Section I

TREATMENT PLANNING
 ANXIETY
MASTER BEHAVIORAL DEFINITION LIST

1. Excessively and persistently worries on a daily basis about several life circumstances that
have no factual or logical basis.
2. Exhibits motor tension such as restlessness, tiredness, shakiness, or muscle tension.
3. Reports autonomic hyperactivity such as palpitations, shortness of breath, dry mouth,
trouble swallowing, nausea, or diarrhea.
4. Reports hypervigilance such as feeling constantly on edge, experiencing concentration diffi-
culties, having trouble falling or staying asleep, and exhibiting a general state of irritability.
5. Repeatedly experiences unexpected, sudden, debilitating panic symptoms (shallow breathing,
sweating, heart racing or pounding, dizziness, depersonalization or derealization, trembling,
chest tightness, fear of dying or losing control, nausea), resulting in persisting concern about
having additional attacks.
6. Fears being in an environment that may trigger intense anxiety symptoms (panic) and,
therefore, avoids traveling in an enclosed environment.
7. Avoids situations where panic attacks have previously occurred or where they may occur.
 CHILD*

BEHAVIORAL DEFINITIONS
A. See Master List

B. Unique Definitions

1. Lacks confidence in ability to cope with the demands of any new situation.
2. Needs reassurance frequently as to significant other adults being present to provide support
for a future event.
.

LONG-TERM GOALS

1. Reduce the overall frequency and intensity of the anxiety response so that daily functioning
is not impaired.
2. Anxiety inhibits exploration of abilities in any new situation.
3. Is preoccupied with possible negative outcomes occurring in the future (e.g., sickness,
accident, death, failure).
4. Stabilize the anxiety level while increasing the ability to function on a daily basis.
5. Resolve the key issue that is the source of the anxiety or fear.
6. Interact with the world without excessive fear, worry, or anxiety.

*
Most of the content of this chapter (with slight revisions) originates from A. E. Jongsma, Jr., L. M. Peterson, and W. P. McInnis,
The Child Psychotherapy Treatment Planner (New York: John Wiley & Sons, 2002). Copyright 2002 by A. E. Jongsma, Jr.,
L. M. Peterson, and W. P. McInnis. Reprinted with permission.

13
14 THE COMPLETE ANXIETY TREATMENT AND HOMEWORK PLANNER

SHORT-TERM THERAPEUTIC
OBJECTIVES INTERVENTIONS
1. Openly share anxious thoughts and 1. Actively build the level of trust with the
feelings with therapist. (1, 2, 3) client through consistent eye contact, active
listening, unconditional positive regard, and
warm acceptance to help increase his/her
ability to identify and express anxious
feelings.
2. Use a therapeutic game (Talking, Feeling,
Doing, available from Creative Therapeu-
tics, or the Ungame available from the
Talicor Company) to expand the client’s
awareness of feelings, self, and others.
3. Conduct play-therapy sessions in which the
client’s anxieties, fears, and worries are
explored, expressed, and resolved.
2. Verbally identify specific past and 4. Ask the client to develop a list of key past
present family conflicts. (4) and present conflicts within the family and
with peers. Process this list with the
therapist.
3. Report a decrease in frequency of 5. Ask the client to complete and process the
experiencing anxiety. (5, 6) exercise “Finding and Losing Your
Anxiety” in the Brief Child Therapy
Homework Planner (Jongsma, Peterson,
and McInnis).
6. Utilize child-centered play-therapy
approaches (e.g., provide unconditional
positive regard, reflect feelings in
nonjudgmental manner, display trust in
child’s capacity to work through issues) to
increase the client’s ability to cope with
anxious feelings.
4. Verbalize an increased understanding of 7. Assess the client’s anxiety by using the
anxious feelings and their causes. Squiggle Wiggle game (Winnicott), in
(7, 8, 9) which therapist or parent makes a squiggly
line and then the client is asked to make a
 CHILD 15

picture out of the squiggle and tell a story

about that picture to help reveal to the
therapist and parent what is going on
internally with the client.
8. Assign the client the task of drawing two or
three situations that generally bring on
anxious feelings.
9. Conduct psychoanalytical play-therapy
sessions (e.g., explore and gain
understanding of etiology of unconscious
conflicts, fixations, or arrests; interpret
resistance or core anxieties) to help the
client work through to resolutions the issues
that are the source of his/her anxiety.
5. Implement positive self-talk to reduce 10. Explore distorted cognitive messages that
or eliminate the anxiety. (10, 11) mediate the anxiety response.
11. Help the client develop reality-based,
positive cognitive messages that will
increase self-confidence in coping with
fears and anxieties.
6. Develop and implement appropriate 12. Train the client to use progressive
relaxation and cognitive diversion relaxation or guided imagery techniques to
activities to decrease the level of induce calm and decrease the intensity and
anxiety. (12, 13) frequency of feelings of anxiety.
13. Assist the client in working toward
resolution (e.g., using problem solving,
assertiveness, acceptance, cognitive
restructuring) of key past and present
conflicts.
7. Identify areas of conflict that precepts 14. Use puppets, felt, or sand tray to enact
anxiety. (14, 15, 16) situations that provoke anxiety in the client.
Involve the client in creating such scenar-
ios, and model positive cognitive responses
to the situations that bring on anxiety.
15. Play the therapeutic game My Home and
Places (Flood) with the client to help
identify and talk about divorce, peers,
alcohol abuse, or other situations that make
the client anxious.
16. Instruct the client to sing a song or play a
musical instrument that reflects his/her
anxious feelings; then discuss a time when
the client felt that anxiety.
8. State a connection between anxiety and 17. Use an interpretive interview method in
underlying, previously unexpressed which the therapist interviews the client to
wishes or thoughts. (17, 18) help express motivation and feelings. Then
16 THE COMPLETE ANXIETY TREATMENT AND HOMEWORK PLANNER

assist the client in making a connection

between fears or anxieties and unexpressed
or unacceptable wishes or “bad” thoughts.
18. Assign the client to complete exercises
from My Own Thoughts and Feelings on
Stopping the Hurt: A Child’s Workbook
about Exploring Hurt and Abuse (Deaton).
Process each exercise with therapist to
increase the client’s understanding of and
ability to cope with and handle anxious
feelings.
9. Identify and utilize specific coping 19. Use a narrative approach (see Narrative
strategies for anxiety reduction. Means to Therapeutic Ends by White) in
(19, 20, 21) which the client writes out the story of
his/her anxiety or fear and then acts out the
story with the therapist to externalize the
issues. Then work with the client to reach a
resolution or develop an effective way to
cope with the anxiety or fear. See “An
Anxious Story” from Brief Child Therapy
Homework Planner (Jongsma, Peterson,
and McInnis).
20. Conduct sessions with a focus on anxiety-
producing situations in which techniques of
storytelling, drawing pictures, and viewing
photographs are used to assist the client in
talking about and reducing the level of
anxiety or fear.
21. Use a mutual storytelling technique (see
Therapeutic Communication with Children:
The Mutual Storytelling Technique by
Gardner) in which the client tells a story
about a central character who becomes
anxious. The therapist then interprets the
story for its underlying meaning and retells
the client’s story while weaving in healthier
adaptations to fear or anxiety and resolution
of conflicts.
10. Increase participation in daily social and 22. Assist the client in identifying behavioral
academic activities. (22) anxiety-coping strategies (e.g., increased
social involvement, participation in school-
related activities); contract for
implementations.
11. Increase physical exercise as a means of 23. Assist the client in implementing schedule
reducing anxious feelings. (23) of physical activity that reduces anxiety.
12. Participate in a camp that focuses on 24. Encourage the parents to seek an
confidence building. (24) experiential camp or weekend experience
 CHILD 17

for the client that will focus on the issues of

fears, taking risks, and building confidence.
Process the experience with the client and
his/her parents.
13. Set aside time for over thinking about 25. Advocate and encourage over thinking
anxieties. (25) (e.g., help the client explore and prepare for
every conceivable thing that could possibly
happen to him/her in facing a new or
anxiety-producing situation). Monitor
weekly results as needed.
14. Parents verbalize an understanding of 26. Educate the client’s parents to increase their
the client’s anxieties and fears. awareness and understanding of which fears
(26, 27, 28) and anxieties are normal for various stages
of child development.
27. Assign the client’s parents to read books
related to child development and parenting
(e.g., Between Parent and Child by Ginott
or How to Talk So Kids Will Listen and
Listen So Kids Will Talk by Faber and
Mazlish).
28. Refer the client’s parents to a parenting
class or support group.
15. Parents verbalize constructive ways to 29. Work with the parents in family sessions to
respond to the client’s anxiety. (29) develop their skills in effectively respond-
ing to the client’s fears and anxieties with
calm confidence rather than fearful
reactivity (e.g., parents remind the client of
a time he/she effectively handled a fearful
situation or express confidence in the
client’s ability to face the fearful situation).
16. Participate in family therapy sessions 30. Conduct family session in which the system
that identify and resolve conflicts is probed to determine the level of fear or
between family members. (30, 31) anxiety that is present or to bring to the
surface underlying conflicts.
31. Work in family sessions to resolve conflicts
and to increase the family’s level of healthy
functioning.
17. Parents reduce their attempts to control 32. Use a structural approach in the family
the child. (32, 33) session, adjusting roles to encourage the
parents to work less on controlling children
and more on allowing children to be children.
33. Conduct a family session to develop and
implement strategic directions designed to
increase the physical freedom of the
children and to adjust the parental control
of the system.
18 THE COMPLETE ANXIETY TREATMENT AND HOMEWORK PLANNER

18. Express confidence and hope that 34. Use a metaphor, fairy tale, or parable to get
anxiety can be overcome. (34, 35, 36) the client’s attention, to evoke possibilities
or abilities, to intersperse suggestions, and
to implant hope of a good outcome. (See
101 Play Therapy Techniques by Maruasti.)
35. Assist the client in implementing internal
structures for self-regulation and the ability
to tolerate his/her anxiety by evoking the
memory of the therapist as a soothing,
encouraging, internal object to help when
he/she confronts an anxiety-producing
situation/issue. (See The Therapist on the
Inside by Grigoryen.)
36. Prescribe a Prediction Task (de Shazer) for
anxiety management. (The client predicts
the night before whether the anxiety will
bother him/her the next day. Therapist
directs the client to be a good detective and
bring back key elements that contributed to
it being a “good day” so therapist then can
reinforce or construct a solution to
increasing the frequency of “good days.”)
. .

. .

. .

DIAGNOSTIC SUGGESTIONS:

Axis I: 300.02 Generalized Anxiety Disorder

300.00 Anxiety Disorder NOS
314.01 Attention-Deficit/Hyperactivity Disorder, Combined Type
309.21 Separation Anxiety Disorder

Axis II: V71.09 No Diagnosis on Axis II