ANXIETYANXIETY

Practice ElementsPractice Elements

Developed by the Center for School Mental Health with support Developed by the Center for School Mental Health with support provided in part from grant 1R01MH71015-01A1 from the provided in part from grant 1R01MH71015-01A1 from the

National Institute of Mental Health and Project # U45 MC00174 National Institute of Mental Health and Project # U45 MC00174 from the Office of Adolescent Health, Maternal, and Child Health from the Office of Adolescent Health, Maternal, and Child Health

Bureau, Health Resources and Services Administration, Bureau, Health Resources and Services Administration, Department of Health and Human ServicesDepartment of Health and Human Services

Practice ElementsPractice Elements

RelaxationRelaxation

Cognitive/CopingCognitive/Coping

ModelingModeling

ExposureExposure

Treatment Manuals for AnxietyTreatment Manuals for Anxiety

Coping CatCoping Cat (Kendall & Hedtke, 2006) (Kendall & Hedtke, 2006)– Cognitive-Behavioral Therapy for Anxious Cognitive-Behavioral Therapy for Anxious

Children Children

The C.A.T. ProjectThe C.A.T. Project (Kendal, et al., 2002) (Kendal, et al., 2002)– Cognitive Behavioral Treatment of Anxious Cognitive Behavioral Treatment of Anxious

AdolescentsAdolescents

What is What is RelaxationRelaxation??

Techniques or exercises designed to Techniques or exercises designed to induce physiological calming, including induce physiological calming, including muscle relaxation, breathing exercises, muscle relaxation, breathing exercises, meditation, and similar activities. meditation, and similar activities.

Guided imagery exclusively for the Guided imagery exclusively for the purpose of physical relaxation is purpose of physical relaxation is considered relaxation.considered relaxation.

Relaxation: Deep BreathingRelaxation: Deep Breathing

Breathe from the Breathe from the stomach rather than stomach rather than from the lungsfrom the lungs

Can be used in class Can be used in class without anyone without anyone noticingnoticing

Can be used during Can be used during stressful moments stressful moments such as taking an such as taking an exam or while trying to exam or while trying to relax at home relax at home

Relaxation: Deep Breathing TipsRelaxation: Deep Breathing Tips

Teach students to breathe in slowly through the Teach students to breathe in slowly through the nose, and out through the mouthnose, and out through the mouthChildren should breathe in to the count of 5, and Children should breathe in to the count of 5, and out to the count of 5out to the count of 5– ““Breathe in, two, three, four, five, and out, two, three, Breathe in, two, three, four, five, and out, two, three,

four, five” (at a rate of about one count per second or four, five” (at a rate of about one count per second or two)two)

Adolescents should breathe in and out to the Adolescents should breathe in and out to the count of 8count of 8Have them take 3 normal breaths in between Have them take 3 normal breaths in between deep breathsdeep breathsHave them imagine a balloon filling with air, then Have them imagine a balloon filling with air, then totally emptyingtotally emptying

Relaxation: Mental Relaxation: Mental Imagery/VisualizationImagery/Visualization

Can enhance other Can enhance other relaxation techniques or relaxation techniques or be used on its ownbe used on its own

Provides relief from Provides relief from troubling thoughts, troubling thoughts, emotions, or feelingsemotions, or feelings

Evokes a pleasing, Evokes a pleasing, calming mental image calming mental image (e.g., the beach, park, (e.g., the beach, park, forest, playing with a forest, playing with a favorite pet)favorite pet)

Relaxation: Mental Relaxation: Mental Imagery/Visualization TipsImagery/Visualization Tips

Have the student close his/her eyes and Have the student close his/her eyes and imagine a relaxing place of their choosingimagine a relaxing place of their choosing

While the imagine this, describe the While the imagine this, describe the place to them, including what they see, place to them, including what they see, hear, feel, and smellhear, feel, and smell

Younger students may use a picture or Younger students may use a picture or drawing to help themdrawing to help them

Relaxation: Progressive Muscle Relaxation: Progressive Muscle RelaxationRelaxation

Alternating between Alternating between states of muscle states of muscle tension and relaxation tension and relaxation helps differentiate helps differentiate between the two between the two states and helps states and helps habituate a process of habituate a process of relaxing muscles that relaxing muscles that are tensedare tensed

Many good Many good tapes/c.d.’s available tapes/c.d.’s available on relaxationon relaxation

Relaxation for ChildrenRelaxation for Children

Coping Cat, Session 5Coping Cat, Session 5

Purpose: Review the cues that indicate Purpose: Review the cues that indicate that the child is tense and anxious. that the child is tense and anxious. Introduce relaxation training and its use in Introduce relaxation training and its use in controlling tension associated with anxiety.controlling tension associated with anxiety.

Relaxation for Children - StepsRelaxation for Children - Steps

Discuss how many feeling associated with Discuss how many feeling associated with anxiety involve muscle tensionanxiety involve muscle tension

Introduce relaxation and practice Introduce relaxation and practice techniquestechniques

Discuss how/when relaxation might be Discuss how/when relaxation might be usefuluseful

Practice with student and parentsPractice with student and parents

Relaxation for Children - TipsRelaxation for Children - Tips

Gently point out muscle tightness that you Gently point out muscle tightness that you noticenotice

Do the exercises along with the studentDo the exercises along with the student

Try different scripts/strategiesTry different scripts/strategies

Explain the procedure to parentsExplain the procedure to parents

Relaxation for AdolescentsRelaxation for Adolescents

The C.A.T. Project, Session 3The C.A.T. Project, Session 3

Purpose: For youth to learn about somatic Purpose: For youth to learn about somatic responses to anxiety and identify own responses to anxiety and identify own responses. Introduce relaxation training responses. Introduce relaxation training and its use in controlling tension and its use in controlling tension associated with anxiety.associated with anxiety.

Relaxation for Adolescents - StepsRelaxation for Adolescents - Steps

Discuss somatic responses to anxietyDiscuss somatic responses to anxiety

Discuss the association between anxiety Discuss the association between anxiety and muscle tensionand muscle tension

Introduce relaxation – discuss how it Introduce relaxation – discuss how it affects the bodyaffects the body

Practice relaxationPractice relaxation

Reinforce how/when relaxation might be Reinforce how/when relaxation might be helpfulhelpful

Relaxation for Adolescents - TipsRelaxation for Adolescents - Tips

Point out muscle tightness that you noticePoint out muscle tightness that you notice

Assure students that it might seem Assure students that it might seem uncomfortable at first but will get easier uncomfortable at first but will get easier with practicewith practice

Do exercises along with studentDo exercises along with student

Encourage student to practice, practice, Encourage student to practice, practice, practice!practice!

What is What is Cognitive/CopingCognitive/Coping??

Any techniques designed to alter Any techniques designed to alter interpretations of events through interpretations of events through examination of the student’s examination of the student’s reported thoughts, typically through reported thoughts, typically through the generation and rehearsal of the generation and rehearsal of alternative counter-statements.alternative counter-statements.

Can include exercises designed to Can include exercises designed to compare the “truth” of the original compare the “truth” of the original thoughts and the alternative thoughts and the alternative thoughts through the gathering or thoughts through the gathering or review of relevant information. review of relevant information. – ““Which is more true?”Which is more true?”

Cognitive/Coping with ChildrenCognitive/Coping with Children

Coping Cat, Session 6Coping Cat, Session 6

Purpose: Discuss how thoughts impact Purpose: Discuss how thoughts impact anxiety-provoking situations. Help child anxiety-provoking situations. Help child recognize his self-talk in anxious situations recognize his self-talk in anxious situations and develop coping self-talk.and develop coping self-talk.

Cognitive/Coping with Children - Cognitive/Coping with Children - StepsSteps

Introduce concept of thoughts (self-talk)Introduce concept of thoughts (self-talk)

Discuss self-talk in anxiety-provoking Discuss self-talk in anxiety-provoking situationssituations

Differentiate anxious self-talk from coping Differentiate anxious self-talk from coping self-talkself-talk

Help child answer the question “What do I Help child answer the question “What do I expect to happen?”expect to happen?”

Practice coping self-talkPractice coping self-talk

Cognitive/Coping with Children - Cognitive/Coping with Children - TipsTips

Ask the child to draw himself in an anxious Ask the child to draw himself in an anxious situationsituation

Provide examples of TV shows in which Provide examples of TV shows in which the main character is the narrator (e.g., the main character is the narrator (e.g., Everyone Hates ChrisEveryone Hates Chris, , Lizzie MaguireLizzie Maguire))

Check with child to see if he believes his Check with child to see if he believes his coping thoughtscoping thoughts

Cognitive/Coping with Children - Cognitive/Coping with Children - TipsTips

Identify people whom the child admires as Identify people whom the child admires as “good at coping” and use as model“good at coping” and use as model

Don’t fall in the trap of trying to convince a Don’t fall in the trap of trying to convince a child that the scary event is not likely to child that the scary event is not likely to happenhappen

Make a list of thinking traps that the child Make a list of thinking traps that the child typically usestypically uses

Cognitive/Coping with AdolescentsCognitive/Coping with Adolescents

The C.A.T. Project, Session 5The C.A.T. Project, Session 5

Purpose: Introduce function of personal Purpose: Introduce function of personal thoughts and their impact on response in thoughts and their impact on response in anxiety-provoking situations. Help teen anxiety-provoking situations. Help teen recognize self-talk and learn to produce recognize self-talk and learn to produce coping thoughts.coping thoughts.

Cognitive/Coping with Adolescents Cognitive/Coping with Adolescents StepsSteps

Introduce concept of thoughts (self-talk)Introduce concept of thoughts (self-talk)

Help teen answer the question “What do I Help teen answer the question “What do I expect to happen?”expect to happen?”

Discuss challenging self-talk and introduce Discuss challenging self-talk and introduce concept of coping thoughtsconcept of coping thoughts

Have teen document anxious experiences Have teen document anxious experiences throughout the week and pay attention to throughout the week and pay attention to thoughtsthoughts

Cognitive/Coping with Adolescents Cognitive/Coping with Adolescents TipsTips

Check with teen about whether s/he Check with teen about whether s/he believes what s/he is saying to him/herselfbelieves what s/he is saying to him/herself

Have teen identify people whom they Have teen identify people whom they admire as good “copers” and use as admire as good “copers” and use as modelmodel

What is Modeling?What is Modeling?

Demonstration of a Demonstration of a desired behavior by desired behavior by a therapist, peer, or a therapist, peer, or someone else to someone else to promote the promote the imitation and imitation and subsequent subsequent performance of that performance of that behavior by the behavior by the anxious studentanxious student

What is Modeling?What is Modeling?

Learning from observing and imitating role Learning from observing and imitating role modelsmodels

Learning about rewards and punishments Learning about rewards and punishments that result from behaviorthat result from behavior

Can be used to strengthen OR weaken Can be used to strengthen OR weaken behaviorbehavior

Types of ModelingTypes of Modeling

Participant modeling – Therapist acts out Participant modeling – Therapist acts out anxiety-provoking behaviors & prompts anxiety-provoking behaviors & prompts student to engage in behaviorstudent to engage in behavior

Covert modeling – Student uses Covert modeling – Student uses imagination to visualize particular behaviorimagination to visualize particular behavior

Symbolic modeling – Using videotape, Symbolic modeling – Using videotape, picture books, plays, etc. demonstrating picture books, plays, etc. demonstrating target behaviortarget behavior

Modeling – Modeling – Cuentos TherapyCuentos Therapy

Storytelling/FolktalesStorytelling/Folktales

Taken from Puerto Rican culture; used Taken from Puerto Rican culture; used historical heroic charactershistorical heroic characters

Used to foster imaginative behavior that Used to foster imaginative behavior that youth are likely to imitateyouth are likely to imitate

More effective when youth is attracted to More effective when youth is attracted to and identifies w/the modeland identifies w/the model

Modeling - TipsModeling - Tips

Clearly demonstrate target behavior Clearly demonstrate target behavior without unnecessary detailswithout unnecessary details

Start with the least difficult level of Start with the least difficult level of behavior and work up to difficult behaviorsbehavior and work up to difficult behaviors

Incorporate a number of models to Incorporate a number of models to perform same target behaviorperform same target behavior

Modeling – TipsModeling – Tips

Use Role PlayingUse Role PlayingProvide feedback – good and badProvide feedback – good and bad

Encourage use of newly learned skillsEncourage use of newly learned skills

Coach student to move them closer to Coach student to move them closer to target behavior, one step at a timetarget behavior, one step at a time

Resources for ModelingResources for Modeling

Psychosocial Treatments for Child and Psychosocial Treatments for Child and Adolescent Disorders (Eds., E. D. Hibbs & Adolescent Disorders (Eds., E. D. Hibbs & P. S. Jensen), 1996P. S. Jensen), 1996

www.minddisoders.com/Kau-Nu/Modelingwww.minddisoders.com/Kau-Nu/Modeling

What is What is ExposureExposure??

Exercises that involve Exercises that involve direct or imagined direct or imagined experience with the experience with the feared stimulusfeared stimulus, , whether performed whether performed gradually or suddenly, gradually or suddenly, and with or without and with or without the therapist’s the therapist’s elaboration or elaboration or intensification of the intensification of the stimulusstimulus

Systematic DesensitizationSystematic Desensitization

Anxiety reducing strategy involving a Anxiety reducing strategy involving a graduated exposure of the phobic graduated exposure of the phobic student to the feared object or situation. student to the feared object or situation.

The student learns to tolerate the The student learns to tolerate the feared object by means of a series of feared object by means of a series of steps beginning with the least anxiety steps beginning with the least anxiety producing aspect of the process and producing aspect of the process and ending with the most difficult step.ending with the most difficult step.

Begin with construction of the Anxiety Begin with construction of the Anxiety HierarchyHierarchy

Exposure with ChildrenExposure with Children

Coping Cat, Sessions 10-15Coping Cat, Sessions 10-15

Purpose: Practice 4-step coping plan Purpose: Practice 4-step coping plan under low and, eventually, high anxiety-under low and, eventually, high anxiety-provoking situationsprovoking situations

1.1. Feeling frightened?Feeling frightened?

2.2. Expecting bad things to happen?Expecting bad things to happen?

3.3. Attitudes and Actions that can helpAttitudes and Actions that can help

4.4. Results and RewardsResults and Rewards

Exposure with Children - StepsExposure with Children - Steps

Review idea of progressing from learning Review idea of progressing from learning to practicing new skillto practicing new skillPractice using imagined exposure in Practice using imagined exposure in anxiety-provoking situations anxiety-provoking situations Practice in-vivo (live) exposure task in Practice in-vivo (live) exposure task in anxiety-provoking situationsanxiety-provoking situationsReview relaxation exercisesReview relaxation exercisesDecide on a situation where child will Decide on a situation where child will practicepractice

Exposure with Children - TipsExposure with Children - Tips

Be encouraging, supportive, and display Be encouraging, supportive, and display confidenceconfidence

Note for the child how imagining situations Note for the child how imagining situations is helpfulis helpful

Continue with imagined exposure until Continue with imagined exposure until anxiety level is reducedanxiety level is reduced

Increase child’s involvement by soliciting Increase child’s involvement by soliciting suggestionssuggestions

Exposure with Children - TipsExposure with Children - Tips

Do not be drawn to “protect” the child from Do not be drawn to “protect” the child from his negative emotionshis negative emotions

Be aware of “subtle avoidance” behaviorBe aware of “subtle avoidance” behavior

Various in-vivo experiences can be Various in-vivo experiences can be arranged in the officearranged in the office

Many natural-occurring exposure tasks Many natural-occurring exposure tasks can occur in public placescan occur in public places

Exposure with AdolescentsExposure with Adolescents

The C.A.T. Project, Sessions 10-16The C.A.T. Project, Sessions 10-16

Purpose: Practice the 4-step coping plan Purpose: Practice the 4-step coping plan under low and, eventually, high anxiety-under low and, eventually, high anxiety-provoking conditions.provoking conditions.

1. Feeling frightened?1. Feeling frightened?

2.2. Expecting bad things to happen?Expecting bad things to happen?

3.3. Attitudes and Actions that can helpAttitudes and Actions that can help

4.4. Results and RewardsResults and Rewards

Exposure with Adolescents - StepsExposure with Adolescents - Steps

Shift focus from learning new skills to practicing Shift focus from learning new skills to practicing them in real situationsthem in real situations

Imaginal practice with anxiety-provoking Imaginal practice with anxiety-provoking situationssituations

In-vivo practice with anxiety-provoking situationsIn-vivo practice with anxiety-provoking situations

Decide on situation that will be practiced nextDecide on situation that will be practiced next

Have teen record 1 anxious experience, Have teen record 1 anxious experience, including 4 stepsincluding 4 steps

Exposure with Adolescents - TipsExposure with Adolescents - Tips

Continue to imaginal exposure until Continue to imaginal exposure until anxiety level is reducedanxiety level is reduced

Present a situation and ask teen to rate Present a situation and ask teen to rate level of anxiety (0-8 scale)level of anxiety (0-8 scale)

Various in-vivo experiences can be Various in-vivo experiences can be arranged in the officearranged in the office

Many natural-occurring exposure tasks Many natural-occurring exposure tasks can occur in public placescan occur in public places

Exposure with Adolescents - TipsExposure with Adolescents - Tips

Refrain from comforting the teen when Refrain from comforting the teen when they become anxious – allow them to they become anxious – allow them to develop independent coping skillsdevelop independent coping skills

Teens may enlist a friend as a support. Teens may enlist a friend as a support. Encourage the selection of a trustworthy Encourage the selection of a trustworthy peerpeer

Solicit suggestions from the teen in Solicit suggestions from the teen in planning exposure tasksplanning exposure tasks