can reinforce the insomnia.

Adapted from http://www.cci.health.wa.gov.au

Session 1: Homework Assignment

Homework 1: Complete at least 1 Simple Cross Sectional Formulation worksheet for review next week (Cross Sectional Formulation HW1)

Homework 2: Practice Deep Breathing

Homework 3: Implement 1 Sleep Hygiene Tip

Cross Sectional Formulation

Identifying Triggers Worksheet

Triggers

While at times it may be difficult to identify a trigger, understanding your triggers for anxiety is an important step in helping you know when to implement and/or emphasize practice of the coping strategies you will learn in Anxiety Toolbox.  Triggers can be external events (e.g., a test) or internal stimuli (e.g., a physical sensation or emotion) that led to your experience of anxiety (i.e., the emotional, physical, cognitive, and behavioral symptoms previously discussed during this workshop).  Remember that sometimes the symptoms themselves can be a trigger that starts the cycle of anxiety. 

The following are some typical categories in which triggers might appear with examples:

Responses to Internal Stimuli:

• Emotions: e.g., feeling down, fear or worry
• Mental Images: e.g., replaying interpersonal interactions or performance experience
• Physical State:  e.g., racing heartbeat, lightheadedness, tightness in chest
• Thoughts: e.g., “I might fail this test”, “That person must not like me”, “If someone talks to me in class, I won’t be able to handle it.”  

Responses to External Stimuli:

• Presence of Others: e.g., attending a social event, meeting with a professor, spending time with roommates, family interactions
• Physical Setting:  e.g., a classroom, open areas on campus, inside a car
• Social Pressure: e.g., feeling pressured to make friends, feeling pressured to perform well in school (in comparison to your peers)

• Activities: e.g., a sports event, a party, going home for the weekend

List some triggers you experience related to your anxiety:

Session 2

Homework Assignments

Homework 1:  Complete Identifying Triggers Worksheet (Identifying Triggers HW2A)

Homework 2:  Complete at least 1 Simple Cross Sectional Formulation worksheet for review next week (Cross Sectional Formulation HW2B)

Homework:  Identifying Triggers

Identifying Triggers HW2A

Pay attention to any triggers for anxiety that you may experience over the next week.  Write them down in the following categories.  You may have triggers in all of the categories or you may notice triggers in only one or two categories.  (Use the “other” category for triggers you feel don’t fit in the options listed.)

Emotions:

1.

2.

3.

Mental Images:

1.

2.

3.

Physical States:

1.

2.

3.

Thoughts:

1.

2.

3.

Presence of Others:

1.

2.

3.

Physical Setting:

1.

2.

3.

Social Pressure:

1.

2.

3.

Activities:

1.

2.

3.

Other:

1.

2.

3.

Cross Sectional Formulation HW2B

Alternative ResponseWorksheet HW3A

Alternative Response Worksheet

If you're having trouble, ask yourself these questions:

Whenever we recognize an anxiety-related thought, feeling or behavior, it can be very helpful to ask ourselves the following questions:

Alternative THOUGHTS:

1. What are other ways of looking at this situation?
2. Am I looking at the whole picture?
3. What might be a more helpful way of picturing this situation?
4. What unhelpful thinking styles might I be using here (see below)?
5. What is the evidence that my thoughts are true?  Is there an alternative way of thinking about this situation that is more true?
6. What is the probability that my thoughts will happen?  What are some other things that could happen that are equally, if not more, probable?
7. Have I had any experiences in the past that suggests that this thought might not be COMPLETELY true ALL of the time?
8. Can I really predict the future?  Is it helpful to try? What is more helpful?
9. Am I exaggerating how bad the result might be?  What is more realistic?
10. Can I read people’s minds?  What else might they be thinking (that’s not so negative)?
11. If a friend or loved one were in this situation and had this thought, what would I tell them?

Alternative BEHAVIORS:

1. What could I do in the moment that would be more helpful?
2. What’s the best thing to do (for me, for others, or for the situation)?
3. If my feared situation happens, how will I cope?  What coping skills can I use to handle my feared situation? What have I done in the past that was successful?
4. Am I needing to work on acceptance, letting go of control, being okay with less than perfect, or having faith in the future and myself?
5. Breathe:  Focus your attention on your breathing.  Imagine you have a balloon in your belly, inflating on the in-breath, deflating on the out-breath.

 Alternative FEELINGS:

1. What might it feel like if I acted/thought differently?
2. When I’m not feeling this way, do I think about this situation differently? 
3. Are there any strengths or positives in me or the situation that I might be ignoring?
4. What else might this anxiety be related to?  Is it really about feeling _______?
5. Tell yourself: “This feeling will pass.  It’s a normal body reaction.”

Alternative Response Worksheet

Alternative ResponseWorksheet HW3A

Pleasant Activities

Putting it all Together: 

My Plan for Managing Anxiety

Puttingit all Together: MyPlan for Managing Anxiety HW3B

1. My primary anxiety symptoms include: 
   1. Emotional:
   2. Physical:
   3. Cognitive:
   4. Behavioral:
2. Some of my unhelpful ways of thinking are: (e.g., all or nothing thinking, catastrophizing, etc.) 
3. My situational and cognitive triggers are: (e.g., unfamiliar situations, negative thoughts, etc.) 
4. The most helpful grounding techniques:
5. The most helpful relaxation exercise:
6. The best time and place to practice relaxation exercises:
7. When I feel overwhelmed, it is helpful for me to: 
8. Positive changes I can make to help my sleep include: (e.g., no TV 30 minutes before bed, wake up at the same time daily, turn phone off, etc.)
9. MY GOALS:  Name 2 goals you would like to achieve over the next few months, related to anxiety and self-care.  Think: specific, achievable, and measurable.
   1. Name 2 goals you would like to achieve related to ANXIETY (e.g., Thinking about the strategies you find most helpful, what would you like to try, how often, when, etc.?)
      1.  
      2.  
   2. Name 2 goals you would like to achieve related to SELF-CARE: (What will your self-care look like over the next few months? These could be goals related to nutrition, exercise, sleep, schoolwork, leisure activities, etc.)
      1.  
      2.  
10. Reminder about plan and goals:

Stress versus Anxiety

Understanding Anxiety Disorders

While anxiety is a normal and adaptive experience for everyone, anxiety disorders are characterized by significant distress or impairment in social, academic/occupational, or other important areas of functioning (e.g., your general ability to function in life). 

Some of the most common anxiety disorders include:

Generalized Anxiety Disorder:      Chronic and unrealistic worry that feels difficult to control about everyday things (i.e., things that do not worry most people)

Social Anxiety Disorder:                  Chronic worry solely related to social situations

Panic Disorder:                                   Characterized by episodes of “panic” that include things like: adrenaline surge, fear of losing control, chest pain, racing heart, shortness of breath, dizziness

Phobias:                                                 Specific fears that are excessive in nature and often lead to avoiding that which is feared (e.g., public speaking, heights, tunnels, etc.)

Obsessive-Compulsive Disorder:    Excessive rumination (thinking) with repetitive behaviors to reduce anxiety

Grounding Exercises

When people become overwhelmed with distressing thoughts or feelings, including intense anxiety, activities that keep your mind and body connected (called “grounding”) can be helpful in regaining a sense of stability and mental focus.  The following are a number of grounding exercises to choose from to help firmly anchor you in the present moment and provide you with space to choose where to focus your energy.  You may need to try multiple different exercises to find one or two that work best for you. 

1. Remind yourself of who you are now. State your name, age and where you are right now.

2. Take ten slow deep breaths.  Focus your attention on each breath on the way in and on the way out. Say the number of the breath to yourself as you exhale.

3. Splash water on your face or place a cool wet cloth on your face.

4. Pay purposeful attention as you hold a cold (non-alcoholic) beverage in your hands. Feel the coldness, and the wetness on the outside. Note the taste as you drink. You can also do this exercise with a warm beverage.

5. Find a “grounding object” to hold, look at, listen to, and/or smell.  This could be a soft object such as a pillow or stuffed animal, a smooth stone you found on the beach, a picture of a beautiful scene or loved one, and/or any other object that represents safety or comfort. 

6. Listen to music. Pay close attention and listen for something new or different.

7. If you wake up suddenly during the night and feel disoriented or distressed, remind yourself who you are and where you are.  Look around the room and notice familiar objects and name them. Feel the bed you are lying on, the softness of the sheets or blankets, the warmth or coldness of the air, and notice any sounds you hear.  Remind yourself that you are safe.

8. Feel the clothes on your body, whether your arms and legs are covered or not, and the sensation of your clothes as you move in them.

9. While sitting, feel the chair under you and the weight of your body and legs pressing down on it.

10. If you are lying down, feel the contact between your head, your body and your legs, as they touch the surface you are lying on. Starting from your head, notice how each part feels, all the way down to your feet, on the soft or hard surface.

11. Stop, look, and listen. Notice and name what you can see and hear nearby and in the distance.

12. Look around you, notice what is front of you and to each side, name first large objects and then smaller ones.

13. Get up, walk around, take your time to notice each step as you take one then another.

14. If you can, step outside, notice the temperature, the sounds around you, the ground under your feet, the smell in the air, etc. 

15. “54321” Grounding Exercise:
    • Name 5 things you can see in the room with you. 
    • Name 4 things you can feel (tactile; e.g. “chair on my back” or “feet on floor”)
    • Name 3 things you can hear right now
    • Name 2 things you can smell right now
    • Name 1 good thing about yourself
16. Write and/or say grounding statements
    • This situation won’t last forever
    • This too shall pass.
    • I can ride this out and not let it get me down.
    • My anxiety/fear/sadness won’t kill me; it just doesn’t feel good right now.
    • These are just my feelings and eventually they’ll go away.   

Adapted from: http://www.livingwell.org.au/well-being/grounding-exercises/

Breathing Exercises

Belly (or Diaphragmatic) Breathing

You can do this exercise in any position, but it is helpful to do this exercise while lying down when first learning belly breathing.

1. Lie comfortably on your back, with a pillow under your head, your knees bent and your back flat. You can stretch your legs out if that's more comfortable.
2. Place one hand on your belly and one hand on your upper chest.
3. Inhale slowly and expand your belly as you breathe so that your lower hand moves with your belly. The hand on your chest should remain as still as possible.
4. Slowly exhale, focusing on the movement of your belly and lower hand as it returns to its original position.
5. Repeat steps 3 & 4 for several minutes, always focusing on the movement of the belly as you breathe. If your mind wanders, gently bring your attention back to your breathing.

Breath-Counting Exercise

This exercise focuses on the use of counting with the rhythm of the breath.  Start with a short period of time and gradually increase the time. Set a timer so that you do not have to worry about when to stop.

1. Find a comfortable position. Take several deep breaths and settle into yourself. You may either close your eyes or keep them open, depending on your own comfort. If you keep them open, fix them on an object or a spot on the floor about four feet in front of you. Your eyes may be either focused or unfocused.
2. Take deep, comfortable breaths. Notice your inhalation. The pause between inhaling and exhaling, your exhalation, and the pause before starting again.
3. As you inhale, count, “one...” As you exhale, count, “two...” Inhale, “three...” Exhale, “four...” Continue until you reach 10 then start over.
4. If you lose count, simply begin with “one” on your next inhalation.
5. If you notice your mind has wandered, gently notice this, and return your focus back to counting your breath.
6. If you notice any body sensations catching your attention, focus on that sensation until it fades. Then return your attention back to counting your breaths.

 Books for Further Reading

The Anxiety and Phobia Workbook by Bourne (2011)

The Anxiety and Worry Workbook by Clark & Beck (2012)

Get Out of Your Mind and Into Your Life by Hayes & Smith (2005)

Self-Esteem by McKay and Fanning (2005)

The Mindful Way Workbook by Teasdale, Williams, Segal, & Kabat-Zinn  (2014)

The Mindfulness Workbook: A Teach Yourself Guide by Langley (2013)

The Relaxation & Stress Reduction Workbook by Davis, Robbins, Eshelman & McKay (2008)