Anxiety Disorder Interventions

Effective
Interventions for
Anxiety Disorders
1
Effective Interventions for Anxiety
Disorders
Table of Contents
Generalized Anxiety Disorder Diagnostic Criteria.........................................1
Post Traumatic Stress Disorder Diagnostic Criteria.....................................2
1.Social Phobia Disorder Diagnostic Criteria................................................3
Seci!ic Phobia Disorder Diagnostic Criteria................................................3
Panic Disorder Diagnostic Criteria................................................................"
Post#Traumatic Stress Disorder # $est Practice Guidelines.......................1%
D&AG'(ST&C )*A+,AT&('...................................................................1%
Anxiety Symtom -atrix.............................................................................2.
1. Anxiety /uestionnaire..........................................................................20
2. Acti1ity Scheduling...............................................................................32
3. Goal#Setting 3or4sheet........................................................................33
...................................................................................................................30
". Acti1e +istening Techni5ues..................................................................30
.. Progressi1e -uscle 6elaxation............................................................."2
7. )ducation 8 Cogniti1e Distortions De!ined.............................................2
%. Cogniti1e Thin4ing 6eort......................................................................."
9. The Daily Plan........................................................................................%
0. 3riting :reely........................................................................................72
12. Desensitize ;oursel!............................................................................72
11. Systematic Desensitization...................................................................7"
12. <o= To -anage Tra1el Anxiety...........................................................%7
13. Tis To Protect ;our Sense o! Personal Sa!ety...................................%9
1". )xosure Theray ...............................................................................%0
1.. )xosure to :eared Situations.............................................................91
17. <ierarchy o! :ears................................................................................92
1%. <ighest <oes> Deeest :ears............................................................97
19. <o= to (1ercome a Phobia..................................................................90
10. <o= to 6educe 3orrying......................................................................01
22. +ogical Analysis....................................................................................00
21. -astery o! +i!e Techni5ue..................................................................121
22. Sel!#Tests .........................................................................................122
23. Asserti1eness &n1entory.....................................................................12%
2". The Com!ort $ag................................................................................129
2.. 6elase Cycle....................................................................................112
27. Coing Cards......................................................................................112
2%. &nteract?...............................................................................................112
29. Staying in the $ox...............................................................................113
20. De!usion and -ind!ulness..................................................................11.
32. 3hat Are Cogniti1e Distortions@.........................................................117
31. Strategies to $eat ;our 'egati1e Thoughts.......................................119
32. Cogniti1e 6ehearsal...........................................................................122
33. 3indo=s.............................................................................................123
3". Grounding Techni5ues.......................................................................123
3.. $io!eedbac4........................................................................................12.
37. $reathe Proerly.................................................................................129
3%. Diahragmatic $reathing....................................................................132
39. )asy $reathing...................................................................................132
30. :eet $reathing....................................................................................13"
"2. The Sigh $reath..................................................................................137
"1. Anxiety )ducation...............................................................................139
"2. <andling :ear.....................................................................................1"2
"3. The Positi1e Data +og........................................................................1""
"". Daily -ood +og...................................................................................1"%
".. Thought 6ecord..................................................................................1"%
"7. Panic Diary.........................................................................................1"0
"%. Positi1e Sel!#Tal4................................................................................1.2
"9. 6e!raming ..........................................................................................1..
"0. Stress &noculation...............................................................................1.9
.2. Day by Day.........................................................................................177
.1. Sur1ey o! Stress Symtoms...............................................................17%
.2. -ental &magery...................................................................................170
.3. Guided 6elaxation..............................................................................1%1
.". <o= to -editate..................................................................................1%3
... Classic ;oga Postures.......................................................................1%.
.7. :irst Ste............................................................................................192
.%. Physical )xercise...............................................................................19"
.9. & Can 6elax? CD :or Children...........................................................197
.0. +earn to 6eally 6elax.........................................................................19%
72. 6elaxation )xercise............................................................................190
71. Toe Tensing .......................................................................................102
72. /uiet )ars ..........................................................................................102
6e!erences...............................................................................................103
A N X I E T Y D I S O R D E R S
Treating Anxiety Disorders
Types of Anxiety Disorders
nxiety is a state experienced by all of us from time to time. Quite often, anxiety is situational
and will dissipate on its own, but from time to time, therapeutic intervention is necessary and
helpful. A
There are a variety of specific disorders that make up the roup of anxiety disorders in the Dianostic
and !tatistical "anual of "ental Disorders # $
th
Edition %American &sychiatric Association, '(($).
Each disorder is characteri*ed by its own uni+ue dianostic criteria, but they all have certain
symptoms in common. Amon those are anxiety, excessive or unreasonable fear, worry,
psycholoical distress, panic attacks, physioloical reactivity, and diminished interest or participation
in activities.
enerali!ed Anxiety Disorder Diagnostic Criteria
,or more than half the days in at least - months, the patient experiences excessive anxiety
and worry about several events or activities.
The patient has trouble controllin these feelins.
Associated with this anxiety and worry, the patient has . or more of the followin
symptoms, some of which are present for over half the days in the past - months/0
1,eels restless, edy, keyed up
1Tires easily
1Trouble concentratin
1Irritability
1Increased muscle tension
1Trouble sleepin %initial insomnia or restless, unrefreshin sleep)
1
C"a#ter
1
2 Aspects of another Axis I disorder do not provide the focus of the anxiety and worry.00
The symptoms cause clinically important distress or impair work, social or personal
functionin.
The disorder is not directly caused by a eneral medical condition or by substance use,
includin medications and drus of abuse.
It does not occur only durin a "ood Disorder, &sychotic Disorder, &osttraumatic !tress
Disorder or &ervasive Developmental Disorder.
$ost Tra%&atic Stress Disorder Diagnostic Criteria
The patient has experienced or witnessed or was confronted with an unusually traumatic
event that has both of these elements/
The event involved actual or threatened death or serious physical in3ury to the patient or
to others, and
The patient felt intense fear, horror or helplessness0
The patient repeatedly relives the event in at least ' of these ways/
1Intrusive, distressin recollections %thouhts, imaes)0
14epeated, distressin dreams0
1Throuh flashbacks, hallucinations or illusions, acts or feels as if the event were
recurrin %includes experiences that occur when intoxicated or awakenin)0
1"arked mental distress in reaction to internal or external cues that symboli*e or
resemble the event.
1&hysioloical reactivity %such as rapid heart beat, elevated blood pressure) in response to
these cues
The patient repeatedly avoids the trauma1related stimuli and has numbin of eneral
responsiveness %absent before the traumatic event) as shown by . or more of/
1Tries to avoid thouhts, feelins or conversations concerned with the event
1Tries to avoid activities, people or places that recall the event
15annot recall an important feature of the event
1"arked loss of interest or participation in activities important to the patient
1,eels detached or isolated from other people
14estriction in ability to love or feel other stron emotions
1,eels life will be brief or unfulfilled %lack of marriae, 3ob, children)
At least 6 of the followin symptoms of hyperarousal were not present before the
traumatic event/
1Insomnia %initial or interval)
1Irritability
1&oor concentration
'
17yperviilance
1Increased startle response
The above symptoms have lasted loner than one month.
These symptoms cause clinically important distress or impair work, social or personal
functionin.
1( Social $"obia Disorder Diagnostic Criteria
The patient stronly, repeatedly fears at least one social or performance situation that
involves facin straners or bein watched by others. The patient specifically fears
showin anxiety symptoms or behavin in some other way that will be embarrassin or
humiliatin.
The phobic stimulus almost always causes anxiety, which may be a cued or situationally
predisposed panic attack.
The patient reali*es that this fear is unreasonable or out of proportion.
The patient either avoids the situation or endures it with severe distress or anxiety.0
Either there is marked distress about havin the phobia or it markedly interferes with the
patient8s usual routines or social, 3ob or personal functionin.
&atients under the ae of '9 must have the symptoms for - months or loner.
The symptoms are not better explained by a different mental disorder, includin Anxiety
Disorders, Dysmorphic Disorder, &ervasive Developmental Disorder or !chi*oid
&ersonality Disorder.
The symptoms are not directly caused by a eneral medical condition or by substance
use, includin medications and drus of abuse.
If the patient has another mental disorder or a eneral medical condition, the phobia is not
related to it.
!pecify whether enerali*ed. The patient fears most social situations.
S#ecific $"obia Disorder Diagnostic Criteria
The patient experiences a stron, persistent fear that is excessive or unreasonable. It is set
off %cued) by a specific ob3ect or situation that is either present or anticipated.
)
The phobic stimulus almost always immediately provokes an anxiety response, which
may be either a panic attack or symptoms of anxiety that do not meet criteria for a panic
attack.
The fear is unreasonable or out of proportion, and the patient reali*es this.0
The patient either avoids the phobic stimulus or endures it with severe anxiety or distress.
&atients under the ae of '9 must have the symptoms for - months or loner.
Either there is marked distress about this fear or it markedly interferes with the patient8s
usual routines or social, 3ob or personal functionin.
The symptoms are not better explained by a different mental disorder, includin Anxiety
Disorders,00 Dysmorphic Disorder, &ervasive Developmental Disorder or !chi*oid
&ersonality Disorder.
!pecify type/000
!ituational Type %airplane travel, bein closed in)
:atural Environment Type %thunderstorms, heihts, for example)
;lood, In3ection, In3ury Type
Animal Type %spiders, snakes)
<ther Type %situations that miht lead to illness, chokin, vomitin)
$anic Disorder Diagnostic Criteria
The patient has recurrent panic attacks that are not expected.
,or a month or more after at least ' of these attacks, the patient has had ' or more of/
1<noin concern that there will be more attacks
1=orry as to the sinificance of the attack or its conse+uences %for health, control, sanity)
1"aterial chane in behavior, such as doin somethin to avoid or combat the attacks
The patient does not have aoraphobia
The panic attacks are not directly caused by a eneral medical condition or by substance
use, includin medications and drus of abuse.
The panic attacks are not better explained by another Anxiety or "ental Disorder.0
(Taken from http://mysite.verizon.net/res7oqx1/index.html
*
+
I N T E R , E N T I O N S
Best Practices for Treatment of Children and Adolescents with Anxiety Disorder
4etrieved by Andrea >in, Teresa ,ields and Terri ?ones :ovember '-, 6@@$
ABSTRACT
Anxiety disorders is one of the most prevalent cateories of psychopatholoy in children and
adolescents. These revised practice parameters hihliht the D!"1IA chanes for anxiety
disorders and review the literature related to the assessment and treatment of anxiety disorders in
children and adolescents. Bp1to1date information on lonitudinal outcome data, assessment of
anxiety, parent1child interventions, and use of selective serotonin reuptake inhibitors has been
added to the previous parameters, published in !eptember '((. 4ecommendations for evaluation
and multimodal approaches to treatment are presented. >ey =ords/ anxiety disorders,
anxiolytics, practice parameters.
These parameters ive clinicians direction in assessin and treatin children and adolescents with
anxiety disorders. 4ecommendations are based on extensive review of the scientific literature
and clinical consensus amon experts in the sub3ect. The literature review, includin references,
and the rationale for specific recommendations are contained in the complete document
%American Academy of 5hild and Adolescent &sychiatry, '((C).
INTRODUCTION
,our of the anxiety disorders listed in D!"1IA are discussed in this parameter. These include
separation anxiety disorder, enerali*ed anxiety disorder, social phobia, and panic disorder. The
essential feature of separation anxiety disorder is excessive anxiety about separation from
attachment fiures. Denerali*ed anxiety disorder is characteri*ed by excessive worry and anxiety
that are hard to control and fre+uently accompanied by restlessness, fatiue, difficulty with
concentration, irritability, muscle tension, and sleep disturbance. !ocial phobia is described as
marked, persistent fear of social or performance situations in which the person is exposed to
unfamiliar people or scrutiny. !elective mutism is characteri*ed by failure to speak in specific
C"a#ter
'
social situations %e.., school) while talkin in other situations %e.., home). !elective mutism has
recently been conceptuali*ed as a type of social phobia. &anic disorder is characteri*ed by
recurrent spontaneous episodes of panic that are associated with physioloical and psycholoical
symptoms.
A number of lare, well1desined epidemioloical studies employin structured psychiatric
interviews indicate that anxiety disorders are one of the most prevalent cateories of childhood
and adolescent psychopatholoy. At least 'E. of children with anxiety disorders meet criteria for
two or more anxiety disorders. Twenty1eiht to -(F have comorbid ma3or depression. There is
an association between attention1deficitEhyperactivity disorder %AD7D) and anxiety disorders.
5hildren with anxiety disorders manifest a spectrum of symptomatoloy ranin from mild
worry and distress to overwhelmin, incapacitatin anxiety that interferes with functionin. In
some cases, children with anxiety disorders may follow a chronic course and may have a low
remission rate. In other cases, the remission rate is hih. In a lonitudinal study of C.$ non1
referred children and adolescents, increased severity of psychiatric disorder was predictive of
reater likelihood of persistence of dianosis at follow1up. In a . to $ year prospective study of
children in an anxiety disorders clinic, separation anxiety disorder had the hihest remission rate
%(-F) and panic disorder had the lowest remission rate %C@F).
ASSESSENT
Important areas to assess when evaluatin a child or adolescent with an anxiety disorder include
history of the onset and development of the anxiety symptoms, associated stressors, medical
history, school history, social history, family psychiatric history, developmental history with
special considerations of temperament, and mental status evaluation. A comprehensive
evaluation also may include structured or semi1structured psychiatric interviews to establish or
confirm the anxiety dianoses and comorbid psychotic disorders. In addition, clinical ratin
scales, self1report scales, and parent1report instruments may be used to determine types and
severity of the anxiety symptomatoloy. It is advantaeous to include instruments from a variety
of perspectives, includin from the child8s or adolescent8s perspective.
EDICA! E"A!UATION
"edical evaluation should include a complete medical history and a physical examination within
the past '6 months, with special evaluation of conditions that may mimic anxiety disorders.
These include hypolycemic episodes, hyperthyroidism, cardiac arrhythmias, caffeinism,
pheochromocytoma, sei*ure disorders, miraine, central nervous system disorders, and
medication reactions. "edication reactions may be to antihistamines, antiasthmatics,
sympathomimetics, steroids, haloperidol and primio*ide %neuroleptic1induced separation anxiety
disorder), selective serotonin reuptake inhibitors %!!4Is), antipsychotics %akathisia), and
nonprescription preparations includin diet pills and cold medicines.
DIA#NOSIS
In makin the dianosis, it is important to note that there are developmental differences in the
presentation of anxiety disorders. ,or example, in separation anxiety disorder, children aed G to
-
9 years most commonly report unrealistic worry about harm to parents or attachment fiures.
5hildren aed ( to '6 years usually manifest excessive distress at times of separation.
Adolescents most commonly manifest somatic complaints.
It is important to reconi*e that isolated, subclinical anxiety symptoms %e.., fears of harm to self
or attachment fiures, or excessive worries) are common in the eneral population. Also, one
needs to differentiate developmental fears, such as fear of the dark, which are often transient,
from phobias. &sychiatric disorders that may be comorbid with or misdianosed as anxiety
disorders include mood disorders, AD7D, ad3ustment disorders, substance use disorders,
borderline or other personality disorders, eatin disorders, somatoform disorders, tic disorders,
trichotillomania, reactive ad3ustment disorder, pervasive developmental disorders, schi*ophrenia,
and sleep terror disorder.
TREATENT
The treatment of anxiety disorders in children and adolescents usually involves a multimodal
approach. 5omprehensive treatment may include education of the patient and parents about the
disorder, consultation with school personnel and primary care physician, behavioral intervention,
psychodynamic psychotherapy, family therapy, and pharmacotherapy.
BE$A"IORA! TREATENT
;ehavioral therapy tarets the patient8s behavior and emphasi*es treatment in the context of
family and school instead of focusin on intrapsychic conflict. 5onitive1behavioral therapy
combines a behavioral approach with chanin the conitions associated with the patient8s
anxiety. &atients are instructed to restructure their thouhts into a more positive framework
resultin in more assertive and adaptive behavior. 5ase reports suest specific behavioral
techni+ues such as systematic desensiti*ation and exposure are of benefit in treatin children
with school refusal. <ther behavioral techni+ues used to treat anxiety in children and adolescents
include modelin, role1playin, relaxation trainin, and rewards.
<ne study of children with school refusal compared behavioral therapy, psychiatric
hospitali*ation, and psychotherapy in combination with home tutorin. At ' year follow1up,
9.F, .'F, and @F of the three roups, respectively, were attendin school reularly. A study
comparin phobic children treated with systematic desensiti*ation, psychodynamic therapy, and
waitin list found the first two types of therapy were superior to the waitin list, as measured by
parents8 reports.
A more recent study compared '- weeks of conitive1behavioral therapy and 9 weeks of waitin
list control for children with anxiety disorders. The roup receivin the conitive1behavioral
treatment compared with the waitin1list control showed a sinificant improvement in anxiety
and depressive symptoms. ,urthermore, sub3ects who received the conitive1behavioral
intervention were less likely to meet criteria for an anxiety disorder post1treatment and at ' year
follow1up.
PS%C$OANA!%SIS
.
The clinical data on the psychoanalytic treatment of childhood anxiety consist larely of case
reports on the treatment of children with phobias, school refusal, or anxiety symptoms comorbid
with other difficulties. 4eview of the Anna ,reud 5entre8s records of .G6 children
retrospectively dianosed with D!"1III14 disorders, primarily anxiety and depressive disorders,
who were treated with psychoanalysis or psychodynamic therapy showed a C6F improvement in
adaptation. &redictors of positive outcome were loner duration of treatment, reater fre+uency
of sessions, youner ae, and phobic symptoms.
PS%C$OD%NAIC PS%C$OT$ERAP%
,or many children with anxiety disorders, psychodynamic psychotherapy focusin on underlyin
fears and anxieties is often an appropriate component of treatment. Anxious children enerally
benefit from masterin themes of separation, autonomy, self1esteem, and ae1appropriate
behavior. &arents should be involved in the treatment so they learn to understand the patient8s
need for reassurance and to encourae their child to be more independent. &arents may need to
resolve their own issues about separation and other sources of anxiety, to avoid exacerbatin the
patient8s fears or communicatin ambivalence about safety, security, and autonomy.
PARENT&&C$I!D INTER"ENTIONS
In a '6 year lonitudinal study of more than 9@@ children, early temperamental traits of passivity
and shyness in irls aed . to G years were associated with subse+uent reports of anxiety
symptoms. ;ehavioral inhibition, a temperamental characteristic of showin fear and withdrawal
in novel or unfamiliar situations, is associated with increased risk of developin anxiety
disorders in childhood. In addition, insecure mother11child attachment is a risk factor for
developin anxiety disorders in childhood or adolescence. Therefore, attention to temperament
and to the parent11child relationship is vital for preventin and treatin anxiety symptoms.
&arent11child interventions may include helpin parents encourae children to face new
situations rather than withdrawin. Infant11parent psychotherapy is recommended for treatment
of attachment problems in infant11parent dyads.
'AI!% T$ERAP%
,amily theory postulates that anxiety symptoms represent problems in the family system. It is
suested that workin with the family system is the key way to decrease the anxiety symptoms
experienced by the child. The aim of the therapy with the family is to disrupt the dysfunctional
family interactional patterns that promote family insecurity and to support areas of family
competence.
P$ARACO!O#ICA! TREATENT
&harmacotherapy should not be used as the sole intervention, but as an ad3unct to behavioral or
psychotherapeutic interventions that help promote active mastery and are important to preventin
symptom return after discontinuation of medication.
5urrent, commonly selected medications for treatin anxiety symptoms include tricyclic
antidepressants %T5As) and !!4Is. !election of the medication is uided by several factors,
/
includin comorbidity pattern. ;en*odia*epines may be used on a short1term basis for anxiety
symptoms. Hess commonly used anxiolytics include buspirone and beta1blockers.
!elective !erotonin 4euptake Inhibitors Hiterature is startin to emere about the use of !!4Is
for children with anxiety disorders. ,luoxetine has been studied in open trials for anxiety
disorders with improvement as documented by parent and self1report. 5ase reports, an open trial,
and a controlled study suest that fluoxetine may be beneficial in the treatment of selective
mutism. Advantaes of !!4Is include the low side1effects profile and relative safety in overdose
with almost no anticholineric or cardiac side effects. Transient anxiety and aitation may occur
when initiatin or increasin the dosae of !!4Is.
Tricyclic Antidepressants
,our double1blind placebo1controlled studies of T5As for separation anxiety disorder or school
refusal in combination with separation anxiety disorder provide contrastin results. 5linical
experience, however, suests that some children and adolescents with anxiety1based school
refusal improve on T5As. There are case reports of children and adolescents with panic disorder
receivin benefit from T5As.
;en*odia*epines
5ase reports and several studies indicate that ben*odia*epines may be useful in treatin anxiety
disorders. Two studies indicate that ben*odia*epines are beneficial for anxiety associated with
medical procedures in children. 5linical trials indicate that ben*odia*epines are tolerated by
children with minimal adverse effects. !edation, drowsiness, and decreased mental acuity are the
most common side effects. ;ecause of the potential for tolerance and dependence in children and
adolescents, it is recommended that ben*odia*epines be used for only short1term treatment.
;eta1blockers
Due to lack of data on their use in children, beta1blockers are enerally not considered unless
other treatments have failed.
;uspirone
There are few case reports and open trials showin decrease in anxiety symptoms after buspirone
treatment. !ome clinical experience with buspirone suests limited antianxiety effects.
Antihistamines
There are virtually no controlled studies evaluatin the efficacy of antihistamines for anxiety
disorders in children and adolescents. Antihistamines have been replaced by anxiolytics in
treatment of children and adolescents.
:euroleptics
;ecause of the risks of impaired conitive functionin and tardive dyskinesia, neuroleptics are
not recommended for treatin anxiety symptoms in children and adolescents in the absence of
indications such as Tourette8s syndrome or psychosis.
10
RE'ERENCE
American Academy of 5hild and Adolescent &sychiatry %'((C), &ractice &arameters for the Assessment and Treatment of 5hildren and Adolescents with
Anxiety Disorders. ? Am Acad 5hild Adolesc &sychiatry, .-%'@suppl)
11
S(ecific Pho)ia Best Practice
Accessed on :ovember '6, 6@@$ from www.merck.micromedex.com
;y "eean Deaton I Deanna 4obinson
DIA#NOSIS AND $ISTOR%
Ask the patient to recount episodes in which he or she encountered specific ob3ects or situations
that elicited an anxious response. Ask about the level of anxiety or fear the patient felt in
response to those ob3ects or situations.
Ask the patient about his or her fear of ob3ects or environments that pertain to all of the different
subtypes of specific phobia JTable 'K.
Determine the patient8s level of intercurrent anxiety.
Determine whether the patient has experienced a panic attack in response to a phobic stimulus.
Determine whether the patient feels that his or her fears are reasonable.
Ask the patient how his or her attempts to avoid the stimulus affect daily routine, occupational
functionin, and social life.
Ask the patient how lon he or she has been experiencin anxiety in response to certain stimuli.
"ake sure that the anxiety, panic attack, or phobic avoidance is not better accounted for by
another mental disorder.
P$%SICA! E*AINATION
&erform a physical examination only if otherwise indicated.
DI''ERENTIA! DIA#NOSIS
>eep in mind that a dianosis of obsessive1compulsive disorder, post1traumatic stress disorder,
separation anxiety disorder, social phobia, panic disorder %with or without aoraphobia), or
aoraphobia without history of panic disorder rules out a dianosis of specific phobia.
4emember that patients with specific phobia, unlike those with other types of anxiety disorders,
do not have pervasive anxiety.
5onsider panic disorder %with or without aoraphobia) if the patient experiences recurrent,
unexpected panic attacks in the absence of exposure to a phobic stimulus.
;ear in mind that some patients may have concurrent specific phobia and panic disorder.
5onsider the dianosis of social phobia if the focus of the patient8s fears is concern about
neative evaluation from others.
5onsider the dianosis of post1traumatic stress disorder if the avoidance starts after a life1
threatenin stressor and is accompanied by other features, such as flashbacks and restricted
affect.
5onsider obsessive1compulsive disorder if the avoidance is associated with the content of the
obsession, such as dirt or contamination.
5onsider separation anxiety disorder if the avoidance behavior is exclusively limited to fears of
separation from persons to whom the patient is attached.
5onsider hypochondriasis if the patient is preoccupied with fears of havin a disease.
1'
4ecall that in patients with eatin disorders such as anorexia nervosa or bulimia nervosa, a
dianosis of specific phobia is not indicated if the avoidance behavior is exclusively limited to
avoidance of food and food1related cues.
4emember that patients with schi*ophrenia or another psychotic disorder may avoid certain
activities in response to delusions, but typically will not reconi*e that the fear is unreasonable.
DIA#NOSTIC CRITERIA
Dianose specific phobia only if the patient has a marked and persistent fear of clearly
discernible, circumscribed ob3ects or situations %phobic stimulus), if exposure to the phobic
stimulus provokes an immediate anxiety response, if the phobia sinificantly interferes with
functionin, and if the patient satisfies the other specific D!"1IA inclusion and exclusion
criteria.
If the patient satisfies D!"1IA criteria for specific phobia, then cateori*e the specific type of
specific phobia accordin to D!"1IA criteria.
TREATENT
"edical Therapy
5onsider a ben*odia*epine for short1term use when the patient must confront a phobic stimulus.
5hoose a ben*odia*epine for sinle1dose use based on the speed of action onset and clearance.
!pecial 5ircumstances
Bse ben*odia*epines with caution in women of child1bearin ae.
=hen to 5onsult or 4efer
4efer the patient to a psychotherapist for conitive behavioral therapy.
&ronosis
=ith ade+uate behavioral therapy, patients with specific phobia can overcome their fears and
avoidant behaviors and reatly improve their ability to function.
PATIENT EDUCATION
Deneral Information
Advise the patient that the main oal of treatment is to decrease fear and phobic avoidance so
that the patient8s functionin in the presence of the phobic stimulus is no loner impaired.
4emind patients to take a ben*odia*epine only when needed to aid in confrontin a phobic
stimulus.
!elf1care Instructions
Take any prescribed medication only as directed by your doctor, and only when absolutely
necessary.
If you have seen a psychotherapist, use the behavioral methods 3ust as you have been tauht to
control fears.
1)
4emember that the ben*odia*epine drus prescribed for phobia will not cure the phobia. They
only relieve the anxiety temporarily, and should be taken only when you have to confront the
particular thin or situation that really scares you. ,or example, if you fear flyin and have to
take an airplane fliht, take the dru only before the fliht.
If you are interested in learnin more about specific phobia, or in learnin about self1help
roups, explore resources such as %in the B!) the Anxiety Disorders Association of America
%''(@@ &arklawn Drive, !uite '@@, 4ockville, "aryland 6@9G6L '1.@'16.'1G$9$L www.adaa.or)
or &hobics Anonymous %&< ;ox ''9@, &alm !prins, 5alifornia (66-.L '1C-@1.6615<&E).
'O!!O+ UP
;e aware that althouh a primary care physician should continue to be available to manae the
patient8s medical problems, follow1up for specific phobia is hihly individuali*ed and usually
determined by the mental health professional who has assumed primary responsibility for
treatin the patient8s specific phobia.
Best Practices for Treatment of Social Pho)ia
4etrieved by 5rystal =ebb :ovember '-, 6@@$
!ocial phobia, or social anxiety disorder, is defined as Ma marked and persistent fear of
social or performance situations in which embarrassment may occurN %American &sychiatric
Association, 6@@@, p. $G@). This fear is not the result of any physioloical substance or medical
conditionL it cannot be directly accounted for by other mental disorders. !tatistics indicate that
this disorder in now the third larest psycholoical problem in our country, trailin only ma3or
depression and substance abuse and affectin as many as fifteen million Americans annually, and
that many with social phobia are misdianosed at much as (@ F of the time %4ichards, 6@@6).
4eports indicate that women experience the phobia perhaps at a rate of twice as often as menL a
hiher proportion of men, however, seek help. =hile the fear experienced by those with social
anxiety disorder can occur in varyin derees, it can become so severe in many that disruption
occurs in educational, occupational and social settins, reachin well beyond the accepted notion
of MshynessN %:ational Institute of "ental 7ealth, '((().
5auses
1 5urrent investiation supports the theory that the brain structure amy!dala may be a
central site controllin fear responses and may be
responsible.
1 ;iochemical basisL scientists hypothesi*e that heihtened sensitivity to
disapproval may be physioloically or hormonally based.
1 Evidence suests the disorder is inherited. !ocial phobia occurs more
fre+uently amon first1deree bioloical relatives than in the eneral population.
1 Environmental influences may play in the developmentL those with the
1*
phobia may ac+uire fear by observation of othersO behavior and conse+uences,
otherwise known as social modelin or observational learnin %:I"7).
There is currently no laboratory test found to be useful in dianosin social phobia or to
distinuish it from other anxiety disorders. =hile other disorders such as panic disorder,
separation anxiety disorder, enerali*ed anxiety, avoidant personality disorder, and specific
medical disorders all share characteristics of social phobia, a separate dianosis of social phobia
is not usually warranted. The suested treatment plan that follows addresses only those
symptoms associated with social phobia in adolescents and youn adults, since the disorder
typically manifests durin mid1teens and late adolescence %=icks1:elson I Israel, '((C). The
dianosis may follow years of children bein labeled as MshyN or MtimidN in unfamiliar social
settins, refusin to participate in roup activities, and stayin close to familiar adults, perhaps
leadin to a decline
in academic performance or in extreme cases refusal to attend school. If symptoms of the
disorder manifest in early childhood, children may fail to achieve at norm1referenced levels
instead of experiencin a decline in social and academic functionin associated with later onset
%A&A).
Dianostic 5riteria for .@@.6. !ocial &hobia
A marked and persistent fear of one or more social or performance situations in which
may take the form of a situationally bound or situationally predisposed panic attack. In
children, the anxiety may be expressed by cryin, tantrums, free*in, or shrinkin from
social situations with unfamiliar people.
The person reconi*es that the fear is excessive or unreasonable. In children, this feature
may be absent.
The feared social or performance situations Jsee descriptive listed belowK are avoided or
else are endured with intense anxiety or distress.
The avoidance, anxious anticipation, or distress in the feared social or performance
situation%s) interferes sinificantly with the personOs normal routin, occupational
%academic) functionin, or social activities or relationships, or there is marked distress
about havin the phobia.
In individuals under ae '9 years, the duration is at least six months.
The fear or avoidance is not due to the direct physioloical effects of a substance or a
eneral medical condition and is not better accounted for by another mental disorder
%&anic Disorder with or without Aoraphobia, !eparation Anxiety Disorder, ;ody
Dysmorphic Disorder).
If a eneral medical condition or another mental disorder is present, the fear in 5riterion
A is unrelated to it %fear is not of stutterin, tremblin in &arkinsonOs disease, or
exhibitin abnormal eatin behavior in Anorexia :ervosa or ;ulimia :ervosa) %A&A,
p.$G-).
Associated ,eatures
7ypersensitivity to criticism
:eative evaluation, or re3ection
Difficulty bein assertive
How self1esteem or feelins or inferiority
1+
,ear of indirect evaluation by others
&<!!I ;HE "A:I ,E!TATI <:!
o &oor social skills %eye contact, speakin aloud in roups)
o <bservable sins of anxiety includin clammy hands, tremors, shaky
voice.
o Bnderachievement in school due to test anxiety or avoidance of classroom
participation.
o Bnderachievement at work because of anxiety durin, or avoidance of,
speakin in roups, in public, or to authority fiures and colleaues %A&A, p. $G6).
o !omatic complaints includin confusion, heart palpitations, sweatin,
shakin, blushin, muscle tension, upset stomach and diarrhea %4ichards, '((().
4esearch indicates that individuals with social phobia may have decreased social support
networks of family and friends, my become dropouts, never be ainfully employed and
eventually fail to seek work due to difficulty in 3ob interviews, clin to unfulfillin
relationships, date rarely or not at all, and remain with family of oriin. If several of these
conditions are present in individuals, suicide ideation may be present as well as related
disorders %A&A).
;est Treatment Duidelines
The most effective treatments to address the symptoms of social phobia include
medications and conitive1behavior therapy. The followin treatment plan utili*es these
treatments to minimi*e and eradicate symptoms.
Hon Term Doals
5lient and counselor will develop a workin relationship buildin trust leadin to openly
discussin thouhts and feelins.
5lient will seek medical treatment to identify possible related symptomsEillnesses.
5lient will work with counselor to identify specific situations causin anxiety and
somatic reactions.
5lient will work with counselor to identify positive social responses to identified
situations.
5lient will modify perceptions and expectations of social situations.
5lient will identify and implement appropriate peer interactions.
5lient will reconi*e appropriate feedback and respond accordinly.
5lient will develop positive self1esteem and demonstrate increased sociability.
RE'ERENCES
American &sychiatric Association. %6@@@). Dia!nosti" and statisti"al man#al of
mental disorders. ,ourth edition. =ashinton, D.5./ Author.
5ormier, !., I 5ormier, ;. %'((9). $ntervie%in! strate!ies for helpers.
5incinnati/ ;rooksE5ole &ublishin.
:elson, 4.=., I Israel, A. %'((C). &ehavior disorders of "hildhood. Third
11
edition. :ew ?ersey/ &rentice17all.
:ational Institute of "ental 7ealth %:I"7). %n.d.). 'o"ial phobia( a real
illness. 4etrieved ,ebruary '9, 6@@$, from
http/EE.www.nimh.nih.ovEanxietyEsocial.pdf.
:ational Institute of "ental 7ealth %:I"7). %n.d.) &enzodiazepines.
4etrieved ,ebruary '9, 6@@$, from
http/EEwww.nimh.ovEanxietyEmedicationsEben*odia*epine.
4oers, 5. %'(9@). A %ay of bein!. ;oston/ 7ouhton1"ifflin.
4ichards, T. %n.d.). 'o"ial phobia/so"ial anxiety asso"iation. )hat is
so"ial anxiety* 4etrieved ,ebruary 6C, 6@@$, from
http/EEwww.socialphobia.orEwhatis.html.
4ichards, T. %n.d.). )hat is "omprehensive "o!nitive+behavioral therapy*
4etrieved ,ebruary 6C, 6@@$, from
http/EEwww.socialanxietyinstitute.orEccbtherapy.html.
Post&Tra-matic Stress Disorder & Best Practice #-idelines
;y/ Hynda D. :ewsome
DIA#NOSTIC E"A!UATION
"any would arue that &ost Traumatic !tress Disorder %&T!D) as a result of trauma and risk
takin behaviors has been a part of the human condition since before written history and
continues into modern history where war, enocide, terrorism, and horrible acts of violence seem
to have become prevalent and people have souht help for the mental problems that result from
these traumatic experiences.
=hen &T!D is suspected, the first step would be to et the client to a +ualified counselor or
roup practice where medicines as well as psychotherapy may be prescribed. =hen evaluatin a
child or adult who may fit into the cateory of &T!D one would look for a certain stressor
criterion. Accordin to the D!"1IA, &T!D must be explained by an outside event of historic
proportions or a traumatic event that is characteri*ed as traumatic by the eneral public such as
rape and enocide.
a. The first criterion is that the person has been exposed to a catastrophic event involvin actual
or threatened death or in3ury. Durin this time, the childOs main emotion was intense fear,
helplessness, or horror.
1-
b. The second criterion is the cripplin problem of flashbacks, or the intrusive recollections that
can last for a decade or a lifetime, in which traumatic nihtmares, psychotic reenactments,
daytime fantasies occur.
c. &atients may at times withdraw from society and meaninful relationships so that they do not
have to worry about exposin themselves to the trauma or related issues ever aain. "any do not
leave their homes.
d. The symptoms must last at least a month

e. Their fundamental ability to work and handle themselves socially, and in life in eneral should
be a determinin factor durin evaluation. =hat types of distress does the &T!D ive the
patientP After this is measured, it can help ive the therapist a picture of where the patient is
mentally and what kind of oals they need to set toether.
SCREENIN#
5hildhood &T!D Interview %5&T!DI)
,letcher, >. %'((-). &sychometric review of the 5hildhood &T!D Interview. In ;. 7. !tamm
%Ed.), ,eas#rement of stress( tra#ma( and adaptation %pp. 9C19(). Hutherville, "D/ !idran
&ress.
To o)tain scale, contact.
5ustomer 5are, The &sycholoical 5orporation, '(G@@ ;ulverde 4d., !an
Antonio, TQ C96G(1.C@', &hone '19@@19C61'C6-, ,ax '19@@16.61'66.,
www.&sych5orp.com
5linician1Administered &T!D !cale for 5hildren and Adolescents for D!"1IA %5A&!15A)
:ewman, E., I 4ibbe, D. %'((-). &sychometric review of the 5linician Administered &T!D
!cale for 5hildren Jsi"K. In ;. 7. !tamm %Ed.), ,eas#rement of stress( tra#ma( and adaptation
%pp. '@-1''$). Hutherville, "D/ !idran &ress.
:ational 5enter for &T!D %''-D), AA "edical 5enter, 6'G :. "ain !t., =hite
4iver ?unction, Aermont @G@@(, ncptsdRncptsd.or.
1.
Dimensions of !tressful Events %D<!E)
,letcher, >. %'((-). &sychometric review of Dimensions of !tressful Events %D<!E) 4atins
!cale. In ;. 7. !tamm %Ed.), ,eas#rement of stress( tra#ma( and adaptation %pp. '$$1'G').
Hutherville, "D/ !idran &ress. %includes measure in its entirety)
>enneth E. ,letcher, &h.D., Department of &sychiatry, Bniversity of
"assachusetts "edical 5enter, GG Hake Avenue :orth, =orcester, "A @'-GG.
&arent 4eport of 5hild8s 4eaction to !tress
,letcher, >. %'((-). &sychometric review of the &arent 4eport of 5hild8s 4eaction to !tress. In
;. 7. !tamm %Ed.), ,eas#rement of stress( tra#ma( and adaptation %pp. 66G166C). Hutherville,
"D/ !idran &ress.
>enneth E. ,letcher, &h.D., Department of &sychiatry, Bniversity of
"assachusetts "edical 5enter, GG Hake Avenue :orth, =orcester, "A @'-GG.
&T!D 4eaction Index
:ader, >. %'((-). Assessin trauma in children. In ?. =ilson I T. ". >eane %Eds.( Assessin!
psy"holo!i"al tra#ma and -T'D. :ew Sork/ Duilford.
!cale can be obtained from measuresRtwosuns.or
Trauma !ymptom 5hecklist for 5hildren %T!55)
;riere, ?. %'((-). Trauma !ymptom 5hecklist for 5hildren professional manual. <dessa, ,H/
&sycholoical Assessment 4esources.
&sycholoical Assessment 4esources, ;ox ((9, <dessa, ,H ..GG-, %9@@) ..'1
9.C9.
Traumatic Events !creenin InventoryT5hild Aersion %TE!I15)
1/
4ibbe, D. %'((-). &sychometric review of Traumatic Event !creenin Instrument Jsi"K for
5hildren %TE!I15). In ;. 7. !tamm %Ed.), ,eas#rement of stress( tra#ma( and adaptation %pp.
.9-1.9C). Hutherville, "D/ !idran &ress.
:ational 5enter for &T!D %''-D), AA "edical 5enter, 6'G :. "ain !t., =hite
4iver ?unction, Aermont @G@@(, ncptsdRncptsd.or.
TREATENT
:either medication nor evidence1based therapies have been shown to work better than the other,
or to necessarily work better toether. 4iht now the evidence1based therapies for &T!D are
5onitive Therapy %5T), Exposure Therapy %ET), !tress Inoculation Trainin %!IT), and Eye
"ovement Desensiti*ation and 4eprocessin %E"D4).
PS%C$OT$ERAPIES
5onitive Therapy, developed by Aaron ;eck at the Bniversity of &ennsylvania is considered to
be perhaps the therapy of choice for most practitioners simply because we know that it does
work and that it is structured, short termed and present1oriented focused mainly on relievin
depression. All of this makes it ideal for helpin a &T!D patient, althouh other therapies have
also proven 3ust as helpful but perhaps not as short term. =ith insurance costs risin, 5onitive
Therapy is often appealin for the patient with few visits allowed, but needin vital assistance.
5T for &T!D typically beins with an introduction of how thouhts affect emotions and
behavior. :ew skills are tauht and neative patterns of thinkin are clarified. Trauma related
thouhts that are distressin are converted into more accurate and calmin thouhts. 5T also
emphasi*es the identification and modification of distorted core beliefs about self, others and the
larer world. 5T teaches that improved accuracy of thouhts and beliefs about self, others and
the world leads to improved mood and functionin.
Exposure Therapy helps men and women with &T!D reduce the fear associated with their
experience throuh repetitive, therapist1uided confrontation of feared places, situations,
memories, thouhts, and feelins. It is also considered short1term therapy, lastin on 91 '6
sessions. Exposure can be accomplished via MimainableN exposure or Min vivoN exposure. It
encouraes the patient to revisit the experience in imaination, recallin details of the trauma.
!tress Inoculation Trainin is a type of 5;T that helps manae anxiety and stress. This treatment
was developed for the manaement of anxiety symptoms and adapted for treatin women rape
trauma survivors. Typically it consists of education and copin skills, deep muscle relaxation
trainin, breathin control, assertiveness, role playin, covert modelin, thouht stoppin,
positive thinkin and self talk.
'0
&sycholoist Dr. ,rancino !hapiro desined Eye "ovement Desensiti*ation and 4eprocessin.
7e believed that one must access and process the traumatic memories to brin about an adaptive
resolution. In this therapy several thins must occur/
6. The patient is asked to produce a disturbin imae that encapsulates the worst part of the
traumatic event.
.. The patient is asked to associate body sensations with that imae.
$. The patient is asked to create a self1referrin concise word or words to express what they
learned from the trauma.
G. The patient is asked for a positive self1referrin concise word or words that they would
like to replace the neative words with. They are then asked to hold the disturbin imae,
sensations and the neative conition in their mind while trackin the clinicianOs movin
finer back and forth in front of his or her visual field for about 6@ seconds. In
successive episodes, the patient concentrates on whatever chanes or new world
associations have occurred. ;etween sessions the patient is directed to keep a 3ournal of
any situations that provoke &T!D symptoms and of any insihts or dreams about the
trauma.
PS%C$OT$ERAPIES 'OR C$I!DREN/ADO!ESCENTS
!everal other types of therapy have been suested for &T!D in children and adolescents.
&lay therapy can be used to treat youn children with &T!D who are not able to deal with the
trauma more directly. The therapist uses ames, drawins, and other techni+ues to help the
children process their traumatic memories.
&sycholoical first aid has been prescribed for children exposed to community violence and can
be used in schools and traditional settins. &sycholoical first aid involves clarifyin trauma
related facts, normali*in the children8s &T!D reactions, encourain the expression of feelins,
teachin problem solvin skills, and referrin the most symptomatic children for additional
treatment.
Twelve !tep approaches have been prescribed for adolescents with substance abuse problems
and &T!D. Another therapy, Eye "ovement Desensiti*ation and 4eprocessin %E"D4),
combines conitive therapy with directed eye movements. =hile E"D4 has been shown to be
effective in treatin both children and adults with &T!D, studies indicate that it is the conitive
intervention rather than the eye movements that accounts for the chane. "edications have also
been prescribed for some children with &T!D. 7owever, due to the lack of research in this area,
it is too early to evaluate the effectiveness of medication therapy.
,inally, speciali*ed interventions may be necessary for children exhibitin particularly
problematic behaviors or &T!D symptoms. ,or example, a speciali*ed intervention miht be
re+uired for inappropriate sexual behavior or extreme behavioral problems.
'1
EDICINES
Ta)le B0. S-mmary Ta)le
R Si1nificant Benefit Some Benefit Un2nown No Benefit/$arm
A
!!4Is

B
T5As
"A<Is

C
!ympatholytics
:ovel
Antidepressants

I
Anticonvulsants
Atypical
Antipsychotics
;uspirone
:on1ben*odia*epine
hypnotics

D
;en*odia*epines
Typical Antipsychotics
R= level of recommendation (see appendix A)
OB3ECTI"E
To minimi*e sins and symptoms of &T!D and maintain function
Ta)le B4. Sym(tom Res(onse )y Dr-1 Class and Indi5id-al Dr-1

#lo)al
Im(ro5ement
Re&
ex(eriencin1
6B7
A5oidance
/N-m)in1
6C7
$y(er&
aro-sal
6D7
SSRIs

,luoxetine Q Q Q Q

!ertraline Q Q Q

&aroxetine Q Q Q Q
TCAs
Q Q
''
AOIs
Q Q Q
Sym(atholytics
Q Q

&ra*osin Q

&ropranolol
No5el
Antide(ressants

Tra*odone Q Q Q

:efa*odone Q Q Q
Anticon5-lsants

5arbama*epine Q Q

Aalproate Q
Ben8odia8e(ines
Q Q
Aty(ical
anti(sychotics
Q Q
(based on "ontrolled and #n"ontrolled trials
Selecti5e Re-(ta2e Serotonin Inhi)itors 6SSRIs7
'l-oxetine
Paroxetine
Sertraline
'l-5oxamine
Citalo(ram
6@ #
-@
mEd
6@ #
-@
mEd
G@ #
6@@
mEd
G@ #
'G@
m
bid
6@ #
-@
mEd
Contraindications
"A< inhibitor
within '$ days
Relative
contraindication
7ypersensitivity
:ausea
7eadache
!exual
dysfunction2
7yponatremiaE!IA
D7 %!yndrome of
Inappropriate
Antidiuretic
7ormone)
!erotonin
syndrome
Avoid abrupt
discontinuation
of all except
fluoxetine
5italopram and
sertraline are
less likely to be
involved in
hepatic en*yme
dru
interactions
,luoxetine and
fluvoxamine
are enerically
available
Therapeutic
blood levels not
established for
&T!D
')
!ON# TER #OA!S
'. To educate the patient and their family as applicable about &!TD and its causes, symptoms
and possible treatments
6. To lessen or end the psycholoical, physical and behavioral problems associated with acute
stress reactions resultin from &T!D such as startle response, flashbacks, and nihtmares.
.. To enable the client to return as easily as possible into society as a student, worker, and
contributin member of society who does not fear trauma or a return of the stressor.
RE'ERENCES
,riedman, "atthew ?., ".D. &7.D %6@@.) &osttaumatic1!tress Disorder/An <verview. 'G
"ay 6@@.. 4etrieved 'C :ovember 6@@$ from www.neptsd.orEfactsEeneralEfs overview.htmlP
printable1yes
:ational 5enter for &ost Traumatic !tress Disorder %6@@.) Assessment. '$ "ay 6@@..
4etrieved :ovember 6., 6@@$ from http/EEwww.ncptsd.orEfactsEeneralEfsUwhatUisUptsd.html
:ational 5&D 5ouncil. AAEDoD 5linical &ractice Duideline ,or the "anaement of &ost
Traumatic !tress/ Interventions "odule !ummary &harmacotherapy Interventions. December
6@@.. 4etrieved 'C :ovember 6@@$ from http/EEwww.+umo.amcdd.army.mil
'*
Anxiety Sy&#to& 2atrix
Sym(toms
Social
Pho)ia
PTSD
S(ecific
Pho)ia
#enerali8ed
Anxiety
Disorder
Panic
Disorder
"arked and &ersistent ,ear of
!pecific ThinsE!ituations

Anxiety

Excessive or Bnreasonable ,ear

Avoidance

Anxious Anticipation %=orry)

&sycholoical Distress

&anic Attacks

Tantrums %in 5hildren)

5linin ;ehavior %in 5hildren)

4ecurrent, Distressin
Thouhts

4ecurrent, Distressin Dreams

Illusions

7allucinations

,lashbacks

&hysioloical 4eactivity

"emory Impairment

Diminished Interest or
&articipation in Activities

,eelins of Detachment

4estricted 4ane of Affect

!ense of ,oreshortened ,uture

!leep Disturbance

Irritability

Aner <utbursts

Difficulty 5oncentratin

7yper viilance

Exaerated !tartle 4esponse

4estlessness

Easily ,atiued

"uscle Tension

&ersistent 5oncern about
5onse+uences of &anic Attacks

Dereali*ation

'+
Depersonali*ation

,ear of Hosin 5ontrol

,ear of Dyin

,IDB4E '.' !ymptoms displayed in con3unction with specific anxiety disorders
T"e Effective Co%nselor3s Toolbox
.ffe"tive Treatment $nterventions for 'pe"ifi" 'ymptoms
The followin treatment interventions may be useful to counselors in the therapeutic process
while workin with clients with anxiety disorders. Each intervention may be useful with a variety of
different anxiety symptoms.
Sym(toms Short&Term #oals Inter5entions
"arked and &ersistent
,ear of !pecific
ThinsE!ituations
To reduce the clientOs level of fear
when confronted with the ob3ect of
hisEher phobia.
',-,C,'@,'','6,'$,'G,'-,'C,'9,G6,G.
Anxiety To reduce the clientOs level of anxiety.
AHH
Excessive or
Bnreasonable ,ear
4educe overall fre+uency and
intensity of excessive, unreasonable
fear so that daily functionin is not
impaired.
G,-,C,'G,'-,'C,'9,'(,66,.-,.C,.9,.(,
$@,$9,$(,G@,G'
Avoidance 4aise the level of self1esteem and
decrease avoidanceEwithdrawal from
fearful or anxiety1provokin
situations, places, thins, or people.
.,$,-,C,'G,'-,'C,'9,'(,$',$6,$.,$$,$G,
$-,$C,$9,$(,G@,G'
Anxious Anticipation
%=orry)
Implement appropriate relaxation and
diversion activities to decrease the
$,-,C,9,(,66,'(,.-,.C,.9,.(,$@,G',G.,
G(,-@
C"a#ter
'
'1
level of anxious anticipation.
&sycholoical Distress To reduce clientOs level of
psycholoical distress
',6,-,C,9,(,66,.',.6,$$,$G,G6,G.,G$,GG
&anic Attacks Eliminate the interference from
normal routines and remove the
distress over feared ob3ects or
situations.
',$,'G,..,.$,.-,.C,.9,.(,$@,$-,G6,G.,
G$,GG
Tantrums %in 5hildren) To reduce the number and intensity of
tantrum behavior.
6$,6-,6C,G9
5linin ;ehavior %in
5hildren)
,acilitate the child returnin to normal
functionin.
6$,6-,6C,G9
Thouhts
To help the client reduce the
fre+uency and intensity of distressin
thouhts.
6,-,C,'G,$',$6,$.,$$,$G,$-,$C,$9,$(,
G@,G'
Dreams
To help the client achieve a restful
sleep and reduce the fre+uency of
distressin dreams.
.,-,C,'G,G6,G.,G$,GG
Illusions To help client reduce incidents of
illusions.
',$,-,C,(,6',.-,.C,.9,.(,$@
7allucinations To help client reduce incidents of
hallucinations
',$,-,C,(,6',.-,.C,.9,.(,$@
,lashbacks To help client reduce incidents of
flashbacks.
',$,(,6',.-,.C,.9,.(,$@
&hysioloical
4eactivity
To uide the client to become aware
of the physioloical reactions
associated with anxiety disorders and
to decrease hisEher level of neative
reactivity.
.$,.G,.-,.C,.9,.(,$@,$(,G6,G.,G$,GG,G
C,
-@,-',
"emory Impairment To help the client improve hisEher
memory skills.
6,-,C,$.,$$,$G,$-,G6,G.,G$,GG
Diminished Interest or
&articipation in
Activities
To uide the client to become aware
of the conitions related to hisEher
reluctance to participate in activities,
and to increase participation.
6,.,-,C,'G,66,.-,.C,.9,.(,$@,$$,$G,$-,
$C,$9
,eelins of
Detachment
7elp client develop social skills and
confidence.
6,$,-,9,(,66,$$,$G,$-,$C,$9
4estricted 4ane of
Affect
To help client expand hisEher rane of
affect.
$,-,C,$$,$G,$-,$C,$9
!ense of ,oreshortened
,uture
To help client reduce level of fear and
develop a more hopeful attitude.
.,'@,'',6@,6'
!leep Disturbance To uide the client to achievin a
more productive and restful sleep
','G,.$,.G,G6,G.,G$,GG,G(,-@,-',-6
Irritability To help client reduce hisEher level of
irritability
',-,C,66,.$,.G,$$,$G,$-,$C,$9
Aner <utbursts To enable the client to control hisEher
anry outbursts
.,$,-,C,66,.$,.G,$$,$G,$-,$C,$9
Difficulty
5oncentratin
To help the client develop better
concentration
',6,9,(,.-,.C,.9,.(,$@,G6,G.,G$,GG
7yper viilance To help client develop a more realistic
and appropriate level of viilance
-,C,9,(,G6,G.,G$,GG
Exaerated !tartle
4esponse
To help the client maintain a more
appropriate startle response.
$,G,'G,.-,.C,.9,.(,$@,G6,G.,G$,GG
'-
4estlessness To help the client reduce hisEher level
of restlessness
-,C,9,(,G',G6,G.,G$,GG,
Easily ,atiued To help the client maintain a reater
deree of enery.
.,'G,.-,.C,.9,.(,$@
"uscle Tension To help client reduce hisEher level of
muscle tension and develop relaxation
skills
G,.-,.C,.9,.(,$@,GC,G9,G(,-@,-',-6
&ersistent 5oncern
about 5onse+uences of
&anic Attacks
To educate client about the
conse+uences of panic attacks to
reduce undue concern
',-,C,9,(,$',$6,$.,$$,$G,$-,$C
Dereali*ation To help client reduce incidence of
dereali*ation
',-,C,'@,'',$.,$$,$G,$-,$C,$9
Depersonali*ation To help client reduce incidence of
depersonali*ation.
',-,C,'@,'',6@,6'
,ear of Hosin 5ontrol To help client reduce level of fear. ',C,9,(,'.,'(,.',.6,.$,$6,$.,$$,$C,$9
,ear of Dyin To help client reduce level of fear. ',C,9,(,'.,'(,.',.6,.$,$6,$.,$$,$C,$9
'.
1( Anxiety 4%estionnaire
Directions. The followin is a list of symptoms of anxiety that people sometimes have. &ut
a check in the space to the riht that best describes how much that symptom or problem has
bothered you durin the past week.
9 V :ot at all 0 V !omewhat 4 V "oderately : V A lot
Cate1ory 0. Anxio-s 'eelin1s @ ' 6 .
'. Anxiety, nervousness, worry or fear
6. ,eelin that thins around you are strane, unreal or foy
.. ,eelin detached from all or part of your body
$. !udden, unexpected panic spells
G. Apprehension or a sense of impendin doom
-. ,eelin tense, stressed, Wuptiht,W or on ede
Cate1ory 4. Anxio-s Tho-1hts
C. Difficulty concentratin
9. 4acin thouhts or havin your mind 3ump from one thin
to the next.

(. ,rihtenin fantasies or daydreams
'@. ,eelin that you8re on the vere of losin control
''. ,ears of crackin up or oin cra*y
'6. ,ears of faintin or passin out
'.. ,ears of physical illness or heart attacks or dyin
'$. 5oncerns about lookin foolish or inade+uate in front of
others

'G. ,ears of bein alone, isolated, or abandoned
A score of reater than '@ may indicate anxiety.
(Taken from %%%."omm#nity"arehospital."om
'/
'( Activity Sc"ed%ling
$O+ DOES T$E T$ERAPIST C$OOSE A 'OCUS 'OR ACTI"IT% SC$EDU!IN#;
=e recommend that the therapist focus activity schedulin on a time period or an activity %or
bothX), with the choice dependent on the nature of the patientOs problem. ,or example, work on
schedulin the patientOs evenin hours, the weekend, ' or 6 complete days, the interval of time
between therapy sessions, or a complete week of activities. 5hoose a time of the day or week in
which the patient is not usin his or her time well. <r focus on a particular activity or type of
activity, such as activities of daily livin %ettin up, brushin oneOs teeth, ettin to work on
time, etc.), particular work or school tasks, pleasurable activities, sociali*in, or therapy
homework.
#UIDE!INES 'OR SUCCESS'U! ACTI"IT% SC$EDU!IN#
To carry out a successful activity schedulin intervention, follow these uidelines.
1. -rovide a rationale.
Bse !ocratic +uestionin and any other method in your armamentarium that will ensure that the
patient understands why activity schedulin is worth doin. %!ocratic +uestionin is +uestionin
desined to help the patient think about thins in a new way.) If activity schedulin seems trivial
or unhelpful to the patient, he or she is unlikely to work hard to follow throuh with it. Take the
time to provide a rationale for the intervention.
/. 0se 'o"rati" q#estionin! to eli"it a"tivity s"hed#lin! s#!!estions from the patient.
Activity schedulin is much more likely to succeed if the therapist sets up the interaction, so that
the patient is tellin the therapist what activities or time periods to schedule rather than the other
way around. Bse !ocratic +uestionin in an attempt to set up this dynamic between the patient
and therapist. If the patient is unable to offer suestions, the therapist can offer two or three
options and ask the patient to choose one.
1. 'tart %here the patient is( not %here the patient thinks he or she sho#ld be.
<ften depressed patients are immobili*ed because they cannot et out of bed but expect
themselves to complete their dissertation or dean the house from top to bottom. It is
important that the therapist not buy into the patientOs unrealistic expectations about
what he or she should be able to do. To ascertain what is realistic, the therapist needs to
carefully assess the patientOs "#rrent level of functionin to do thisL the therapist can ask the
patient to simply record, on the Activity !chedule, how he or she spends every hour durin the
week. A completed Activity !chedule can ive both the patient and therapist useful information
about how much the patient can realistically expect of him1 or herself.
2. &e spe"ifi" and "on"rete: )here( %hen( %ith %hom( and for ho% lon!*
Aaueness is death to activity schedulin. It is important to be concrete and specific when you
make an activity plan. !pecify exactly what activity will be carried out, where, when, with
)0
whom, how, for how lon, and so on. ,or example, the patient miht aree to spend 'G minutes
filin papers on her desk immediately after returnin home after the therapy session. It is a ood
idea to use the Activity !chedule form to write down the plan that you and your patient aree onL
if possible, keep a copy and send one home with your patient. Ask your patient to brin the
Activity !chedule to the next therapy session to review how successful he or she was at
completin the planned activities.
3. -lan ahead for potential obsta"les.
=ork with your patient to try to anticipate and make a plan to handle obstacles and problems that
miht arise. <ften the therapist can anticipate obstacles that the patient cannot. The therapist can
point these out and work in the session to solve problems and overcome obstacles before they
arise outside of the session and block the patient from movin forward. ,or example, the patient
may set a plan to o to the movies with a friend. 7owever, if none of his friends are reach1able
by phone or have time to o out, the plan will fail. To address this obstacle, the therapist can
suest that the patient make a plan to call a friend and to o to the movies alone if his friend is
not availableL this plan is much more likely to succeed.
!ometimes, the patientOs view that activity schedulin is too trivial or simplistic is an obstacle.
5onitive restructurin may be helpful to overcome this problem. The patient may insist that he
or she has an alternative approach to the problem that is more likely to succeed. To address this,
the therapist can suest a behavioral experiment to test the patientOs hypothesis. The therapist
can work with the patient to try the patientOs intervention for a week, with the areement that if
this is not successful, the patient will try activity schedulin.
4. 5inally( %ork "ollaboratively6
If you and the patient are not workin toether, the intervention is unlikely to succeed.
+$O NEEDS ACTI"IT% SC$EDU!IN#;
Y &assive, immobili*ed patients benefit a reat deal from activity schedulin. Bnless a
patientOs activity level is ade+uate, he or she is usually not able to make much use of conitive
interventions. The mood lift patients obtain from most activities may be enouh to spark more
action in an upward spiral.
Y &atients who are procrastinatin, avoidin, or feelin MstuckN can use activity schedulin
to help them take steps to move forward. =ith activity schedulin, a vaue plan to do somethin
can become concrete and real and, therefore, more likely to be carried out.
Y &atients who have trouble ettin started doin anythin because they are overwhelmed
and have too much to do can use activity schedulin to structure their time and activities. These
patients can use the Activity !chedulin form to schedule one, two, or a small number of
activities at concrete, specific, realistic times.
Y &atients strulin with suicidal thouhts and impulses can also benefit from activity
schedulin. &articipation in pleasurable activities can provide direct evidence to disconfirm
common thouhts of suicidal patients %e.., MI donOt en3oy anythin,N Mlife is not worth livin,NN
)1
thin has meaninN). Activity schedulin also counters suicide when the patient and therapist
work toether to schedule activities that are incompatible with plannin and carryin out a
suicidal act.
Acti5ity Sched-le
Time !unday "onday Tuesday =ednesday Thursday ,riday
!aturday
C/@@ am
9/@@ am
(/@@ am
'@/@@ am
''/@@ am
'6/@@
noon
'/@@ pm
6/@@ pm
./@@ pm
$/@@ pm
G/@@ pm
)'
-/@@ pm
Evenin
)( oal5Setting 6or7s"eet
The &rocess/
'. Identify a concern or a problem.
6. !tate the desired outcome of the problem.
.. Assess the desired outcome.
a. Does it specify what you want to doP
$. In what ways is achievement of this oal important to youP To othersP
G. =hat will achievin the oal re+uire of youP <f othersP
-. To what extent is this oal somethin you want to doP
C. Is this oal based on
a. Hoical ideasP
b. 4ealistic expectationsP
c. Irrational ideas or thouhtsP
d. &erfectionist standardsP
9. 7ow will achievin this oal help youP
(. =hat problems could achievin this oal create for youP
'@. If this oal re+uires others to chane, can you understand that such a chane is not likely
to occur and that you can only work on yourselfP
''. !pecify exactly what you will be
a. Doin UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
b. Thinkin UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
c. ,eelin UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
))
'6. !pecify your oal definition by indicatin/
a. =here this will occur
b. =hen this will happen
c. =ith whom this will occur
d. 7ow often this will happen
'.. Develop a plan that specifies how you will attain your
oal by identifyin action steps included in the plan.
a. UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
b. UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
c. UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
d. UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
e. UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
'$. 5heck your list of action steps/
a. Are the aps between steps smallP If not, add a step or two.
b. Does each step represent only one ma3or activityP If not, separate this one step
into two or more steps.
c. Does each step specify what, where, when, with whom, and how much or how oftenP
If not, o back and define your action steps more concretely.
'G. Develop a oal pyramid to se+uence your list of action steps, startin with the easiest,
most immediate step on the top and proceedin to the bottom of the pyramid by deree of
difficulty and immediacy or proximity to the oal.
'-. ,or each action step %startin with the first), brainstorm what could make it difficult to
carry out or could interfere with doin it successfully. 5onsider feelins, thouhts, places,
people, and lack of knowlede or skills. =rite down the obstacles.
'C. ,or each action step %startin with the first), identify existin resources such as feelins,
thouhts, situations, people and support systems, information, skills, beliefs, and self1
)*
confidence that would make it more likely for you to carry out the action or complete it
more successfully. =rite down the resources in the space provided on pae 6G(.
'9. Identify a way to monitor your proress for completion of each action step.
'(. Develop a plan to help yourself maintain the action steps once you have attained them.
Ste(s for the co-nselor and <-estions the co-nselor sho-ld as2
'. Explain the purpose and importance of havin oals or positive out1comes to the client.
78et9s talk abo#t some areas yo# %o#ld like to %ork on d#rin! "o#nselin!. This %ill help #s to
do thin!s that are related to %hat yo# %ant to a""omplish.:
6. Determine positive chanes desired by client %MI would likeN versus canOtN).
7)hat %o#ld yo# like to be doin! ;thinkin!( feelin!< differently*:
7'#ppose some distant relative yo# haven9t seen for a %hile "omes here in several months. )hat
%o#ld be different then from the %ay thin!s are no%*:
7Ass#min! %e are s#""essf#l( %hat do yo# %ant to be doin!( or ho% %o#ld this "han!e for
yo#*:
7$n %hat %ays do yo# %ant to benefit from "o#nselin!*:
.. Determine whether the oal selected represents chanes owned by the client rather than some1
one else %MI want to talk to my mom without yellin at her,N rather than MI want my mom to stop
yellin at meN).
7=o% m#"h "ontrol do yo# have to make this happen*:
7)hat "han!es %ill this req#ire of yo#*: 7)hat "han!es %ill this req#ire someone else to
make*:
7>an this be a"hieved %itho#t the help of anyone else*:
7To %hom is this "han!e most important*:
)+
$. Identify advantaes %positive conse+uences) to client and others of oal achievement.
7$n %hat %ays is it %orth%hile to yo# and others to a"hieve this*:
7=o% %ill a"hievin! this !oal help yo#*: 7)hat problems %ill "ontin#e for yo# if yo# don9t
p#rs#e this !oal*:
7)hat are the advanta!es of a"hievin! this "han!e?for yo#* others*:
7)ho %ill benefit from this "han!e?and ho%*:
G. Identify disadvantaes %neative conse+uences) of oal achievement to client and others.
7)hat ne% problems in livin! mi!ht a"hievin! this !oal pose for yo#*:
7Are there any disadvanta!es to !oin! in this dire"tion*:
7=o% %ill a"hievin! this "han!e affe"t yo#r life in adverse %ays*:
7=o% mi!ht this "han!e limit or "onstrain yo#*:
-. Identify whether, as the helper, you can pursue counselin with this particular client.
7These are thin!s $ am able to help yo# %ork %ith.:
7$ feel #n"omfortable %orkin! %ith yo# on this iss#e be"a#se of my o%n personal val#es ;or la"k
of kno%led!e<. $9d like to !ive yo# the names of several other "o#nselors 7This %o#ld be hard
for me to help yo# %ith be"a#se it seems as if yo#9re "hoosin! somethin! that %ill restri"t yo#
and not !ive yo# any options. 8et9s talk more abo#t this.:
C. Identify what the client will be doin, thinkin, or feelin in a concrete, observable way as a
result of oal achievement %MI want to be able to talk to my mom without yellin at her,N rather
than MI want to et alon with my momN).
7)hat do yo# %ant to be able to do ;think( feel< differently*:
7)hat %o#ld $ see yo# doin! ;thinkin!( feelin!< after this "han!e*:
7Des"ribe a !ood and a poor example of this !oal.:
9. !pecify under what conditions and what situations oals will be achieved/
=hen, where, and with whom %MI want to be able to talk to my mom at home durin the next
month without yellin at herN).
)1
7)hen do yo# %ant to a""omplish this !oal*:
7)here do yo# %ant to do this*:
7)ith %hom*:
7$n %hat sit#ations*:
I
(. !pecify how often or how much client will do somethin to achieve oal %MI want to be able to
talk to my mom at home durin the next month without yellin at her at least once a dayN).
7=o% m#"h ;or ho% often< are yo# doin! this ;or feelin! this %ay6 no%*:
7)hat is a realisti" in"rease or de"rease*:
7=o% m#"h ;or ho% often< do yo# %ant to be doin! this to be s#""essf#l at yo#r !oal*:
7)hat amo#nt of "han!e is realisti"( "onsiderin! %here yo# are ri!ht no%*:
'@. Identify and list small action steps the client will need to take to reach the oal %that is, break
the bi oal down into little sub oals).
7=o% %ill yo# !o abo#t doin! ;thinkin!( feelin!< this*:
7)hat exa"tly do yo# need to do to make this happen*:
78et9s brainstorm some a"tions yo#9ll need to take to make yo#r !oal %ork for yo#.:
7)hat have yo# done in the past to %ork to%ard this !oal*:
7=o% did it help*:
78et9s think of the steps yo# need to take to !et from %here yo# are no% to %here yo# %ant to
be.:
Hist of Action !teps
'.
6.
..
$.
G.
-.
C.
9.
(.
)-
'@.
''. !e+uence the action steps on the oal pyramid %a hierarchy) in terms of
a. deree of difficulty %least to most)
b. immediacy %most to least immediate)
7)hat is yo#r first step*:
7)hat %o#ld yo# be able to do most easily*:
7)hat %o#ld be most diffi"#lt*:
7)hat is yo#r foremost priority*:
7)hat is most important for yo# to do soon* 8east important*:
7=o% "o#ld %e order these steps to maximize yo#r s#""ess in rea"hin! yo#r !oal*:
78et9s think of the steps yo# need to take to !et from %here yo# are no% to %here yo# %ant to be
and arran!e them in an order from %hat seems easiest to yo# to the ones that seem hardest.:
7>an yo# think of some thin!s yo# need to do before some other thin!s as yo# make pro!ress
to%ard this o#t"ome*:
'6. Identify any people, feelins, or situations that could prevent the client from takin action to
reach the oal.
7)hat are some obsta"les yo# may en+"o#nter in tryin! to take this a"tion*:
7)hat people ;feelin!s( ideas( sit#ations< mi!ht !et in the %ay of !ettin! this done*:
7$n %hat %ays "o#ld yo# have diffi"#lty "ompletin! this task s#""essf#lly*:
7)hat do yo# need to kno% to take this a"tion*: or 7)hat skills do yo# need to have*:
'.. Identify any resources %skill, knowlede, support) that client needs to take action to meet the
oal.
7)hat reso#r"es do yo# have available to help yo# as yo# "omplete this a"tivity*:
7)hat parti"#lar tho#!hts or feelin!s are yo# a%are of that mi!ht make it easier for yo# to
@@@@@*
7)hat kind of s#pport system do yo# have from others that yo# "an #se to make it easier to
@@@@@@*
7)hat skills ;or information< do yo# possess that %ill help yo# do this more s#""essf#lly*:
).
'$. Develop a plan to evaluate proress toward the oal.
7)o#ld it be pra"ti"al for yo# to rate these feelin!s ;"o#nt the times yo# do this< d#rin! the next
t%o %eeks* This information %ill help #s determine the pro!ress yo# are makin!.:
78et9s dis"#ss a %ay yo# "an keep tra"k of ho% easy or hard it is for yo# to take these steps this
%eek.:
*( Active 8istening Tec"ni9%es
Bse Active Histenin Techni+ues to develop a relationship. ,our active listenin
responses will allow the client to feel that the counselor is really listenin to them.
a. Clarification 1 A +uestion beinnin with, for example, MDo you mean thatN or
MAre you sayin thatN plus a rephrasin of the clientOs messae. The purpose of
this is to encourae more client elaboration, to check out the accuracy of what you
heard the client say and to clear up vaue, confusin messaes.
b. Para(hrase # 4espondin to content. A rephrasin of the content of the clientOs
messae. The purpose of doin this is to help the client focus on the content of
)/
his or her messae and to hihliht the content when attention to feelins is
premature or self1defeatin.
c. Reflection # 4espondin to feelins. A rephrasin of the affective part of the
clientOs messae. The purpose is to have the client to express more of his or her
feelins, to have the client experience feelins more intensely, to help the client
become more aware of the feelins that dominate him or her, to help the client
acknowlede and manae feelins and to help the client discriminate accurately
amon feelins.
d. S-mmari8ation # Two or more paraphrases or reflections that condense the
clientOs messaes or the session. The purpose of this is to tie toether multiple
elements of client messaes, to identify a common theme or pattern, to interrupt
excessive ramblin, and to review proress.
+( $rogressive 2%scle Relaxation
&roressive muscle relaxation is a systematic techni+ue for achievin a deep state of relaxation. It was
developed by Dr. Edmund ?acobson more than fifty years ao. Dr. ?acobson discovered that a muscle
could be relaxed by first tensin it for a few seconds and then releasin it. Tensin and releasin
various muscle roups throuhout the body produces a deep state of relaxation, which Dr. ?acobson
found capable of relievin a variety of conditions, from hih blood pressure to ulcerative colitis.
In his oriinal book, &roressive 4elaxation, Dr. ?acobson developed a series of 6@@ different muscle
relaxation exercises and a trainin proram that took months to complete. "ore recently the system
has been abbreviated to 'G16@ basic exercises, which have been found to be 3ust as effective, if
practiced reularly as the oriinal more elaborate system.
&roressive muscle relaxation is especially helpful for people whose anxiety is stronly associated
with muscle tension. This is what often leads you to say that you are Wuptiht8 or Wtense.W Sou may
experience chronic tihtness in your shoulders and neck, which can be effectively relieved by
practicin proressive muscle relaxation. <ther symptoms that respond well to proressive muscle
relaxation include tension headaches, backaches, tihtness in the 3aw, tihtness around the eyes,
*0
muscle spasms, hih blood pressure, and insomnia. If you are troubled by racin thouhts, you may
find r. hat systematically relaxin your muscles tends to help slow down your mind. Dr. ?acobson
himself once said, WAn anxious mind cannot exist in a relaxed body.8
The immediate effects of proressive muscle relaxation include all the benefits of the relaxation
response described at the beinnin of this chapter. Hon1term effects of re!#lar practice of
proressive muscle relaxation include/
A decrease in enerali*ed anxiety
A decrease in 8anticipatory anxiety related to phobias
4eduction in the fre+uency and duration of panic attacks
Improved ability to face phobic situations throuh raded exposure
Improved concentration
An increased sense of control over moods
Increased self1esteem
Increased spontaneity and creativity
These lon1term benefits are sometimes called !eneralization effe"ts: the relaxation experienced
durin daily sessions tends, after a month or two, to enerali*e to the rest of the day. The reular
practice of proressive muscle relaxation can o a lon way toward helpin you to better manae your
anxiety, face your fears, overcome panic, and feel better all around.
There are no contraindications for proressive muscle relaxation unless the muscle roups to be tensed
and relaxed have been in3ured. If you take tran+uili*ers, you may find that reular practice of
proressive muscle relaxation will enable you to lower your dosae.
#-idelines for Practicin1 Pro1ressi5e -scle Relaxation
6or Any 'orm of Dee( Relaxation7
The followin uidelines will help you make the most use of proressive muscle relaxation. They are
also applicable to any form of deep relaxation you undertake to practice reularly, includin self1
hypnosis, uided visuali*ation, and meditation.
'. &ractice at least 6@ minutes per day. Two 6@1minute periods are preferable. <nce a day is
mandatory for obtainin enerali*ation effects. %Sou may want to bein your practice with .@1minute
periods. As you ain skin in relaxation techni+ue, you will find that the amount of time you need to
experience the relaxation response will decrease.)
*1
6. ,ind a +uiet location to practice where you won8t be distracted. Don8t permit the phone to rin while
you8re practicin. Bse a fan or air conditioner to blot out backround noise if necessary.
.. &ractice at reular times. <n awakenin, before retirin, or before meals are enerally the best
times. A consistent daily relaxation routine will increase the likelihood of enerali*ation effects.
$. &ractice on an empty stomach. ,ood diestion after meals will tend to disrupt deep relaxation.
G. Assume a comfortable position. Sour entire body, includin your head, should be supported. Hyin
down on a sofa or bed or sittin in a reclinin chair are two ways of supportin your body most
completely. %=hen lyin down, you may want to place a pillow beneath your knees for further
support.) !ittin up is preferable to lyin down if you are feelin tired and sleepy. It8s advantaeous to
experience the full depth of the relaxation response consciously without oin to sleep.
-. Hoosen any tiht clothin and take off shoes, watch, lasses, contact lenses, 3ewelry, and so on.
C. "ake a decision not to worry about anythin. Dive yourself permission to put aside the concerns of
the day. Allow takin care of yourself and havin peace of mind to take precedence over any of your
worries. %!uccess with relaxation depends on ivin peace of mind hih priority in your overall
scheme of values.)
9. Assume a passive, detached attitude. This is probably the most important element. Sou want to
adopt a Wlet it happenW attitude and be free of any worry about how well you are performin the
techni+ue. Do not try to relax. Do not try to control your body. Do not 3ude your performance. The
point is to let o.
Pro1ressi5e -scle Relaxation Techni<-e
&roressive muscle relaxation involves tensin and relaxin, in succession, sixteen different muscle
roups of the body. The idea is to tense each muscle roup hard %not so hard that you strain, however)
for about '@ seconds, and then to let o of it suddenly. Sou then ive yourself 'G16@ seconds to relax,
noticin how the muscle roup feels when relaxed in contrast to how it felt when tensed, before oin
on to the next roup of muscles. Sou miht also say to yourself WI am relaxin,W WHettin o,W WHet the
tension flow away,W or any other relaxin phrase durin each relaxation period between successive
muscle roups. Throuhout the exercise, maintain your focus on your muscles. =hen your attention
wanders, brin it back to the particular muscle roup you8re workin on/ The uidelines below
describe proressive muscle relaxation in detail/
"ake sure you are in a settin that is +uiet and comfortable. <bserve the uidelines for practicin
relaxation that were previously described.
*'
=hen you tense a particular muscle roup, do so viorously without strainin, for C1'@ seconds. Sou
may want to count Wone1thousand1one,8 Wone1thousand1two,W and so on, as a way of markin off
seconds.
5oncentrate on what is happenin. ,eel the buildup of tension in each particular muscle roup. It is
often helpful to visuali*e the particular muscle roup bein tensed.
=hen you release the muscles, do so abruptly, and then relax, en3oyin the sudden feelin of
limpness. Allow the relaxation to develop for at least 'G16@ seconds before oin on to the next roup
of muscles.
Allow all the other muscles in your body to remain relaxed, as far as possible, while workin on a
particular muscle roup.
Tense and relax each muscle roup once. ;ut if a particular area feels especially fiht, you can tense
and relax it two or three times, waitin about 6@ seconds between each cycle.
<nce you are comfortably supported in a +uiet place, follow the detailed instructions below/
'. To bein, take three deep abdominal breaths, exhalin slowly each time. As you exhale, imaine
that tension throuhout your body beins to flow away.
6. 5lench your fists. 7old for C1'@ seconds and then release for 'G16@ seconds. 0se these same time
intervals for all other m#s"le !ro#ps.
.. Tihten your biceps by drawin your forearms up toward your shoulders and Wmakin a muscleW
with both arms. 7old ... and then relax.
$. Tihten your triceps11the muscles on the undersides of your upper arms11by extendin your arms
out straiht and lockin your elbows. 7old ... and then relax.
G. Tense the muscles in your forehead by raisin your eyebrows as far as you can. 7old ... and then
relax. Imaine your forehead muscles becomin smooth and limp as they relax.
-. Tense the muscles around your eyes by clenchin your eyelids tihtly shut. 7old...and then relax.
Imaine sensations of deep relaxation spreadin all around the
C. Tihten your 3aws by openin your mouth so widely that you stretch the muscles around the hines
of your 3aw. 7old ... and then relax. Het your lips part and allow your 3aw to han loose.
9. Tihten the muscles in the back of your neck by pullin your head way backL as if you were oin
to touch your head to your back %be entle with this muscle roup to avoid in3ury). ,ocus only on
tensin the muscles in your neck. 7old ... and then relax. !ince this area is often especially tiht, it8s
ood to do the tense1relax cycle twice.
(. Take a few deep breaths and tune in to the weiht of your head sinkin into whatever surface it is
restin on.
*)
'@. Tihten your shoulders by raisin them up as ff you were oin to touch your ears. 7old ... and
then relax.
''. Tihten the muscles around your shoulder blades by pushin your shoulder blades back as if you
were oin to touch them toether. 7old the tension in your shoulder blades ... and then relax. !ince
this area is often especially tense, you miht repeat the tense1relax se+uence twice.
'6. Tihten the muscles of your chest by takin in a deep breath. 7old for up to '@ seconds ... and
then release slowly. Imaine any excess tension in your chest flowin away with the exhalation.
'.. Tihten your stomach muscles by suckin your stomach in. 7old ... and then release.
Imaine a wave of relaxation spreadin throuh your abdomen.
'$. Tihten your lower back by archin it up. %Sou should omit this exercise if you have lower
back pain.) 7old ... and then relax.
'G. Tihten your buttocks by pullin them toether. 7old ... and then relax. Imaine the muscles
in your hips oin loose and limp.
'-. !+uee*e the muscles in your thihs all the way down to your knees. Sou will probably have
to tihten your hips alon with your thihs, since the thih muscles attach at the pelvis. 7old ...
and then relax. ,eel your thih muscles smoothin out and relaxin completely.
'C. Tihten your calf muscles by1pullin your toes toward you %flex carefully to avoid cramps).
7old ... and then relax.
'9. Tihten your feet by curlin your toes downward. 7old ... and then relax.
'(. "entally scan your body for any residual tension. If a particular area remains tense, repeat
one or two tense1relax cycles for that roup of muscles.
6@. :ow imaine a wave of relaxation slowly spreadin throuhout your body, startin at your
head and radually penetratin every muscle roup all the way down to your toes.
The entire proressive muscle relaxation se+uence should take you 6@1.@ minutes the first time.
=ith practice you may decrease the time needed to 'G16@ minutes. Sou miht want to record the
above exercises on an audio cassette or you may wish to obtain a professionally made tape of the
muscle 1relaxation exercise.
%Taken from Therapist9s A#ide to >lini"al $ntervention: The 1+/+19s of Treatment -lannin!( by
'haron 8. Bohnson)
Co-nselor=s Scri(t 'or -scle Relaxation
**
I> Rationale
UUUUUUUU '. 5ounselor explains purpose of muscle relaxation.
7The name of the strate!y that $ believe %ill be helpf#l is m#s"le relaxation. ,#s"le relaxation
has been #sed very effe"tively to benefit people %ho have a variety of "on"erns like insomnia(
hi!h blood press#re( anxiety( or stress or for people %ho are bothered by everyday tension.
,#s"le relaxation %ill be helpf#l in de"reasin! yo#r tension. $t %ill benefit yo# be"a#se yo# %ill
be able to "ontrol and to dispel tension that interferes %ith yo#r daily a"tivities.:
UUUUUUUU 6. 5ounselor ives overview of how muscle relaxation works.
7$ %ill ask yo# to tense #p and relax vario#s m#s"le !ro#ps. All of #s have some tensions in o#r
bodies?other%ise %e "o#ld not stand( sit( or move aro#nd. 'ometimes %e have too m#"h
tension. &y tensin! and relaxin!( yo# %ill be"ome a%are of and "ontrast the feelin!s of tension
and relaxation. 8ater %e %ill train yo# to send a messa!e to a parti"#lar m#s"le !ro#p to relax
%hen nonessential tension "reeps in. Co# %ill learn to "ontrol yo#r tension and relax %hen yo#
feel tension.:
UUUUUUUU .. 5ounselor describes muscle relaxation as a skill.
7,#s"le relaxation is a skill. And( as %ith any skill( learnin! it %ell %ill take a lot of pra"ti"e. A
lot of repetition and trainin! are needed to a"q#ire the m#s"le+relaxation skill.:
UUUUUUUU $. 5ounselor instructs client about movin around if uncomfortable and informs
client of sensations that may feel unusual.
7At times d#rin! the trainin! and m#s"le exer"ises( yo# may %ant to move %hile yo# are on yo#r
ba"k on the floor ;or on the re"liner. B#st feel free to do this so that yo# "an !et more
*+
"omfortable. Co# may also feel heady sensations as %e !o thro#!h the exer"ise. These sensations
are not #n#s#al. Do yo# have any q#estions "on"ernin! %hat $ D#st talked abo#t* $f not( do yo#
%ant to try this no%*:
II> Client Dress
UUUUUUUU G. 5ounselor instructs client about what to wear for trainin session.
75or the next session( %ear "omfortable "lothin!.9 7)ear re!#lar !lasses instead of yo#r
"onta"t lenses.:
Ill> Comforta)le En5ironment
UUUUUUUU -. 5ounselor uses +uiet environment, padded recliner chair, or floor with a pillow
under clientOs head.
7D#rin! trainin!( $9d like yo# to sit in this re"liner "hair. $t %ill be more "omfortable and less
distra"tin! than this %ooden "hair.:
I"> odelin1 the Exercises
UUUUUUUU C. 5ounselor models some exercises for muscle roups.
7$ %o#ld like to sho% yo# ;some of< the exer"ises %e %ill #se in m#s"le relaxation. 5irst( $ make
a fist to "reate tension in my ri!ht hand and forearm and then relax it.:
"> Instr-ctions for -scle Relaxation
UUUUUUUU 9. 5ounselor reads or recites instructions from memory in conversational tone and
*1
practices alon with client.
UUUUUUUU (. 5ounselor instructs client to et comfortable, close eyes, and listen to instructions.
7Eo%( !et as "omfortable as yo# "an( "lose yo#r eyes( and listen to %hat $9m !oin! to be tellin!
yo#. $9m !oin! to make yo# a%are of "ertain sensations in yo#r body and then sho% yo# ho% yo#
"an red#"e these sensations to in"rease feelin!s of relaxation.:
UUUUUUUU'@.5ounselor instructs client to tense and relax alternately each of the 'C muscle
roups (t%o times for each muscle roup in initial trainin). Also occasionally makes muscle1
roup comparisons.
UUUUUUUUa. ,ist of dominant hand
75irst st#dy yo#r ri!ht arm( yo#r ri!ht hand in parti"#lar. >len"h yo#r ri!ht fist. >len"h it
ti!htly and st#dy the tension in the hand and in the forearm. 't#dy those sensations of tension.
J&ause.K And no% let !o. B#st relax the ri!ht hand and let it rest on the arm of the "hair. J&ause.K
And note the differen"e bet%een the tension and the relaxation.: JTen1second pause.K.
UUUUUUUUb. ,ist of no dominant hand
7Eo% %e9ll do the same %ith yo#r left hand. >len"h yo#r left fist. Eoti"e the tension Jfive1
second pauseK and no% relax. .nDoy the differen"e bet%een the tension and the relaxation.:
JTen1second pause.K
UUUUUUUUc. <ne or both wrists
7Eo% bend both hands ba"k at the %rists so that yo# tense the m#s"les in the ba"k of the hand
and in the forearm. -oint yo#r fin!ers to%ard the "eilin!. 't#dy the tension( and no% relax.
J&ause.K 't#dy the differen"e bet%een tension and relaxation.: JTen1second pause.K
*-
UUUUUUUUd. ;iceps of one or both arms
7Eo%( "len"h both yo#r hands into fists and brin! them to%ard yo#r sho#lders. As yo#
do this( ti!hten yo#r bi"ep m#s"les( the ones in the #pper part of yo#r arm. 5eel the tension
in these m#s"les. J&auseK Eo% relax. 8et yo#r arms drop do%n a!ain to yo#r sides. 'ee the
differen"e bet%een the tension and the relaxation.: JTen1second pause.K
UUUUUUUUe. !houlders
7Eo% %e9ll move to the sho#lder area. 'hr#! yo#r sho#lders. &rin! them #p to yo#r ears. 5eel
and hold the tension in yo#r sho#lders. Eo%( let both sho#lders relax. Eote the "ontrast
bet%een the tension and the relaxation that9s no% in yo#r sho#lders. JTen1second pause.K Are
yo#r sho#lders as relaxed as yo#r arms*:
UUUUUUUUf. ,orehead
7Eo% %e9ll %ork on relaxin! the vario#s m#s"les of the fa"e. 5irst( %rinkle #p yo#r forehead
and bro%. Do this #ntil yo# feel yo#r bro% f#rro%. J&ause.K Eo% relax. 'mooth o#t the forehead.
8et it loosen #p.: JTen1second pause.K
UUUUUUUU. Eyes
7Eo% "lose yo#r eyes ti!htly. >an yo# feel tension all aro#nd yo#r eyes* J,ive1second pause.K
Eo% relax those m#s"les( notin! the differen"e bet%een the tension and the relaxation.: JTen1
second pauseK
UUUUUUUUh. Tonue or 3aw
7Eo% "len"h yo#r Da% by bitin! yo#r teeth to!ether. -#ll
*.
the "orners of yo#r mo#th ba"k. 't#dy the tension in the Da%s. J,ive1second pause.K Felax yo#r
Da%s no%. >an yo# tell the differen"e bet%een tension and relaxation in yo#r Da% area*: JTen1
second pause.K
UUUUUUUi. Hips
7Eo%( press yo#r lips to!ether ti!htly. As yo# do this( noti"e the tension all aro#nd the
mo#th. J&ause.< Eo% relax those m#s"les aro#nd the mo#th. B#st enDoy the relaxation in yo#r
mo#th area and yo#r entire fa"e.: J&ause.K
UUUUUUUU3. 7ead backward
7Eo% %e9ll move to the ne"k m#s"les. -ress yo#r head ba"k a!ainst yo#r "hair. >an yo# feel the
tension in the ba"k of yo#r ne"k and in the #pper ba"k* =old the tension. Eo% let yo#r head rest
"omfortably. Eoti"e the differen"e. Geep on relaxin!.: J&ause.K
UUUUUUUUk. 5hin in chest
7Eo% "ontin#e to "on"entrate on the ne"k area. 'ee %hether yo# "an b#ry yo#r "hin into yo#r
"hest. Eote the tension in the front of yo#r ne"k. Eo% relax and let !o.: %Ten1second pause.K
UUUUUUUUl. ;ack
7Eo% dire"t yo#r attention to yo#r #pper ba"k area. Ar"h yo#r ba"k as if yo# %ere sti"kin! o#t
yo#r "hest and stoma"h. >an yo# feel tension in yo#r ba"k* 't#dy that tension. J&ause.K Eo%
relax. Eote the differen"e bet%een the tension and the relaxation.:
UUUUUUUUm. 5hest muscles
7Eo% take a deep breath( fillin! yo#r l#n!s( and hold it. 'ee the tension all thro#!h yo#r "hest
and into yo#r stoma"h area( hold that tension. J&ause.K Eo% relax and let !o. 8et yo#r breath
*/
o#t nat#rally. .nDoy the pleasant sensations. $s yo#r "hest as relaxed as yo#r ba"k and sho#l+
ders*: %Ten1second pause.K
UUUUUUUUn. !tomach muscles
7Eo% think abo#t yo#r stoma"h( li!hten the abdomen m#s"les. =old this tension. ,ake yo#r
stoma"h like a knot. Eo% relax. 8oosen these m#s"les no%.: %Ten1second pause.K
UUUUUUUUo. ;uttocks
75o"#s no% on yo#r b#tto"ks. Tense yo#r b#tto"ks by p#llin! them in or "ontra"tin! them. Eote
the tension that is there. Eo% relax?let !o.: JTen1second pause.K
UUUUUUUUp. Hes
7$9d like yo# no% to fo"#s on yo#r le!s. 'tret"h both le!s. 5eel tension in the thi!hs. J,ive1
second pause.K Eo% relax. 't#dy the differen"e a!ain bet%een the tension in the thi!hs and the
relaxation yo# feel no%.: JTen1second pause.K
UUUUUUU+. Toes
7Eo% "on"entrate on yo#r lo%er le!s and feet. li!hten both "alf m#s"les by pointin! yo#r
toes to%ard yo#r head. -retend a strin! is p#llin! yo#r toes #p. >an yo# feel the p#llin! and
the tension* Eote that tension. J&ause.K Eo% relax. 8et yo#r le!s relax deeply. .nDoy the
differen"e bet%een tension and relaxation.: JTen1second pause.K
"> Instr-ctions for -scle Relaxation
UUUUU''. 5ounselor instructs client to review and relax all muscle roups.
+0
7Eo%( $9m !oin! to !o over a!ain the different m#s"le !ro#ps that %e9ve "overed. As $ name
ea"h !ro#p( try to noti"e %hether there is any tension in those m#s"les. $f there is any( try to
"on"entrate on those m#s"les and tell them to relax. Think of drainin! any resid#al tension o#t
of yo#r body. Felax the m#s"les in yo#r feet( ankles( and "alves. J&ause.K 8et !o of yo#r knee and
thi!h m#s"les. J&ause.K 8oosen yo#r hips. J&ause.K 8oosen the m#s"les of yo#r lo%er body.
J&ause.K Felax all the m#s"les of yo#r stoma"h( %aist( and lo%er ba"k. J&ause.K Drain any
tension from yo#r #pper ba"k( "hest( and sho#lders. J&ause.K Felax yo#r #pper arms( forearms(
and hands. J&ause.K 8et !o of the m#s"les in yo#r throat and ne"k. J&ause.K Felax yo#r fa"e.
J&ause.< 8et all the m#s"les of yo#r body be"ome loose. Drain all the tension from yo#r body.
J&ause.K Eo% sit q#ietly %ith yo#r eyes "losed.:
UUUUU'6. 5ounselor asks client to rate relaxation eve followin trainin session.
7Eo% $9d like yo# to think of a s"ale from H to 3( %here H is "omplete relaxation and 3 extreme
tension. Tell me %here yo# %o#ld pla"e yo#rself on that s"ale no%.:
"I> Post trainin1 Assessment
UUUU'.. 5ounselor asks client about first session of relaxation trainin, discusses problems
with trainin if client has any.
7=o% do yo# feel*:
7)hat is yo#r overall rea"tion to the pro"ed#re*: 7Think ba"k abo#t %hat %e did?did yo#
have problems %ith any m#s"le !ro#p*:
7)hat rea"tion did yo# have %hen yo# fo"#sed on the tension* )hat abo#t relaxation*:
7=o% did the "ontrast bet%een the tension and relaxation feel*:
"II> $omewor2 and 'ollow&-(
UUUU'$. 5ounselor assins homework and re+uests that client complete homework lo for
practice sessions.
7Felaxation trainin!( like any skill( takes a lot of pra"ti"e. $ %o#ld like yo# to pra"ti"e %hat
+1
%e9ve done today. Do the exer"ises t%i"e a day for 13 to /H min#tes ea"h time. Do them in a
q#iet pla"e in a re"linin! "hair( on the floor %ith a pillo%( or on yo#r bed %ith a head pillo%.
Also( try to do the relaxation at a time %hen there is no time press#re?like arisin!( after s"hool
or %ork( or before dinner. Try to avoid any interr#ptions( like telephone "alls and people
%antin! to see yo#. >omplete the home%ork lo! $ have !iven yo#. ,ake s#re yo# fill it in for
ea"h pra"ti"e session. Do yo# have any q#estions*:
UUUUU'G. 5ounselor arranes for follow1up session.
7)hy don9t yo# pra"ti"e %ith this over the next t%o %eeks and "ome ba"k then*:
%Taken from &reathin! Te"hniq#es >o#rse Do"#ments( >I0 J2J( 5all /HH2( .G0.)
1( Ed%cation : Cognitive Distortions Defined
O5er1enerali8ation. The error of concludin the eneral from the specific. ,or example,
Mmy wife didnOt smile and say hello when she came home last niht. !he must be
unhappy.N <r Mhe was really nice to me today. This means heOs a wonderful person, and I
can trust him completelyN
'oc-s on the ne1ati5e %Mdoom and loomN). The distortion of selectively attendin to
neative informationL this is the Mlass1half1emptyN view of the world. ,or example, ?ane
focuses on the G items she missed on a '@@1item exam and feels like a total failure.
Dis<-alifyin1 the (ositi5e. The fallacy of inorin or devaluin positive evidence,
positive events, and positive information. ?ane, who aoni*es about the G items she
missed and inores the (G items she ot riht, is dis+ualifyin the positive. Another
example is the woman who, when evaluatin her performance as a mother, refuses to
include the fact that she ets her kids to school on time everyday as evidence that she is a
ood mother because MIOm s#pposed to do that.N
Predictin1 the f-t-re. The error of predictin the future based on the present. This is
often a problem because the view of the present is distorted, so the view of the future then
becomes distorted as well. ,or example, Mthe first couple I treated broke upL this means
+'
IOll never be a successful couples therapist.N <r Mthat date didnOt o well. IOll never find a
life partner.N
. The fallacy of drawin loical conclusions from
emotional experiences. ,or example, a person who is afraid of elevators concludes on
the basis of his fear reaction when he ets in an elevator that elevators are danerous.
ple is a depressed patient who concludes from his feelins of hopelessness
never et better.
All&or&nothin1 thin2in1 %also termed Mdichotomous thinkinN). The error of viewin
thins in Mblack and whiteN terms, inorin the Mrays.N ,or example, M?oe didnOt return
my call promptly 7eOs a totally unreliable person.N <r MI ot a mediocre rade on my first
case conceptuali*ation write upL I fail at everythin I tryN
Personali8ation> The mistake of drawin a conclusion about oneself from an event or
situation that miht have other meanins. ,or example, M?ack didnOt return my call. This
means he doesnOt like me.N <r Mthe fact that !usan turned me down for a date means that
IOm a loser.N
Catastro(hi8in1. The error of drawin conclusions, usually about the future, that involve
exaerated horrendous outcomes. ,or example, MI overdrew my checkin account. This
means my credit ratin will be ruined.N <r MI failed that exam. That means IOll fail out of
raduate school.N
!a)ellin1> The fallacy of drawin eneral conclusions about a person or situation, often
usin a neative or inflammatory term, on the basis of one or two specifics about that
person or situation. ,or example, Mmy supervisor was curt with me today This means heOs
a 3erk.N <r Mmy patient didnOt do his homework last week. This means he doesnOt really
want to et better.N
ind readin1. The error of makin inferences about another personOs thouhts or feel1
ins without collectin direct information from the person in +uestion. ,or example, Mmy
boss frowned at me in the hail today This means heOs thinkin of firin me.N <r Mmy
patient was late to therapy today 7e thinks that the therapy is not helpin him.N
?Sho-ld@ statements> The error of translatin oneOs wishes and preferences into moral
imperatives for oneself and others. ,or example, Mshe should be on time for meetins
with me. If sheOs not, sheOs not a responsible, professional person.N M&eople should drive
courteously If they donOt, they shouldnOt be allowed to drive.N <r ?I should always be on
+)
time.N
(Taken from Korrath( =.( L &rendtro( 8. (1MJ3. -ositive -eer >#lt#re. =a%thorne( EC: Aldine
de Ar#yter.
-( Cognitive T"in7ing Re#ort
:ame/ UUUUUUUUUUUUUUUUUUUUUUUUUUUUU Date/ UUUUUUUUUUUUU
0> Sit-ation. This is not a re(ort of thin2in1 )-t descri)es the sit-ation where the thin2in1
too2 (lace> This (art of the Thin2in1 Re(ort sho-ld )e )rief and o)Aecti5e B statin1 the
facts of the sit-ation and incl-din1 the )eha5ior done in that sit-ation )y yo->
UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
UUUUUUUU
+*
4> Tho-1hts. This is a list of all the tho-1hts yo- can remem)er ha5in1 d-rin1 the 1i5en
sit-ation or moment of time> After listin1, la)el each tho-1ht in the order they occ-rred>
A Thin2in1 Re(ort (resents yo-r tho-1hts as (-re, o)Aecti5e information> Criticism of the
thin2in1 or exc-ses for the thin2in1 is not a((ro(riate in a Thin2in1 Re(ort>
UUU
UUUU
UUU
UUU
:> 'eelin1s. This is a list of all the feelin1s the (erson can remem)er ha5in1 d-rin1 the
1i5en sit-ation or moment of time, li2e the tho-1hts, the feelin1s are (resented as (-re,
o)Aecti5e information>
UUUU
UUUU
U
++
C> Attit-des/Beliefs. This is a descri(tion of the more )asic le5el of a (erson=s thin2in1 B
their ?)ac21ro-nd thin2in1>@ +e don=t ma2e a technical distinction )etween attit-des and
)eliefs )-t -se whiche5er term seems most a((ro(riate in a 1i5en context> Attit-des and
)eliefs can )e defined as o-r 1eneral way of thin2in1 a)o-t a 2ind of (erson or 2ind of
sit-ation or a)o-t the way we thin2 thin1s sho-ld )e <4 attit-des and )eliefs can )e
defined as ?the thin2in1 )ehind o-r (artic-lar tho-1hts and feelin1s>@
Attit#de N mental state+ho% yo# present yo#rselfO a res#lt of ho% yo# think or feelO %ith yo# all
the time.
&elief N Ipinions/expe"tations that %e believe to be tr#e P learned from family or experien"es.
UUUUUUUUU
D> Ex(lain why these are Eey Tho-1hts and why they were Critical to the Sit-ation>
UUUUUU
F> Tri11erin1 E5ent. +hat started yo- thin2in1 these Eey Tho-1hts;
+1
UUUUUUUUUU
(Taken from Korrath( =.( L &rendtro( 8. (1MJ3. -ositive -eer >#lt#re. =a%thorne( EC: Aldine
de Ar#yter.
.( T"e Daily $lan
+-
The Daily &lan is a practical techni+ue for reducin mental stress and tension, anxiety, and
provides you with a means of ettin your thouhts in order before sleep so that you can bein to
overcome insomnia.
This is a method of puttin thins1to1be1attended1to on paper, rather than tryin to remember
them, and of reducin the unnecessary mental activity of continually 8oin over thins in your
head8.
The Daily &lan helps you manae both your time and youOre thinkin by enablin you to
prioriti*e your activities, think more clearly about them and reduce unnecessary self1talk.
Bsin the Daily &lan is an excellent way to bein your stress1manaement proram because by
plannin the day ahead you have a reater sense of order and a better chance of achievin more.
Sou also feel more in chare of events rather than at the mercy of whatever occurs. It is true that
thins will occur that have not been anticipated in your &lan. This is especially likely in the first
couple of weeks of usin this method. ;ut with practice you will be able to anticipate and
include more of the thins that are likely to crop up. And you will become more skilled at
allowin sufficient time for the unexpected.
=ith the Daily &lan you invest about '@ minutes each evenin in order to list everythin that
needs your attention the followin day. Sou will et an excellent return on this investment.
+hy Sho-ld I Use A Daily Plan;
Sou don8t have to keep your mind Mon the oN all day lon 1 continuously oin over thins
in your mind, remindin yourself about thins, or worryin whether you can fit everythin
in.
Sou avoid creatin or addin to a sense of on1oin urency
Sou will find it easier to mentally relax, switch off, and en3oy recreation time durin the day
Sou are able to utili*e your unconscious mind 1 to mentally rehearse and ready you for what
is ahead.
Sou are better able to ensure that thouhts about different topics do not contaminate one
another
Sou are better able to switch off in the evenins and foret about the next day.
Sou make it less likely that, at niht, you will spend time lyin awake tryin to decide what
and when and how to do thins the followin day
Sou have an internal imae of what you will do next day and when you will do it 1 this
reduces the amount of self talk
+.
Sou have a sense of order in your day and are more likely to o throuh your tasks more
easily and systematically
Sou have a daily reminder that, throuh this course, you have made a new start and that you
are takin chare of your own mind.
$ow Do I Use A Daily Plan;
Do it fairly early each evenin 1 after your evenin meal is an excellent time.
Quickly list everythin you can think of that needs attention next day.
=rite down the approximate time you think each task will take. And remember to allow time
for relaxation, recreation, washin, meals, travelin, etc.
Dive task each a star ratin for importance.
4emove those tasks for which you do not have enouh time and put them on the list for the
day after tomorrow. %And remember to inform anyone who may be affected by this alteration
in plans. &ut this on the plan tooX)
,inally list what you will do, when you will do it and how lon it will take on a final draft. In
doin keep about 6@F of your day unplanned 1 this is your comfort marin to allow for
"urphy8s Haw and the thins you have forotten to include on the &lan.
%Sou may find it useful to use a "ind "ap rather than a traditional list. This creates a more
effective and more easily remembered inner imae.)
<nce planned put tomorrow out of your mind. =hen apprehensive or Zplannin8 thouhts
occur simply visuali*e your &lan and say to yourself WItOs on the &lan 1 it8s taken care ofXW
%And if you think of somethin that is not on the plan simply add it to the list and ad3ust the
time element accordinly).
Bse the Daily &lan consistently for about 61. weeks and you will find it much easier to relax
in the evenins and at niht 1 allowin your mind and body to re1create enery and
enthusiasm for the day ahead.
(Taken from %%%.pe/HHH."om
+/
/( 6riting ;reely
This is stream1of1consciousness writin. It enables you to become even more
aware of your self1talk 1 the sub vocalisin that we all enae in durin most of our
wakin hours.
The content, or sub3ect1matter, of this self talk often can be unhelpful. ,or
example, we may spend a lot of our time self1criticisin, or underminin our own
confidence or self esteem, or dismissin our own achievements, or runnin 8should1do
patterns8 which may have been relevant when we were children but are no loner
appropriate.
This =ritin ,reely techni+ue is a useful way of ettin to know and of
updatin what you sub vocalise about. It is also an excellent mental1sprin1cleanin
exercise to run occasionally. And it can be especially helpful when you are in a very
stressful, or pressured, or panicky period. The followin is 3ust one way of applyin it
1 experiment to discover what works best for you.
'. &ick a period each day when you can be alone and undisturbed for about '@1'G
minutes.
6. 7ave a pen or pencil and a few sheets of paper 1 scrap paper will do as you will be
destroyin what you have written afterwards.
.. :ow bein writin. And, once you have, beun keep writin non1stopX It doesn8t
matter if you cannot think of anythin to write 1 in this case simply write WI cannot
think of anythin to write etc etcW
$. Sou are writin everythin that comes into your head 1 as +uickly as you can 1 non1
stop A! it occurs to youX
G. :o censorin 1 let everythin come out on paper 1 no matter how unusual or surprisin
or unacceptable.
10
-. Sou are actually transcribin your own inner self1talk. =rite fast and furiously. Every
sinle thouht. Even the seeminly irrelevant ones.
C. !top writin after doin this for at least ten minutes or, ideally, when the thouhts
fully dry up.
9. :ow take a break for G minutes or so. Det up and walk around. Do somethin un1
related to this activity. Sou are doin this to chane your mood.
(. :ext o back and read what you have written. :otice the themes that have come up.
'@. :ow rationali*e these 1 or, if you are an :H& &ractitioner, use the Hanuae "odels
to reconise the themes and patterns of your own thinkin.
''. =hen you have finished destroy the notes. This is a very important step because
destroyin the notes shortly after writin them convinces yourself that no1one except
you will ever read what you have written. This convinces you that it is <> to put
thins on paper.
This method works best when it is done reularly for a few weeks. It is both a way of clearin
your mind and of developin awareness what you are sayin to yourself inside your head.
11
10( Desensiti!e Yo%rself
Developed by =olpe in the $@8s, 8systematic desensiti*ation8 is a very effective, tried and tested
method of becomin less sensitive to the stimulus, or sub3ect, of your phobia. Althouh normally
applied by a therapist, you can use this as a self help method. It is a rather slow process so you will
need patience and the determination to stick with it for weeks or even months.
7ow to desensiti*e yourself
Hearn the skill of relaxation.
;uild a hierarchy of fears
Desensiti*e yourself 1 while deeply relaxed think about one of the steps. 4epeat this until this
step no loner evokes anxiety. Do not o on to the next step until you are +uite comfortable at
the previous one.
ild or Se5ere Pho)ia;
Bse desensiti*ation only on mild phobias. !elf help usin desensiti*ation is not suitable for severe
phobias because the emotions are likely to be too powerful for self help methods. A severe phobia is
best resolved with professional assistance.
It is likely that you will know instinctively whether yours is a phobia that will respond to this self help
approach. 7owever as a rouh uide check where your phobic reaction lies on an intensity scale of '1
'@.
Imaine that '@ is the hihest intensity 1 virtually bein overwhelmed at the thouht of the stimulus 1
and ' is a mild 8ho1hum8 uneasiness.
If your response to even thinkin about the sub3ect evokes an intensity of 9 or hiher you would be
well advised to seek professional help rather than attemptin to do it by yourself. ;elow 9 indicates
that self help methods are likely to work 1 with a systematic and persistent approach.
Com(lex Pho)ias
Sou can use desensiti*ation on 8complex phobias8, such as fear of flyin, and on 8social phobias8.
7owever do prepare thorouhly as this will make the difference between success and disappointment.
&repare very detailed hierarchy. Take a few weeks to do this, addin to it as the ideas occur to you.
=hile doin this you can be practicin your relaxation skills.
1'
$ow to desensiti8e yo-rself to yo-r fears
After completin your hierarchy you systematically [desensiti*eO yourself to thouhts and
imaes on your fourth list.
The ste(s
'. !elect your fearful thouht for the session 1 pick the item on your fourth list that has the
lowest intensity.
6. 4elax deeply 1 usin your relaxation tape andEor the skills you have been practicin.
.. :ow bein thinkin of the selected thouht. This will cause you to tense up somewhat.
$. ;ein immediately to reain your deeply relaxed state while thinkin of the thouht.
G. As you do allow your relaxation to deepen.
-. =hen you can think about this anxiety stimulus without any discomfort o on to the next
hihest on your hierarchy. Then do the same with this fear and then continue up the
hierarchy in the same way.
:ever desensiti*e yourself to more than one item per day. "ake haste slowly. Sou have
probably had the fears for some years so spendin a few weeks systematically and thorouhly
dissolvin them is a ood investment of your time.
1)
11( Syste&atic Desensiti!ation
Rationale
5ounselor ives client rationale for desensiti*ation, clearly explainin how it works.
7This pro"ed#re is based on the idea that yo# "an learn to repla"e yo#r fear (or other
"onditioned emotion in "ertain sit#ations %ith a better or more desirable response( s#"h as
relaxation or !eneral feelin!s of "omfort.9 7Co# have des"ribed some sit#ations in %hi"h yo#
have learned to rea"t %ith fear (or some other emotion. This pro"ed#re %ill !ive yo# skills to
help yo# "ope %ith these sit#ations so they don9t "ontin#e to be so stressf#l.:
5ounselor describes brief overview of desensiti*ation procedure.
7There are three basi" thin!s that %ill happen?first( trainin! yo# to relaxO next( "onstr#"tin! a
list of sit#ations in %hi"h yo# feel anxio#sO and finally( havin! yo# ima!ine s"enes from this list(
startin! %ith lo%+anxiety s"enes( %hile yo# are deeply relaxed.:
5ounselor checks to see whether client is willin to use stratey.
75irst yo# %ill learn ho% to relax and ho% to noti"e tension so yo# "an #se it as a si!nal to
relax. Then %e9ll identify sit#ations that( to varyin! de!rees( #pset yo# or make yo# anxio#s.
'tartin! %ith the least dis"omfortin! sit#ations( yo# %ill pra"ti"e the skill of relaxation as a %ay
to "ope %ith the stress. Are yo# ready to try this no%*:
1*
Identification of Emotion&Pro5o2in1 Sit-ations
5ounselor initiates at least one of the followin means of identifyin anxiety1provokin stimulus
situations/
a. Interview assessment throuh problem leads
7)hen do yo# noti"e that yo# feel most @@@@@@@@
7)here are yo# %hen this happens*:
7)hat are yo# #s#ally doin! %hen yo# feel @@@@@@@@
7)hat types of sit#ations seem to brin! on this feelin!*:
b. 5lient self1monitorin
7This %eek $9d like yo# to keep tra"k of any sit#ation that seems to brin!
on these feelin!s. In yo#r lo!( %rite do%n %here yo# are( %hat yo#9re
doin!( %hom yo#9re %ith( and the intensity of these feelin!s.:
c. !elf1report +uestionnaires
7Ine %ay that %e mi!ht learn more abo#t some of the spe"ifi" sit#ations
that yo# find stressf#l is for yo# to "omplete this short q#estionnaire.
There are no ri!ht or %ron! ans%ers?D#st des"ribe ho% yo# #s#ally feel
or rea"t in the sit#ations presented.:
5ounselor continues to assess anxiety provokin situations until client identifies some specific
situations.
78et9s "ontin#e %ith this exploration #ntil %e !et a handle on some thin!s. Fi!ht no% yo#9ve
said that yo# !et nervo#s and #pset aro#nd "ertain kinds of people. >an yo# tell me some types
1+
or "hara"teristi"s of people that bother yo# or make yo# anxio#s almost al%ays*: 7IG( !ood(
so yo# noti"e yo#9re al%ays very anxio#s aro#nd people %ho "an eval#ate or "riti"ize yo#( like a
boss or tea"her.:
$ierarchy Constr-ction
5ounselor identifies a type of hierarchy to be constructed with client.
7Eo% %e9re !oin! to make a list of these anxiety+provokin! sit#ations and fill in some details
and arran!e these in an order( startin! %ith the least anxiety+provokin! sit#ation all the %ay to
the most anxiety+provokin! one.:
a. 5onventional
7&e"a#se yo# !et more and more anxio#s as the time for the spee"h !ets "loser and
"loser( %e9ll "onstr#"t these items by "loser and "loser times to the spee"h.:

b. Idiosyncratic
7)e9ll arran!e these items a""ordin! to the different kinds of sit#ations in %hi"h people
"riti"ize yo#? dependin! on %ho does it( %hat it9s abo#t( and so on.:
5ounselor identifies the number of hierarchies to be developed.
a. !inle hierarchy
7)e %ill take all these items that refle"t different sit#ations that are anxiety+prod#"in!
for yo# and arran!e them in one list.:
11
b. "ultiple hierarchies
7&e"a#se yo# find several types of sit#ations stressf#l( %e9ll "onstr#"t one list for
sit#ations involvin! "riti"ism and another list for sit#ations involvin! so"ial events.:
5ounselor initiates identification of hierarchy items throuh one or more methods.
7$9d like #s to %rite do%n some items that des"ribe ea"h of these anxiety+provokin! s"enes %ith
q#ite a bit of detail.:
a) Interview +uestions %not when client is enaed in relaxation)
i. 7Des"ribe for me %hat yo#r mother "o#ld say that %o#ld bother yo# most.
=o% %o#ld she say it* Eo% %ho( other than yo#r mother( "o#ld "riti"ize
yo# and make yo# feel %orse* )hat thin!s are yo# most sensitive to bein!
"riti"ized abo#t*:
b) 5lient completion of note cards %homework)
i. 7This %eek $9d like yo# to add to this list of items. $9m !oin! to !ive yo#
some blank index "ards. .a"h time yo# think of another item that makes
yo# !et anxio#s or #pset abo#t "riti"ism( %rite it do%n on one "ard.:
5ounselor continues to explore hierarchy items until items are identified that meet the followin
criteria/
a. !ome items, if carried out in vivo, are under clientOs control %do not re+uire
instiation from others).
i. 7>an yo# think of some items that( if yo# a"t#ally %ere to "arry them o#t(
%o#ld be thin!s yo# "o#ld initiate %itho#t havin! to depend on someone
else to make the sit#ation happen*:
b. Items are concrete and specific.
i. 7IG( no% D#st to say that yo# !et nervo#s at so"ial f#n"tions is a little
1-
va!#e. Aive me some details abo#t a so"ial f#n"tion in %hi"h yo# mi!ht
feel pretty "omfortable and one that "o#ld make yo# feel extremely
nervo#s.:
c. Items are similar to or represent past, present, or future situations that have
provoked or could provoke the emotional response from client.
i. 7Think of items that represent thin!s that have made yo# anxio#s before
or "#rrently P and thin!s that "o#ld make yo# anxio#s if yo# en"o#ntered
them in the f#t#re.:

d. Items have sampled broad rane of situations in which emotional
response occurs.
i. 7>an yo# identify items representin! different types of sit#ations that
seem to brin! on these feelin!s*:
e. Items represent different levels of emotion aroused by representative stimulus
situations.
i. 78et9s see if %e have items here that refle"t different amo#nts of the
anxiety yo# feel. =ere are some items that don9t make yo# too anxio#s.
)hat abo#t ones that are a little more anxiety+provokin!( #p to ones
%here yo# feel pani"ky*:
5ounselor asks client to identify several control items %neutral, non1emotion1arousin).
7'ometimes it9s helpf#l to ima!ine some s"enes that aren9t related to thin!s that make yo# feel
anxio#s. >o#ld yo# des"ribe somethin! yo# "o#ld ima!ine that %o#ld be pleasant and
relaxin!*:
5ounselor explains purpose of rankin and spacin items accordin to increasin levels of
arousal.
7$t may take a little time( b#t yo# %ill rank these hierar"hy items from least anxiety+prod#"in! to
1.
most anxiety+prod#"in!. This !ives #s an order to the hierar"hy that is !rad#al( so %e "an %ork
D#st %ith more mana!eable sit#ations before movin! on to more stressf#l ones.:
5ounselor asks client to arrane hierarchy items in order of increasin arousal, usin sud
methodL explains method to client.
7Eo% $ %o#ld like yo# to take the items and arran!e them in order of in"reasin! anxiety( #sin!
the follo%in! method. $9d like yo# to arran!e these items #sin! a H+to+1HH s"ale. H represents
total relaxation and 1HH is "omparable to "omplete pani". $f an item doesn9t !ive yo# any
anxiety( !ive it a H. $f it is D#st a little stressf#l( may be a 13 or /H. Kery stressf#l items %o#ld !et
a hi!her n#mber( dependin! on ho% stressf#l they are.:
5ounselor adds or deletes items if necessary to achieve reasonable spacin of items in hierarchy.
78et9s see( at the lo%er end of the hierar"hy yo# have many items. )e mi!ht drop o#t a fe% of
these. &#t yo# have only three items at the #pper end( so %e have some bi! !aps here. >an yo#
think of a sit#ation provokin! a little bit more anxiety than this item b#t not q#ite as m#"h as this
next one* )e "an add that in here.:
Selection and Trainin1 of Co-nter conditionin1 Res(onse
5ounselor selects appropriate counter conditionin response to use to counter condition anxiety
%or other conditioned emotion)/
a. Deep muscle relaxation
i. %contrastin tensed and relaxed muscles)
b. Duided imaery
i. %evokin pleasurable scenes in imaination)
c. "editation
i. %focusin on breathin and countin)
d. 5opin thouhts or statements
1/
i. %concentratin on copin or productive thouhts incompatible with self1
defeatin ones)
5ounselor explains purpose of particular response selected and describes its role in
desensiti*ation.
7This response is like a s#bstit#te for anxiety. 8earnin! it %ill take time( b#t it %ill help to
de"rease yo#r anxiety so that yo# "an fa"e rather than avoid these feared sit#ations. This
trainin! %ill help yo# re"o!nize the onset of tension. Co# "an #se these "#es yo# learn as a
si!nal to relax a%ay the tension.:
5ounselor trains client in use of counter conditionin response and suests daily practice of this
response.
7)e %ill spend several sessions learnin! this so yo# "an #se it as a %ay to relax. This relaxation
on yo#r part is a very important part of this pro"ed#re. After yo# pra"ti"e this here( $9d like yo#
to do these at home t%o times ea"h day over the next fe% %eeks. .a"h pra"ti"e %ill make it
easier for yo# to relax.:
5ounselor asks client before and after each trainin session to rate felt level of anxiety or
arousal.
70sin! a s"ale from H to 1HH( %ith H bein! "omplete relaxation and 1HH bein! intense anxiety(
%here %o#ld yo# rate yo#rself no%*:
5ounselor continues with trainin until client can discriminate different levels of anxiety and can
use nonanxiety response to achieve '@ or lower ratin on @1to1 ' @@ scale.
78et9s "ontin#e %ith this #ntil yo# feel this trainin! really has an effe"t on yo#r relaxation state
after yo# #se it.:
Ima1ery Assessment
5ounselor explains use of imaery in desensiti*ation.
7$n this pro"ed#re( $9ll ask yo# to ima!ine ea"h hierar"hy item as if yo# %ere a"t#ally there. )e
-0
have fo#nd that ima!inin! a sit#ation "an be very similar to a"t#ally bein! in the sit#ation.
&e"omin! desensitized to anxiety yo# feel %hile ima!inin! an #npleasant sit#ation %ill transfer
to real sit#ations( too.:
5ounselor assesses clientOs capacity to enerate vivid imaes by/
a. &resentin control items when client is usin a relaxation response
1. 7Eo% that yo#9re relaxed( !et a pi"t#re in yo#r mind of sittin! in
the s#n on a %arm day. The sky is very bl#e( not a "lo#d in it. The
!rass and trees are !reen. Co# "an feel the %armth of the s#n on
yo#r body.:
b. &resentin hierarchy items when client is not usin a relaxation response
1. 7IG( D#st ima!ine that yo#9re at this party. Co# don9t kno%
anyone. Aet a pi"t#re of yo#rself and the other people there. $t9s a
very lar!e room.:
c. Askin client to describe imaery evoked in a and b
1. 7>an yo# des"ribe %hat yo# ima!ined* )hat %ere the "olors yo#
sa%* )hat did yo# hear or smell*:
5ounselor, with clientOs assistance, determines whether clientOs imaery meets the followin
criteria and, if so, decides to continue with desensiti*ation/
a. 5lient is able to imaine scene concretely with details.
1. 7)ere yo# able to ima!ine the s"ene "learly* =o% many details
"an yo# remember*:
b. 5lient is able to imaine scene as participant, not onlooker.
1. 7)hen yo# ima!ined the s"ene( did yo# feel as if yo# %ere
a"t#ally there and involved?or did it seem as if yo# %ere D#st an
-1
observer( perhaps %at"hin! it happen to someone else*:
c. 5lient is able to switch scene on and off when instructed to.
1. 7=o% soon %ere yo# able to !et an ima!e after $ !ave it to yo#*
)hen did yo# stop the ima!e after $ said 'top*: 7Did yo# ever
feel as if yo# "o#ldn9t "on"entrate on the s"ene and started to drift
off*:
d. 5lient is able to hold scene without driftin off or revisin it.
1. 7Did yo# ever "han!e anythin! abo#t the s"ene d#rin! the time
yo# ima!ined it*:
e. 5lient shows no evidence of other difficulties.
1. 7)hat else did yo# noti"e that interfered %ith !ettin! a !ood
pi"t#re of this in yo#r mind*:
$ierarchy Scene Presentation
5ounselor explains method of scene presentation.
7$ am !oin! to present an item in the hierar"hy and $9d like yo# to ima!ine the s"ene as "learly
as yo# "an. $ %ill %ait %hile yo# ima!ine the s"ene and %at"h to see %hether yo# si!nal any
anxiety.:
5ounselor checks clientOs anxiety levelL allows the client to hold the imae of the scene for five
to seven seconds and terminates it by sayin,
7'top the s"ene. =o% m#"h did ima!inin! this s"ene in"rease yo#r s#d level*:
,or each session of scene presentation/
-'
a. 5ounselor precedes scene presentation with muscle relaxation or other procedures
to help client achieve relaxation before scenes are presented.
78et yo#r %hole body be"ome heavier and heavier as all yo#r m#s"les relax. . . .
5eel the tension drainin! o#t of yo#r body.... Felax the m#s"les of yo#r hands and
arms...:
b. 5ounselor beins initial session with lowest %least anxiety1provokin) item in
hierarchy and for successive sessions beins with last item successfully completed
at previous session.
7$9m !oin! to start this first session %ith the item that is at the bottom of the
hierar"hy.: Ir 7Today %e9ll be!in %ith the item %e ended on last %eek for a
revie%.:
c. 5ounselor describes item and asks client to imaine it for five to seven
seconds.
7B#st ima!ine yo# are sittin! in the "lassroom %aitin! for the test to be passed to
yo#( %onderin! ho% m#"h yo# "an remember.: J5ounts five to seven seconds.K
d. If client held imae and did not sinal anxiety, counselor instructs client to stop
imae and relax for '@ to .@ seconds.
7Eo%( stop vis#alizin! this s"ene and D#st take a little time to relax. Think of
sittin! in the s#n on a %arm day( %ith bl#e sky all aro#nd yo#.:
If client indicated anxiety durin or after visuali*in scene, counselor asks for a
sud ratin and tells the client to erase the scene and relax for '@ to .@ seconds.
5ounselor then represents that same scene for five to seven seconds and watches
to see whether the client sinals any anxiety by raisin her finer.
7)hat is yo#r s#d ratin!*:
e. After pause of '@ to .@ seconds between items, counselor presents
-)
each item to client a second time.
7Eo% $ %ant yo# to ima!ine the same thin!. >on"entrate on bein! very relaxed(
and then ima!ine that yo# are sittin! in the "lassroom %aitin! for the test to be
passed to yo#( %onderin! ho% m#"h yo# "an remember.:
f. Each item is successfully completed %with no anxiety) at least two successive
times %more for items at top of hierarchy) before new item is presented.
7$9m !oin! to present this s"ene to yo# on"e more no%. B#st relax( and then
ima!ine that.:
. If an item elicits anxiety after three presentations, counselor makes some
ad3ustments in hierarchy or in clientOs visuali*ation process.
78et9s see %hat mi!ht be bo!!in! #s do%n here. Do yo# noti"e that yo# are
driftin! a%ay from the s"ene %hile yo#9re ima!inin! it?or revisin! it in any
%ay* >an yo# think of a sit#ation %e mi!ht add here that is D#st a little bit less
stressf#l for yo# than this one*:
h. !tandardi*ed instructions are used for each phase of scene presentationL
reinforcement of l#st the no1anxiety items is avoided.
7IG( $ see that %as not stressf#l for yo#. B#st "on"entrate on relaxin! a min#te.:
7)hat %as yo#r feelin! of anxiety on the H+to+1HH s"ale* /H. IG( $ %ant yo# to
D#st relax for a min#te( and then $9ll !ive yo# the same s"ene.:
i. Each scene1presentation session ends with a successfully completed item %no
anxiety for at least two successive presentations).
7IG( let9s end today %ith this item %e9ve D#st been %orkin! on( sin"e yo#
reported 3 s#ds d#rin! the last t%o presentations.:
3. Each session is terminated after 'G to 6@ minutes of scene presentation or after
indications of client restlessness or distractibility
-*
7)e9ve done q#ite a bit of %ork today. B#st spend a fe% min#tes relaxin!( and
then %e %ill stop.:
5ounselor uses written recordin method durin scene presentation to note clientOs proress
throuh hierarchy.
7As %e !o thro#!h this session( $9m !oin! to make some notes abo#t the n#mber of times %e
%ork %ith ea"h item and yo#r anxiety ratin! of ea"h presentation.:
$omewor2 and 'ollow&U(
5ounselor assins homework tasks that correspond to treatment proress of desensiti*ation
procedure/
7There is somethin! $9d like yo# to do this %eek on a daily basis at home.:
'. Daily practice of selected relaxation procedure
7-ra"ti"e this relaxation pro"ed#re t%o times ea"h day in a q#iet pla"e.:
6. Aisuali*ation of items successfully completed at previous session
7In this tape there are three items %e "overed this %eek. Eext %eek at home(
after yo#r relaxation sessions( pra"ti"e ima!inin! ea"h of these three items.:
.. Exposure to in vivo situations correspondin to successfully completed
hierarchy items.
7Co# are ready no% to a"t#ally !o to a party by yo#rself. )e have !otten to
a point %here yo# "an ima!ine doin! this %itho#t any stress.:
5ounselor instructs client to record completion of homework on daily lo sheets.
7.a"h time yo# "omplete a home%ork pra"ti"e( re"ord it on yo#r lo! sheets.:
-+
5ounselor arranes for follow1up session or check1in.
7>he"k in %ith me in t%o %eeks to !ive me a pro!ress report.:
1'( <o= To 2anage Travel Anxiety
,rom 5athleen 7ennin
Sour Duide to &anicEAnxiety Disorders.
If you have an anxiety disorder, an upcomin trip may be filled with any number of activities that
trier some or all of your fears and anxieties. Is it possible to travel if you have anxiety about itP ,ind
out how to assess your situation and fiure out a plan for makin travel possible 11 and even
en3oyableX %Note. $ re"ommend that yo# %rite do%n yo#r tho#!hts as yo# !o thro#!h these steps and
talk to yo#r therapist abo#t %hat yo# are doin!.)
Assess the sit-ation and yo-r fears> !tep by step, o throuh the entire trip, includin how you8ll
travel, your accommodations %such as hotel vs. stayin with friendsEfamily), whom you8ll see, what
activities you will do, etc. Then, for each step, evaluate your anxiety about it, and try to rate the level
of that anxiety.
Be honestly realistic a)o-t what is (ossi)le> &lease 1 work with a therapist on this one. :othin is
impossible, of course, but you need to decide if you have an appropriate amount of time to prepare for
the trip and related activitiesEevents. &ut pressure from other people aside for now. If you decide you
cannot take this particular trip, you then owe it to yourself to make a concerted effort to work on those
fears that kept you from oin.
-1
Create a (lan to wor2 on yo-r fears> <nce you have decided to take your trip, you should now have
a list of each step on the trip alon with any related fears. :ow it8s time to decide what you can
reasonably do about each fear in the time you have before the trip.
Decide which fears yo- mi1ht wor2 on eliminatin1> ,or example, if you have - months to prepare
and you have a fear of flyin. 5onsider workin with a conitive1behavioral therapist particularly on
this fear. A trip actually is a ood time to work on many anxieties that may affect your day1to1day life.
Talk with your therapist about which fears you have time to work on in a systematic way.
Decide which fears yo- will need to mana1e> &erhaps you have been workin on your flyin fear
and it isn8t oin away. A possibility miht be that you talk to your doctor about an anti1anxiety
medication 3ust for the fliht. <r maybe you need to drive a distance alone but could do it with far less
anxiety if you have a companion 11 maybe a friend can o. In the lon run, of course, the oal is to et
well, but, alon the way, there may be times you need to work around the anxiety.
Decide which fears yo- will need to remo5e> !ometimes it8s 3ust not possible to et over or manae
a fear in a particular amount of time. !ee if you have an alternative. Afraid to flyP Is a train possibleP
5an8t ive a speech at your sister8s weddinP !ee if there8s somethin else you can do, but handle it in
a lovin way. !ometimes people understand and sometimes they don8t. All you can do is try your best
and offer alternatives as much as possible. !how you are makin an effort.
Be comforta)le> Do whatever you can to make the trip comfortable and don8t feel silly about itX If
stayin at your crowded parents8 home full of relatives is too much, stay at a hotel but visit them every
day. Take relaxation tapes, comfy pa3amas, a stuffed animal in your carry1on 11 whatever worksX
Be or1ani8ed> ;e orani*ed about plannin your trip 11 both with your anxiety plan as well as the
details about the trip. Don8t add to your anxiety by mis1placin tickets or waitin until the last minute
to make reservations. "ake lists 11 don8t be afraid to write it all down. Do all that you can to feel as
safe as you can.
+or2 with a (rofessional> I know it8s already been said, but, please work with a therapist on this. ;e
sure your therapist understands that you want to set oals alon with what specifically you want to
address. 5reate a plan toether and decide what you reasonably can accomplish before the trip.
Tal2 to other (eo(le with anxiety, too> If you8re not in a local support roup %and even if you are),
try our Anxiety !upport ,orum for tips, support, and advice about your trip and anythin else related
to anxiety and ettin well.
ore Ti(s
After assessin your fears and creatin a manaement plan, write a list of everythin about the trip
you will en3oy. >eep a list of these %or put them on index cards) to remind yourself of the positive
reasons why you are takin this trip.
--
Don8t be afraid to tell your travel companions about your anxiety. ;e clear that you don8t expect them
to take care of you, but consider ivin them a task or two that will help you with a specific problem
%such as ivin you the aisle seat on the plane). &eople want to help, but they don8t want to be
overwhelmed and they like to have spe"ifi" ideas of what they can do to help.
%Taken from http://pani"disorder.abo#t."om/"s/ht.htm)
1)( Ti#s To $rotect Yo%r Sense of $ersonal Safety
Even if you are not directly involved, witnessin or hearin about a crisis can erode your sense of
personal safety. Indirect exposure to trauma can evoke feelins and imaes, particularly if you have
had a personal history of trauma. !elf1awareness can be a tool in creatin a personal sense of self1
control in midst of others8 crises. (Taken from:
http://%%%."onversationsin"are."om/%eb@book/printerfriendly/"hapter1pf.html
4econi*e the early warnin sins of secondary trauma and compassion fatiue,
includin overreaction to patients8 concerns, recurrent thouhts about situations in your
practice that are particularly difficult, feelins of burnout, and avoidance activities.
Identify what brins a sense of security, and find a safe place %visuali*ed or real) where
you can relax and feel protected.
;e flexible.
&ay attention to your feelins and reactions to patients and situations.
Hearn as much as you can about what is oin to happen in advance on topics that can
cause trauma, as well as treatment options.
-.
Dlean facts for yourself about real issues from your personal reactions to the crisis.
Bnderstand the facts about the threatenin situation and what they mean to you.
Identify the beliefs that cause you distress about the crisis.
Evaluate the pros and cons of those beliefs.
Examine alternative approaches for thinkin about the same facts to make them less
distressin.
4espect your feelins by allowin yourself to rieve losses.
=hen you experience a traumatic memory or reaction, take slow, deep breaths and try to
reain some measure of soothin and calm throuh visuali*ation or movement.
Bse relaxation and other techni+ues to manae memories so that you can tolerate stron
feelins without becomin overwhelmed.
4eaffirm your confidence and competence by realistically addressin your
responsibilities and strenths.
1*( Ex#os%re T"era#y
Exposure therapy is suested to be one of the best ways to overcome your anxiety. To master
somethin in life it is necessary first to think about it, and then actually practice doin it. The more
you practice the better you become. This is the basis of exposure therapy. Sou actually need to o
into the situation and think about it in a different way, implement the other skills and knowlede you
have to mane your anxiety, and then reflect on how it went. There is a word of caution here. !ome
research suests to [face the fear and do it anyway8. ,or some people this may workL however for
others it doesn8t. Hearnin the skills and techni+ues of conitive therapy and educatin yourself on
where your anxiety is actually comin from in the first place, prior to exposin yourself to the
situation, can often have better outcomes as you can feel more in control before you enter the
situation, rather than oin in feelin absolutely terrified.
=hen you feel anxious, it is suested that you o throuh it firstly in your mind %realistic
thinkinEskills of conitive therapy), and then o and secondly, put yourself in the situation that you
fear. This part is called exposure therapy. If you continue to avoid situations because you are feelin
anxious, it only makes it harder to overcome your anxiety. =hen you avoid doin somethin, you
often convince yourself that there is a very ood reason why you are not doin it. If you continue to
avoid situations, no amount of thinkin about it in another way will actually help you overcome your
anxiety in the situations. The more often you do somethin, the easier it becomes each time.
-/
There are some helpful techni+ues suested to use when enain in exposure therapy. 4on 4apee
in his book, 8<vercomin !hyness and !ocial &hobia8 suests the followin techni+ues. These
include/
<ne step at a time 1 don8t 3ump in the deep end first. Take a small step and work you way up
to the most uncomfortable situations.
!tay in the situation 1 try not to leave if you suddenly feel anxious. 4ather, implement some
of the other techni+ues such as rational thinkin, focusin, breathin and relaxation. <f
course, if you absolutely have to leave then do 1 it is suested that you try and do it aain as
soon as possible. Alternatively, try and back away a little bit, instead of leavin the situation
completely.
4epeats 1 doin somethin once can be interpreted as a flukeX The more often you do
somethin, the more you will start to feel more comfortable %the more techni+ues you
implement, the reater the ability you will have to control your anxiety)
Bps and Downs 1 these are a part of life, and some days you will have ood days, and some
days you will not have such ood days. Try not to beat yourself up on the not so ood days by
enain in neative self talk. 4ather, accept it for what it is 1 a not so ood dayXX Do back to
the drawin board and set your oals a little lower until you are feelin stroner and more
confident aain.
;e aware of avoidance 1 try and be aware of all your avoidances. ;y not doin somethin that
you fear, you are only makin it harder for yourself. Avoidance is only an excuse and keeps
your fears oin. If you have enaed in some anxiety education, you will be more aware that
it is you who is controllin your anxiety, so it is you who can decrease and manae it as well.
It 3ust takes some practice %and patienceXXX) It is also important to try and be aware of subtle
avoidance when overcomin hih levels of anxiety. ,or e.. Sou miht o to a party, and talk
to only a few people you know well, avoidin meetin new people. <r you miht travel '@
kms to o to a shop rather than visit the shoppin centre 'km from your home.
Everyone has different fears and experiences different levels of anxiety in different situations. It is
important to try and overcome all your avoidances usin the techni+ues of exposure therapy.
(Taken from Fapee(F.,.( (1MMJ( Iver"omin! 'hyness and 'o"ial -hobiaQ( >hapter 4( p!. 41+73(
passim( 8ifestyle -ress.
.0
1+( Ex#os%re to ;eared Sit%ations
This techni+ue, also called in vivo exposure, involves confrontin a feared situation repeatedly,
until the situation no loner triers fear. ,or exampleL someone who identifies talkin to people
of authority as a fearful situation miht purposefully o to a professor and ask +uestions about
homework, or o to a pharmacist and ask +uestions about medication he or she is takin.
Exposure works best when it occurs fre+uently %e.., several times per week), and lasts lon
enouh for the fear to decrease %up to two hours).
Exposure therapy is essential if you are to overcome your social anxiety, ie you must put
yourself in the social situations you are worried about. Althouh this sounds frihtenin, your
therapist will ive you the tools to cope with confrontin your fears %e.. rational thinkin, slow
breathin I isometric relaxation)
The exposure sessions must be
raded
repeated and reular
proloned
#raded Sessions
Sour therapist will work with you to determine what would be an appropriate first stepL it should
be difficult enouh to provoke some anxiety but easy enouh for you to be fairly confident you
can do it. <nce you can cope with !tep ' confidently, then you can move onto a more difficult
situation and radually work up your most feared social scenarios.
It is important not to confront a feared situation that is far too difficult for you, as if you tackle
somethin too stressful, without sufficient preparation, you may become extremely anxious or
even have a panic attack. !uch a neative experience would only strenthen the association
between fear and the social settin.
Re(eated Sessions
Sou need to confront your feared situations fre+uently and reularly if you are oin to
overcome your anxiety. If your exposures are too far apart your fear will have risen aain by the
next time you do it.
.1
Prolon1ed Sessions
Denerally, it is advised that you stay in the feared situation until your anxiety starts to decrease.
!ocially anxious people often approach or attempt a feared situation but then choose to escape
from the feared social or performance situation. =hen you avoid or leave feared situations your
fear of them increases because the decrease in anxiety which follows escape ives you the idea
that avoidance was a helpful stratey. 7owever, if you stayed in the feared situation your anxiety
would eventually decrease and the next time you confronted the situation you would be less
anxious.
Therefore, it is important to your recovery that you stay in the social situation you are
attemptin. Try not to panic or flee if the anxiety becomes severe. If your anxiety is hih, you
may feel you temporarily need time out from your feared activity, e.. if you were attendin a
house party you miht o to the bathroom or sit outside in the arden, do some slow breathin,
develop some rational thouhts and wait for the fear to decrease for oin back into the party.
4emember exposure is necessary for your recovery.
(Taken from Andre%s( A.( >rino(F.( =#nt(>.( 8ampe( 8.( L -a!e( A. (1MM2. The Treatment of
Anxiety Disorders >ambrdi!e( .n!land. >ambrid!e 0niversity -ress
11( <ierarc"y of ;ears
$ow to )-ild yo-r hierarchy
This takes a little time and thouht but it is worth it. It provides a framework for systematically
reducin your anxiety.
Constr-ctin1 the $ierarchy
5onstructin a ood hierarchy is very important since it provides the framework for
approachin the problem. Time and care must be devoted to it. As was stated above, the
hierarchy is a list of the situations related to your taret behavior which you react to with raded
amounts of anxiety. !uch a hierarchy is constructed in three steps. :ow, please et a pencil and
some paper and follow the instructions closely.
') '. =rite down as many situations as you can think of in which the problem occurs. If you
are nervous with straners or members of the opposite sex, for instance, write down these
specific situations in which you experience difficulty. =rite down all you can think of.
.'
Sour list will include some situations which are worse than others. !ome will be very
frihtenin, some hardly frihtenin at all, and some in between.
6) 6. "ake a list of some of the AA4IA;HE! that affect your anxiety level. This can increase
your insiht into the causes of your anxiety and make it easier to create a ood hierarchy.
a ) Examples of variables affectin the amount of anxiety in presentin a speech to a class/
class si*eL lenth of speechL amount of preparationL importance of speechL how critical
instructor isL lenth of time before the speech %week before, niht before, walkin to
classroom, bein called upon to ive speech, etc.)L how personal the speech isL deree to
which others will disaree with itL etc.
b ) <ther common variables affectin anxiety levelsL amount of re3ection expectedL sex of
other personL attractiveness of other personL difficulty of testL etc.
c ) Hook at some of the sample hierarchies and identify variables affectin the amount of
anxiety in them. <f course each person is uni+ue, but there are often similarities between
hierarchies.
.) :ow arrane these items in order from the least upsettin to the most upsettin by thinkin
about each one and imainin 3ust how bad it would be to be in that situation.
$) :ow build your final hierarchy. "ost people include about '@16@ items %you may have
more) beinnin with items so mild that they are practically non1frihtenin. Sou miht
have to invent some very mild items such as havin someone say the word !irl %for uys who
are afraid of irls), or lookin at the picture of a professor %for people who are afraid of those
with hih status), etc. The ten to twenty items should be chosen so as to contain very small
3umps in severity from one item to the next, so that when you have finished an item you
donVt have a very much harder item 3ust in front of you. The final items, of course, should
be the most severe items from the oriinal list.
G) This ranked list of anxiety evokin items constitutes the hierarchy that you will use in your
treatment. "odifications additions, combinin of items and further breakin1down of items
on the hierarchy may be made at any time durin the desensiti*ation therapy. "ost peopleVs
hierarchies re+uire some modification as desensiti*ation.
Sam(le $ierarchies
To aid you in constructin your hierarchy, we have included five sample hierarchies
below. !tudyin these hierarchies will ive you a ood idea of how they are constructed and
should help you construct yours. These are, however, samples only to show you the form. Sou
must construct your own hierarchy which applies to your specific case.
.)
$ierarchy G0
Tar1et Beha5ior. Anxiety when interactin1 with mem)ers of the o((osite sex>
;ein with a member of the opposite sex who is a member of my family.
;ein with a member of the opposite sex I know very well, not a family member.
!eein a member of the opposite sex I know fairly well.
!milin at a member of the opposite sex I know fairly well.
Talkin to a member of the opposite sex I know fairly well.
!eein a member of the opposite sex I know slihtly or not at all on campus.
!milin at a member of the opposite sex I know slihtly or not at all.
!ayin hello to a member of the opposite sex I know slihtly or not at all.
"eetin a very attractive member of the opposite sex for the first time.
Talkin on the phone a short time with a member of the opposite sex.
Talkin on the phone a short time with a member of the opposite sex.
Talkin in person for a short time with a member of the opposite sex.
Talkin for a lon time %e.., one hour) with a member of the opposite sex.
Askin out or bein asked out by an attractive member of the opposite sex.
;ein on a date with a very attractive member of the opposite sex.
O5er5iew of the (rocess
Sou are oin to make . separate lists on three sheets of paper and then use these to prepare a
fourth list # which becomes your hierarchy of anxiety. %The followin list is one that you miht
create if yours were a fear of flyin phobia. 7owever you use the same process for any phobia. )
Sour three lists are/
The various steps you encounter in oin throuh the phobic situation
The likely physical and mental sensations that you miht experience and which would add to
your discomfort
The various aspects of a 8worst case scenario8 in which you lose self control
!ist No> 0 B the ste(s in 1oin1 thro-1h the sit-ation
.*
This is a list of different aspects of what you are phobic of which you sort into ascendin order
of intensity. ,or example, if you are a nervous flyer you miht bein your hierarchy by listin
all of the steps in a plane 3ourney in some detail/
Thinkin about travelin by plane
Telephone to book your seat
&ackin your luae
Travelin to the airport
Arrivin at the airport
5heckin in
Doin into the departure area
;oardin the plane
The doors closin
The safety drill
Taxiin
Takin off
5limbin
Experiencin turbulence
5hanes in plane speed
5hanes in enine noise
The plane maneuverin
;einnin descent
,inal approach
Touch down
Deceleratin
!ist No> 4 B the (hysical and emotional sensations
This is a list of the thouhts, behaviors and sensations which miht further increase your anxiety,
for example/
,eelin nervous
Dry mouth
7eartbeat increasin and becomin more pronounced
7ands or les tremblin
A look of concern from one of the cabin staff as they pass by your seat
7avin to ask for help from the cabin staff
!ist No> : & yo-r worst case scenario
.+
Do this list because in enterin a phobic situation we can be as fearful of our own responses, in
particular of losin self control, as of the actual phobic stimulus. ;y desensiti*in yourself to
these internal Odisaster movies8 you make it unlikely that you will be overwhelmed by your fears.
&ick three or four scenarios ranin from mildly panickin to completely losin control. ,or
example/
;ecomin very weepy
;ecomin weepy and tremblin noticeably
;ecomin weepy, tremblin and bein unable to sit still in your seat
Hosin control and havin to be restrained by the cabin staff
Sou may, at first, feel reluctant to do this list because these may be imaes you would prefer to
not even think about. ;ut remember that they are likely to occur to you in the phobic situation 1
so it8s best to use your new desensiti*ation skills to defuse your disaster movies in advance.
!ist no> C & yo-r final wor2in1 list
:ow you need to select your personal anxiety peaks from your . initial lists. !o put them side by
side and select the most fearful thouht. =rite this on the fourth list and then cross it off the
initial list that it appears on.
:ow select the next most terrifyin thouht and put this on Hist :o. $. This is number 6 in your
hierarchy. 4epeat this process until the thouhts and imaes you are addin to Hist :o. $ are so
mild as to be unimportant. Sour list1makin is complete.
(Taken from %%%.pe/HHH."om.
1-( <ig"est <o#es> Dee#est ;ears
O)Aecti5es
I> Beha5ioral
"embers will/
i. Identify hopes and fears in writin
ii. Interact spontaneously with other roup members
.1
iii. &ractice empathic skills by listenin to a partner
II> Co1niti5e
"embers will/
i. Decrease sense of isolation by ivin and receivin feedback with roup
members
ii. Increase empathy with other members by explainin partnerOs worksheet
aterials
'. 5opy of M7ihest 7opes, Deepest ,earsN worksheet for each member
6. Ink pens or pencils
ethod
Droup members work independently to identify on the worksheet their hihest hopes and
deepest fears. After the leader determines that most members are finished, partners are assined.
&artners pair up and discuss their worksheets toether. The roup then reconvenes in a circle,
and each member explains his or her partnerOs worksheet to the roup. ,eedback is encouraed.
Instr-ctions
7and out copies of the worksheet and instruct members to thin about their hihest hopes
and deepest fears. Tell the roup to identify their hopes and fears on the worksheet by writin
them out in the spaces provided. After everyone is finished, divide the roup into partners, either
selected randomly or assined carefully by desin. Instruct the couples to share their worksheets
with one another, makin sure they have a ood understandin of what their partner means by
the material written on his or her worksheet. Encourae partners to +uestion and explore one
anotherOs work. This done, call members back to the roup circle. Then ask each member to
share his or her partnerOs worksheet with the roup. Encourae feedback from the roup,
althouh +uestions and comments should be directed to the presenter of the worksheet, not the
.-
author. After this is accomplished, explain that the author now has a chance to comment on how
well the presenter understood him or her. Then call on the next member, in round1robin fashion.
Concl-sion
5onclude the session with some comments about the followin/
'. 5ommonality of hopes and fears expressed.
6. Importance of understandin anotherOs perspective %empathy).
$i1hest $o(es, Dee(est 'ears
+or2sheet
$i1hest $o(es
'.UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
6.UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
..
..UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
$.UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
G.UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
Dee(est 'ears
'.UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
6.UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
..UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
$.UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
G.UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
(Taken from >arrell( '. (/HHH. Aro#p .xer"ises for Adoles"ents: A ,an#al for Therapists.
Tho#sand Iaks( >alifornia: 'a!e -#bli"ations( $n".
1.( <o= to Overco&e a $"obia
<vercomin a phobia entails learnin how to relax and calm
yourself so that you can radually face the feared ob3ect or situation
and feel less afraid.

./
Ste(s
'. Explore exactly what it is you are afraid of about the ob3ect or situation. Is there some
underlyin reason that you are avoidin the ob3ect or situationP Is there somethin you ain by
avoidin the ob3ect or situation %besides avoidin the fear or anxiety)P

6. Hearn how to relax and calm yourself. There are many ways to do this. 7ere is one method/
Take a slow deep breath into your belly to the count of six and then breathe out slowly to the
count of six. &ractice this daily for five minutesL increase over time to 6@ minutes.

.. "ake a list startin with the feared ob3ect or situation 1 for example, drivin on freeways.
Then, write down what ob3ect or situation would be slihtly less anxiety1producin 1 for
example, drivin on small hihways.

$. Explore exactly what it is you are afraid of. Is there some underlyin reason or past event that
causes you to avoid an ob3ect or situationP Is there somethin you ain by avoidin it %besides
avoidin the fear or anxiety)P

G. Hearn how to relax and calm yourself. There are many ways to do this. 7ere is one method/
Take a slow, deep breath into your belly to the count of six and then breathe out slowly to the
count of six. &ractice this daily for G minutesL increase over time to 6@ minutes.

-. "ake a list startin with the feared ob3ect or situation8for example, drivin on freeways. Then,
write down what ob3ect or situation would be slihtly less anxiety1producin for example,
drivin on small hihways.

C. 5ontinue makin a list of items that are slihtly less anxiety1producin than the previous item
for example, drivin on bi, busy streets, then drivin on less conested streets, and so forth.

9. Det into a relaxed state usin whatever method you have been practicin. !tartin with the
least anxiety1producin item on your list %the last item), imaine yourself in that situation as
vividly as possible while continuin to breathe and stay relaxed.
(. Do on to the next item up. Aisuali*e yourself in that situation while continuin to practice
relaxation and calm yourself.

/0
'@. =ork up the list, imainin yourself in each situation while continuin to practice remainin
relaxed and calm. <nly o to the next item when you can successfully stay calm imainin the
previous item. If one of the items produces too much anxiety, stop the exercise and come back to
it later. !tart at the beinnin of your list each time, and proress as far as you can. It may take
you several sessions before you proress to the top of the list.

''. =rite down all the thouhts you have when facin your phobia, such as 8I8m oin to die,8
8I8m oin to have a heart attack8 or 8I can8t breathe.8

'6. =rite down alternative thouhts that would help you calm down, such as 8I am not oin to
die,8 8I can breathe8 or 8I can relax.8

'.. In real life, put yourself in the least anxiety1producin situation on your list %the last item)
and practice relaxin and calmin yourself 3ust as you imained. Include tellin yourself the
alternative thouhts to help you calm down.

'$. =ork yourself up to your most feared situation or ob3ect %your phobia) while practicin
bein relaxed and calm.
(Taken from %%%.eho%."om.
1/( <o= to Red%ce 6orrying
,ortunately, there are strateies that you can learn and practice that can be useful for reducin
worry. ;ut because worryin is a habit that has been well practiced, you should reali*e that it
/1
will take fre+uent practice of other courses of action, ones that are incompatible with worry, to
reduce the habit of worryin.
The more the methods are practiced, the stroner the new habit becomes and the weaker the old
habit of worry becomes. This will take some effort in the beinnin.
Additionally, it is important to reali*e that what works for one person may not work for another.
;ecause each person is uni+ue, the way in which he or she worries, and the best ways for that
person to learn to reduce his or her worryin, may vary.
The most effective way to reduce worry is to choose a method and practice it. If after a few
weeks of conscientious practice you do not notice a decline in your worryin, it is sensible to
shift to a different method and to practice that for a while.
The important point is to ive a method a ood try before abandonin it, and to reali*e that while
some methods work well for some types of worryin, others may be better for other types of
worryin. Sou can try combinin methods until you find which combination works best for you.
"ethods include/
<bserve your worryin and catch it early
5ount your worryin
Himit worryin with the worry period
&ostpone worries to the worry period
Attend to the immediate environment
Bse worry period for problem solvin
Try conitive restructurin
4elaxation methods for bodily disturbance
Track the outcome of your worries
!eekin professional help
O)ser5e %o-r +orryin1 and Catch It Early
"ost of us, when we worry, are not even aware that it has started. That is the nature of habits.
ThatOs why learnin to become aware of your worryin is fundamental to any method of worry
/'
reduction. ;ein by observin your worryin/ ;ecome more aware of itL observe it with the oal
in mind of catchin the worry as soon as it beins.
In applyin any of these worry1reduction methods, the earlier it is applied, in other words the
earlier you can catch the worry, the more effective in the lon run the method will be. This is
because the loner an episode of worryin lasts, the more the habit is strenthened and the more
you are strenthenin the bonds between the specific worrisome thouhts in particular. In other
words, you are reinforcin the habit. !o, the earlier the worryin is cauht, the less that habit is
strenthened.
;y becomin increasinly conscious of the habit of worryin, it is possible to a reater and
reater deree to switch it off before it becomes obsess ional. It is a ood sin when you are
consciously catchin the worryin early. Sou are approachin the position of bein able to do
somethin about it more effectively.
Co-nt %o-r +orryin1
In learnin to observe youOre worryin, it is useful to keep track of how often it occurs durin the
day.
"akin marks on a notepad %that you carry with you) or usin a wristwatch olf1counter
would allow you to record this information.
At the end of each day write down the total and watch this trend over a number of days.
This procedure is helpful as a reminder to you to observe and catch worryin. It also provides
information on how much time you spend worryin. Hater, as you bein practicin worry1
reduction methods and continue to track the daily fre+uency of worryin, youOll be able to see
what impact your methods are havin.
!imit +orryin1 +ith the +orry Period
=orryin can take place any time and in any place, and it can occur without you even bein
aware of it. ;ecause of this, worryin can become associated with many times and many places.
=hen some action like worryin is fre+uently associated with a particular place, returnin to that
place will tend to elicit the action in the future. That is, the place comes to remind you of the
worryin, so you start worryin aain. In this way, worryin comes to be triered at many times
and places, until it oes on all day.
/)
<ne useful stratey, then, is to practice limitin the occurrence of worry to, ideally, one place
and one time of day. To do this, set up a W.@1minute worry period.W
5hoose a particular time and place for worryin. That time and place should always be
the same each day. "ake the place uni+ue, a place where you will only worry and where
you will not do anythin else. 5hoosin the kitchen table, or bed, or your favorite livin
room chair would not be a sensible idea, because you o to those places often. A chair
placed in a corner of a room only durin the worry period would be a better idea. It
creates a uni+ue environment that will only be associated with worry.
5hoose a time that is convenient each day so that you are rarely busy with somethin else
that miht prevent you from usin your worry period. Avoid choosin a time too close to
bedtimeL it is not sensible to associate worry with oin to sleepX
There are several strateies discussed below for how you can use the worry period, and some
traditional methods to be used in con3unction with the worry period to make it effective.
Post(one +orries to the +orry Period
Sou have been observin your worries and have beun to practice catchin them early. The next
step is to postpone those worries to your worry period as soon as you become aware of them.
=hen you catch the beinnin of a worry, remind yourself that/
Sou will have time later on to think about that worry. There is no need to worry about it
now. In fact, youOre worryin later durin the worry period will likely lead to better
solutions to the problem than doin it now, when you donOt have the time.
There are other thins oin on in your life that either re+uire your attention or would be
more pleasant to attend to than makin yourself upset with worryin.
!o, postpone the worry. =rite down the topic in case you are worried that you miht foret it
before you et to your worry period.
Attend To the Immediate En5ironment
/*
The next method to use in combination with postponement is to focus your attention on the
immediate environment or the task at hand. 4emember, the events that you think about durin
worry donOt exist riht now. !o focus your attention back to what does immediately exist.
As you practice this, become increasinly aware of the difference between attendin to what
exists Wout thereW and attendin to what doesnOt actually exist except in your thouhts and
imaes. &ractice spendin more and more time attendin to what does exist.
&ostponin a worry when it has been cauht early and focusin attention on the immediate
environment can help to reduce the fre+uency and duration of worry episodes. Each time these
are practiced, the worry habit lessens in strenth and alternative habits are strenthened.
7owever, you should reali*e that old habits are hard to break. After postponin and focusin, the
worry will try to intrude, often almost immediately. ?ust repeatedly follow the same procedure
each time you catch it intrudin. Immerse yourself in your immediate environment, and donOt et
discouraed if the worry continues to try to intrude.
Use +orry Period for Pro)lem Sol5in1
=hen you reach your worry period, there are several strateies that can be employed to make it
particularly useful. ?ust the fact of the existence of such a worry period will make it possible to
postpone worries durin other times.
The worry period can also be used to start whittlin away the strenth of the worry. Bse the
worry period to list the worries you have and distinuish between those worries about which you
can do somethin and those you cannot.
,or those worries about which you can do somethin, use the worry period for problem solvin
and decision makin.
=hat steps can you take to reduce the likelihood of the bad event happeninP
Is there information you can find that can ive you a better estimate of the chances of
such an event happenin or information that can help you come up with a solutionP
Talk to someone about your concerns and et their perspective on the reasonableness of the
worry or possible solutions. Decide on some actions to take over the next few days that can
reduce the likelihood of the bad event happenin.
Try Co1niti5e Restr-ct-rin1
/+
Sou can also use the worry period to do some conitive restructurin. This involves several
steps/
'. Identify the specific thouhts that you have when you worry. =hat is it, exactly, that you
are sayin to yourself when you are worryinP =rite these thouhts down. Sour
observation of those worries durin the day should provide you with the material for this.
6. :ow take each thouht and loically analy*e it. That is, what is the evidence for that
thouhtP =hat is the probability of it happeninP 7as the event happened beforeP Is it
reasonable or loical to predict that the event will happen, iven the evidenceP
.. Even if the event happens, will you be able to handle itP =hat actions can you take to
minimi*e its effectsP 7ave you handled such situations in the past without terrible
conse+uencesP A year after the event, should it happen, what difference will it make by
thenP
$. As you answer such +uestions, find those that indicate that the likelihood of thins
workin out all riht is ood and that you would have ways of copin with the event if it
happens. 5reate new thouhts from these and write them down next to the relevant
worrisome thouhts you previously wrote down.
Bse these new, more adaptive and reasonable thouhts whenever you catch one of the worrisome
thouhts durin the day. At first, the new thouhts may not rin true compared to the old
worrisome thouhts. ?ust remind yourself that they are true, based on your loical evidence1
based analysis. They will, with repeated practice, start feelin more true as you fre+uently use
them to replace the worrisome thouhts and as you catch them earlier and earlier.
,or some worries, it is useful durin your worry period to ask, W=hat is the worst thin that
could happenPW !ometimes it turns out not to be so terrible, that you would survive it, that you
would be able to handle it and then move on with your life. The future is sometimes scary
because it is unknown. ;y lookin at known and likely possible futures, the future becomes less
scary.
!o the point of the worry period is to/
&rovide a way of postponin worrisome thinkin from other times
Do what problem solvin you can
5reate ways of talkin to yourself or seein thins that are more adaptive and reasonable
Bse these newly created thouhts whenever you catch yourself worryin
/1
Relaxation ethods 'or Bodily Dist-r)ance
The worry period steps are desined to help reduce worrisome thinkin durin the day. ;ut
worry can also create uncomfortable bodily sensations as well, such as muscle tension, stomach
disturbance, and a poundin heart.
Imainin awful thins can affect our bodies 3ust as if they were actually happenin. These
sensations may be ood clues to help you catch your worrisome thouhts earlier. =henever you
catch yourself worryin or feelin such sensations, you can replace these with a relaxation
response to calm your body and make it easier to think more reasonably and clearly and to focus
your attention better on your immediate environment.
$ow&To Information
There are many types of relaxation methods, and you may find that one is better for you than
another with some experimentation.
'. &ractice a relaxin imae. &icture a scene that creates a sense of calm and peacefulness,
for example lyin on a warm beach, sittin next to a brook in a beautiful valley, or
reclinin in your favorite chair at home. Het o of all other thouhts and immerse
yourself in this picture as if you were actually there.
6. ,ocus your attention on your breathin, every time you inhale and exhale. !ay the word,
WrelaxW or WcalmW or any other word that is sinificant to you, upon each exhalation.
.. Deliberately tense up different roups of muscles for about five seconds, then release that
tension all at once and concentrate for a minute on the feelins of relaxation that enter
those muscles once they are released.
$. ;reathe with your stomach, rather than you chest, and with practice learn to breathe at a
rate of around eiht to ten cycles per minute.
=ith each of these techni+ues, you will notice thouhts intrudin. ?ust let those thouhts pass
throuh your mind and ently focus your attention back to the relaxation process. =ith practice,
your ability to let o of thinkin is likely to increase, makin it easier to let o of worrisome
thouhts durin the day.
/-
Sou can practice such methods for ten to 'G minutes twice a day, 3ust to build up your ability to
elicit a relaxation response briefly whenever you catch yourself beinnin to worry or notice
bodily tension or upset.
Trac2 the O-tcome of %o-r +orries
There is one other useful piece of information that you can ather. Durin your worry period
each day/
=rite down every event that youOre worryin about and list next to it the possible
outcomes, ood and bad, that miht happen.
>eep that list until the event actually happens and see which outcome occurred.
Do this for every outcome that comes alon and keep track of how often thins actually
turned out ood, bad, or indifferent and whether you handled the outcome well, or not.
<ver time, you will be able to collect your own evidence about your worries and your ability to
cope with events that you worried about.
It is very likely that you will find that few thins really turn out badly or that, even when they do,
you are capable of handlin them +uite well. !uch evidence will increase your confidence in
yourself and your trust that, whatever the future holds, you will be ready for it.
/.
(Taken from %%%.yo#rmedi"also#r"e."om.
'0( 8ogical Analysis
7ere are three simple steps from a 5onitive Therapy techni+ue called Hoical Analysis
that one can take to reduce their worry/
') !ince we are often unaware of what we are thinkin, the first step is to write down the
thouhts that o throuh your mind when you are worryin. ;e as specific as possible. ,or
example/ If I miss the deadline at work I will lose my 3ob.
6) The next step is to examine how realistic your thouht is. ;e like a trial lawyer
examinin your thouhts, lookin for ways to find distorted, inaccurate thouhts. Do you have
evidence to support or refute your thouhtP Is your thinkin based on loicP Are you payin
attention to all the details of a situation or 3ust the neative onesP ,or example/ 7ave you missed
deadlines beforeP 7ave othersP =hat happensP
.):ow come up with a new thouht 11 a rational response 11 that is more realistic than the
oriinal thouht. ,or example/ missin the deadline at work is not somethin I want to happen,
but it is very unlikely that I will lose my 3ob because of this one event, even if your boss is anry.
//
Another stratey that can be effective is Decatastrophi*in. =orriers are catastrophi*ers.
They can turn almost any situation into a potential catastrophe 11 one minor worry can snowball
into several other ma3or worries. ,or example, a worrier will think that she will be alone forever
if her boyfriend ended their relationship. Instead of repeatedly worryin W=hat if ...,W by
Decatastrophi*in, we ask you to imaine it did happen and think about what will result from
this and how you will cope with it. 7avin solutions will ive you more control over the
situation because you now are not helpless # there is somethin you can do about it.
,inally, some people find the followin process useful to reduce worry, somethin that
we call !timulus 5ontrol. This techni+ue comes from the learnin1theory branch of psycholoy.
=e know that when people do somethin in one situation, they are likely to do it aain the next
time they are in that situation. ;ecause one can worry nearly any time and any place, it becomes
associated with many situations. !o to reduce its fre+uency, a person attempts to limit where and
when worry occurs. ,or example/
') !et a .@ minute worry period, to take place the same time and in the same place each
day.
6) Hearn to identify when you start worryin. &ostpone your worryin, as soon as you do
catch yourself, until your worry period. If you are worried you will foret write it down and
make a list for your worry period.
.) To stop worryin durin non worry times, replace worrisome thouhts by distractin
yourself with somethin else, like listenin to music. The oal is to focus on somethin else.
100
$) =hen your worry time comes, close your eyes and force yourself to think in detail
about all the thins you worry about. Try to fill up the entire .@ minutes. The oal is that you
don8t worry all the time 11 3ust in one spot at one time. This can reduce your worries a lot.
(Taken from %%%.drsanderson."om/%orry.htm.
'1( 2astery of 8ife Tec"ni9%e
P-r(ose
<n the road to achievin oneOs oals, Mstuff happens.N &eople who are successful accept what
happens as part of the process1 learn from it, ain insihts, make appropriate corrections1 and
proceed toward their oals. &eople who are not successful treat what happens as insurmountable
obstacles or as evidence that they are not able to achieve their oals, and then they drop out. The
purpose of this activity is to support you in mappin out the path to success, and in acceptin
whatever happens as part of the process.
Proced-re
'. Det a lare piece of paper and some colored markers.
6. !tart by placin an Q somewhere on the pae to represent where you are now %like the
MSou Are 7ereN sins found in parkin araes and shoppin malls).
.. :ext draw a picture of your vision of success on the pae, an appropriate distance from
Mwhere you are now.N Bse sins, symbols, or words to represent the vision you have.
$. :ow draw in the milestones to be accomplished as you proress from where you are now
to the completion of your vision. Each milestone represents a ma3or oal that will be
achieved as part of this process.
G. :ext consider possible obstacles, roadblocks, or barriers that could et in the way of your
accomplishin your oals, and draw these on your pae.
-. ,inally, put in the resources available to you to overcome these obstacles. These can
include both internal resources %such as patience, self1confidence, and determination) as
well as external resources %such as friends, classes, and books).
101
(Taken from ,yri"k( F.( L 5olk( &. (1MM1. -eervention. ,inneapolis( ,E: .d#"ational ,edia
>orporation.
''( Self5Tests
!ocial phobia, or social anxiety disorder, affects more than '. percent of Americans. It is a real and
serious health problem that responds to treatment. The first step is seekin help. If you suspect that
you miht suffer from social phobia, complete the followin self1test and show the results to your
health care professional.
$O+ CAN I TE!! I' ITHS SOCIA! P$OBIA;
Ses or noP Are you troubled by/
Ses :o
An intense and persistent fear of a social situation in which people miht
3ude youP
Ses :o
,ear that you will be humiliated by your actionsP
10'
Ses :o
,ear that people will notice that you are blushin, sweatin, tremblin, or
showin other sins of anxietyP
Ses :o
>nowin that your fear is excessive or unreasonableP
Does the feared situation cause you to/
Ses
:o
Always feel anxiousP
Ses
:o
Experience a Wpanic attackW, durin which you suddenly are overcome by intense fear or
discomfort, includin any of these symptomsP
Ses :o
&oundin heart
Ses :o
!weatin
Ses :o
Tremblin or shakin
Ses :o
!hortness of breath
Ses :o
5hokin
Ses :o
5hest pain
Ses :o
:ausea or abdominal discomfort
10)
Ses :o
W?ellyW les
Ses :o
Di**iness
Ses :o
,eelins of unreality or bein detached from yourself
Ses :o
,ear of losin control, Woin cra*yW
Ses :o
,ear of dyin
Ses :o
:umbness or tinlin sensations
Ses :o
5hills or hot flashes
Ses
:o
Do to reat lenths to avoid participatin in the feared situationP
Ses
:o
Does all of this interfere with your daily lifeP
7avin more than one illness at the same time can make it difficult to dianose and treat the different
conditions. Illnesses that sometimes complicate anxiety disorders include depression and substance
abuse. =ith this in mind, please take a minute to answer the followin +uestions/
Ses :o
7ave you experienced chanes in sleepin or eatin habitsP
"ore days than not, do you feel/
Ses :o
!ad or depressedP
Ses :o
Disinterested in lifeP
Ses :o
=orthless or uiltyP
Durin the last year, has the use of alcohol or drus/
10*
Ses :o
4esulted in your failure to fulfill responsibilities with work, school, or
familyP
Ses :o
&laced you in a danerous situation, such as drivin a car under the
influenceP
Ses :o
Dotten you arrestedP
Ses :o
5ontinued despite causin problems for you andEor your loved onesP
AN*IET% DISORDES IN C$I!DREN. A TEST 'OR PARENTS
If you think your child may have an anxiety disorder, please answer the followin +uestions WSesW or
W:oW, and show the results to your child8s health care professional/
Ses :o
Does the child have a distinct and onoin fear of social situations involvin
unfamiliar peopleP
Ses :o
Does the child worry excessively about a number of events or activitiesP
Ses :o
Does the child experience shortness of breath or a racin heart for no apparent
reasonP
Ses :o
Does the child experience ae1appropriate social relationships with family
members and other familiar peopleP
Ses :o
Does the child often appear anxious when interactin with her peers and avoid
themP
Ses :o
Does the child have a persistent and unreasonable fear of an ob3ect or situation,
such as flyin, heihts, or animalsP
Ses :o
=hen the child encounters the feared ob3ect or situation, does he react by
free*in, clinin, or havin a tantrumP
Ses :o
Does the child worry excessively about her competence and +uality of
performanceP
Ses :o
Does the child cry, have tantrums, or refuse to leave a family member or other
familiar person when she mustP
Ses :o
7as the child experienced a decline in classroom performance, refused to o to
school, or avoided ae1appropriate social activitiesP
10+
Ses :o
Does the child spend too much time each day doin thins over and over aain
%for example, hand washin, checkin thins, or countin)P
Ses :o
Does the child have exaerated fears of people or events %i.e., burlars,
kidnappers, car accidents) that miht be difficult, such as in a crowd or on an
elevatorP
Ses :o
Does the child experience a hih number of nihtmares, headaches, or
stomachachesP
Ses :o
Does the child repetitively re1enact with toys scenes from a disturbin eventP
Ses :o
Does the child redo tasks because of excessive dissatisfaction with less1than1
perfect performanceP
101
')( Assertiveness Inventory
The followin +uestions will help determine how passive, assertive, or aressive you are.
Answer the +uestions honestly and write out how you would handle each situation.
'. Do you say somethin when you think someone is unfairP
6. Do you find it difficult to make decisionsP
.. Do you openly critici*e the ideas, opinions, and behavior of othersP
$. If someone takes your place in line, do you speak upP
G. Do you avoid people or events for fear of embarrassmentP
-. Do you have confidence in your own ability to make decisionsP
C. Do you insist that the people you live with share choresP
9. Do you have a tendency to Mfly off the handlePN
(. Are you able to say MnoN when someone is pressurin you to buy or do somethinP
'@. =hen someone comes in after you at a restaurant and is waited on first, do you say
somethinP
''. Are you reluctant to express your thouhts or feelins durin a discussion or a debateP
'6. If a person is overdue in returnin somethin that they have borrowed from you, do you
brin it upP
'.. Do you continue to arue with someone after they have had enouhP
'$. Do you enerally express what you think and feelP
'G. Does it bother you to be observed doin your 3obP
'-. If someoneOs behavior is botherin you in a theatre or lecture, do you say somethinP
'C. Is it difficult for you to maintain eye contact while talkin with someoneP
'9. If you are not pleased with your meal at a restaurant, do you talk to the waitress about
correctin the situationP
'(. =hen you purchase somethin that is flawed or broken, do you return itP
6@. =hen you are anry, do you yell, name1call, or use obscene lanuaeP
6'. Do you step in and make decisions for othersP
66. Are you able to ask for small favorsP
6.. Do you shout or use bullyin tactics to et your wayP
6$. Are you able to openly express love and concernP
6G. Do you respond respectfully when there is a difference of opinionP
10-
'*( T"e Co&fort ?ag
$ow To P-t To1ether a Comfort Ba1
Sour Duide to &anicEAnxiety Disorders
=hat do you do when you8re away from home and anxiety strikesP 4each into your comfort ba for
security, distraction or relaxation.
$ereHs $ow
Decide what kind of ba is appropriate for your needs. If you drive a lot, you can take more in the car.
If you carry a purse, maybe a lare one is in order. A backpack is an option for anyone.
:ow it8s time to brainstorm. !it down with pen and paper, and write down anythin that comes to
mind that has helped relieve your anxiety in the past. Add to it anythin that you8d like to try.
After your list is complete, decide what is portable, and put toether your comfort ba. ;elow are a
number of suestions to help you complete your list.
4elaxation/ Index cards with relaxationEbreathin exercisesL lavender oilL hand cream %for hand
massae)L music I walkmanL relaxation tapesL herbal tea
5omfort/ &hotosL cardsEletters from loved onesL teddy bearL reliiousEspiritual itemsL index cards with
poems, +uotes, reminders
!timulation/ 4ubberbands %snap on wrist)L mints or tart candyL cold waterL mentholated cream %to
smell)L upbeat music
Distraction/ &u**le booksL maa*inesL portable computer amesL 3ournalL small children8s toysL books
on tapeL pens I pencils
10.
Emerencies/ 5ell phoneL extra clothesL blanketL extra medicationL small phonebook with all
important numbersL chane for phoneL moneyL toilet paperL maps.
ore Ti(s
7ave a list people you can call if you8re stuck somewhere. They would be people who could come et
you or talk to you until you feel calm aain %make sure they8ve areed ahead of time).
4emember that anxiety can make easy tasks more difficult, so be sure to brin distractions for an
anxious mind %i.e., maybe a children8s pu**le book rather than an adult8s).
Don8t be embarrassed about brinin what soothes you. If brinin that childhood teddy bear will help
you take a few more recovery steps, then it8s worth itX
10/
"ore 7ow To8s from your Duide To &anicEAnxiety Disorders
http/EEpanicdisorder.about.comEcsEht.htm
'+( Rela#se Cycle
INTER"ENIN# IN T$E RE!APSE C%C!E
ana1in1 Stress
Bse strateies such as relaxation, meditation, and exercise.
Challen1in1 Ne1ati5e/Traditional Thin2in1
Bse positive self1talk, remind yourself that the stressor will not last forever.
Bse your 3ournal to identify patterns of neative self1talk bein initiated by specific situations, and
deal with it.
Resol5in1 Internal/External Conflicts
The conflicts were initiated by the stressors at the beinnin of the cycle, and then aain throuh
neative self1talk. Take the opportunity to understand the conflict and problem solve it. This is an
opportunity to resolve and let o of past issues and dysfunctional thinkin patterns.
110
Some +arnin1 Si1ns of Rela(se
:eative Thinkin 5ontrollin ;ehavior
Excessive =orry &erfectionistic ;ehavior
5hane in Appetite 5odependent ;ehavior
Difficulty with !leep Difficulty with =akin
,atiueEHethary ,eelin ;ad about Sourself
,eelin Hess 7opeful Decreased Exercise
&rocrastination !ocial Isolation
=ithdrawal from Activities Bse of Alcohol or other Drus
IrritableEAitated Bnwillin to Ask for =hat you
=antE:eed
Impatient Hackin 5onfidence
:eative Attitude Destructive ;ehavior
&oor ?udment 4isk1Takin ;ehavior
Distrustful of <thers <bsessive Thouhts
"isperceptions !uicidal Thouhts
111
%Taken from Therapist9s A#ide to >lini"al $ntervention: The 1+/+19s of Treatment -lannin!( by 'haron 8. Bohnson)
'1( Co#ing Cards
4esearch has shown that children8s thouhts and Wself1statementsW can actually affect their
physical feelins of anxiety. =hen children say positive, affirmin statements to
themselves, they often report feelin less anxiety and feel more capable of handlin
stressful moments or anxious feelins. ,or example, a child who is able to say statements
such as, WI am brave and smart and can take ood care of myselfW is typically able to cope
better than the child who continually says neative Wself1statementsW such as, WI can8t
handle this1I8ll failW.
5opin 5ards are palm1si*ed, colorful cards that have pre1printed positive Wself1
statementsW that have been desined specifically for children. 5hildren can read the
statements on the cards anytime, and can store them easily in a backpack or pocket for
+uick, easy reminders of their ability to cope with whatever comes their way.
In its newest edition, 5opin 5ards now include several blank cards in addition to the pre1
printed cards for your child to personally tailor specific cards to his or her fears or
concerns.
Appropriate for children between the aes of approximately G1'$ years, 5opin 5ards are a reat tool
for boostin younsters8 confidence in their ability to cope with stress and anxiety.
'-( Interact@
The InteractX proram is a classroom based universal intervention desined to/
%') to build basic behavioral and conitive social skills
%6) to reinforce prosocial attitudes and character traits
%.) to build adaptive copin strateies for social problems.
11'
InteractX is desined to be tauht within the classroom settin, and includes parent handouts, in
con3unction with web and television components to bride school and home life. As childrenOs social
skills improve and they ain practice and reinforcement for positive social behavior in the classroom,
their self1esteem and self1confidence increases. Dreater confidence enables children to try new social
behaviors with peers outside of the safety net of the classroom.
InteractX provides the opportunity for students to learn throuh multiple channels with an innovate use
of visual, oral, tactile, experiential, and multi1media experiences. InteractOs will enae students of all
learnin styles. Additionally, many of the InteractX lesson plans are desined to be interated into the
existin classroom curriculums. The multi1media components, flexible structure, and !panish
translations of InteractX will be better able to reach a broad audience and increase the likelihood of
chane.
(Taken from http://1"isd."om/step.php
'.( Staying in t"e ?ox
=hen we are feelin upset, we are likely to focus narrowly on our distress, perhaps also tellin
ourselves that we canOt stand to feel like this another minute. =e are carried away by the experience
or we are paraly*ed by itL we may fiht it or we may look for ways to escape from it.
At other times, instead of bein focused directly on the emotion, our attention may stray to thouhts of
other places %real or imainary) and other times %the past, or the future as we imaine it) that are
associated with it. =e stew about experiences that miht have otten us into our current predicament,
or uess at what fate awaits us if we donOt et out of it, or perhaps think about how nice thins once
were or will be if we can ever escape from it.
The trouble is, by thus reactin blindly %MunmindfullyN) to the mood or emotion T by automatically
makin a bi deal of it and elaboratin on it T we are
stren!thenin! its hold on us. Therefore, to weaken its rip we
need to partly disenae from it T thouh not by denyin its
reality or escapin from it.
In practice, this means re1focusin on somethin that is oin on
riht here and riht now T but this time %itho#t all the #s#al
elaboration of the emotion. If we can train ourselves to do this
%and there are a number of ways that one can learn), we will
make a startlin discovery . . .
Done with the windP
The mood or emotion will in time lose its strenth or even
disappear all by itself. And if we do this repeatedly, it will recur
less often and less intensely, and will last a shorter amount of time if it does come back.
11)
The idea is to keep our attention as much as possible on whatever we are aware of in the present
moment, without 3udin it or interpretin it or tryin to run away from it ? in fa"t( %itho#t rea"tin!
to it in any %ay ex"ept to simply note that it is !oin! on. %This is basically what is meant by bein
Mmindful.N)
Bsin the diaram above as a uide, you learn to put your attention Minto the boxN and not on the
reactions, thouhts or imaes outside of it.
;y Mstayin in the boxN T by bein mindful and tryin to accept your experience 3ust as it is at the
moment T you will learn that even an unpleasant mood or emotion can be tolerated lon enouh for
its intensity to fade spontaneously. "ore important still, it will bit by bit lose its power over your
thouhts and behavior. Sou will be ainin round aainst the conditioned reactions that have been
makin you unhappy and keepin you that way.
Then, havin altered your neative emotion or mood in the direction of M3ust another thin that is
oin on at the moment,N you will be in a better position to identify and chane any ways of thinkin!
or a"tin! that have been trierin or maintainin your distress.
Interestin1 fact G0. This is very similar to the effects of certain widely1prescribed medications T
except that you will have achieved it throuh the cultivation of valuable skills that will be yours for
life, and do not have to be repeatedly prescribed by a physician and purchased from a drustore. It is
therefore likely that your recovery will be more durable and consistent than it would be if you 3ust
relied on drus.
Interestin1 fact G4. ;y focusin your attention Min the boxN T that is, in the here1and1now T you
are a#tomati"ally keepin it away from thins that are outside your personal control. 4emember, there
is nothin you can do to chane the past, and the future isnOt here yet. The only time you can make a
difference is riht now, and the only place from which you can make it is riht here.
Interestin1 fact G:. "indfulness is not some brand1new discovery, straiht from the psycholoy lab.
It is a re1discovery of one of the key teachins of !iddhartha Dautama, better known as ;uddha, who
lived 6,G@@ years ao. Set despite its ancient lineae, it is strikinly consistent with what has been
found in 6@th1century research on &avlovian conditionin and behavior therapy.
11*
(Taken from http://%%%."o!nitivetherapy."om/mindf#l.html
'/( Def%sion and 2indf%lness
These are probably unfamiliar terms to you T not surprisin, since they refer to processes that have
only recently been reconi*ed by psycholoists as potent strateies for overcomin social phobia and
other emotional difficulties. 7ere are brief definitions/
Def-sion T This is what happens when you discover %in your own direct experience, not 3ust as an
intellectual proposition) the difference between your conitions, emotions and bodily sensations and
the reality they are supposed to represent faithfully but often donOt. Sou become proressively better
able to reconi*e thouhts as M3ust thouhts,N feelins as M3ust feelinsN and sensations as M3ust
sensations.N The point is not that thouhts, feelins and sensations are wholly misleadinL that is not
necessarily or even usually the case. ;ut because they are a ood deal less reliable than they seem to
be, it is vitally important that you learn not to take them literally or at face value 3ust because they
occur. =e are talkin here about cultivatin a realisti" deta"hment and skepti"ism about your
conitions, emotions and physical sensations.
indf-lness T <ne definition/ brinin your complete attention to your present experience on a
moment1to1moment basis. Another/ payin attention in a particular way T on purpose, in the present
moment, and non13udmentally. The homework assinment described below is intended as your
introductory exercise in mindfulness. Hater, you will have an opportunity to cultivate mindfulness in
other ways and in other contexts, so that it becomes a reular part of your daily life.
;oth defusion and mindfulness are powerful ways of weanin you away from behavior that interferes
with the natural habituation and extinction of your fears about other people, and of openin the way to
pursuin your personal values in life more effectively.
11+
$omewor2
,irst, spend a few minutes each day doin nothin more than +uietly observin your inner experience
T your thouhts, memories, fantasies, imaes, emotions, moods and bodily sensations. Sou will
notice how often and easily you are distracted from the present moment, and how automatically you
form one 3udment after another. =hen you discover that your attention has wandered from the
present moment, !ently brin it back. As for 3udin, donOt try to make yourself stop T D#st noti"e
that youOre doin it, and then o back to observin your experience in the moment. A ood way to do
this is to find a +uiet place where you wonOt be intruded upon, and dedicate a few minutes to
experiencin how your mind works when you stop and take notice of it.
As you become more aware of your distractibility and 3udmental thinkin, look for opportunities in
your everyday life to focus attention in the present moment and cultivate an attitude of a""eptan"e
towards whatever your experience brins you. The more you can do these thins, the more your social
anxiety will ive way to the normal processes of habituation and respondent extinction T leavin you
better able to en3oy interactin with other people rather than dreadin or avoidin it.
(Taken from http://%%%."o!nitivetherapy."om/so"-hob-rint.html
)0( 6"at Are Cognitive DistortionsA
=hich came first/ the chicken or the eP =hich came first/ the depression or the pessimistic
thouhtsP I can8t answer the first +uestion, but the answer to the latter may surprise you.
In many, many cases anxiety actually is the result of neative thouhts. =hen bad thins happen, we
bein chastisin ourselves with such thouhts as/ WI8m no ood.WL WI8m a total failure.WL or W:othin
ever oes my way.W These thouhts can send us spiralin into developin anxiety. Sou see, we are
what we think.
This concept is the uidin principle behind 5onitive Therapy. If we think somethin often enouh,
we bein to believe it8s true. To con+uer depression, we must stop those automatic thouhts and
replace them with more positive, truthful ones. ;y nippin these thouhts in the bud, we can put a halt
to feelin anxiety before it even starts.
5onitive Therapy is directed at '@ common 5onitive Distortions, or faulty thouht patterns, that
send us into depression. !ee if you reconi*e yourself in any of these.
All&or&Nothin1 Thin2in1. ?ohn recently applied for a promotion in his firm. The 3ob went to
another employee with more experience. ?ohn wanted this 3ob very badly and now feels that
he will never be promoted. 7e feels that he is a total failure in his career.
111
O5er1enerali8ation. Hinda is very lonely and often spends most of her time at home. &eople
sometime suest that she should et out and meet people. Hinda feels that that is it useless to
try to meet people. !he believes that no one really could like her.
ental 'ilter. "ary is havin a bad day. As she drives home, a kind entleman waves her to
o ahead of him as she meres into traffic. Hater in her trip another driver cuts her off. !he
rumbles to herself that there are nothin but rude and insensitive people in her city.
Dis<-alifyin1 the Positi5e. 4honda 3ust had her portrait made. 7er friend tells her how
beautiful she looks. 4honda brushes aside the compliment by sayin that the photorapher
must have touched up the picture. !he never looks that ood in real life.
3-m(in1 to Concl-sions. 5huck is waitin for his date at a restaurant. !he8s now 6@ minutes
late. 5huck laments to himself that he must have done somethin wron and now she has
stood him up. "eanwhile across town, his date is stuck in traffic.
a1nification and inimi8ation. !cott is playin football. 7e bunles a play that he8s been
practicin for weeks. 7e later scores the winnin touchdown. 7is teammates compliment him.
7e tells them he should have played betterL the touchdown was 3ust dumb luck.
Emotional Reasonin1. Haura looks around her untidy house and feels overwhelmed by the
prospect of cleanin. WThis is hopelessW, she says to herself. W=hy should I even tryPW
Sho-ld Statements. David is sittin in his doctor8s waitin room. 7is doctor is runnin late.
David sits stewin thinkin, W=ith how much I8m payin him he should be on time. 7e ouht
to have more consideration.W 7e ends up feelin bitter and resentful.
!a)elin1 and isla)elin1. Donna 3ust cheated on her diet. W=hat a fat pi I amXW, she thinks.

11-
Personali8ation. ?ean8s son is doin poorly in school. !he feels that she must be a bad
mother. !he feels that it8s all her fault that he isn8t studyin.
If you reconi*e any of these behaviors in yourself, then you8re halfway there. 7ere8s a homework
assinment for you. <ver the next couple of weeks, bein to watch yourself closely for self1defeatin
ways that you respond to situations. &ractice reconi*in your automatic responses. Then come back
here for the !eptember - issue. =e will take each of the above 5onitive Distortions and discuss
some powerful copin strateies that will help you dispel the blues before they even start.
(Taken from http://depression.abo#t."om/"s/psy"hotherapy/a/"o!nitive@p.htm
)1( Strategies to ?eat Yo%r Negative T"o%g"ts
All&or&Nothin1 Thin2in1
?ohn recently applied for a promotion in his firm. The 3ob went to another employee with more
experience. ?ohn wanted this 3ob very badly and now feels that he will never be promoted. 7e feels
that he is a total failure in his career.
This type of thinkin is characteri*ed by absolute terms like WalwaysW, WneverW, and WforeverW. ,ew
situations are ever this absolute. There are enerally ray areas. Eliminate these words from your
vocabulary except for the cases where they truly apply and look for a more accurate description of the
situation. 7ere8s how ?ohn could have coped with not ettin that promotion/
WI wanted this 3ob very much, but it went to someone with more experience. This is disappointin to
me, but it doesn8t mean I8m not a ood employee. There will be other opportunities available in the
future. I8ll keep workin on my skills so that I8ll be ready for them when they arrive. This one setback
does not mean my career is over. <verall, I have excelled in my work.W
11.
O5er1enerali8ation
Hinda is very lonely and often spends most of her time at home. &eople sometimes suest that she
should et out and meet people. Hinda feels that that is it useless to try to meet people. :o one really
could like her. &eople are all mean and superficial anyway.
=hen one overenerali*es, one takes an isolated case or cases and assumes that all others are the
same. Are people really all mean and superficial and could never like herP =hat about her friends
who are tryin to et her to o outP <bviously she does have someone who cares about her very
much. The next time you catch yourself overenerali*in, remind yourself that even thouh a roup of
people may share somethin in common, they are also separate and uni+ue individuals. :o two people
are exactly the same. There may be mean and superficial people in this world. There may even be
people who dislike you. ;ut not every sinle person will fit this description. ;y assumin that
everyone doesn8t like you, you are buildin a wall that will prevent you from havin what you crave
the most11friendship.
ental 'ilter
"ary is havin a bad day. As she drives home another driver cuts her off. !he rumbles to herself
that there are nothin but rude and insensitive people in her town. Hater a kind entleman waves her
o ahead of him. !he continues on her way still anry at how rude all the people in her city are.
=hen a person falls victim to mental filters they are mentally sinlin out only the bad events in their
lives and overlookin the positive. Hearn to look for that silver linin in every cloud. It8s all about how
you choose to let events effect you. "ary could have turned her whole day around if she had paid
attention to that nice man who went out of his way to help her.
Dis<-alifyin1 the Positi5e
4honda 3ust had her portrait made. 7er friend tells her how beautiful she looks. 4honda brushes aside
the compliment by sayin that the photorapher must have touched up the picture. !he says she never
looks that ood in real life.
=e depressives are masters at takin the ood in a situation and turnin it to a neative. &art of this
comes from a tendency to low self1esteem. =e feel like we 3ust don8t deserve it. 7ow to turn this
around is actually very simple. :ext time someone compliments you resist that little voice inside that
says you don8t deserve it. ?ust say Wthank youW and smile. The more you do this the easier it will
become.
11/
3-m(in1 to Concl-sions
5huck is waitin for his date at a restaurant. !he8s now 6@ minutes late. 5huck laments to himself that
he must have done somethin wron and now she has stood him up. "eanwhile across town his date
is stuck in traffic.
<nce aain, we fall victim to our own insecurities. =e expect the worst and bein preparin early for
the disappointment. ;y the time we find out that all our fears were unfounded we8ve worked ourselves
into a fren*y and for whatP :ext time do this/ ive them the benefit of the doubt. Sou8ll save yourself
a lot of unnecessary worry. If your fears have some basis in reality, however, drop that person from
your life like a hot potato.
a1nification and inimi8ation
!cott is playin football. 7e bunles a play that he8s been practicin for weeks. 7e later scores the
winnin touchdown. 7is teammates compliment him. 7e tells them he should have played betterL the
touchdown was 3ust dumb luck.
Ever looked throuh a telescope from the wron directionP Everythin looks tinier than it really is.
=hen you look throuh the other end everythin looks larer. &eople who fall into the
manificationEminimi*ation trap look at all their successes throuh the wron end of the telescope and
their failures throuh the other end.
=hat can you do to stay away from this errorP 4emember the old sayin Whe can8t see the forest for
the treesWP =hen one mistake bos us down, we foret to look at the overall picture. !tep back and
look at the forest now and then. <verall !cott played a ood ame. !o what if he made a mistakeP
Emotional Reasonin1
Haura looks around her untidy house and feels overwhelmed by the prospect of cleanin. This is
hopeless, she says to herself. =hy should I even tryP
Haura has based her assessment of the situation on how it makes her feel not how it really is. It may
make her feel bad to think of the lare task ahead of her, but is it really hopelessP In reality, cleanin
her house is a very doable task. !he 3ust doesn8t feel up to doin it. !he has reached the conclusion that
it is useless to try based upon the fact that it makes her feel overwhelmed.
=hen a situation feels overwhelmin, try this. ;reak down the task down into smaller ones. Then
prioriti*e what is most important to you. :ow, do the first task on your list. ;elieve it or not, you will
bein to feel better and ready for more. The important thin is to 3ust do somethin towards your oal.
:o matter how small, it8s a start and will break you out of feelin helpless.
1'0
Sho-ld Statements
David is sittin in his doctor8s waitin room. 7is doctor is runnin late. David sits stewin thinkin
W=ith how much I8m payin him he should be on time. 7e ouht to have more consideration.W 7e
ends up feelin bitter and resentful.
=e all think thins should be a certain way, but let8s face it, they aren8t. 5oncentrate on what you can
chane and if you can8t chane it accept it as part of life and o on. Sour mental health is more
important than Wthey way thins should be.W
!a)elin1 and isla)elin1
Donna 3ust cheated on her diet. =hat a fat pi I am, she laments. I8ll never be thin and pretty.
=hat Donna has done is label herself as la*y and hopeless. !he most likely will reason that since she
can8t lose weiht she may as well eat. !he has now effectively trapped herself by livin up to the label
she placed on herself. =hen we label ourselves we set ourselves up to become whatever that label
entails. This can 3ust as easily work to our advantae.
7ere8s what Donna could have done to make labelin work in her favor. !he could have considered
the fact that up until now she has been very stron, much stroner than the averae person because she
is fihtin aainst one of our body8s basic needs11to eat. !he could then forive herself for only bein
human and acknowlede that she has been workin very hard to lose weiht and has been succeedin.
This is only a temporary setback that she can overcome. !he is overall a very stron person and has
proven it by her successful weiht loss. =ith this type of positive thinkin, Donna will be back Won
the waonW in no time.
Personali8ation
?ean8s son is doin poorly in school. !he feels that she must be a bad mother. It8s all her fault that he
isn8t studyin.
?ean is takin all the responsibility for how her son is doin in school. !he is failin to take into
consideration that her son is an individual who is ultimately responsible for himself. !he can do her
best to uide him, but in the end it is he who controls his actions. :ext time you find yourself doin
this, ask yourself, W=ould I take credit if this person were doin some praiseworthyP 5hances are
you8d say,Wno, he accomplished that by himselfW. !o why blame yourself when he does somethin not
so praiseworthyP ;eatin yourself up is not oin to chane his behavior. <nly he can do that.
0The solutions I8ve presented here are to some of the common situations we find ourselves in. Take
these as examples and create your own positive solutions to your neative thouhts. 4econi*in that
you do it is the first step. Then play Devil8s Advocate and challene yourself to find the positive. Turn
your thouhts around and your moods will follow suit. 4emember, you are what you thinkX
1'1
(Taken from http://depression.abo#t."om/"s/psy"hotherapy/a/"o!nitive@p.htm
)'( Cognitive Re"earsal
Bse !chiraldiOs %6@@@)5onitive 4ehearsal activity to cultivate self1esteem by Mmindfully
acknowledin what is presently riht about oneOs self.N %p. 696169.). The 5onitive 4ehearsal
techni+ue uses G steps. They are/
Develop a list of ten positive statements about yourself that are meaninful and realisticEtrue.
=rite the ten statements on a sheet of paper.
1''
,ind a place to relax for fifteen to twenty minutes. "editate upon one statement and the
evidences for its accuracy for a minute or two.
4epeat this for each statement.
4epeat this exercise for '@ days.
!everal times each day look at an item on the list, and for about two minutes, meditate on the
evidence for its accuracy.
))( 6indo=s
M=indowsN is where the client draws a window and what one miht see lookin throuh the window
into the clientOs life. This techni+ue will be used to identify the anxiety provokin obsessive thouhts
and compulsive behaviors that the client is exhibitin.
)*( ro%nding Tec"ni9%es
Trierin, as it is enerally used in this community, refers to bein transported mentally or
emotionally back in time to when the abuse was occurrin. &erhaps somethin that someone said
reminded a part of you about that time, maybe even on an entirely subconscious level. It may be as
severe as a flashback or WabreactionW, or it could result in a enerali*ed sense of anxiety and terror.
<ne of the fastest ways to round, or brin yourself back from the past mentally is to shock your body
of sorts. "any people recommended ice or ice water for this. 7oldin an ice cube is the simplest way.
,illin a bowl or even the sink with ice cubes and then coverin the ice with water will allow you to
put your hand or arm in the cold water. Sou can even splash the water on your face.
1')
In eneral stron sensory input of any kind will help. !mells can help. !prit* some of your favorite
perfume. &eel an orane or a lemon. Aanilla is also a stron aroma. Ammonia snaps miht be handy
to have nearby.
!ometimes when we et very scared, we try to become invisible by doin thins like closin our eyes,
or holdin our breath. ;ein conscious of these thins, focusin on breathin slowly and deeply as
opposed to shallowly and rapidly can help us et our bearins and calm down. <penin our eyes and
noticin the thins around us can help us reorient to the here and now.
Det involved with your body. Take your shoes off and rub your feet flat on the round. 4emarkably,
doin this can be really WroundinW. "ove your body. Aain, this reverses the Wet invisibleW
reaction. Det up and move around if you can. =ave your arms. ?ump up and down. &ay attention to
how your body feels in a physical sense.
>eep tellin yourself WThat was then, this is nowW. !ay it out loud. :otice thins that reinforce that
knowlede. Det in touch with where you are. 5hances are you are havin a hard time rememberin
that the memory, whatever it is, is not happenin now. Hook around you. !ee where you are. ;e aware
of what is different in this place than what was in that place. Det up and touch ob3ects. ,eel their
reality. "ake it a point to W!ee G thins. :ame G thins. Touch G thins.W !ometimes rememberin it
that way can et throuh the ha*e of memories. 7ave a calendar nearby that has the year prominently
displayed.
!ometimes havin an item that you know you couldn8t possibly have had back then helps remind you
that it8s now, and couldn8t possibly be happenin. :otice this ob3ect and pay attention to it when you
are in a more settled state. 4einforce that this is an item that will help you round should any of you
et triered.
If there is another person in the house, talk to them. Ask for a reality check. 5all a friend, if no one is
home. <nce you et somewhat more settled, do somethin that normally calms you down anyway.
Take a warm bubble bath. &lay your favorite computer ame. =atch a fun movie. Do for a walk.
7ave one of your favorite comfort foods. 4ead a ood book.
I-ic2 !ist of Thin1s to Do to #ro-nd.
;reathe 1 slow and deep, like blowin up a balloon.
Take your shoes off and rub your feet on the round.
<pen your eyes and look around. !ee you are in a different place than then.
"ove around. ,eel your body. !tretch out your arms, hands, finers.
1'*
&eel an orane or a lemon. :otice the smell. Take a bite. ,ocus on the taste.
&et your cat, do or rabbit.
!pray yourself with favorite perfume.
Eat ice creamX <r any favorite food. &ay attention to the taste.
7old a stuffie. &ay attention to the feel of it.
4epeat Wthis is now, not thenW
5all a friend.
Take a shower.
Take a bath.
Do for a walk. ,eel the sunshine %or rain, or snowX)
5ount nice thins.
Di in the dirt in your arden.
Turn lihts on.
&lay your favorite music.
7u a treeX
%Taken from http://%%%.mosai"minds.or!/safe+!ro#nd.shtml)
)+( ?iofeedbac7
;iofeedback is not a passive treatment. It re+uires your intensive participation as you learn to control
such normally involuntary %WautonomicW) functions as heart rate, blood pressure, brain waves, skin
temperature, muscle tension, breathin, and diestion.
1'+
At your first session, you8ll be asked a few +uestions about your own health and that of family
members. The biofeedback therapist will then apply sensors to various points on your body. The
location depends on the problem that needs treatment. If you have miraines, sleep problems, and
mood disorders, for example, the electrodes are often attached to your scalpL to treat heart problems
and muscle tension, they will be placed on your skin. <ther possible sites include the hands, feet, or
finers.
The sensors are connected to a computer, a polyraph, or another piece of monitorin e+uipment that
provides instant feedback to you on the function you8re tryin to control, such as the tension in a
particular set of involuntary muscles or circulation to a specific part of the body. !ome biofeedback
machines sinal chanes raphically on a computer display, others beep, bu**, or blink to indicate the
strenth or level of the function you8re taretin.
The therapist will teach you mental or physical exercises that can help you affect the function that8s
causin a problem. Sou can easily aue your success by notin any chanes in the intensity, volume,
or speed of the sinals from the machine. Dradually, you8ll learn to associate successful thouhts and
actions with the desired chane in your involuntary responses.
<nce you8ve thorouhly learned an effective pattern of actions, you8ll be able to assert control without
the aid of the feedback device.
Amon the feedback instruments you8re most likely to encounter are the followin/
Electromyo1ra(hs 6E#s7 measure muscle tension. Therapists use them to relieve muscle
stiffness, treat incontinence, and recondition in3ured muscles.
S2in Tem(erat-re #a-1es show chanes in the amount of heat iven off by the skin, a
measurement that indicates any chane in blood flow. These aues are used in the treatment
of 4aynaud8s disease, hih blood pressure, anxiety, and miraines.
#al5anic S2in Res(onse Sensors 6#SRs7 use the amount of sweat you produce under stress
to measure the conductivity of your skin. They are often used to reduce anxiety.
Electroence(halo1ra(hs 6EE#s7 measure brain1wave activity. 5onditions that may benefit
from trainin on these machines include attention deficitEhyperactivity disorder, tooth
rindin, head in3uries, and depression %includin bipolar depression and seasonal affective
disorder).
Electrocardio1ra(hs 6EC#s7 monitor the heart rate and may be useful in relievin an overly
rapid heartbeat and controllin hih blood pressure.
1'1
Res(iration 'eed)ac2 De5ices concentrate on the rate, rhythm, and type of breathin to help
lessen symptoms of asthma, anxiety, and hyperventilation and promote relaxation.

Alon with biofeedback trainin, the therapist may also ive you instruction in deep breathin,
meditation, visuali*ation, and muscle relaxation11all of which may aid in relievin stress1related
symptoms.
Treatment Time/ !essions usually last between .@ minutes and ' hour.
Treatment ,re+uency/ In most cases, people can learn to raise or lower their heart rate, relax specific
muscles, lower blood pressure, and control other functions in 9 to '@ sessions. !ome problems, such
as attention deficitEhyperactivity disorder, take loner11sometimes up to $@ sessions. Dependin on the
severity of the problem and the techni+ue used, therapists suest you attend ' to G sessions per week
(Taken from %%%.biofeedba"kzone."om.
1'-
)1( ?reat"e $ro#erly
$ow To Breathe Pro(erly
Sour Duide to &anicEAnxiety Disorders.
"any people with anxiety disorders breathe shallowly which may lead to increased anxiety and even
panic. This techni+ue will help you learn the riht way to breathe.
;ein by lyin flat on your back or standin up straiht. Sou may also sit up straiht in a
chair, if that is more comfortable.
&lace your hand on your stomach area.
;reathe as you normally would and notice whether your hand rises or your chest rises.
To breathe properly, your stomach area must rise as your diaphram expands.
To learn to breathe correctly, bein by slowly breathin in throuh your nose on the count of G
while ently pushin your hand up with your stomach.
7old the breath for a count of G.
!lowly exhale throuh your mouth for a count of five while ently pushin down on your
stomach.
4epeat this process for G minutes.
If the process causes you to bein panickin, only do it for as lon as you are able.
Increase the lenth of time each day until you can do the exercise for at least G minutes twice
per day.
If you continue to practice breathin this way, you will soon be doin it naturally throuhout
the day.
An additional benefit will be that once you are familiar with the exercise, you can do it while
experiencin anxiety or the beinnin of a panic attack, and you will feel relief.
1'.
Ti(s
Do not be anry with yourself or ive up if you cannot do this exercise correctly riht away. It takes
practice. Dive yourself time.
Do not be afraid of the exercise causin panic. 4emember/ you are in control and can stop at any time.
Take it as slowly as needed.
1'/
,ore =o% ToQs from yo#r A#ide To -ani"/Anxiety Disorders
http://pani"disorder.abo#t."om/"s/ht.htm
)-( Dia#"rag&atic ?reat"ing
Diaphramatic breathin is the healthiest form of breathin and is very effective in helpin you
overcome anxiety or panic symptoms.
It is also the most natural 1 observe how a very youn baby breathes. They will use their
diaphram and full torso for each breath.
After years of poor posture, anxious thinkin, tension and pressure result n may of us breathin
in a shallow and inade+uate manner.
;y utili*in your diaphram you activate your natural means of emptyin and re1fillin your
luns effectively. Sou also reduce some of the un1useful effects of anxiety and tension.
Re&learn to -se yo-r dia(hra1m
Imaine that your chest is a somewhat conical cavity with the luns lihtly attached to the inside.
And with the floor of the cone bein made up of a lare muscle called the diaphram. It8s the
movements of the wall and the floor of this cone that result in the movement of air into and out
of your body.
;ein more like spones than muscles your luns cannot et rid of the stale air on their own. ,or
this they must rely on the contraction of the Zcone8 which surrounds them 1 in particular the floor
of that cone 1 the diaphram. This is why usin your abdominal or stomach muscles in breathin,
which indirectly activate your diaphram, ensures a better supply of refreshin oxyen.
If you use mainly the top of the cone it8s called upper1chest breathin. If you mainly enae the
lower walls and floor of the cone it is called diaphramatic breathin.
Chec2 %o-r Breathin1
4est one hand on your upper chest and the other over your navel area. :otice which hand rises
first when you inhale. If the upper hand rises first you are usin upper chest breathin. If the
lower hand rises first you are breathin with your diaphram. If both move at the same time you
are usin a mix of both.
U((er&Chest Breathin1
This is not wron but it does mean that your breathin will be a lot more rapid than if you were
usin your diaphram. This is because the amount you can inhale and exhale is considerably less
1)0
1 because the upper ribcae does not have the ability to expand and contract as well as the
combination of lower ribcae and diaphram 8floor8 1 diaphramatic breathin.
Bpper1chest rapid breathers do also have a tendency to be prone to hyperventilation 1 a
potentially distressin condition that can result in a bi*arre rane of symptoms.
Usin1 yo-r Dia(hra1m
Diaphramatic breathin, particularly if combined with mid1 and upper1chest breathin, is much
slower and more calmin that upper1chest breathin alone.
An added bonus to diaphram breathin is that it ives a wonderful massae to your internal
orans such as the heart, liver, and diestive orans %includin colon) keepin them toned and
ensurin they et a healthy blood supply.
"ost better1breathin techni+ues rely on your ability to breathe usin your diaphram. !o if you
have habitually used the mid1 or upper1chest it is worthwhile to first develop your ability to use
your diaphram. That way, if you need to use a special techni+ue you will have the diaphram1
breathin skill ready.
Practice -sin1 yo-r dia(hra1m
!pend a few minutes a couple of times a day practicin usin your diaphram/
'. Hie flat on the floor. 4aise your knees. %Sou can put a cushion under them if you wish.)
6. &ut one palm on your upper chest and the other over your navel. %Sour ob3ective is to have the
lower hand rise first when you breathe in.)
.. ;reathe out fully 1 and then a little bit more. =ith practice you will find you can do this by
drawin in your abdomen. &ause for 61$ seconds.
$. Allow the air to naturally flow in aain.
!lowly and calmly repeat this cycle a few times.
1)1
).( Easy ?reat"ing
"aintainin an easy breathin pattern, where your chest and diaphram are relaxed and movin
naturally in harmony with each inhale and exhale helps re1develop and maintain a comfortable
physical state with a clear and alert mind.
$ow to -se Easy Breathin1
'. &ay attention to the natural, effortless movement of your breathin cycle. ,eel the movements
and sensations.
6. &ay attention to the inhale, then the sliht pause, followed by the natural exhale, and then
another sliht pause.
.. Do this for three or four minutes 1 payin attention to nothin else.
%In the beinnin it is likely that accumulated tensions and poor breathin habits may have
produced an uneven breathin pattern. If this is the case you may find it helpful to first use the
!ih ;reath method a few times to calm and reulari*e your breathin.)
Throuh practice you may discover ways of utili*in Easy ;reathin as a Quick 4elaxer 1 a way
of relaxin +uickly for a few moments. As you encounter these experiments to discover which
methods you find most suitable for the different situations in your life.
+hen to -se Easy Breathin1
'. =henever you wish to pace yourself and maintain a calmer and more centered internal state 1
at work, in sport, socially, etc.
6. =hen you wish to clear your thinkin in order to ive your full attention to an important
matter.
.. As a Quick 4elaxer1 especially when it is inappropriate to relax with eyes closed, or to fully
stop what you are doin.
1)'
$. To develop the habit of maintainin a clear mind and calm body. Bse Easy ;reathin in odd
spare moments/ in lifts, in +ueues, in waitin rooms, at traffic lihts, durin the TA Zadverts8,
while listenin to someone, waitin on the phone, or when you are bein delayed. In this way
you can turn what miht otherwise been a frustratin or irritatin event into a beneficial and
centerin experience.
G. To develop an on1oin natural awareness of your physical state 1 so that any chest tihtness
or breathin unevenness alerts you to take action to clear your thinkin and calm your body.
-. To train yourself to feel mentally and physically comfortable even when under pressure.
Benefits of Easy Breathin1
7elps defuse the physical effects of the stress response
&rovides an instant break and reduces frantic mental activity by centerin your attention on a
sinle issue rather than havin it scattered
Enables you to take a mental and physical break without stoppin what you are doin
Enables you to maintain physical comfort while bein mentally active.
1))
)/( ;eet ?reat"ing
This is a method of dealin with anxiety by takin a short relaxation break in which you link
slower and more even breathin with mental imaery.
+hy -se 'eet Breathin1
Bsin ,eet ;reathin enables you to take a short relaxation break whenever and wherever you
wish.
4elaxationEmeditation is not a mysterious or mystical experience available only to a select few
adepts. It is a natural and valuable ability which we all possess, even thouh we may not have
practiced the skill for many years.
4elaxation is the bed1rock of effective anxiety manaement and with a little persistence you can
+uickly become skilled at it once aain.
Sou can use ,eet ;reathin with eyes closed or open. In company or alone. At work, at home,
while travelin on public transport. Sou can use it to take a break on lon car 3ourneys %althouh
it is not suitable for use whilst drivin).
4eular relaxation breaks even if only for a couple of minutes at a time interrupt the daily
accumulation of tension. They also remind you how it feels to be calm and, in doin so, create a
desire to feel like this more of the time.
Temporarily attainin this calmer state reminds you that you can manae your own state and do
not have to be a victim of daily pressures.
Sou can also use this method to help you et to sleep or, if you awake durin the niht, to et
back to sleep.
1)*
$ow to -se 'eet Breathin1
'. Het your body relax. Bse Easy ;reathin 1 in which you simply pay attention to your natural
in1 and out1breath. As you do this imaine that with each in1breath you are drawin the air in
thouh the soles of your feet, up throuh your les, and into your torso.
6. As you let o and exhale imaine the reverse happenin. The air leavin your torso, flowin
down throuh your les and out throuh the soles of your feet.
.. Then add whichever additional refinements you personally find work best for you/
<n the in1breath silently think I am... and on the out breath think ...takin a break or ...lettin
o or ...becomin calmer or use any other calmin phrase that suits you.
<n the in breath feel your body tensin slihtly and on the out breath feel it lettin o more
and more with each breathin cycle.
<n the in1breath imaine the color of calmness flowin into your body. <n the out breath
imaine the color of tension flowin down throuh your body and out throuh your feet.
1)+
*0( T"e Sig" ?reat"
The !ih ;reath is a very simple breathin method for releasin tension in your chest, diaphram
and neck areas.
It is an excellent way of reducin the symptoms of anxiety or panic.
It is a moderate %rather than very deep) inhale throuh the nose followed by a fairly proloned
exhale throuh the nose or mouth.
+hy -se the Si1h Breath;
The !ih ;reath can become your 8instant tran+uilliser8. It is a deceptively simple little techni+ue
which has many benefits.
It enables you to/
Instantly reduce your tension level throuh temporarily raisin your blood carbon
dioxide level
The !ee 5learly 1 7ear 5learly part of the method directs your attention outside of
yourself. This interrupts the common and +uite un1useful tendency that most of us have,
when anxious or upset, to ruminate 1 to become very absorbed with our thouhts and
feelins.
1)1
Enaes your attention for a few moments. =hen you use it reularly you momentarily
interrupt your internal stress1buildin loop in which your stressful thouhts result in
stressful feelins which, in turn, exacerbate the stressful thouhts. of neative thouhts 1
neative feelins 1 neative thouhts. This takes you out of the loop and into practical
action.
Interrupt any tendency to hold or restrict your breath
;ein reducin accumulated physical tension throuhout your body 1 and especially in
the throat, chest, and abdomen.
D< somethin, when you feel anxious or panicky, rather than simply remain a passive
victim of your moods.
"akes you aware of and interrupts the common tendency, in anxiety states, to hold or
restrict your breath.
$ow to -se the Si1h Breath
'. "entally think or say to yourself !topX
6. Then breathe in throuh nose and, pausin only briefly, let the air out +uite slowly throuh your
nose. This inhale is a moderate %rather than very deep) in1breath. The out breath is the key to the
method. ;e sure to prolon 1 to l1e1n11t1h1e1n 1 your exhale.
.. As you let the air out let oX 4elax your muscles, especially your shoulders. Het o of tension in
your chest and stomach. Het your arms and les relax. Het your 3aw relax. Het your forehead relax,
and....
$. ...direct your attention outside yourself to what is happenin in the outside world 1 Z!ee clearly8
and Z7ear clearly8. !ilently pay attention to what you can see and hear, without listin or namin
them.
%Althouh the method involves four steps the whole cycle of in breath 1 pause 1 out breath takes
only a few seconds.)
+hen to -se the Si1h Breath
If you are oin throuh a 8bad patch8 use it +uite a lot 1 at least one or two every 'G1.@ minutes.
1)-
It8s best used to 8nip thins in the bud8 1 before the anxiety state escalates. Take one or two !ih
;reaths whenever you feel yourself beinnin to become aitated or tense.
*1( Anxiety Ed%cation
'i1ht or 'li1ht echanism
The ,iht or ,liht "echanism is the same as anxiety. It is the bodyOs response to daner,
fear or threat.
=hen our mind reconi*es daner %either real or perceived), the body reacts in a
particular way. As stated above, it prepares us throuh a number of physioloical chanes to
protect ourselves from the daner or threat with two main outcomes/ T< ,ID7T or T< ,HID7T
,or example, if we take ourselves back to the days of the cave man we would aree that
he was in real daner on a reular basis. At times he may have been confronted with tiers, lions
and other animals huntin him for his life. At other times he may have been confronted with
other cave men willin to kill him to obtain his food. The cave man had to protect himself and
1).
his life. The fiht or fliht mechanism or the anxiety response ave the cave man a reater
chance of survivin the daner or threat.
!ee if you can identify with any of the side effects of the physioloical chanes that take place
in response to havin a fearful thouht. If you notice these symptoms when you are feelin anxious,
then your body is workin properly. It is protectin you from the daner you are perceivin.
7owever, in our life as it is today, we don8t really need that sort of protection, and most of the time it
only makes us feel very uncomfortable.
If you experience these symptoms in everyday life, it is important to work backwards, and try
and identify the fear based thouht you are havin in which is resultin in your symptoms of anxiety.
Ask yourself if the fear you perceive is really warranted.
Psycholo1ical
Awareness of 'ear,
Threat, or Dan1er
A-tomatic Physiolo1ical Res(onse
Side Effects
6Sym(toms
of Anxiety7
W=hat if I dieXW, W=hat
if I cannot escapeXW
W=hat if they think I am
an idiotXW
Hare amount of adrenaline pumped
into the body to put us in a state of
increased alertness
!weatin
Tremblin and
!hakin
:ausea
1)/
;lood is redirected away from the
extremities to the lare muscles of the
body
&ins and
:eedles
andEor
feelin
di**y
5old hands and
feet
The heart starts workin harder to
move the blood to the lare muscle
roups as +uickly as it can
4acin
7eart
Increase in 4espiratory 4ate to brin
more oxyen into the body
Increased
4espiratory
4ate
4elease of red blood cells to carry
more oxyen to the ma3or muscle
roups of the body

4elease of suar by liver as an instant
form of enery
Bre to run
Increase in metabolic rate to break
down the suar for enery
Bre to run
(Taken from http://%%%.so"ialanxiety."om.a#/Treatment/AnxietyR/H.d#"ation/treatment.htm
*'( <andling ;ear
Everyone has times when they8re afraid of somethin. ,ear has a leitimate function for us
because it alerts us to somethin which could possibly be harmful to us. Bsually, we are able to
evaluate the situation and see if there is any real daner, then take steps to deal with it.
!ometimes, however, our fear ets in our way and interferes with our daily livin. This is often
frustratin because we think of our fear as unrealistic but are still hampered by it. 5onsider the
followin strateies for overcomin these WunrealisticW fears.
1*0
Ste( One
The first step in handlin your fears is to determine exactly what you8re afraid of. It8s very
important that you are very specific about what you8re frihtened of. ,or example, to say, WI8m
afraid of people.W would not be enouh. =hat kinds of people frihten youP "aleP ,emaleP
&eople you don8t likeP &eople you likeP Sou miht also ask yourself +uestions like/ WIn what
kinds of situations am I afraid of peoplePW Is it when you are with a lare roup, or a smaller,
more intimate oneP
;ein clear about exactly what frihtens you is necessary for two reasons/ first, it will enable
you to o ahead and do the thins that don8t actually bother you, but that you8ve been avoidin.
;ecause you have over1enerali*ed and included all the activities connected to the situation
which is fearful with the actual thin you fear, you have probably deprived yourself of the
pleasure of those activities. !econd, it will allow you to focus your enery on solvin the real
problem and not 3ust some small aspect of it. =hen tryin to et clear about what you fear, it8s
often helpful to ask yourself/ Wwhat am I really afraid ofPW !o, for example, if you think you8re
afraid of women, ask yourselfL W=hat is it about women that frihten meP Am I afraid of
somethin they miht do or sayP If so, what is itPW <nce you8ve become very specific about
exactly what scares you, it is easier to bein talkin with someone else, perhaps a close friend,
about the fear. ;ein able to tell someone about it often helps the feared situation become less
fearful.
Ste( Two
The second step in dealin with our fears is to become aware of what you8re sayin to yourself
that scares you so much. "ost of us don8t reali*e it, but in a very real sense we talk to ourselves
a reat deal. "uch of this talk is silent and it can be one of the ways we make ourselves afraid.
!o, for example, if you8re afraid that you8re oin to fail a test, what are you sayin to yourself
about itP Are you sayin that, if you fail, your whole academic career is ruinedP Are you
predictin that your parents are oin to et very anryP ;e aware of what you are sayin to
yourself. If you are focused on how awful it will be to fail the test, you are already startin to
scare yourself and that will interfere with your actual performance. Almost always when we8re
afraid of somethin we8re talkin to ourselves and tellin ourselves that somethin bad is oin
to happen. Bnconsciously, we are forcin our minds and bodies into a stress mode preparin to
meet the imained disaster. To reduce the fear, say somethin positive to yourself, somethin
like, Wfailin is no fun, but the world certainly won8t end,W or, Wmy rade on this test has nothin
to do with my value as a person, so I8ll prepare as well as I can and see how well I can do.W
Ste( Three
The next step in handlin our fears is to exaerate the bad thins that you are afraid are oin to
happen. Althouh you probably haven8t said it, it8s these exaerated bad effects that you fear.
!o, for example, if you know you8d like to call someone you8d like to et to know better, socially,
but are afraid to pick up the phone to do so, you miht exaerate possible outcomes and say to
1*1
yourself, WIf I call, I8m oin to be lauhed at or re3ected and I8m oin to be depressed for three
months. Everyone will know I8m a loser and will treat me like I8m nothin.W In fact, it can be a
lot of fun tryin to think up the most dire conse+uences imainable. Sou can really et creative
if you try. After catastrophi*in for a few minutes, you8ll probably bein to reali*e that the world
couldn8t possibly be as bad as your imaination can make it. The world won8t end if you o
ahead and make that call and it doesn8t work out 3ust the way you8d want it to11A:D11it is
possible that the outcome could be even better than you8re hopin. Sou can8t find out until you
make the call.
Ste( 'o-r
!tep four involves your usin your imaination in a more positive way for dealin with your
fear. ,irst, relax in the followin way/ Take a deep breath while at the same time tensin your
muscles. Then slowly let out the breath and at the same time let the tension in your body o. Do
this several times, allowin yourself to relax more and more each time. After you are relaxed,
imaine yourself approachin the feared situation. <nce you8re able to imaine it well, imaine
yourself comin close to the condition or situation you fear. Aisuali*e yourself bein a little
afraid, but still oin ahead and enain in the feared behavior and copin with it. It8s
important to et a mental picture and a feelin of what it8s like to deal with the situation in a
successful way even while you are still feelin a little fearful. !o, for example, if you8re afraid to
ask a store clerk for your money back on an item, try to picture yourself askin for the refund
even thouh you8re still a little afraid. Try to et a ood picture of this. Imaine yourself in the
situation without all those terribly unpleasant conse+uences you8ve been scarin yourself with.
Another way to approach this is to imain that you have already dealt with the situation in a
successful way and review how you have done it. Sou miht be pleasantly surprised by how
creative you had been at dealin with the situation. As you en3oy the feelin of mastery that
comes with havin dealt successfully with the situation that has made you fearful, you will
become more confident and less fearful. After you have done these exercises several times and
bein to feel an easin of your fear you8re ready for the last step.
Ste( 'i5e
In this last step, you will need to actually approach the thin, person, or situation head on. This
doesn8t mean you have to chane your entire behavior in one dramatic step. Sou can break the
behavior down into a number of increasinly difficult steps if you want. ,or example, if you are
afraid to ive your opinion in class, you miht bein by askin the professor a +uestion after
class. After doin this a couple of times, you could ask a +uestion in class. 5ontinue the process
by ivin your opinion after class. ,inally, you would work up to ivin your opinion durin
class. A similar techni+ue would be to vary the amount of time you spend enain in the
feared behavior. If you8re afraid to talk to members of the opposite sex, bein by sayin WhiW
then o on to ask one a +uestion, and from there perhaps bein to share your own interests or
feelins.
1*'
As you8re learnin to deal with your fear, continue to be aware of your self1talk and continue to
be aware of the exaerations you8re usin to scare yourself. The process of radually exposin
yourself to the feared situation will re+uire some time and commitment on your part. <ften a
ood way to bein is to write down a list of 9 or '@ thins %or WstepsW) which lead up to the thin
you most fear. Each step involves a little more anxiety to perform as you approach the final
oal. Bse your relaxation exercise and positive imaery on each step. Don8t continue to the next
step until you can feel yourself relaxed and calm on the current step. ;efore takin each step,
take a deep breath and alternatively tense and loosen your muscles. 5ontinue doin this until
you can feel relaxed and calm while imainin bein in the fearful situation. ;y radually
workin up to the most feared situation, you ive yourself practice in not bein terribly afraid
even thouh you are still dealin with some fear. Sou will discover that all of those awful thins
you were sure would happen are not inevitable and that there can be pleasant surprises and
rewardin outcomes.
Re5iew And S-mmary
;efore we review the five steps above, please be aware of two common myths. ,irst, it is a myth
in most cases that you can stop bein afraid by makin a conscious choice. It takes a lot of
thinkin and work to chane old ways of reactin to situations. !econd, it is a myth that you
should stop bein afraid before you act. In most cases, you must act with at least a little fear11or
even substantial fear11before the fear will o away.
:ow let8s review the five steps.
4emember that you could be usin any or all of these steps at one time if necessary.
'. Det clear in your mind what it is that you8re afraid of. Ask +uestions like, W=hat about
that scares mePW
6. ;ecome aware of your self1talk. =hat are you sayin to yourself that scares youP
.. Exaerate the bad conse+uences you fear. ;ein to reconi*e that you were probably
already exaeratin and didn8t know it and that what you feared is indeed and
exaeration already.
$. Aisuali*e yourself still bein afraid, but handlin the situation in an acceptable manner.
G. Dradually expose yourself to the feared situation by doin thins that more and more
closely approximate what you fear.
(Taken from http://%%%."o#nsel.#fl.ed#/self=elp.asp.
1*)
*)( T"e $ositive Data 8og
A &ositive Data Ho is a lo of evidence in support of an individualOs positive or balancin
schema. The use of the &ositive Data Ho as a schema chane stratey is based on three observations
about schema.
S A given schema can be activated in many situations. A person who believes MIOm
incompetentN can experience emotional, behavioral, and conitive reactions when this schema is
activated in multiple diverse situations. A business executiveOs incompetence schema can be activated
at work when a colleaue does not return his telephone call promptly, in heavy traffic when an
impatient driver honks at him, and at home after a shoppin trip when he discovers the expensive shirt
he 3ust bouht does not fit properly.
S Schema include both positive and negative information. ,rom the information1processin
literature, we know that schema are multidimensional and contain both positive and neative
information %for a review, see !eal, '(99). The executive who feels incompetent in the situations 3ust
described can feel hihly competent when he receives a promotion from his boss or a compliment
from a colleaue. &adesky %'((-) called the schema that oppose the neative schema Mbalancin
schema.N Accordin to conitive theory, problems arise both when neative schema are too stron or
activated too often and when balancin or positive schema are too weak or activated too infre+uently
%A. T. ;eck, '(C-).
S Schema determine what people notice, attend to, and remember. A lare experimental
literature demonstrates the way schema uide and select the information people take in and remember
%see =illiams, =atts, "acleod, I "athews, '(99, for a useful overview). Depressed individuals
remember fewer and less specific positive autobioraphical memories and more specific neative
memories. They also have a bias to attend to neative information %=illiams, '((6). There is some
evidence that these deficits persist in vulnerable individuals, even when they recover from depression
%for a review, see Dotlib I >rasnoperova, '((9).
The &ositive Data Ho capitali*es on all three of these observations about schema. The &ositive Data
Ho teaches the patient to notice the multiple situations in which schema are activated, helps the
patient strenthen the positive or balancin schema, and helps the patient notice and overcome biases
in processin information driven by schema.
#UIDE!INES 'OR SETTIN# UP A POSITI"E DATA !O#
=e offer these uidelines to assist the therapist in settin up a &ositive Data Ho.
S -rovide a rationale. >eepin a &ositive Data Ho is a difficult task because, as the
information1processin literature shows, individuals often fail to perceive or remember information
that contradicts their neative schema. ,or this reason, it is essential to provide your patient with a
convincin rationale for doin the hard work necessary to keep a &ositive Data Ho. Sou can provide
a rationale to the patient by usin an idea suested by 5hristine &adesky %'((.), namely, the concept
of the schema as a Mself1pre3udice.N
1**
S $dentify balan"in! s"hema. ;ecause the patient is asked to record evidence in support of his or
her positive or balancin schema, it is important to be certain the balancin schema is clear and
specific. Bse the patientOs words for reater impact. ,or example, if a patient, an accountant, used a
&ositive Data Ho to coiled data to support her belief that MI[m on the A team.N The A1team and ;1
team metaphor could be her own hihly personal way of capturin her neative %; team) and
balancin %A team) view of herself.
S 'tart the -ositive Data 8o! d#rin! the session. !pend some time startin the &ositive Data
Ho durin the session and demonstratin how to use the &ositive Data Ho form. If the accountant
above has difficulty findin evidence that she is on the A team, the therapist could suest several
entries on the basis of her awareness of what was oin on in the patientOs life. ,or example, the
therapist was able to point out to the accountant that she had 3ust been assertive with a coworker and
that this miht be viewed as A1team behavior.
S $nstr#"t patients to enter eviden"e on the -ositive Data 8o! as soon as possible.
Explain to patients that it is important that they enter evidence on the &ositive Data Ho as soon as
they observe it. If they wait until the end of the day or even ' or 6 hours after to enter the evidence, the
evidence may be lost because the patient will foret it, minimi*e it, or discount it.
#UIDE!INES 'OR RE"IE+IN# A POSITI"E DATA !O#
:ext we offer uidelines for reviewin the &ositive Data Ho when the patient brins it to the session.
S &e s#re to revie% the -ositive Data 8o!. $t is important to review the &ositive Data Ho to
encourae compliance and to et as much benefit from the intervention as possible. it is easy for both
the patient and the therapist to ive up too soon when the patient has difficulty completin the lo.
S Fe%ard small steps. &atients may not see evidence in support of their balancin schema when
you can see it very dearly. Take advantae of any opportunity to add an item to the lo, no matter how
insinificant it seems to the patient, and praise patients for their efforts to accomplish the difficult task
of keepin the lo.
S Femember that depressed individ#als are biased to i!nore( minimize( and for!et information
that s#pports the balan"in! s"hema (A patient with an anxiety disorder who no loner finds pleasure
in those activities she once en3oyed is likely to become depressed also.) The patientOs neative
schema uide his or her processin of information in such a way as to block the receipt of information
that supports the balancin schema and belons on the &ositive Data Ho. &atients will inore,
invalidate, distort, dis+ualify\ and foret information that supports the balancin schema. &oint this
type of distortion out to patients whenever you see it, and teach patients to do this for themselves. A
Thouht 4ecord can be used to structure this type of therapeutic work.
S )at"h for opport#nities d#rin! the session to add items to the -ositive Data 8o!.
Assume that patients have overlooked evidence in support of their balancin schema. Treat all
discussions and all information you obtain about the patient as opportunities to add to the patientOs
1*+
&ositive Data Ho. =hen you hear somethin that miht be evidence in support of the patientOs
balancin schema, ask MDid you % put that on your &ositive Data HoPN if the answer is no( ask the
patient to et out the lo and add the item.
POSITI"E DATA !O#
Instructions/ Describe your maladaptive schema and alternative schema in the space provided. Then
write down each piece of evidence in support of your alternative schema and the date and time when
you observed the evidence. ;e as specific as you can. ,or example, rather than writin M!omeone said
somethin nice to me,N write MTom said he liked the shoes I was wearin.N 4emember, you are to
write down all evidence in support of your alternative schema, reardless of how small or insinificant
you miht think it is.
"aladaptive schema/
UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
Alternative schema/
Date and time Evidence in support of alternative schema
1*1
**( Daily 2ood 8og
;einnin with a Daily "ood Ho encouraes the patient to identify her automatic thouhts %those
that occur without effort) when she thinks about doin somethin she knows would be ood for her
but that she is resistin. !he will be tauht to look for distortions %irrational thinkin) and to replace
those distortions with more rational responses.
The MDaily "ood HoN is a simple three1column rid. 5olumns are labeled MAutomatic Thouhts,N
MDistortions,N and M4ational 4esponsesN respectively. After enterin automatic thouhts the client
also rates her belief in each one usin a scale of @1'@@ %;urns, '(9().
,irst the counselor exposes the patient to a list of 5onitive Distortions. They discuss some of the
patientOs automatic thouhts and distortions. The patient is iven the Daily "ood Ho as a homework
assinment. !he is asked to record her thouhts each time she finds herself Mdown in the dumpsN
about an activity she is doin or anticipatin. =hen the patient returns for the next session, she and
the counselor examine the lo. They discuss her automatic thouhts and distortions one at a time.
The counselor uses !ocratic +uestionin to uide the patient in replacin the distortions with rational
responses. %!ocratic +uestionin is a line of +uestionin meant to lead the client into discoverin new
ways of thinkin about the sub3ect.) This continues from session to session with counselor and patient
reviewin older los and evaluatin proress. ,ewer distortions or lower ratins for those distortions
sinal improvement. As clients reconi*e erroneous thinkin, they often chane behavior. In this
case the patient should bein to report more en3oyment and, as a result, more participation in activities.
*+( T"o%g"t Record
It is the belief of conitive therapists that, M neative mood and maladaptive behaviors are caused by
neative, maladaptive, irrational, distorted conitions.N %Abramson, "etalsky, I Alloy, '(9(). The
Thouht 4ecord has this as its basis.
The therapist uses the Thouht 4ecord to help the patient examine the usefulness of her conitions,
identify conitive distortions %which often helps a patient feel better by itself), and analy*e in detail the
evidence supportin and not supportin a distortion. Then the therapist returns to the place in the
1*-
Thouht 4ecord where the oriinal distorted thouht appeared and uses !ocratic +uestionin to uide
the client to healthier responses. !ocratic +uestionin is recommended rather than directives because it
ives the patient ownership, and therefore, more investment in the outcome.
Tho-1ht Record
Date
Sit-ation
6e5ent,
memory,
attem(t to do
somethin17
Beha5iors Emotions Tho-1hts Res(onses
1*.
*1( $anic Diary
The panic diary is a tool used to let clients become aware of situations or triers that lead to a
panic attack.
Panic Diary Instr-ctions
Sou can recover from panic attacks by learnin how to cope with them, because the attacks will
enerally fade away once you lose your fear of them. In order to do this, it is essential that you
learn as much about your attacks as possible, and train yourself to be a ood observer durin an
attack. Bse the accompanyin panic diary to record each attack and your responses by followin
the instructions below. 5omplete a description for each attack as it occurs. DonOt wait until
later1 fill out the form durin the attackX That will seem difficult, but will probably be less
difficult than it seems.
Ste( 0 ,ill in MDateN and M:ameN
Ste( 4 :ext to MHevelN, rate your level of panic on a scale of @ to '@, in which @ means
no panic, and '@ means the worst panic possible.
Ste( : :ext to MTime beanN and MTime endedN, record those times. AH=AS! time
your attacks whenever they occur. DonOt rely on estimatesX
Ste( C :ext to M!ymptomsN, record the symptoms you experience durin the attack.
Ste( D :ext to M=hat typePN classify your attack as one of the followin types/
1*/
!&<:TA:E<B! ATTA5>/ a panic attack that appears to come Mout of the
blue.N This classification is not used when your are in a feared situation, or
thinkin about somethin fearful.
A:TI5I&AT<4S ATTA5>/ a panic attack that occurs while thinkin of
facin a feared situation, or thinkin about somethin fearful.
!ITBATI<:AH ATTA5>/ a panic attack that occurs while you are in a
feared situation.
Ste( F :ext to M=here are youPN record your location at the time of the attack.
Ste( J :ext to M=hat were you doin when the attack beanPN record your activity at the
time of the attack.
Ste( K :ext to MAre you alonePN answer yes or no. If no, record who is with you.
Ste( L 4ecord your thouhts and imaes immediately before the panic attack.
Ste( 09 4ecord your disturbin thouhts and imaes durin the panic attack. ;E
!&E5I,I5X
Ste( 00 Describe what you say to yourself to calm yourself.
Ste( 04 Describe what you do to calm yourself.
Ste( 0: Describe how the panic attack ends %what causes it to endP).
Ste( 0C 4ecord any different responses that you want to use next time you have an attack.
Ste( 0D ;rin the diary to meetins with your counselor.
1+0
DateUUUUUUUUUUUUUUUUUU :ameUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
Hevel %@1'@)UUUUUUUUUUUU Time bean/UUUUUUUUUUU Time ended/UUUUUUUUUUUUUUU
!ymptomsUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
UU
=hat typePUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
=here are youPUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
=hat were you doin when the attack beanP
UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
Are you aloneP %If not, list who is
present)UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
=hat were thinkin before the attackP
=hat were you thinkin durin the attackP
7ow did you talk back to the fearsP
UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
1+1
=hat actions did you take to calm yourselfP
7ow did the attack endP
UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
7ow do you want to respond differently next timeP
UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
(Taken from %%%.anxiety"oa"h."om.
*-( $ositive Self5Tal7
P-r(ose
It is important for students to take responsibility for their lanuae1 especially what they say
about themselves. An important aspect of positive mental health is acceptin and acknowledin
oneOs strenths and ood +ualities. &ositive self1talk is an act of self1love. &ositive self1talk can
lift our spirits and help us focus our eneries on the positive aspects of ourselves, both of which
accelerate our 3ourney to a more successful life.
Proced-re
Two activities make up this lesson on positive self1talk. The first is an exercise we call
Mbrain.N
Bra11in1
It is important to receive reconition and positive support for what we do. Exercises such as the
followin provide a leitimate forum for disclosin those thins about ourselves that are positive
and rowth1promotin.
If a person is to become fully self1actuali*in, it is important for him or her to learn to
express positive as well as neative feelins. 7owever, our society does not provide much
opportunity for this/ brain is enerally frowned on. Hoot at all the Mput1downsN that are
commonly used in reard to brain/
1+'
M7eOs really a stuffed shirt.N
MIf his head ets any bier, he wonOt be able to wear a hat.N
M!heOs the most self1centered person I know.N
M7eOs always blowin his own horn.N
MThere she oes aain1 beatin her own drum.N
Set despite these societal taboos, bein able to Mtell the truthN about ourselves and our
manificence is important.
'. 4ead the followin story from the Hos Aneles Times %!eptember '9, '(9G) entitled
M:othin but the TruthPN/
6. Ask the students to find a partner, preferably someone with whom they havenOt had a lot
of interaction yet. Tell them that each person will have (@ seconds to boast about
anythin in his or her life/ accomplishments, awards, skills, thins he or she does well,
personal characteristics or attributes. Ask that they be Munder oathN about themselves as
they bra.
.. After you have iven them the instructions, ask them how many of them are feelin a
little bit uncomfortable about doin the exercise. Ask them to raise their hand if they are.
%Bsually over half will respond MyesN to this +uestion.) Ask if anyone can remember
what they said or thouht to themselves that would make them feel uncomfortable. !ome
common responses are/
MI didnOt think I could fill up (@ seconds.N
M"y parents tauht me never to bra.N
MIf you bra about yourself, people miht think youOre conceited and not like
you.N
MI started thinkin of all the thins that are wron with me. ItOs easier to think of
those thins.N
M"y partner miht be bored with what I have to say.N
If nobody volunteers an answer, which sometimes happens, then 3ust ask M7ow many of
your were thinkin].P %and then say the thins 3ust listed). Ask them to say MyesN by
raisin their hands. Even if they donOt raise their hands, but lauh when you mention one
of the thouhts that could make one uncomfortable, their lauhter indicates that they were
thinkin that thouht.
$. :ext tell them each to face their partners, maintain eye contact, and take a few deep
breaths as they +uiet down. Tell them aain that they will have (@ seconds to tell their
partners what they like about themselves, what they see as their strenths and positive
+ualities.
1+)
G. At this point, before they start, model the behavior by sharin for (@ seconds what you
see as your positive strenths and +ualities. 7ave one of the students time you. Sou can
include such thins as/
I am a ood teacher.
I have a reat sense of humor.
I am very patient with people.
I am well orani*ed.
I love music. I dance, play the piano, and sin in the church choir.
I keep I shape by oin to aerobics class three times a week.
I recently learned how to chane the oil in my car.
I overcame a fear of mechanical thins and I feel ood about that.
I am a ood debater. I won a medal at it once.
I am a ood cook.
I am a ood listener.
I am ood with plants.
I play basketball well.
I am a very carin and sensitive person.
I am intellient.
-. After you have completed your demonstration, tell them to face their partners once aain.
Ask them to decide who will o first.
C. Tell them to bein. After (@ seconds, tell them to stop. Ask the listeners to ive the
speakers a round of applause for doin the task successfully. Acknowlede that it can be
hard at first.
9. :ow the partners bein their turn. At the end of (@ seconds, tell them to stop. Aain, ask
the listeners to ive the speakers a round of applause.
(. This activity usually results in everybody feelin very ood about themselves, as well as
feelin close to each other. Ask students to share whatever feelins they have about the
brain they 3ust did. The followin +uestions may be useful/
7ow comfortable were you brain about yourselfP
7ow comfortable were you listenin to your partner braP
;y a show of hands, how many of you feel a little bit closer to your partner after
doin thatP =hyP
1+*
This exer"ise "an be modified to #se %ith an individ#al.
(Taken from >anfield( B.( L 'i""one( 5. (1MM3. 1H1 )ays to Develop 't#dent 'elf+.steem and
Fesponsibility. Eeedham =ei!hts( ,A: Allyn and &a"on.
*.( Refra&ing
Rational for Reframin1
5ounselor explains purpose of reframin.
7Iften %hen %e think abo#t a problem sit#ation( o#r initial or int#itive rea"tion "an lead to
emotional distress. 5or example( %e fo"#s only on the ne!ative feat#res of the sit#ation and overlook
other details. &y fo"#sin! only on the sele"ted ne!ative feat#res of a sit#ation( be"ame nervo#s or
anxio#s abo#t the sit#ation.:
5ounselor provides overview of refrainin.
1++
7)e9ll identify %hat feat#res yo# attend to %hen yo# think of the problem sit#ation. In"e yo# be"ome
a%are of these feat#res( %e %ill look for other ne#tral or positive aspe"ts of the sit#ation that yo# may
i!nore or overlook. Then %e %ill %ork on in"orporatin! these other thin!s into yo#r per"eptions of
the problem sit#ation.:
5ounselor confirms clientOs willinness to use the stratey.
7=o% does this all so#nd* Are yo# ready to try this*:
Identification of Client Perce(tions and 'eelin1s in Pro)lem Sit-ation
5ounselor has client identify features typically attended to durin problem situation. %"ay have to use
imaery with some clients.)
7)hen yo# think of the problem sit#ation or one like it( %hat feat#res do yo# noti"e or attend to*
)hat is the first thin! that pops into yo#r head*:
5ounselor has client identify typical feelins durin problem situation.
7=o% do yo# #s#ally feel*: 7)hat do yo# experien"e (or are yo# experien"in!< d#rin! this
sit#ation*:
Deli)erate Enactment of Selected Perce(t-al 'eat-res
5ounselor asks client to reenact situation %by role play or imaery) and to deliberately attend to
selected features. %This step may need to be repeated several times.)
78et9s set #p a role play (or ima!ery< in %hi"h %e a"t o#t this sit#ation. This time $ %ant yo# to
deliberately fo"#s on these aspe"ts of the sit#ation %e D#st identified. Eoti"e ho% yo# attend to
@@@@@@@@@@@@@:
1+1
Identification of Alternati5e Perce(tions
5ounselor instructs client to identify positive or neutral features of problem situation. The new
reframes are plausible and acceptable to the client and fit the clientOs values and ae, ender, race, and
ethnicity.
7Eo%( $ %ant #s to identify other feat#res of the problem sit#ation that are ne#tral or positive. These
are thin!s yo# have for!otten abo#t or i!nored. Think of other feat#res.: 7)hat other aspe"ts of this
sit#ation that aren9t readily apparent to yo# "o#ld provide a different %ay to vie% the sit#ation*:
odification of Perce(tions in Pro)lem Sit-ations
5ounselor instructs client to modify perceptions of problem situation by focusin on or attendin to
the neutral or positive features. %Bse of role play or imaery can facilitate this process for some
clients.) %This step may need to be repeated several times.)
7)hen %e a"t o#t the problem sit#ation( $ %ant yo# to "han!e %hat yo# attend to in the sit#ation by
thinkin! of the ne#tral or positive feat#res %e D#st identified. B#st fo"#s on these feat#res.:
5ounselor encouraes client to practice modifyin perceptions durin in viva situations.
7-ra"ti"e is very important for modifyin! yo#r per"eptions. .very time yo# think abo#t or en"o#nter
the problem sit#ation( fo"#s on the ne#tral or positive feat#res of the sit#ation.:
5ounselor instructs client to monitor aspects of the stratey on homework lo sheet.
7$9d like yo# to #se this lo! to keep tra"k of the n#mber of times yo# pra"ti"e or #se this. Also re"ord
yo#r initial and res#ltin! feelin!s before and after these kinds of sit#ations.:
1+-
5ounselor arranes for a follow1up. %Durin follow1up, counselor comments on clientOs lo and points
out small perceptual shifts.)
78et9s !et to!ether in t%o %eeks. &rin! yo#r lo! sheet %ith yo#. Then %e "an see ho% this is %orkin!
for yo#.:
*/( Stress Inoc%lation
Rationale
'. 5ounselor explains purpose of stress inoculation.
7'tress ino"#lation is a %ay to help yo# "ope %ith feelin! anxio#s so that yo# "an mana!e yo#r
rea"tions %hen yo#9re "onfronted %ith these sit#ations.:
1+.
6. 5ounselor provides brief overview of stress inoculation procedure.
75irst %e9ll try to #nderstand ho% yo#r anxio#s feelin!s affe"t yo# no%. Then yo#9ll learn some
"opin! skills that %ill help yo# relax physi"ally?and help yo# #se "opin! tho#!hts instead of self+
defeatin! tho#!hts. Then yo#9ll have a "han"e to test o#t yo#r "opin! skills in stressf#l sit#ations %e9ll
set #p.:
.. 5ounselor checks to see whether client is willin to use stratey.
7=o% do yo# feel no% abo#t %orkin! %ith this pro"ed#re*:
Information #i5in1
5ounselor explains nature of clientOs emotional reaction to a stressful situation.
7-robably yo# realize that %hen yo# fee anxio#s( yo# are physi"ally tense. Also( yo# may be thinkin!
in a %orried %ay?%orryin! abo#t the sit#ation and ho% to handle it. &oth the physi"al tenseness and
the ne!ative or %orry tho#!hts "reate stress for yo#.:
5ounselor explains possible phases of reactin to a stressful situation.
7)hen yo# feel anxio#s( yo# probably tend to think of it as one !iant rea"tion. A"t#ally( yo#9re
probably anxio#s at "ertain times or phases. 5or example( yo# mi!ht feel very #pti!ht D#st
anti"ipatin! the sit#ation. Then yo# mi!ht feel #pti!ht d#rin! the sit#ation( espe"ially if it starts to
over%helm yo#. After the sit#ation is over( yo# may feel relieved?b#t do%n on yo#rself( too.:

-. 5ounselor explains specific kinds of copin skills to be learned in stress inoculation and
importance of clientOs input in tailorin copin strateies.
7)e9ll be learnin! some a"tion kinds of "opin! strate!ies?like physi"al or m#s"le relaxation( mental
relaxation( and D#st "ommonsense %ays to minimize the stress of the sit#ation. Then also yo#9ll learn
some different %ays to vie% and think abo#t the sit#ation. Eot all these "opin! strate!ies may seem
best for yo#( so yo#r inp#t in sele"tin! the ones yo# feel are best for yo# is important.:
1+/
Ac<-isition and Practice of Direct&Action Co(in1 S2ills
C. 5ounselor discusses and models direct1action copin strateies %or uses a symbolic model)/
a.5ollectin ob3ective or factual information about stressful situation.
75irst( $9ll explain and %e "an talk abo#t ea"h "opin! method. Then $9ll demonstrate
ho% yo# "an apply it %hen yo#9re provoked.:
7'ometimes it helps to !et any information yo# "an abo#t thin!s that provoke and
an!er yo#. 8et9s find o#t the types of sit#ations and people that "an do this to yo#.
Then %e "an see %hether there are other %ays to vie% the provo"ation. 5or example(
%hat if yo# looked at it as a sit#ation to "hallen!e yo#r problem+solvin! ability rather
than as a personal atta"k*:
b.Identifyin short1circuit or escape routesTalternative ways to deescalate stress of
situation.
7'#ppose yo#9re "a#!ht in a sit#ation. Co# feel it9s !oin! to !et o#t of hand. )hat are
some %ays to !et o#t of it or to dees"alate it before yo# strike o#t* 5or example( little
thin!s like "o#ntin! to 4H( leavin! the room( #sin! h#mor or somethin! like that.:
c. "ental relaxation # Attention diversion
7IG( one %ay to "ontrol yo#r an!er is to distra"t yo#rself?take yo#r attention a%ay
from the person yo# feel an!ry %ith. $f yo# have to stay in the same room( "on"entrate
very hard on an obDe"t in the room. Think of all the q#estions abo#t this obDe"t yo#
"an.:
d. Imaery manipulations
110
7IG( another %ay yo# "an prevent yo#rself from strikin! o#t is to #se yo#r
ima!ination. Think of somethin! very "almin! and very pleas#rable( like listenin! to
yo#r favorite re"ord or bein! on the bea"h %ith the hot s#n.:
e. &hysical relaxation # "uscle relaxation
7,#s"le relaxation "an help yo# "ope %henever yo# start to feel aro#sed and feel
yo#r fa"e !ettin! fl#shed or yo#r body ti!htenin! #p. $t "an help yo# learn to relax
yo#r body( %hi"h "an( in t#rn( help yo# "ontrol yo#r an!er. 'tart %ith yo#r fa"e.
Ti!hten all the m#s"les in yo#r fa"e and "o#nt to ten by tho#sands P one tho#sand(
t%o one tho#sand( three one tho#sand( fo#r one tho#sand( five one tho#sand( six one
tho#sand( seven one tho#sand( ei!ht( one tho#sand( nine one tho#sand( ten one
tho#sand. Eo% ti!hten all the m#s"les in yo#r sho#lders and hold that %hile yo# "o#nt
to ten a!ain by one tho#sands. Then do the same %ith yo#r arms( yo#r stoma"h( yo#r
ba"k( yo#r "alves( and yo#r feet and toes.:
f. ;reathin techni+ues
7&reathin! is also important in learnin! to relax physi"ally. 'ometimes( in a ti!ht
spot( takin! slo%( deep breaths "an !ive yo# time to !et yo#rself to!ether before
sayin! or doin! somethin! yo# don9t %ant to. Take a breath and hold it to the "o#nt of
ten( a!ain "o#ntin! to ten by #sin! one tho#sands. =old yo#r breath #ntil yo# rea"h
ten one tho#sand and then slo%ly exhale. Do this ten times before yo# speak or
move.:
. &alliative copin strateies # &erspective takin
78et9s try to look at this sit#ation from a different perspe"tive?%hat else abo#t the
sit#ation mi!ht yo# be overlookin!*:
h. !ocial support network
78et9s p#t to!ether some people and reso#r"es yo# "o#ld #se as a s#pport system.
)hen yo# feel #pset( %ho %o#ld yo# most likely talk to* )hen yo# are do%n( %ho
111
"omforts yo#* )hen yo# !et mad( %ho helps yo# !et over it* )ho is yo#r best friend*
)ho( in the past( has !iven yo# advi"e that really %orked*:
i. Aentilation of feelins
7-erhaps it %o#ld be helpf#l D#st to spend some time !ettin! yo#r feelin!s o#t in the
open. 0se an 7$: messa!e to do that. 'tate T)hen @@@@@@@@@@@@@@@@@@@( $ feel
@@@@@@@@@@@@@@@@@@@@@@@
be"a#se@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@
:
9. 5lient selects most useful copin strateies and practices each under counselorOs direction.
7)e9ve !one over a lot of possible methods to help yo# "ontrol yo#r an!er so it doesn9t res#lt in
ab#sive behavior. $9m s#re that yo# have some preferen"es. )hy don9t yo# pi"k the methods that yo#
think %ill %ork best for yo#* )e9ll pra"ti"e %ith these so yo# "an !et a feel for them.:
Ac<-isition and Practice of Co1niti5e Co(in1 S2ills
(. 5ounselor describes four phases of usin conitive copin skills to deal with a stressful
situation.
7As yo# may remember from o#r earlier dis"#ssion( %e talked abo#t learnin! to #se "opin!
pro"ed#res at important points d#rin! a stressf#l or provokin! sit#ation. Eo% %e %ill %ork on
helpin! yo# learn to #se "opin! tho#!hts d#rin! these fo#r important times?preparin! for the sit#a+
tion( handlin! the sit#ation( dealin! %ith "riti"al moments d#rin! the sit#ation( and en"o#ra!in!
yo#rself after the sit#ation.:
11'
Ac<-isition and Practice of Co1niti5e Co(in1 S2ills
'@. ,or each phase, counselor models examples of copin statements.
7$9d like to !ive yo# some ideas of some possible "opin! tho#!hts yo# "o#ld #se d#rin! ea"h of these
fo#r important times. 5or instan"e( %hen $9m tryin! to psy"h myself #p for a stressf#l sit#ation( here
are some thin!s $ think abo#t.:
''. ,or each phase, client selects most natural copin statements.
7The examples $ !ave may not feel nat#ral for yo#. $9d like yo# to pi"k or add ones that yo# "o#ld #se
"omfortably( that %o#ldn9t seem forei!n to yo#.:
'6. 5ounselor instructs client to practice usin these copin statements for each phase.
7'ometimes( be"a#se yo# aren9t #sed to "on"entratin! on "opin! tho#!hts at these important times( it
feels a little a%k%ard at first. 'o $9d like yo# to !et a feel for these D#st by pra"ti"in! alo#d the ones
yo# sele"ted. 8et9s %ork first on the ones for preparin! for a provokin! sit#ation.:
'.. 5ounselor models and instructs client to practice se+uence of all four phases and verbali*e
accompanyin copin statements.
7IG( next $9d like yo# to pra"ti"e verbalizin! the "opin! tho#!hts alo#d in the seq#en"e that yo#9ll be
#sin! %hen yo#9re in provokin! sit#ations. 5or example( Jcounselor modelsK. Eo% yo# try it.:
A((lication of All Co(in1 S2ills to Pro)lem&Related Sit-ations
'$. Bsin copin strateies and skills selected by client, counselor models how to apply these in a
copin manner while imainin a stressful %problem1related) situation.
7Eo% yo# "an pra"ti"e #sin! all these "opin! strate!ies %hen "onfronted %ith a problem sit#ation.
5or example( s#ppose $9m yo# and my boss "omes #p to me and !ives me "riti"ism based on
misinformation. =ere is ho% $ mi!ht #se my "opin! skills in that sit#ation.:
11)
'G. 5lient practices copin strateies while imainin problem1related stressful situations. %This
step is repeated as necessary.)
7IG( this time %hy don9t yo# try it* B#st ima!ine this sit#ation?and ima!ine that ea"h time
yo# start to lose "ontrol( that is a si!nal to #se some of yo#r "opin! skills.:
'-. 5lient practices copin strateies in role play of problem1related situation. %This step is
repeated as necessary.)
7)e "o#ld pra"ti"e this in role play. $ "o#ld take the part of yo#r boss and initiate a meetin! %ith yo#.
B#st be yo#rself and #se yo#r "opin! skills to prepare for the meetin!. Then( d#rin! o#r meetin!(
pra"ti"e yo#r skills %henever yo# !et tense or start to blo% #p.:
A((lication of All Co(in1 S2ills to Potential Pro)lems
'C. 5ounselor models application of client1selected copin strateies to non1problem1related or
other potentially stressful situations.
78et9s %ork on some sit#ations no% that aren9t problems for yo# b#t "o#ld arise in the f#t#re. This
%ill !ive yo# a "han"e to see ho% yo# "an apply these "opin! skills to other sit#ations yo# en"o#nter
in the f#t#re. 5or instan"e( s#ppose (D#st fo#nd o#t $ didn9t !et a promotion that $ believe $ really
deserved. =ere is ho% $ mi!ht "ope %ith this.:
'9. 5lient practices, as often as needed, applyin copin strateies to potentially stressful
situations by/
a. Imainin a potentially stressful situation
7IG( yo# try this no%. )hy don9t yo# ima!ine yo#9ve D#st fo#nd o#t yo#9re bein!
transferred to a ne% pla"e* Co# are s#rprised by this. $ma!ine ho% yo# %o#ld "ope.:
b. Takin part in a role1play practice
7This time let9s role+play a sit#ation. $9ll be yo#r h#sband and tell yo# $9ve D#st fo#nd
o#t $ am very ill. Co# pra"ti"e yo#r "opin! skills as %e talk.:
11*
c. Takin part of a teacher in a role play and teachin a novice how to use copin
strateies for stressful situations
7This time $9m !oin! to pretend that $ have "hroni" arthritis and am in "onstant pain.
$t9s really !ettin! to me. $9d like yo# to be my trainer or helper and tea"h me ho% $
"o#ld learn to #se some "opin! skills to deal %ith this "hroni" dis"omfort.:
'(. 5ounselor and client discuss application of copin strateies to in viva situations.
7$ believe no% yo# "o#ld apply these "opin! skills to problem sit#ations yo# en"o#nter d#rin! a
typi"al day or %eek. Co# may not find that these %ork as q#i"kly as yo#9d like( b#t yo# sho#ld find
yo#rself "opin! more and not losin! "ontrol as m#"h.:
5ounselor instructs client how to use lo to record uses of stress inoculation for in viva situations.
7.a"h time yo# #se the "opin! skills( mark it do%n on the lo! and briefly des"ribe the sit#ation in
%hi"h yo# #sed them.:
5ounselor arranes for a follow1up.
7)e "o#ld !et to!ether next %eek and !o over yo#r lo!s and see ho% yo#9re doin!.:
11+
+0( Day by Day
7ere is the heart of the treatment. Sour recovery from social phobia will depend crucially on ho%
often and ho% "onsistently you are willin to enter and remain in the presence of other people lon
enouh for your fears to subside spontaneo#sly. This will mean radually ivin up your self1
protective T but also self1defeatin T tendency to under1participate in normal social encounters.
Sou will not be asked to plune into situations that are beyond your copin ability. It will be more like
learnin to swim startin at the shallow end of the pool. =e will, workin toether, draw up a list of
situations that offer opportunities to interact with other people, in particular the ones that arise most
often in your life or that you can most readily arrane on your own initiative. Examples/
4eturnin a reetin from a neihbor or co1worker.
!ayin hello to a neihbor or co1worker without waitin to be reeted first.
Askin a retail clerk where to find somethin in the store.
Askin directions of a straner.
Acceptin an invitation to lunch with a small roup where other people will do most of the
talkin.
Acceptin a compliment with a word of thanks.
Divin someone a small compliment.
4espondin to a simple +uestion with a brief answer if you have one.
4espondin to a +uestion you honestly canOt answer with a simple admission that youOre sorry
but you donOt know.
If these behaviors and others like them seem too easy or trivial to make a dent in your social anxiety,
ask yourself if you already perform them consistently and comfortably. If in fact you do, then weOre
ready to make lists of more challenin situations. If not, try to perform them at every possible
opportunity until you are fairly comfortable doin them on a reular basis. 4emember that 4ome
wasnOt built in a day T and neither will be your social self1confidence. The most important thin is
ettin the practice T the more fre+uently and consistently the better.
111
(Taken from http://%%%."o!nitivetherapy."om/so"-hob-rint.html
+1( S%rvey of Stress Sy&#to&s
5heck each symptom that you have experienced in the last month, and then count the number of items
that you have checked. The symptoms must be experienced to the level that you identify it as a
problem.
PS%C$O!O#ICA! S%PTOS
UUUUUanxiety UUUUUloneliness
UUUUUintrusive thouhts UUUUUdepression
UUUUUdifficulty concentratin UUUUUrelationship problems
UUUUUforetful UUUUUfamily problems
UUUUUaitation UUUUUwork problems
UUUUUfeelin overwhelmed UUUUUirritability
UUUUUirrational thouhtsEfears UUUUUexcessive worryinEobsessin
UUUUUcompulsive behavior UUUUUfeelins of uilt
UUUUUconfusion UUUUUtearful
UUUUUfeelins of unreality UUUUUnihtmares
UUUUUfeelins of detachment UUUUUsocial isolationEwithdrawal
UUUUUrestlessEon ede UUUUUapathyEindifference
11-
UUUUUmood swins UUUUUsexual dysfunction
P$%SICA! S%PTOS
UUUUUheadaches UUUUUfatiue
UUUUUmuscle tension UUUUUhih blood pressure
UUUUUlow back pain UUUUUsleep disturbance
UUUUUupper back, neck pain UUUUUappetite disturbance
UUUUUclenchin teeth UUUUUdiarrhea
UUUUUabdominal distress UUUUUdiestive problems
UUUUUnausea UUUUUconstipation
UUUUUshakinEtremblin UUUUUrashEhivesEshinles
UUUUUnumbnessEtinlin UUUUUthyroid dysfunction
UUUUUfeelins of chokin UUUUUbowel problems
UUUUUchills or hot flashes UUUUUuse of alcoholEciarettesEdrus
UUUUUsweatin to deal with stress
UUUUUsleep disturbance UUUUUother stress1related health
problems
ESTIATE %OUR STRESS !E"E!
N-m)er of items chec2ed Estimated !e5el of Stress
11.
@1C How %=ithin normal rane)
91'$ "oderate %Experiencin some stress)
'G16' 7ih %Experiencin difficulty copin)
66^ Aery 7ih %Bnable to cope)
'haron 8. Bohnson
+'( 2ental I&agery
The purpose of mental imaery is to calm your body, thouhts, and emotions, usin all your senses to
create a relaxin place. Sou may use a special place from your memory, or any place that will help
create a relaxed, calm environment, includin the scenario provided below.
&repare your environment so that you can complete the exercise without interruption. Det
comfortable, and scan your body for tension. If you find tension, release it. Het it o and relax.
Felax yo#r head and fa"e.
Felax yo#r sho#lders.
Felax yo#r arms and hands.
Felax yo#r "hest and l#n!s.
Felax yo#r ba"k.
Felax yo#r stoma"h.
Felax yo#r hips( le!s( and feet.
.xperien"e a pea"ef#l( pleasant( and "omfortable feelin! of bein! relaxed as yo# prepare to take an
ima!inary trip to a bea#tif#l pla"e. Take a deep breath and breathe o#t slo%ly and easily. Take
another deep breath( and slo%ly breathe o#t. Allo% yo#r breathin! to be"ome smooth and rhythmi".
-i"t#re yo#rself on a mo#ntaintop. $t has D#st rained and a %arm %ind is "arryin! the "lo#ds a%ay.
The sky is "lear and bl#e( and the s#n is shinin! do%n. &elo% yo# are bea#tif#l !reen trees. Co#
enDoy the fra!ran"e of the forest after the rain. $n the distan"e yo# "an see a bea#tif#l %hite( sandy
bea"h. &eyond that( as far as yo# "an see( is "rystal "lear( brilliant bl#e %ater. A fl#ffy "lo#d drifts in
11/
the !entle breeze #ntil it is ri!ht over yo#. 'lo%ly( this little "lo#d be!ins to sink do%n on yo#. Co#
experien"e a very pleasant( deli!htf#l feelin!. As the fl#ffy "lo#d moved do%n a"ross yo#r fa"e( yo#
feel the "ool( moist to#"h of it on yo#r fa"e. As it moves do%n yo#r body( all of the tension slips a%ay(
and yo# find yo#rself "ompletely relaxed and happy.
As the soft "lo#d moves a"ross yo#r body( it !ently brin!s a feelin! of total "omfort and pea"e. As it
sinks do%n aro#nd yo# it brin!s a feelin! of deep relaxation. The little "lo#d sinks #nderneath yo#(
and yo# are no% floatin! on it. The "lo#d holds yo# #p perfe"tly and safely. Co# feel se"#re. The
little "lo#d be!ins to move slo%ly do%n%ard and from yo#r se"#re position on it( yo# "an see the
bea#tif#l forest leadin! do%n to the bea"h. There is a !entle ro"kin! motion as yo# drift alon!. Co#
feel no "ares or "on"erns in the %orld( b#t are fo"#sed "ompletely on the relaxed feelin! yo#
experien"e. The "lo#d "an take yo# any pla"e yo# %ant to !o and yo# "hoose to !o to the bea"h. As
yo# move to the bea"h( the "lo#d !ently "omes to the !ro#nd and stops. Co# !et off the soft "lo#d on o
the bea"h( and yo# are at pea"e. Co# take some time to look aro#nd at the %hite sandy bea"h( and
the bea#tif#l bl#e %ater. Co# "an hear sea !#lls and the roar of the %aves. As yo# feel the s#n
shinin! on yo#( yo# "an smell the o"ean air. $t smells !ood. As yo# %alk slo%ly on the bea"h( yo#
enDoy the feelin! of the %arm "lean sand on yo#r feet. B#st ahead on the ea"h is a soft blanket and
pillo%. Co# lie do%n and enDoy the feelin! of the soft material on the ba"k of yo#r le!s and arms. As
yo# listen to the %aves and the sea !#lls( and feel the %armth of the s#n tho#!h the "ool breeze( yo#
realize that yo# are "omfortable( relaxed( and at pea"e. Co# feel espe"ially happy be"a#se yo#
realize that yo# "an ret#rn to this spe"ial and bea#tif#l pla"e any time yo# %ant to. 5eelin! very
relaxed( yo# "hoose to !o ba"k to the pla"e %here yo# started( kno%in! that yo# %ill take these
pea"ef#l and relaxed feelin!s %ith yo#. There is a stair%ay "lose by that leads ba"k to the room
%here yo# started. A' yo# "limb the five steps( yo# %ill be"ome more a%are of yo#r s#rro#ndin!s(
b#t yo# %ill feel relaxed and refreshed. Co# are at the bottom of the stairs no%( and be!in "limbin!.
!tep <ne to !tep Two/ movin! #p%ard
!tep Two to !tep Three/ feelin! relaxed and more a%are
!tep Three to !tep ,our/ yo# are a%are of %hat is aro#nd yo# and yo#r body is relaxed
!tep ,our to !tep ,ive/ yo#r mind is alert and refreshed( open yo#r eyes and stret"h !ently
'haron 8. Bohnson)
1-0
+)( %ided Relaxation
In this exercise, participants relax by takin an imainary 3ourney alon a beach, listenin to the
birds and waves and watchin a brilliant sunset. It is helpful to have a 5D of soft ocean sounds
playin in the backround.
Scri(t
,ake yo#rself as "omfortable as possible. >lose yo#r eyes and be"ome a%are of %hi"h parts of
yo#r body are feelin! tense and %hi"h parts are relaxed.
Eo% take a fe% deep breaths( takin! the air in thro#!h yo#r nose( holdin! it momentarily . . .
and then slo%ly exhalin! thro#!h yo#r nose . . . And %ith ea"h exhale( yo# %ill find yo#rself
relaxin! more and more deeply( more and more "ompletely.
Take the air in and let the air o#t. Allo%in! yo#rself to relax . . . relax . . . relax.
$n a fe% moments( $ am !oin! to des"ribe a very vivid s"ene in %hi"h yo# %ill pi"t#re yo#rself
%alkin! alon! a bea"h. $ %ant yo# to ima!ine this s"ene as tho#!h yo# are there experien"in!
not only the si!hts( b#t the so#nds( smells( tastes( and to#"hes.
1-1
$t is a bri!ht s#mmer day. $t is late in the day. Co# de"ide to !o for a %alk alon! the bea"h. The
s#n is radiatin! %armth and "omfort as it shines boldly. The sky is "rystal "lear %itho#t a "lo#d
in si!ht. The !rains of sand beneath yo#r feet shine from the s#nli!ht and %arm the soles of yo#r
feet. The so#nd of the %aves beatin! a!ainst the shore e"hoes in the air.
Co# feel the %arm( li!ht breeze br#sh a!ainst yo#r fa"e as yo# %alk on%ard. 5ar off in the
distan"e( yo# "an hear the "ries of sea !#lls . . . Co# %at"h them !lide thro#!h the sky( s%oop
do%n into the sea( and then fly off on"e a!ain.
As yo# %alk f#rther alon! the shore( yo# de"ide to rest. Co# sit do%n on a mo#nd of p#re %hite
sand and !aze o#t at the sea( starin! intently at the rhythmi"( methodi"al motion of the %aves
rollin! into shore.
.a"h %ave breaks a!ainst the "oast . . . rises slo%ly #p%ard alon! the bea"h( leavin! an a#ra of
%hite foam( and then slo%ly retreats ba"k o#t to sea( only to be repla"ed by another %ave that
"rashes a!ainst the shore . . . %orks its %ay #p the bea"h . . . then slo%ly retreats ba"k o#t to
sea.
)ith ea"h motion of the %ave as it !lides in and as it !lides o#t( yo# find yo#rself feelin! more
and more relaxed( more and more "alm . . . more and more serene.
The %aves are !lidin! in . . . and the %aves are !lidin! o#t . . . Co# feel more and more "alm . . .
>ontin#e to %at"h the %aves !lide in . . . and o#t.
Eo%( as yo# stare off into the distan"e( yo# see that the s#n is be!innin! to sink into the horizon.
The s#n is sinkin! do%n and yo# feel more and more relaxed as yo# see its movement !oin!
do%n . . . do%n . . . do%n.
The sky is t#rnin! brilliant "olors of red . . . oran!e . . . yello% . . . !reen . . . bl#e . . . and
p#rple . . . As the s#n sets( sinkin! do%n . . . do%n . . . do%n . . . into the horizon( yo# feel very
relaxed and soothed. Co# %at"h the s#n as it sinks do%n . . . do%n . . . do%n.
The beatin! of the %aves( the smell and taste of the sea( the salt( the "ries of the !#lls( the
%armth a!ainst yo#r body+all these si!hts( so#nds( and smells leave yo# feelin! very soothed(
very "alm( very serene.
Felax . . . relax . . . relax.
-a#se
$n a fe% moments( $ %ill "o#nt from one to three. )hen $ rea"h the "o#nt of three( yo#r eyes %ill
open and yo# %ill feel "ompletely refreshed and totally relaxed.
1 . . . / . . . 1.
1-'
4epeat the above instruction until everyone is alert.
+*( <o= to 2editate
Sim(le Directions
') !it down.
6) ;e +uiet.
.) &ay attention to your breathin. ,eel your belly risin and fallin with each breath.
1-)
Extended Play
') ,ind a comfortable sittin position where your back is straiht. Het your body be
balanced and at ease. &lace your hands comfortably on your lap or knees. 5lose your
eyes. If you arenOt comfortable closin your eyes, you can chose a place nearby and
focus your vision in a relaxed way.
6) ;rin your attention to your breathin. At first you can focus on your belly risin and
fallin. :otice the chanin sensations in your body as you breathe in and out. ?ust feel
your breath. DonOt try to control it. ;reathe naturally. !ometimes your breathin may
be deep, sometimes it may be shallow. Sour M3obN is to simply be aware of your
breathin and the chanin sensations in your body as the air oes in and out.
.) Sour mind will naturally wander away from your breathin aain and aain. =hen you
reali*e that your mind has drifted, 3ust notice it with a Mno bi deal attitudeN and return
your attention to your breathin aain.
$) After focusin on the belly for a while, you can expand your awareness beyond the belly.
As you breathe in and out, become aware of the chanin sensations throuhout your
body. Aain, remember, itOs normal for your mind to sneak off into other thouhts. ?ust
ently brin it back.
G) Do this everyday. !hoot for at least fifteen to twenty minutes everyday. If possible,
choose a reular time. It makes it easier to remember to do it.
1-*
(Taken from >asarDian( &.( L >asarDian( F. (/HH1. -o%er 'o#r"e: Takin! >har!e of Co#r
8ife.
&oston( ,A: ,"Ea#!hton L A#nn.
++( Classic Yoga $ost%res
Classic %o1a Post-res
Sit/Easy Position B S-2hasana
A startin position that helps focus awareness on breathin and the bodyL
helps strenthen lower back and open the roin and hips.

1-+

!it cross1leed with hands on knees. ,ocus on your breath. >eep your spine
straiht and push the sit bones down into the floor. Allow the knees to ently
lower. If the knees rise above your hips, sit on a cushion or block. This will
help support your back and hips. Take G1'@ slow, deep breaths. <n the next
inhale, raise your arms over your head. Exhale and brin your arms down
slowly. 4epeat G1C times.

Do1 and Cat
Increases flexibility of spine
This is really two poses, one flowin into the other. ;ein on your hands and
knees. >eep your hands 3ust in front of your shoulders, your les about hip
width apart. As you inhale, tilt the tailbone and pelvis up, and let the spine
curve downward, droppin the stomach low, and lift your head up. !tretch
ently. As you exhale, move into cat by reversin the spinal bend, tiltin the
pelvis down, drawin the spine up and pullin the chest and stomach in.
4epeat several times, flowin smoothly from do into cat, and cat back into
do.

o-ntain B Tadasana
Improves posture, balance and self1awareness.
A deceptive pose in that it appears so simple that some students may ask 1
Wwhy botherPW ;ut 3ust as there8s more to breathin than meets the eye, there
is more to standin, too.
!tand with feet toether, hands at your sides, eyes lookin forward. 4aise
your toes, fan them open, then place them back down on the floor. ,eel your
heel, outside of your foot, toes and ball of your foot all in contact with the
floor. Tilt your pubic bone slihtly forward. 4aise your chest up and out, but
within reason 1 this isn8t the army and you8re not standin at attention. 4aise
your head up and lenthen the neck by liftin the base of your skull toward
the ceilin. !tretch the pinky on each hand downward, and then balance that
movement by stretchin your index finers. &ush into the floor with your
1-1
feet and raise your les, first the calves and then the thihs.
;reathe. 7old the posture, but try not to tense up. ;reathe. As you inhale,
imaine the breath comin up throuh the floor, risin throuh your les and
torso and up into your head. 4everse the process on the exhale and watch
your breath as it passes down from your head, throuh your chest and
stomach, les and feet.
7old for G to '@ breaths, relax and repeat.
<n your next inhale, raise your arms over head %Brdhava 7astasana) and
hold for several breaths. Hower your arms on an exhale.
As a warm up, try synchroni*in the raisin and lowerin of your arms with
your breath 1 raise, inhaleL lower, exhale. 4epeat G times.

'orward Bend or Extension & Uttanasana II
!tretches the les and spine, rests the heart and neck, relaxes mind and body.
;ein standin straiht in "ountain pose or Tadasana. Inhale and raise the
arms overhead. Exhale, bend at the hips, brin the arms forward and down
until you touch the floor. It8s okay to bend your knees, especially if you8re
feelin stiff. Either rasp your ankles or 3ust leave your hands on the floor
and breathe several times. 4epeat .1G times. <n your last bend, hold the
position for G or '@ breaths. To come out of the pose, curl upward as if
pullin yourself up one vertebra at a time, stackin one on top of another,
and leavin the head hanin down until last.
Variations
'. ,ollow the instructions for the basic pose described above, but instead of
holdin the pose for several breaths, come up on the inhale. Extend your
arms forward as your rise until you are standin straiht and your arms are
overhead. Exhale and bend forward. 4epeat the process G times.
6. Do into the pose and take . deep breaths. Inhale and raise your head, but
keep your hands on the floor. 7ook each index finer around each bi toe,
exhale and come down. 7old for several breaths
.. Inhale and raise your head, aain keepin your hands on the floor. This
time, slide your hands under your feet so that the tips of your toes are
touchin heel of your hands. 7old for several breaths.
$. After bendin forward, fold your arms and han for as lon as is
comfortable. A very relaxin pose.
G. To come out of the pose, curl upward as if pullin yourself up one
vertebra at a time, stackin one on top of another, and leavin the head
hanin downuntil last.

Tri2onasana & the Trian1le
1--
!tretches the spine, opens the torso, and improves balance and
concentration.

!tart with your spread .1$ feet apart, feet parallel. Turn your left foot (@
derees to the left and your riht foot about $G derees inward. Inhale and
raise both arms so they8re parallel with the floor. Exhale, turn your head to
the left and look down your left arm toward your outstretched finers. 5heck
that your left knee is alined with your left ankle. Take a deep breath and
stretch outward to the left, tiltin the left hip down and the riht hip up.
=hen you8ve stretched as far as you can, pivot your arms, lettin your left
hand reach down and come to rest aainst the inside of your calf, while your
riht arms points straiht up. Turn and look up at your riht hand. ;reathe
deeply for several breaths. Inhale, and straihten up. Exhale, lower your
arms. &ut your hands on your hips and pivot on your heels, brinin your
feet to face front. 4epeat the posture on the other side.

+arrior I I & "ira)hadrasana II
!trenthens les and armsL improves balance and concentrationL builds
confidence.
;ein in mountain pose with feet toether and hands at side. !tep your feet
$1G feet apart. Turn your riht foot about $G derees to the left. Turn your
left foot (@ derees to the left so that it is pointin straiht out to the side.
!lowly bend the left knee until the thih is parallel with the floor, but keep
the knee either behind or directly over your ankle. 4aise your arms over
head. Then slowly lower them until your left arm is pointin straiht ahead
and your riht arm is pointin back. 5oncentrate on a spot in front of you
and breathe. Take $ or G deep breaths, lower your arms, and brin your les
toether. 4everse the position.

The Co)ra B Bh-Aan1asana
!tretches the spine, strenthens the back and arms, opens the chest and
heart.
Hie down on your stomach. >eep your les toether, arms at your side, close
to your body, with your hands by your chest.
!tep '/ Inhalin, slowly raise your head and chest as hih as it will o. >eep
your buttocks muscles tiht to protect your lower back. >eep your head up
and chest and heart out. ;reathe several times and then come down. 4epeat
as necessary.
!tep 6/ ,ollow the steps above. =hen you8ve one as hih as you can, ently
raise yourself on your arms, stretchin the spine even more. <nly o as far
1-.
as you are comfortable. Sour pelvis should always remain on the floor.
;reathe several times and come down.

Downward 'acin1 Do1 & Adho -2ha S5anasana
;uilds strenth, flexibility and awarenessL stretches the spine and
hamstrinsL rests the heart.
!tart on your hands and knees. >eep your les about hip width apart and
your arms shoulder width apart. Sour middle finers should be parallel,
pointin straiht ahead. 4oll your elbows so that the eye or inner elbow is
facin forward. Inhale and curl your toes under, as if ettin ready to stand
on your toes. Exhale and straihten your lesL push upward with your arms.
The oal is to lenthen the spine while keepin your les straiht and your
feet flat on the round. 7owever, in the beinnin its okay to bend the knees
a bit and to keep your heels raised. The important thin is to work on
lenthenin the spine. Don8t let your shoulders creep up by your ears 11 keep
them down. =eiht should be evenly distributed between your hands and
feet. 7old the position for a few breaths. 5ome down on and exhale. 4epeat
several times, synchroni*in with your breath/ up on the exhale and down on
the inhale.

1-/

$ead to Enee && 3an- Shirshasana
!tretches and opens back and hamstrins, improves flexibility.

!it on the floor with les extended in front of you. ;end one le, brinin
the heel of the foot as close to the roin as possible. Sou may want to place
a pillow under the bent knee for comfort. "ake sure your sit* bones are
firmly rounded on the floor and that your spine is straiht. Turn your body
slihtly so you face out over the extended le. Inhale and raise your arms
over head. Exhale and bein to move forward slowly. Try to keep the back
as straiht as possible. Instead of bendin at the hips, focus on liftin the
tailbone and rollin forward on your sit* bones. Inhale and lenthen and
straihten the spine. Exhale and roll forward, however slihtly. To et a bit
more forward movement, enae your +uadriceps %thih muscles) as you
move forward. This releases the hamstrins, ivin you a bit more
flexibility. =hen you8ve moved as far forward as you can, lower the arms
and rasp your foot, or le. 7old the position for a moment and breathe.
Then on the next exhale ently pull yourself forward. Do slowly and
remember to keep the back straiht. =hen done, straihten up and do the
other side.

$alf Sho-lderstand && Ardha Sar5an1asana
&romotes proper thyroid function, strenthens abdomen, stretches upper
back, improves blood circulation, induces relaxation.
Sou probably remember doin this as a kid. Hie on your back and lift your
les up into air. &lace your hands on your lower back for support, restin
your elbows and lower arms on the round. "ake sure your weiht is on
your shoulders and mid to upper back 11 not your neck. ;reathe deeply and
hold for at the posture for at least G1'@ breaths, increasin the hold over
time. To come down, slowly lower your les, keepin them very straiht 11 a
little workout for your abdominal muscles.

1.0

The Brid1e & Seth- Bandhasa
Increases flexibility and supplenessL strenthens the lower back and
abdominal musclesL opens the chest.
Hie on your back with your knees up and hands at your side Sour feet
should be near your buttocks about six inches apart. To bein, ently raise
and lower your tail. Then, slowly, raise the tailbone and continue liftin the
spine, tryin to move one vertebra at a time until your entire back is arched
upward. &ush firmly with your feet. >eep your knees straiht and close
toether. ;reathe deeply into your chest. 5lasp your hands under your back
and push aainst the floor.
Take five slow, deep breaths.
5ome down slowly and repeat.

The Cor(se B Sa5asana
4elaxes and refreshes the body and mind, relieves stress and anxiety, +uiets
the mind.
&ossibly the most important posture, the 5orpse, also known as the !pone,
is as deceptively simple as Tadasana, the "ountain pose. Bsually performed
at the end of a session, the oal is conscious relaxation. "any people find
the WconsciousW part the most difficult because it is very easy to drift off to
sleep while doin !avasana. ;ein by lyin on your back, feet slihtly apart,
arms at your sides with palms facin up. 5lose your eyes and take several
slow, deep breaths. Allow your body to sink into the round. Try focusin
on a specific part of the body and willin it to relax. ,or example, start with
your feet, imaine the muscles and skin relaxin, lettin o and slowly
meltin into the floor. ,rom your feet, move on to your calves, thihs and so
on up to your face and head. Then simply breathe and relax. !tay in the pose
for at least G1'@ minutes.
1.1
(Taken from %%%.yo!asite."om/post#res.html.
+1( ;irst Ste#
P-r(ose
It is now the time to take action. =ith your vision and oals identified, you are ready to define
some action steps.
Proced-re
'. Bsin the M,irst !tep =orksheet,N consider the first milestone to be achieved between
where you are now and your vision.
1.'
6. Bsin this oal as a focal point, set a date by when it is to be accomplished.
.. =orkin chronoloically backward from this oal, write down all the individual action
steps that need to be taken durin this period of time.
$. :ow determine what one thin you can complete in the next 6$ hours toward achievin
your oal. Interate this into whatever system you use to orani*e your schedule %such as
calendar or daily planner).
G. 7ow will you measure your successP 7ow will you know when you have completed the
taskP
-. "ake a commitment to complete these steps Mno matter whatN.
C. 5onratulate yourselfX Sou are now on the road to achievin your vision %and maybe
even winnin the :obel &ri*e).
'irst Ste(
+or2sheet
'. ,irst ma3or milestone.
UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
UUU
6. Date by when this oal is to be achieved UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU.
.. Action !tep 5ompletion Date
UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU UUUUUUUUUUUUU
1.)
UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU UUUUUUUUUUUUU
$. Immediate next step %within 6$ hours)
UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU
G. "easurement of !uccess
+-( $"ysical Exercise
&hysical exercise is extremely important for people who live with hih levels of anxiety as it can
directly release the build up of tension in the muscles from turnin on the anxiety response. Do you
exerciseP Think about how you feel when you do, and how you feel when you don8t. It is important
to try and make exercise a reular part of your life. Exercise, when used in con3unction with other
therapies, will more than likely brin you wonderful benefits in helpin to manae, reduce and
eliminate unwanted anxiety from your life.
!ome ood reasons for exercisin include/
&eople often report that they feel ood after exercisin, HE!! stressed, anxious or depressed.
Exercise triers feelins of calmness or happiness from a few minutes to hours afterwards.
1.*
4eular exercise boosts physical fitness and helps control weiht, which in turn affects self
esteem positively.
It helps reulate sleep cycles 1 leavin you feelin more rested and more eneretic.
Increases enery levels and therefore you are better prepared to tackle the day.
&eople who exercise usually make healthier nutrition choices.
7elps increase concentration and mental alertness.
Exercise is nurturin to body and mind.
It can ive you a sense of accomplishment.
It can aid in takin your mind off your worries.
7elps release pent1up stress, tension and frustration.
&romotes a sense of well bein.
Decreases muscle tension 1 helps increase relaxation I decrease feelins of bein uptiht.
Decreases excess adrenaline in the bloodstream.
As you can see, there are many benefits of exercisin. To maximi*e its effect for mood
enhancement and decreasin stress, the exercise proram should strive to achieve the
followin ob3ectives.
The activity should be performed most days of the week %$1G x a week is ideal).
Aariety should be incorporated.
The more fun the activity, the more likely it will facilitate a lifestyle chane.
Aerobic activity has been reported to be more beneficial.
!tart slowly and build up if you havenOt exercised for a while, or ask a friend or relative to help
motivate you. <verall, it shows that physical activity is ood for the mind, body and spirit. If youOre
not exercisin on a reular basis, you miht be missin out on an easy, inexpensive and safe way to
help cope with stress, anxiety and worry. =hich can also increase your mood and en3oyment of life.
1.+
The information above has been provided by ?anet !chloss, a +ualified :aturopath and :utritionist
from ;risbane, Australia.
(Taken from http://%%%.so"ialanxiety."om.a#/Treatment/-hysi"alR/H.xer"ise/treatment.htm
+.( I Can Relax@ CD ;or C"ildren
It8s easy to tell your children W?ust relax and stop worryin so muchXW, but this is rarely effective in
reducin their feelins of stress and anxiety. 4elaxation strateies such as proressive muscle
relaxation and visual imaery have been shown to be extremely effective
treatment components for child anxiety, and also can be reat eneral
stress reducers for children.
Does your child et stressed before bedtimeP
1.1
5ould your child use some help with manain anerP
Does your child et nervous before exams at schoolP
5ould your child use some help relaxinP
Almost any child can benefit from havin the skill of relaxation. :ow your child can experience a
uided relaxation trainin session, and will learn specific relaxation skills that he or she can use
anywhere. =ritten by Dr. Donna &incus, creator of The 5hild Anxiety :etwork, the U$ >an Felax6U
5D focuses on teachin children relaxation skills while also promotin positive self1imae. The 5D
features the voice of Dr. &incus alon with music and sound effects. This 5D is appropriate for
children aes $ to '6.
+/( 8earn to Really Relax
4elaxationEmeditation is not a mysterious or mystical experience available only to a select
few adepts.
It is a natural and valuable ability which we all possess, even thouh we may not have
practiced the skill for many years. It8s a natural skill that most of us have forotten how to
use. As children we could relax at will, anywhere.
=ith 3ust a little persistence, a ood tape or two, and about 'G minutes a day you can +uickly
become skilled at it once aain.
It8s time to re1learn this life1enhancin skill.
+$% 6 RE& 7 !EARN TO RE!A*;
4elaxation enables you to take a break and switch off from the stresses of life whenever you
wish.
It provides a few precious moments in which to re1chare your mental and physical batteries.
4elaxation is the bed1rock of effective stress manaement.
It enables you to stand back and switch off from problems 1 so that, often, when you return to
them you can perceive solutions that had previously escaped you.
1.-
If you have intense fears or phobias you will find your relaxation skills essential for usin
systematic desensiti*ation to dissolve your fears.
$O+ TO RE!A* & +I T$ A RE!A*ATI ON TAPE
'. Det a ood relaxation tape and spend a few weeks or even months becomin skilled at
switchin off and deeply relaxin whenever you wish.
6. It may be helpful to use a tape with a commentary at first, since this will take you
throuh a series of steps to help you become deeply relaxed.
.. 7owever once you have learned how to do this it is best to use a music1only tape and
to use your own imaination to relax deeply and to actively utili*e imaery durin the
session.
$O+ TO RE!A* & +I T$OUT A RE!A*ATI ON TAPE
The followin is a simple method of relaxin which you can develop by usin mental imaery
andEor soft relaxin music/
'. "ake yourself physically comfortable. Initially shru, stretch, and then sit comfortably
upriht with hands restin on your thihs or lap. Bse a few lon exhales to help you
settle. >eep your eyes open for now.
6. &ay attention to what you can see, hear, and feel.
.. 5lose your eyes. This ives your brain a break by reducin the amount of in1comin data
it has to process.
$. :ow pay attention to what you can see, hear and feel with your eyes closed.
G. Do five lon exhales. As you do this relax %') your feet and les, %6) Sour hands and
arms, %.) Sour torso, %$) Sour head and neck, %G) Sour entire body. &ay attention to the
relaxin effect of each of these out1breaths. %"ore on breathin methods here.)
-. :ow continue to allow yourself to switch off 1 breathin normally 1 payin attention to
how your body can relax a little more each time you exhale.
1..
TI PS 'OR %OUR RE!A*ATI ON SESSI ON
Sears of Znormal8 stressful livin undermine our natural ability to switch off and relax
anywhere, anytime. Sou are now simply re1learnin this natural ability.
4elaxation is somethin you allow to happen. Sou cannot force the issue. It is a radual
process of discoverin your personal forms of emotional and physical tension and then
discoverin which ways of releasin these work best for you.
At first most people find it much easier to relax the body rather than the mind. This is
normal. Sou can certainly learn to allow your mind to become +uieter 1 it simply takes a
little loner.
,or the first few weeks relax in a sittin position. It is easier to relax lyin down but if
you make yourself too comfortable you risk fallin asleep or becomin too drowsy and
this neates some of the benefits.
There is no riht way to relaxX !o rather than attemptin to Zet it riht8 experiment to
discover what works best for you.
The +uality of your relaxation will vary considerably durin any session. <ne moment
you may think you are losin the experience and the next you may be even more relaxed
than before. !o if you think it is not workin calmly stay at ease for another minute or so.
Then, if necessary, ive up and have another session .@1-@ minutes later.
There is no Zriht8 time to relax. Take a break any time you like 1 especially when you
notice tension or a neative mood beinnin to build up. ,or the first few weeks you may
find it more beneficial to take lots of short .1G minute breaks. "ost people find it useful
to have a relaxin session at the beinnin of the day.
Initially your tension level may rise aain soon after a session and you may wonder what is
the point in relaxin. 7ere remind yourself that had you not taken a break the tension would
now be much hiher 1 and that these breaks are conditionin your bodyEmind to react
differently to pressures.
10( Relaxation Exercise
1./
Basic Instr-ctions
4elaxation is the opposite of tension. The followin exercise can be a tool for you to use to
control tension and enhance relaxation in both your body and your mind. It will probably be
most useful to you if you or a friend would tape record the followin exercise and listen to it
rather than to 3ust try to read and remember the various parts of the exercise. 4ead the exercise
slowly with pauses to allow the relaxation to occur. If you do make a tape for yourself, please
remember to use it only when you are sittin or lyin comfortably at home or where you are not
needin to be involved in an activity re+uirin you to be fully alert. Do not use the tape while
operatin any kind of machinery, includin cars. <ne of the main activities suested in this
exercise involves alternatively tensin and relaxin muscle roups. &ut enouh tension into the
muscles to make them tense, but not enouh to cause pain. ,eelin pain means that you are
tensin too much.
Tension Red-cin1 Exercise
!ettle back and et as comfortable as you possibly can. 5lose your eyes ently. Tune in to your
breathin. %-a#se) :otice it8s pace and rhythm. %-a#se) take another breath, a little deeper this
time, lettin yourself feel completely calm, peaceful, comfortable and relaxed. %-a#se) :ow ,
with the rest of your body feelin more and more comfortable and relaxed, slowly clench your
riht fist. 5lench it tihter and tihter and study the tension. >eep it clenched and feel the
tension in your fist, hand, and forearm. %'hort -a#se) :ow let your hand relax and o limp,
allowin your finers to become loose. :otice the contrast between the feelin of tension and
now the feelin of relaxation. %'hort -a#se) Het your whole body o and relax even more
completely. %'hort -a#se) :ow bend both of your elbows and tense your biceps. Tense them
hard until they almost +uiver. 7old them tiht and study the tension. %'hort -a#se) :ow let
your arms straihten out and drop ently to your sides. o limp, feelin heavy and relaxed.
:otice the tension leave your muscles and experience relaxation that replaces the tension. Het
the feelin flow and spread into the rest of your body so that you feel peaceful and calm. ,eel
yourself becomin more and more relaxed. %-a#se) %5rom this point on%ard( pa#se %here it
seems appropriate to allo% eno#!h time for the tensin! and relaxin! to o""#r.)
,ocus all your attention on your neck, your shoulders, and your upper back. As you breathe,
imaine that you are releasin tension from your neck, shoulders, and upper back. =ith each
breath you take, feel your neck, shoulders, and upper back row heavier and more and more
relaxed. As you release tension in your arms, neck, shoulders, and upper back, feel the wave of
relaxation movin downwards throuh your torso, lower back and stomach. =ith each breath,
you become more and more relaxed.
:ow tihten and flex the muscles in your buttocks and thihs. Sou can flex your thihs by
pressin down on your heels with your toes in the air. 7old the tension. >eep the muscles tiht
and tense. now let o. 4elax and notice the difference as you let your hips and thihs relax and
allow that feelin to proceed on its own until you feel completely and deeply relaxed.
1/0
:ow press your toes straiht out away from your body as if you were on tiptoes. ,eel the
muscles in your calves become tauht and tense. 7old the tension. !tudy the tension and now
relax. ,eel the difference between the tension and the delihtful, calm, peaceful feelin of bein
deeply relaxed. ,eel the heaviness of your entire lower body as you relax further still.
If you wish, you can become even more deeply relaxed by merely takin a deep breath and
slowly exhalin. As you breath deeply, feel your entire body become heavy, comfortable and
relaxed. Think the followin thouhts to yourself/ WI feel +uiet. I am feelin deeply relaxed.
"y body feels calm and +uiet. "y neck, my 3aws, my forehead are all calm and smooth. "y
whole body is heavy, comfortable, relaxed, and +uiet. "y arms and hands are heavy and warm. I
am at peace.W %At this point( !ive yo#rself a fe% more min#tes of deep relaxation before movin!
on to%ard endin! the relaxation session.)
%.ndin! the experien"e) Take a deep breath, wile your toes and open your eyes. when you do
so you will feel refreshed and calm.
Enhancin1 the Ex(erience
Sou can practice deepenin this feelin of relaxation by takin deep breaths and releasin
tension with each exhalation and imainin a wave of relaxation movin from the top of your
head to the ends of your toes. As you become aware, throuh this exercise, of different muscle
roups and how deliberately you can control the experience of tension and relaxation in your
muscles, you increase your capacity to relax. In similar fashion, each time you practice this
relaxation exercise you will find it more familiar and easier to use.
(Taken from %%%."o#nsel.#fl.ed#/self=elp.asp.
1/1
11( Toe Tensing
;y alternately tensin and relaxin your toes, you actually draw tension from the rest of the
body.
'. Hie on your back, close your eyes.
6. !ense your toes.
.. :ow pull all '@ toes back toward your face. 5ount to '@ slowly.
$. :ow relax your toes.
G. 5ount to '@ slowly.
:ow repeat the a
bove cycle '@ times.
(Taken from %%%.sleepynyp."om.
1'( 4%iet Ears
'. Hie on your back with your eyes closed.
6. &lace your hands behind your head. "ake sure they are relaxed.
.. &lace your thumbs in your ears so that you close the ear canal.
$. Sou will hear a hih1pitched rushin sound. This is normal.
G. Histen to this sound for '@#'G minutes.
Then put your arms at your sides, actively relax them and o to sleep.
(Taken from %%%.sleepynyp."om.
1/'
References
American &sychiatric Association. %'(($). Dianostic and statistical manual of mental
disorders %$
th
ed.). =ashinton, D5/ Author ;oston, "A/ "c:auhton I Dunn.
Andrews, D., 5rino,4., 7unt,5., Hampe, H., I &ae, A. %'(($). The Treatment of
Anxiety Disorders 5ambrdie, Enland. 5ambride Bniversity &ress
5allahan, 5. %6@@$) 5onitive1behavior therapy for depression/ !chema chane methods.
5<B 9GG 5lass "aterials, Eastern >entucky Bniversity.
5anfield, ?., I !iccone, ,. %'((G). '@' =ays to Develop !tudent !elf1Esteem and
4esponsibility. :eedham 7eihts, "A/ Allyn and ;acon.
5arrell, !. %6@@@). Droup Exercises for Adolescents/ A "anual for Therapists.
Thousand <aks, 5alifornia/ !ae &ublications, Inc.
5areiver Information %6@@$). ,#s"le relaxation. 4etrieved "arch, 6., 6@@$, from
http/EEcareiver1information.comE4elaxationEmuscleUrelaxation.htm.
5asar3ian, ;., I 5asar3ian, 4. %6@@.). &ower !ource/ Takin 5hare of Sour Hife.
7ennin, 5athleen %6@@$) =o% to mana!e travel anxiety. 4etrieved <ctober 6@, 6@@$,
from http/EEpanicdisorder.about.comEcsEht.htm
?ohnson, !.H. %'((C). TherapistOs uide to clinical intervention/ The '161.Os of treatment
plannin. !an Dieo/ Academic &ress.
Heahy, 4. H. and 7olland, !.?. %6@@$). Treatment plans and interventions for depression
and anxiety disorders.
"orrison, ?ames %6@@$). >omplete D',+$K Dia!nosis. 4etrieved <ctober 6$, 6@@$,
from http/EEmysite.veri*on.netEresCo+x'Eindex.html
"yrick, 4., I ,olk, ;. %'(('). &eervention. "inneapolis, ":/ Educational "edia
5orporation.
1/)
4apee,4."., %'((9), <vercomin !hyness and !ocial &hobia8, 5hapter -, p. -'1CG, passim,
Hifestyle &ress.
Aorrath, 7., I ;rendtro, H. %'(9G). &ositive &eer 5ulture. 7awthorne, :S/ Aldine de
Druyter.
1/*
1/+

Anxiety Disorder Interventions

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