ANXIETY
Practice Elements
Developed by the Center for School Mental Health with support provided
in part from grant 1R01MH71015-01A1 from the National Institute of
Mental Health and Project # U45 MC00174 from the Office of Adolescent
Health, Maternal, and Child Health Bureau, Health Resources and Services
Administration, Department of Health and Human Services
Practice Elements
Relaxation
Cognitive/Coping
Modeling
Exposure
Treatment Manuals for Anxiety
Coping Cat (Kendall & Hedtke, 2006)
– Cognitive-Behavioral Therapy for Anxious
Children
The C.A.T. Project (Kendal, et al., 2002)
– Cognitive Behavioral Treatment of Anxious
Adolescents
What is Relaxation?
Techniques or exercises designed to
induce physiological calming, including
muscle relaxation, breathing exercises,
meditation, and similar activities.
Guided imagery exclusively for the
purpose of physical relaxation is
considered relaxation.
Relaxation: Deep Breathing
Breathe from the
stomach rather than
from the lungs
Can be used in class
without anyone
noticing
Can be used during
stressful moments
such as taking an
exam or while trying
to relax at home
Relaxation: Deep Breathing Tips
Teach students to breathe in slowly through
the nose, and out through the mouth
Children should breathe in to the count of 5,
and out to the count of 5
– “Breathe in, two, three, four, five, and out, two,
three, four, five” (at a rate of about one count per
second or two)
Adolescents should breathe in and out to the
count of 8
Have them take 3 normal breaths in between
deep breaths
Have them imagine a balloon filling with air,
then totally emptying
Relaxation: Mental
Imagery/Visualization
Can enhance other
relaxation techniques or
be used on its own
Provides relief from
troubling thoughts,
emotions, or feelings
Evokes a pleasing,
calming mental image
(e.g., the beach, park,
forest, playing with a
favorite pet)
Relaxation: Mental
Imagery/Visualization Tips
Have the student close his/her eyes and
imagine a relaxing place of their choosing
While the imagine this, describe the
place to them, including what they see,
hear, feel, and smell
Younger students may use a picture or
drawing to help them
Relaxation: Progressive Muscle
Relaxation
Alternating between
states of muscle
tension and relaxation
helps differentiate
between the two
states and helps
habituate a process of
relaxing muscles that
are tensed
Many good
tapes/c.d.’s available
on relaxation
Relaxation for Children
Coping Cat, Session 5
Purpose: Review the cues that indicate
that the child is tense and anxious.
Introduce relaxation training and its use in
controlling tension associated with anxiety.
Relaxation for Children - Steps
Discuss how many feeling associated with
anxiety involve muscle tension
Introduce relaxation and practice
techniques
Discuss how/when relaxation might be
useful
Practice with student and parents
Relaxation for Children - Tips
Gently point out muscle tightness that you
notice
Do the exercises along with the student
Try different scripts/strategies
Explain the procedure to parents
Relaxation for Adolescents
The C.A.T. Project, Session 3
Purpose: For youth to learn about somatic
responses to anxiety and identify own
responses. Introduce relaxation training
and its use in controlling tension
associated with anxiety.
Relaxation for Adolescents - Steps
Discuss somatic responses to anxiety
Discuss the association between anxiety
and muscle tension
Introduce relaxation – discuss how it
affects the body
Practice relaxation
Reinforce how/when relaxation might be
helpful
Relaxation for Adolescents - Tips
Point out muscle tightness that you notice
Assure students that it might seem
uncomfortable at first but will get easier
with practice
Do exercises along with student
Encourage student to practice, practice,
practice!
What is Cognitive/Coping?
Any techniques designed to alter
interpretations of events through
examination of the student’s
reported thoughts, typically through
the generation and rehearsal of
alternative counter-statements.
Can include exercises designed to
compare the “truth” of the original
thoughts and the alternative
thoughts through the gathering or
review of relevant information.
– “Which is more true?”
Cognitive/Coping with Children
Coping Cat, Session 6
Purpose: Discuss how thoughts impact
anxiety-provoking situations. Help child
recognize his self-talk in anxious situations
and develop coping self-talk.
Cognitive/Coping with Children Steps
Introduce concept of thoughts (self-talk)
Discuss self-talk in anxiety-provoking
situations
Differentiate anxious self-talk from coping
self-talk
Help child answer the question “What do I
expect to happen?”
Practice coping self-talk
Cognitive/Coping with Children Tips
Ask the child to draw himself in an anxious
situation
Provide examples of TV shows in which
the main character is the narrator (e.g.,
Everyone Hates Chris, Lizzie Maguire)
Check with child to see if he believes his
coping thoughts
Cognitive/Coping with Children Tips
Identify people whom the child admires as
“good at coping” and use as model
Don’t fall in the trap of trying to convince a
child that the scary event is not likely to
happen
Make a list of thinking traps that the child
typically uses
Cognitive/Coping with Adolescents
The C.A.T. Project, Session 5
Purpose: Introduce function of personal
thoughts and their impact on response in
anxiety-provoking situations. Help teen
recognize self-talk and learn to produce
coping thoughts.
Cognitive/Coping with Adolescents
Steps
Introduce concept of thoughts (self-talk)
Help teen answer the question “What do I
expect to happen?”
Discuss challenging self-talk and introduce
concept of coping thoughts
Have teen document anxious experiences
throughout the week and pay attention to
thoughts
Cognitive/Coping with Adolescents
Tips
Check with teen about whether s/he
believes what s/he is saying to him/herself
Have teen identify people whom they
admire as good “copers” and use as
model
What is Modeling?
Demonstration of a
desired behavior by
a therapist, peer, or
someone else to
promote the
imitation and
subsequent
performance of that
behavior by the
anxious student
What is Modeling?
Learning from observing and imitating role
models
Learning about rewards and punishments
that result from behavior
Can be used to strengthen OR weaken
behavior
Types of Modeling
Participant modeling – Therapist acts out
anxiety-provoking behaviors & prompts
student to engage in behavior
Covert modeling – Student uses
imagination to visualize particular behavior
Symbolic modeling – Using videotape,
picture books, plays, etc. demonstrating
target behavior
Modeling – Cuentos Therapy
Storytelling/Folktales
Taken from Puerto Rican culture; used
historical heroic characters
Used to foster imaginative behavior that
youth are likely to imitate
More effective when youth is attracted to
and identifies w/the model
Modeling - Tips
Clearly demonstrate target behavior
without unnecessary details
Start with the least difficult level of
behavior and work up to difficult behaviors
Incorporate a number of models to
perform same target behavior
Modeling – Tips
Use Role Playing
Provide feedback – good and bad
Encourage use of newly learned skills
Coach student to move them closer to
target behavior, one step at a time
Resources for Modeling
Psychosocial Treatments for Child and
Adolescent Disorders (Eds., E. D. Hibbs &
P. S. Jensen), 1996
www.minddisoders.com/Kau-Nu/Modeling
What is Exposure?
Exercises that involve
direct or imagined
experience with the
feared stimulus,
whether performed
gradually or suddenly,
and with or without
the therapist’s
elaboration or
intensification of the
stimulus
Systematic Desensitization
Anxiety reducing strategy involving a
graduated exposure of the phobic
student to the feared object or situation.
The student learns to tolerate the
feared object by means of a series of
steps beginning with the least anxiety
producing aspect of the process and
ending with the most difficult step.
Begin with construction of the Anxiety
Hierarchy
Exposure with Children
Coping Cat, Sessions 10-15
Purpose: Practice 4-step coping plan
under low and, eventually, high anxietyprovoking situations
1.
2.
3.
4.
Feeling frightened?
Expecting bad things to happen?
Attitudes and Actions that can help
Results and Rewards
Exposure with Children - Steps
Review idea of progressing from learning
to practicing new skill
Practice using imagined exposure in
anxiety-provoking situations
Practice in-vivo (live) exposure task in
anxiety-provoking situations
Review relaxation exercises
Decide on a situation where child will
practice
Exposure with Children - Tips
Be encouraging, supportive, and display
confidence
Note for the child how imagining situations
is helpful
Continue with imagined exposure until
anxiety level is reduced
Increase child’s involvement by soliciting
suggestions
Exposure with Children - Tips
Do not be drawn to “protect” the child from
his negative emotions
Be aware of “subtle avoidance” behavior
Various in-vivo experiences can be
arranged in the office
Many natural-occurring exposure tasks
can occur in public places
Exposure with Adolescents
The C.A.T. Project, Sessions 10-16
Purpose: Practice the 4-step coping plan
under low and, eventually, high anxietyprovoking conditions.
1.
2.
3.
4.
Feeling frightened?
Expecting bad things to happen?
Attitudes and Actions that can help
Results and Rewards
Exposure with Adolescents - Steps
Shift focus from learning new skills to practicing
them in real situations
Imaginal practice with anxiety-provoking
situations
In-vivo practice with anxiety-provoking situations
Decide on situation that will be practiced next
Have teen record 1 anxious experience,
including 4 steps
Exposure with Adolescents - Tips
Continue to imaginal exposure until
anxiety level is reduced
Present a situation and ask teen to rate
level of anxiety (0-8 scale)
Various in-vivo experiences can be
arranged in the office
Many natural-occurring exposure tasks
can occur in public places
Exposure with Adolescents - Tips
Refrain from comforting the teen when
they become anxious – allow them to
develop independent coping skills
Teens may enlist a friend as a support.
Encourage the selection of a trustworthy
peer
Solicit suggestions from the teen in
planning exposure tasks