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Brief Interventions for Anxiety Disorders with Children and Adults

Appendix A - Reproducible Client Worksheets

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Reproducible Assessment Sheet # 1
Client Anxiety Assessment


Cognitive Symptoms in Anxiety Disorders

1. Sensory-Perceptual
"Mind" haze, cloudy, foggy, dazed
Objects seem blurred/distant
Environment seems different/unreal
Feeling of unreality

2. Thinking Difficulties
Can't recall important things
Confused, Unable to control thinking
Difficulty in concentration
Distractibility, Blocking
Difficulty in reasoning
Loss of objectivity and perspective

3. Conceptual
Cognitive distortion, Repetitive fearful ideation Fear of losing control
Fear of not being able to cope
Fear of physical injury/death
Fear of mental disorder, negative evaluations Frightening visual images

Affective Adjectives

Behavioral Symptoms
Tonic immobility
Speech dysfluency
Impaired coordination
Postural collapse

Symptoms According to Physiological Symptoms

Heart racing
Increased blood pressure
Faintness (P)
Actual fainting (P)
Decreased blood pressure (P)
Decreased pulse rate (P)

Rapid breathing Difficulty in getting air
Shortness of breath
Pressure on chest
Shallow breathing
Lump in throat, Gasping
Choking sensation
Spasm of bronchi (P)
Increased reflexes
Startle reaction
Eyelid twitching
Strained face
Generalized weakness
Clumsy motions

Urinary Tract
Pressure to urinate (P)
Frequency of urination (P)
Abdominal pain (P)
Loss of appetite
Revulsion toward food
Nausea (P)
Heartburn (P)
Abdominal discomfort
Vomiting (P)

Face flushed
Face pale
Localized sweating (palm region)
Generalized sweating
"Hot and cold spells"

Note: (P) Represents parasympathetic symptoms that facilitate the strategy of collapse



Reproducible Client Worksheet # 2
Six Stages in the Creation of Anxiety


If you need additional space use the back of this paper or add sheets.
The more I know about my anxiety, the more confident I feel to cope with it. I choose to explore my anxiety to reduce it.

Stage One: Facing an Unknown
A. What was the situation that caused me to feel anxious?

B. Is there a mismatch between my perception of reality and my expectation of what happened?

C. What did I expect to have happen?

D. What do I feel actually happened?

E. Is there a difference between my expectation and my perception of what actually happened?

Stage Two: Activating Emotional Memories
A. What is a past similar situation this brings to mind?

B. What are similar memories I have of vulnerability? Related to my self-esteem or self-respect concerning... Approval? Competence? and/or Control?

C. Did I feel an initial panic if I could not think of any circumstances I had faced that were similar?

D. Did my mood and the specifics of the current situation affect the way I recalled situations from the past?

E. What successful experiences can I recall?


Stage Three: Creating Images
A. Is my image an exaggeration of the current situation?

B. Am I "what if-ing"? What if I go crazy?" for "What if I die?"?

C. Am I using "availability logic?" Whatever springs to mind most easily I judge to be most
probable and most believable?

D. Are you creating pseudoproblems by pretending or imagining the worst? Are your fantasies worse than what really happens?

E. The Trance: A state of anxiety has a hypnotic trance-like quality:
___I restrict my awareness and get tunnel vision.
___My "what if" thinking makes me act "as if" something will happen.
___I act as I did in a past similar situation.
___What I imagine will happen, I start to believe will happen.

Stage Four: Activating Belief Systems
Did I use reactive thinking? I labeled the event...
___1) In an unacceptable way "This should not be"?
___2) By exaggerating the situation, "It's awful."?
___3) By direct self-instruction, "I have to get out of here."?
___4) By minimizing my ability to deal with the new information, "I can't handle it." "I can't stand it."?

B. Reactive thinking serves to stop the intrusion of frightening images, however it escalates the flow of these images. Note, the Reactive thinking above in A. is based on the premise that others are responsible for my thoughts, feelings, and actions.

C. Did I use rationalization (excuse making) and use selective attention to see what I believed to be true based upon a past memory?

D. What can I say to myself to help me substitute my need for control for one of making emotional choices?

E. Most clients can learn to move into the choice system relatively easily. However, clients can just as easily move out of it and back into the reactive system. As you know, the more your client practices, the easier and more automatic this flexibility becomes. Clients who appear to have changed may in fact have simply reinforced a new deep-structural belief system.

F. Affirmation: I move from reactive thinking to "choice thinking" easily.

Stage Five: Blocking of Acceptance... Creating Subjective Feelings
The image and thoughts clash. This clash causes a stopping of the accepting or processing of incoming information. This creates a psychological response that your client experiences subjectively as a feeling.

B. The clash between my images and my reactive thinking stops me from processing information. This creates the experience of feeling what? how?

C. Working It Through... being "in the flow."
___When I accept reality, I feel "in the flow."
___When I reject my thoughts and images of reality, I feel "stuck," "blocked," or "conflicted" like "I'm taking it poorly" or "I can't take it."
___When I accept information about the world, I feel I am "taking it easy" or "taking it in stride" when the process is blocked.
___An accumulation of big and small setbacks can block my acceptance of a situation.
___When I am in a state of resistance I have trouble accepting anything.
___When I accept information I have been fighting I experience a physical change, feeling clearer, lighter and more energetic.

Stage Six: Motivation
The feeling is a kinetic self-signal for your client to take action. Once he or she takes this action, the self-signal stops. Because the feeling often is experienced as an unknown, this sets the stage for spiraling of emotions.

My feelings motivate me to take some action; for example with anger, to attack; with depression, to shut down; with happiness, to approach; and with anxiety, to flee or protect myself. Once I take action, the motivating emotion starts to disappear. However, the beliefs that helped create the emotions are strengthened. Avoidance, for example, decreases anxiety and fear.

Do I procrastinate and use the anxiety of being late to motivate myself?

I choose to switch from a motivation based on feelings of anxiety to motivation based upon choice by using ACT:
A = Accept current reality.
C= Choose the experience I want to have and act as if I already have this experience. For example, if I am socially anxious, I can accept my feelings and lack of social skills. I then have a feeling of confidence for upcoming events.
T = Task is done directly without anxiety as a motivator. I act as if I am confident when I am in the social situation. Complete the following: A = Accept reality; C = Choose feelings; T = Task is acted upon based on chosen feeling.

AWARE Technique
The goal of the AWARE is to help you to accept and know your anxiety by remaining present in the context of the situation.
Anxiety is welcomed; deciding to be with the experience.
Watching anxiety as an observer, separate from the experience.
Acting as if one is not anxious.
Repeating acceptance; create affirmation "I can handle this." "I am okay."
Expecting the best and accepting future anxiety by giving up the hope that the anxiety will never recur and connecting that with trust in one's ability to handle anxiety.

Short-circuit Technique
Experiences or feels the anxiety for 45 to 60 seconds. However, during this time, do not try to fight or change it, and without feeding the anxiety any frightening thoughts or images. Just feel.


Reproducible Client Worksheet # 3
Questions About My Anxiety


1. What is the evidence for or against this idea? Make a list of pros and cons.

2. What is the logic behind my thoughts? Are you jumping to conclusions?

3. Am I oversimplifying the result of your actions? Does one failure mean all is lost?

4. Is this thought coming from reality or is it coming from my habit of thinking a certain way? (I am used to thinking I will fail and worthy of success, therefore I am failing now.)

5. Is my interpretations of the situation too far removed from reality to be accurate? If so, what did I see or hear?

6. Am I confusing my opinion of the facts with the facts as they are? I really do not know what another person is thinking.

7. Am I thinking in all-or-nothing terms? (For example, everyone will hate me or everyone will like me. What is the middle ground?)

8. Am I using words or phrases that are extreme or exaggerated? (like, always, or never)

9. Am I taking selected examples out of context? One year from now, how do I think I will view this situation?

10. Am I using cognitive defense mechanisms? (For example, denial: "I'm not afraid, I just don't want to go out"; projections: "The other people expect me to be perfect"; or rationalizations: "I don't want to make the call because I don't have the time."

11. Is my source of information reliable? What is the other person's vested interest, level of experience, or prejudice in this matter?

12. Am I trying to be 100 certain instead of accepting life is made up of probabilities?

13. Am I confusing a low probability with a high probability? Is it probability or a possibility? Am I confusing probability with possibility?

14. Are my judgments based on feelings rather than on facts? Am I in the habit of feeling anxious, therefore I am telling myself there is something to be anxious about... rather than reviewing the fact?

15. Am I over focusing on irrelevant factors? What are the key factors?


Optional Reproducible Client Worksheet # 4
Client Diagrams: The Vicious Cycle


Fill in the boxes to the right with ideas regarding your Anxiety. If you need added space, use the back of this sheet or additional paper. Briefly describe the situation that caused you to be anxious.

Relation of Appraisal to Components of Your Fear
Appraisal: Degree of Danger <-> Anxiety <-->Behavioral Mobilization

The Vicious Cycle, Incorporating Unpleasant Emotional Feedback (Anxiety),
Unpleasant Performance Feedback, and Unpleasant Feedback

Cognitive Appraisal:
1. Danger
2. Inadequate performing skills <--> Anxiety <-->
Flaws in performance <--> Negative reaction of others


Reproducible Client Assessment Sheet # 5


1) Motor aspects: What does the child do when he or she is afraid?

2) Cognitive components: What does the child think or say to himself or herself when afraid?

3) Physiological components: How does the body react when the child is afraid? Which part(s) of the body are involved?

4) Under which conditions does he or she become fearful?

Assessment of Child's awareness of their phobia or anxiety
Can the child identify the various aspects of his or her fear ?

1) Motor aspects: What does the child do when he or she is afraid?

2) Cognitive components: What does the child think or say to himself or herself when afraid?

3) Physiological components: How does the child's body react when afraid and which part(s) of the body is involved?

4) Conditional components:
---Under which conditions is he or she becoming fearful?
---Does the child have the verbal capacity to generate, with the therapist, a series of self-statements and rules?
---Can these self-statements and rules be incorporated by the child, at least temporarily, into his or her verbal repertoire?
---Is the child able to apply these self-statements and rules under those conditions in which he or she experiences anxiety?

Medical Treatment Procedure
1. Preoperative information: What preoperative information could you provide the child? Is a puppet appropriate for presentation of the information?

2. Coping procedures: What coping procedures could you teach the child?
---Cue-controlled muscle relaxation, such as using the cue "calm."
---Distracting mental imagery training; an example is imagining a scene that was "quiet and made them feel happy."
---Comforting self-talk; the children, for example, were encouraged to think of the phrase "I will be all better."

3. Media: Video modeling children receiving preoperative information.

4. Tour and refreshments: a 15-minute hospital tour and 15 to 20 minutes eating ice cream and cookies following the tour.



Reproducible Client Worksheet # 6
The Five R's of Anxiety


The First R: Realize Anxiety is part of my thoughts.
The first step in overcoming a distorted view of myself is to realize that my negative and irrational thoughts are a part of our consciousness. Once I admit the possibility that I am not thinking clearly, I can choose a new lens with which to look at myself so that I can see my real potential.
What are some anxious thoughts I have?

The Second R: Recognize 10 ways Anxiety may be effecting my life.
1. Perfectionism causes me to set unreasonably high standards for myself and others.
2. Rejectionitis is the practice of exaggerating a single rejection until it affects everything else in my life.
3. Negative focus is the habit of letting one negative situation in my life obliterate all the positives.
4. Refusing the positives goes a step farther than negative focus. I tell myself that even the good things in my life are negatives!
5. The white-is-black phenomenon occurs when I use neutral or even positive facts to make negative conclusions. I interpret someone else's actions as being hostile to me when they actually indicate that person's own discomfort.
6. Stretch-or-Shrink thinking is the habit of either stretching the truth into an anxiety-producing fiction when I've done something that I'm less than proud of, or shrinking it until it's invisible, if I did something positive.
7. Creating "excuses" means letting emotions substitute for the truth about what is happening. Counter excuses by realizing that your distorted thoughts bring on negative feelings. Affirm that you are already feeling calm, happy and at peace. Use affirmations to change your feelings.
8. "Should" and "ought" statements cause me to act in ways I would prefer not to, simply because I believe some imaginary person is telling me that I will be less than perfect if I don't.
9. Mistaken identity means telling myself I am all bad because I made a mistake.
10. Saying "My fault" assumes responsibility for a negative event even when the responsibility is not mine.

The Third R: Refuse to let Anxiety control my life.
It is one thing to recognize cognitive distortions after I have suffered the consequences. It is still another to be able to spot them while I am in the process of distorting so that I can immediately replace them with a positive thought.

The Fourth R: Replace negative and irrational thoughts with reality.
Reprograming my unconscious. It involves planning ahead. I monitor my cognitive distortions and plan how I will confront them with reality. I can record them in in three columns: 1. Problem Thinking, 2. Cognitive Distortion, and 3. Positive Replacement.

The Fifth R: Relax and reprogram my unconscious mind.
With the Fifth R, I can learn to reprogram my unconscious so that my anxiety is decreased in the future. I do this by relaxing, using visualizations and affirmations.

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