James Fitzgerald Therapy PLLC

Sample Treatment Plan

For educational purposes only. This is not an actual treatment plan. An individual’s actual treatment plan is specific and unique to each person, taking many factors and variables into account. Clients of James Fitzgerald will have a treatment plan that is co-created and stored in the software used for electronic health records, schedules, claims, and billing. This template can be used to develop the treatment plan, utilizing the goals, objectives, interventions, lessons, handouts, and worksheets. If you have any questions, concerns, or comments, please contact me.

Generalized Anxiety Disorder

Reference: American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th edition, text revision). Arlington, VA: American Psychiatric Association.

DESCRIPTION & DIAGNOSIS

Generalized anxiety disorder (GAD) has gained increasing attention during the last few decades, as several methods of therapy have been advanced to address its core cognitive feature — excessive worry. GAD is generally a chronic condition, often preceding the onset of depression by several years. Many people with GAD appear to “normalize” their problem, describing themselves as “worriers” all their lives. They also hold an ambivalent view of their problem: They believe that they need to worry to be prepared, but at the same time they feel that their worry is causing them harm and that they need to stop worrying.

Diagnostic Features

The essential feature of generalized anxiety disorder is excessive anxiety and worry (apprehensive expectation) about a number of events or activities. The intensity, duration, or frequency of the anxiety and worry is out of proportion to the actual likelihood or impact of the anticipated event. The individual finds it difficult to control the worry and to keep worrisome thoughts from interfering with attention to tasks at hand. Adults with generalized anxiety disorder often worry about everyday, routine life circumstances, such as possible job responsibilities, losing their job, health and finances, the health of family members, misfortune to their children, or minor matters (e.g., doing household chores or being late for appointments). Children with
generalized anxiety disorder tend to worry excessively about their competence or the quality of their performance. During the course of the disorder, the focus of worry may shift from one concern to another.

Several features distinguish generalized anxiety disorder from nonpathological anxiety.

• Worries associated with generalized anxiety disorder are excessive and typically interfere significantly with psychosocial functioning, whereas the worries of everyday life are not excessive and are perceived as more manageable and may be put off when more pressing matters arise.
• Worries associated with generalized anxiety disorder are more pervasive, pronounced, and distressing; have longer duration; and frequently occur without precipitants.
• The greater the range of life circumstances about which a person worries (e.g., finances, children’s safety, job performance), the more likely his or her symptoms are to meet criteria for generalized anxiety disorder.
• Everyday worries are much less likely to be accompanied by physical symptoms (e.g., restlessness or feeling keyed up or on edge). Individuals with
  generalized anxiety disorder report subjective distress as a result of constant worry and related impairment in social, occupational, or other important areas of functioning.

The anxiety and worry are accompanied by at least three of the following additional symptoms: restlessness or feeling keyed up or on edge, being easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, and disturbed sleep, although only one additional symptom is required in children..

Associated Features

Associated with muscle tension, there may be trembling, twitching, feeling shaky, and muscle aches or soreness. Many individuals with generalized anxiety disorder also experience somatic symptoms (e.g., sweating, nausea, diarrhea) and an exaggerated startle response. Symptoms of autonomic hyperarousal (e.g., accelerated heart rate, shortness of breath, dizziness) are less prominent in generalized anxiety disorder than in other anxiety disorders, such as panic disorder. Other conditions that may be associated with stress (e.g., irritable bowel syndrome, headaches) frequently accompany generalized anxiety disorder.

Development and Course

Many individuals with generalized anxiety disorder report that they have felt anxious and nervous all their lives. The mean age at onset for generalized anxiety disorder in North America is 35 years, later than that for the other anxiety disorders; the disorder rarely occurs prior to adolescence. However, age at onset is spread over a very broad range and tends to be older in lower-income countries worldwide. The symptoms of excessive worry and anxiety may occur early in life but are then manifested as an anxious temperament. Generalized anxiety disorder symptoms tend to be chronic and wax and wane across the life span, fluctuating between syndromal and subsyndromal forms of the disorder. Course is more persistent in lower-income countries, but impairment tends to be higher in high-income countries. Rates of full remission are very low.

The earlier in life individuals have symptoms that meet criteria for generalized anxiety disorder, the more comorbidity and impairment they tend to have. Younger adults experience greater severity of symptoms than do older adults.

The clinical expression of generalized anxiety disorder is relatively consistent across the life span. The primary difference across age groups is in the content of the individual’s worry; thus, the content of an individual’s worry tends to be age appropriate.

In children and adolescents with generalized anxiety disorder, the anxieties and worries often concern the quality of their performance or competence at school or in sporting events, even when their performance is not being evaluated by others. There may be excessive concerns about punctuality. They may also worry about catastrophic events, such as earthquakes or nuclear war. Children with the disorder may be overly conforming, perfectionistic, and unsure of themselves and may tend to redo tasks because of excessive dissatisfaction with less-than-perfect performance. They may be overzealous in seeking reassurance and approval and require excessive reassurance about their performance and other things they are worried about. In the elderly, the advent of chronic physical disease can be a potent issue for excessive worry. In the frail elderly, worries about safety—and especially about falling—may limit activities.

Problems and Impact

Treatment Plan Outline for Anxiety

Reminder: The long term goals are those that you choose for yourself. You may have goals for anxiety that are not listed here. Objectives are the tasks you will be accountable and responsible for. The interventions are the tasks I will be accountable and responsible for. Handouts and worksheets will be shared through the Electronic Health Records (Therapy Notes).

General Plan of Treatment for Generalized Anxiety Disorder

• Assessment
  • Tests and clinical interviewing
  • Consideration of medication
• Socialization to treatment
• Relaxation training
• Mindfulness training
• Assessing and confronting avoidance: Exposure and other techniques
• Monitoring worries and assigning “worry time”
• Cognitive evaluation and treatment of worrying
  • Step 1: Distinguishing between productive and unproductive worry
  • Step 2: Acceptance and commitment
  • Step 3: Challenging worried automatic thoughts and maladaptive assumptions
  • Step 4: Examining core beliefs about self and others
  • Step 5: Examining fear of failure
  • Step 6: Using emotions rather than worrying about them
  • Step 7: Putting time on the patient’s side
• Interpersonal interventions
• Problem-solving training
• Phasing out treatment

Long Term Goals

Reduce the overall frequency, intensity, and duration of the anxiety symptoms so that daily functioning is not impaired. To be measured by the Generalized Anxiety Disorder assessment instrument.

Stabilize anxiety level while increasing ability to function on a daily basis. To be measured with the life domain satisfaction survey.

Resolve the core conflict that is the source of anxiety. As evidenced by self-reports of the conflict being resolved or having been accepted as reality.

Enhance ability to effectively cope with the full variety of life’s worries and anxieties. As evidenced by self-reports of fewer periods of worry and anxiety.

Learn and implement coping skills (emotion regulation and distress tolerance) that will result in a reduction of anxiety and worry, and improved daily functioning. As evidenced by the practical application of skills and tracking your progress in a journal. 

Start with these Videos

Video [5:34] Real Therapist Fake Therapy # 1: Anxiety Treatment (Dr. Ali Mattu)

Video [9:21] Real Therapist Fake Therapy # 2: How to explain Anxiety to someone (Dr. Ali Mattu)

Video [22:17] 10 Quick Anxiety Relief Techniques (Dr. Ali Mattu)

Objective:

Describe situations, thoughts, feelings, and actions associated with anxieties and worries, their impact on functioning, and attempts to resolve them.

Intervention:

Focus on developing a level of trust with the client; provide support and empathy to encourage the client to feel safe in expressing his/her GAD. Ask the client to describe his/her past experiences of anxiety and their impact on functioning; assess the focus, excessiveness, and uncontrollability of the worry and the type, frequency, intensity, and duration of his/her anxiety symptoms.

Objective:

Complete psychological tests designed to assess worry and anxiety symptoms.

Intervention:

Administer psychological tests or objective measures (assessments) to help assess the nature and degree of the client’s worry and anxiety and their impact on functioning.

Objective:

Complete a medical evaluation to assess for possible contribution of a medical or substance-related condition to the anxiety.

Intervention:

Refer the client to a physician for a medical evaluation to rule out general medical or substance-related causes of the anxiety symptoms.

Objective:

Provide behavioral, emotional, and attitudinal information toward an assessment of specifiers relevant to a DSM diagnosis, the efficacy of treatment, and the nature of the therapy relationship.

Interventions:

Assess the client’s level of insight (syntonic versus dystonic) toward the “presenting problems” (i.e., demonstrates good insight into the problematic nature of the “described behavior,” agrees with others’ concern, and is motivated to work on change; demonstrates ambivalence regarding the “problem described” and is reluctant to address the issue as a concern; or demonstrates resistance regarding acknowledg­ment of the “problem described,” is not concerned, and has no motivation to change).

Assess the client for evidence of research-based correlated disorders (e.g., oppositional defiant behavior with ADHD, depression secondary to an anxiety disorder) including vulnerability to suicide, if appropriate (e., increased suicide risk when comorbid depression is evident).

Assess for any issues of age, gender, or culture that could help explain the client’s currently defined “problem behavior” and factors that could offer a better understanding of the client’s behavior.

Assess for the severity of the level of impairment to the client’s functioning to determine appropriate level of care (e.g., the behavior noted creates mild, moderate, severe, or very severe impairment in social, relational, vocational, or occupational endeavors); continuously assess this severity of impairment as well as the efficacy of treatment (e.g., the client no longer demonstrates severe impairment but the presenting problem now is causing mild or moderate impairment).

DSM 5 TR – Diagnostic Criteria:

A. Have you experienced excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance)?

B. Have you found it difficult to control the worry?

C. Is the anxiety and worry associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months)

1. Restlessness or feeling keyed up or on edge.
2. Being easily fatigued.
3. Difficulty concentrating or mind going blank.
4. Irritability.
5. Muscle tension.
6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).

D. Do these anxiety, worry, or physical symptoms cause a significant amount of distress or impact your daily functioning in the interpersonal, social, occupational, recreational, educational, or other important areas of your life?

E. Can you attribute these disturbances to the physiological effects of a substance (alcohol, marijuana, illicit drug, or medication) or another medical condition (hyperthyroidism, neurocognitive disorders).

F. Can the disturbance be explained by another mental disorder

• anxiety or worry about having panic attacks in panic disorder
• negative evaluation in social anxiety disorder
• contamination or other obsessions in obsessive-compulsive disorder
• separation from attachment figures in separation anxiety disorder
• reminders of traumatic events in posttraumatic stress disorder
• gaining weight in anorexia nervosa
• physical complaints in somatic symptom disorder
• perceived appearance flaws in body dysmorphic disorder
• having a serious illness in illness anxiety disorder
• the content of delusional beliefs in schizophrenia or delusional disorder

Objective:

Cooperate with a medication evaluation by a physician (sign an authorization to release information to allow therapist to speak with physician and vice versa). 

Interventions:

Refer the client to a physician for a psychotropic medication consultation.

Monitor the client’s psychotropic medication compliance, side effects, and effectiveness.

Consult regularly with the physician.

Objective:

Verbalize an understanding of the social, cognitive, emotional, physiological, and behavioral components of anxiety and its treatment.

Interventions:

Discuss how generalized anxiety typically involves excessive worry about unrealistic threats, various bodily expressions of tension, overarousal, and hypervigilance, and avoidance of what is threatening that interact to maintain the problem

Mastery of Your Anxiety and Worry: Therapist Guide by Zinbarg, Craske, and Barlow

Treating Generalized Anxiety Disorder by Rygh and Sanderson.

Discuss how treatment targets worry, anxiety symptoms, and avoidance to help the client manage worry effectively, reduce overarousal, and eliminate unnecessary avoidance.

Assign the client to read psychoeducational sections of books or treatment manuals on worry and generalized anxiety

Mastery of Your Anxiety and Worry: Workbook by Craske and Barlow

Overcoming Generalized Anxiety Disorder by White

Psychoeducation:

Genetic/Biological Factors:
Although some estimates indicate that GAD may have a moderate heritability of 30%, other findings suggest lack of specificity of transmission (Hettema et al., 2001; Kendler et al., 1992; Weissman & Merikangas, 1986). GAD is associated with other specific traits, such as neuroticism, nervousness, depression, low frustration tolerance, and inhibition (Angst & Vollrath, 1991).

Reference:

Leahy, R. L., Holland, S. J., & McGinn, L. K. (2011). Treatment plans and interventions for depression and anxiety disorders. Guilford press.

Psychoeducation:

Distinguishing between Productive and Unproductive Worry

Many worriers believe that their worry will prepare them, prevent surprise, and help them solve problems before they get out of hand. Indeed, some worry can be useful. For example, if I need to get from New York City to San Diego, California, it would be useful for me to “worry” about having plane and hotel reservations and ground transportation in California. The question is how long this worry needs to be sustained. Productive worry is a set of questions leading to solutions to a problem that can be addressed today (Leahy, 2005). For instance, I can get reservations for a flight, hotel, and rental car today. Unproductive worry involves a series of “what-if” questions about problems over which I have no control and that I cannot really solve today. In the present example, these might include “What if my car breaks down in California?” or “What if my talk goes badly?” The therapist and patient categorize the patient’s worries as productive or unproductive, using the following list as a guide:

Signs of unproductive worry:

• You worry about unanswerable questions.
• You worry about a chain reaction of events.
• You reject a solution because it is not a perfect solution.
• You think you should worry until you feel less anxious.
• You think you should worry until you control everything.

Signs of productive worry:

• There is a question that has an answer.
• You are focused on a single event, not a chain reaction.
• You are willing to accept imperfect solutions.
• You do not use your anxiety as a guide.
• You recognize what you can control and what you cannot control.

Psychoeducation:

Acceptance and Commitment

Reality Acceptance – Radical Acceptance. Treatment of anxiety involves your acceptance of limitations, such as uncertainty, imperfection, and lack of complete control. The patient can be asked to indicate the advantages and disadvantages of accepting these limitations; to give examples of current acceptance of limitations; and to decide whether acceptance of limitations implies lack of responsibility or bad outcomes. Intolerance of uncertainty can be addressed with the patient in the following ways:

• Ask yourself, “What are the advantages and disadvantages of accepting uncertainty?”
• In what areas of your life do you currently accept uncertainty?
• Are you equating uncertainty with a negative outcome?
• If you had to make a bet, how would you bet? For instance, if you think, “It’s possible that this blemish is cancer,” how much would you bet that it is?
• What would be the advantage of saying, “It’s good enough for me to act on?”
• Practice repeating to yourself, “It’s possible that something bad will happen.” Repeat this slowly, over and over, for 20 minutes each day. Repeat your specific worries in this way as well.
• Ask yourself, “Do I actually have a need for some uncertainty?” Life would be boring otherwise.
• Would you watch the same television program if it were entirely predictable—or watch a sporting event if you always knew the final score before the game occurred—and you knew before the game exactly what would happen?
• In this current interaction, can I control what another person thinks or behaves? Our two realities are different and we both perceive the current experience based on our interpretations and expectations, which are based on how we remember our past experiences.

In addition, a worried thought can be treated as an intrusive thought that the patient negatively evaluates. For example, the patient may believe that an intrusive thought about a possible bad outcome needs to be addressed immediately, predicts the future, is personally relevant, and needs to be suppressed or feared (D. A. Clark, 2005; Purdon, Rowa, & Antony, 2005; Wells, 2003). A number of interventions may be useful. One is to have the patient flood him- or herself for 30 minutes with the negative thought until it becomes boring; another is to practice mindful awareness and nonjudgmental, noncontrolling observation of the thought (e.g., to observe “This is just a thought,” or “I can see that there is a mental event”). A worried thought can be imagined as a small figure marching out of one’s head, or some other diminishing/externalizing acceptance technique can be used.

Commitment to change involves two processes: (1) “successful imperfection,” in which the individual is willing to accept less than 100% in order to make progress; and (2) “constructive discomfort,” in which the individual tolerates unpleasant emotions and sensations in order to get things done (Leahy, 2005). Worry is a form of emotional or experiential avoidance, and these guidelines can be helpful in breaking free from maladaptive beliefs such as “I can’t do anything until I am ready,” or “I can’t do it because I am anxious.”

Objective:

Learn and implement calming skills to reduce overall anxiety and manage anxiety symptoms.

Interventions:

Teach the client calming/ relaxation skills (e.g., applied re­ laxation, progressive muscle relaxation, cue controlled relaxation; mindful breathing; biofeedback) and how to discriminate better between relaxation and tension; teach the client how to apply these skills to his/her daily life

New Directions in Progressive Muscle Relaxation by Bernstein, Borkovec, and Hazlett-Stevens

Treating Generalized Anxiety Disorder by Rygh and Sanderson

Assign the client homework each session in which he/she practices relaxation exercises daily, gradually applying them progressively from non-anxiety­ provoking to anxiety-provoking situations; review and reinforce success while providing corrective feedback toward

Assign the client to read about progressive muscle relaxation and other calming strategies in relevant books or treatment manuals

Progressive Relaxation Training by Bernstein and Borkovec

Mastery of Your Anxiety and Worry: Workbook by Craske and Barlow

Objective:

Learn and implement a strategy to limit the association between various environmental settings and worry, delaying the worry until a designated “worry time.”

Interventions:

Explain the rationale for using a worry time as well as how it is to be used; agree upon and implement a worry time with the client.

Teach the client how to recognize, stop, and postpone worry to the agreed upon worry time using skills such as thought stopping, relaxation, and redirecting attention to assist skill development); encourage use in daily life; review and reinforce success while providing corrective feedback toward improvement.

“Making Use of the Thought­ Stopping Technique” and/or “Worry Time” in the Adult Psychotherapy Homework Planner by Jongsma 

Objective:

Verbalize an understanding of the role that cognitive biases play in excessive irrational worry and persistent anxiety symptoms.

Interventions:

Discuss examples demonstrating that unrealistic worry typically overestimates the probability of threats and underestimates or overlooks the client’s ability to manage realistic demands.

“Past Successful Anxiety Coping” in the Adult Psychotherapy Homework Planner by Jongsma

Assist the client in analyzing his/her worries by examining potential biases such as the probability of the negative expectation occurring, the real consequences of it occurring, his/her ability to control the outcome, the worst possible outcome, and his/her ability to accept it

“Analyze the Probability of a Feared Event” in the Adult Psychotherapy Homework Planner by Jongsma

Cognitive Therapy of Anxiety Disorders by Clark and Beck

Help the client gain insight into the notion that worry may function as a form of avoidance of a feared problem and that it creates acute and chronic tension

Objective:

Identify, challenge, and replace biased, fearful self-talk with positive, realistic, and empowering self-talk.

Interventions:

Explore the client’s schema and self-talk that mediate his/her fear response; assist him/her in challenging the biases; replace the distorted messages with reality-based alternatives and positive, realistic self-talk that will increase his/her self­ confidence in coping with irrational fears

Cognitive Therapy of Anxiety Disorders by Clark and Beck

Assign the client a homework exercise in which he/she identifies fearful self-talk, identifies biases in the self-talk, generates alternatives, and tests through behavioral experiments; review and reinforce success, providing corrective feedback toward improvement.

“Negative Thoughts Trigger Negative Feelings” in the Adult Psychotherapy Homework Planner by Jongsma

Challenging Worried Automatic Thoughts and Maladaptive Assumptions

Many of the thoughts characterizing worry are negative automatic thoughts or maladaptive assumptions. The therapist and patient can utilize the Questions to Ask Yourself If You Are Worrying, to evaluate specific predictions; the tendency to jump to conclusions; the difference between possibility and probability; the safety or protection factors available; the tendency to catastrophize outcomes; and other responses that may indicate a sense of negativity, imminence, and exaggerated outcome. (This form may be simplified, expanded, or modified by the therapist to fit the needs of the individual patient.) In addition, the patient may be assigned to write a story where positive instead of negative outcomes occur, and to outline the actual steps, they might need to take to make this happen. The therapist can also address the specific categories of negative automatic thoughts underlying worrying, such as labeling (“I’m incapable of handling stress”), catastrophizing (“I’m going to lose everything”), fortunetelling (“I’ll get rejected”), dichotomous thinking (“Nothing is working out”), and discounting the positives (“I don’t have anything going for me”). The therapist can focus as well on the patient’s particular maladaptive assumptions (needs for approval, perfection, and certainty; assumptions of essentialness and emergency; etc.). Finally, the patient’s rhetorical questions that reflect worrying, such as “What if it doesn’t work out?” or “What’s wrong with me?”, can be examined and rephrased as propositional statements that can be tested, such as “Nothing will work out,” or “Everything is wrong with me.” 

Objective:

Undergo gradual repeated imaginal exposure to the feared negative consequences predicted by worries and develop alternative reality-based predictions.

Interventions:

Direct and assist the client in constructing a hierarchy of two to three spheres of worry for use in exposure (e.g., worry about harm to others, financial difficulties, relationship problems).

Select initial exposures that have a high likelihood of being a success experience for the client; develop a plan for managing the negative effect engendered by exposure; mentally rehearse the procedure.

Ask the client to vividly imagine worst-case consequences of worries, holding them in mind until anxiety associated with them weakens (up to 30 minutes); generate reality-based alternatives to that worst case and process them.

Mastery of Your Anxiety and Worry: Therapist Guide by Zinbarg, Craske, and Barlow

Assign the client a homework exercise in which he/she does worry exposures and records responses; review, reinforce success, and provide corrective feedback toward improvement.

Mastery of Your Anxiety and Worry: Workbook by Craske and Barlow

Generalized Anxiety Disorder by Brown, O’Leary, and Barlow)

Objective:

Learn and implement problem­ solving strategies for realistically addressing worries.

Interventions:

Teach the client problem-solving strategies involving specifically defining a problem, generating options for addressing it, evaluating the pros and cons of each option, selecting and implementing an optional action, and reevaluating and refining the action.

“Applying Problem-Solving to Interpersonal Conflict” in the Adult Psycho­ therapy Homework Planner by Jongsma

Assign the client a homework exercise in which he/she problem-solves a current problem; review, reinforce success, and provide corrective feedback toward improvement.

Mastery of Your Anxiety and Worry: Workbook by Craske and Barlow

Generalized Anxiety Disorder by Brown, O’Leary, and Barlow

Objective:

Identify, create a list, and engage in pleasant activities on a daily basis.

Interventions:

Engage the client in behavioral activation, increasing the client’s contact with sources of reward, identifying processes that inhibit activation, and teaching skills to solve life problems; use behavioral techniques such as instruction, rehearsal, role-playing, role reversal as needed to assist adoption into the client’s daily life; reinforce success.

“Identify and Schedule Pleasant Activities” in the Adult Psychotherapy Homework Planner by Jongsma

Objective:

Learn and implement personal and interpersonal skills to reduce anxiety and improve interpersonal relationships.

Interventions:

Use instruction, modeling, and role-playing to build the client’s general social, communication, and/or conflict resolution skills.

Assign the client a homework exercise in which he/she implements communication skills training into his/her daily life; review, reinforce success, and provide corrective feedback toward improvement.

“Restoring Socialization Comfort” in the Adult Psychotherapy Homework Planner by Jongsma

Objective:

Learn and implement relapse prevention strategies for managing possible future anxiety symptoms.

Interventions:

Discuss with the client the distinction between a lapse and relapse, associating a lapse with an initial and reversible return of worry, anxiety symptoms, or urges to avoid, and relapse with the decision to continue the fearful and avoidant patterns.

Identify and rehearse with the client the management of future situations or circumstances in which lapses could occur.

Instruct the client to routinely use new therapeutic skills (e.g., relaxation, cognitive restructuring, exposure, and problem-solving) in daily life to address emergent worries, anxiety, and avoidant tendencies.

Develop a “coping card” on which coping strategies and other important information (e.g., “Breathe deeply and relax,” “Challenge unrealistic worries,” “Use problem-solving”) are written for the client’s later use.

Schedule periodic “maintenance” sessions to help the client maintain therapeutic gains.

Objective:

Learn to accept limitations in life and commit to tolerating, rather than avoiding, unpleasant emotions while acomplishing meaningful goals.

Intervention:

Use techniques from Acceptance and Commitment Therapy to help client accept uncomfortable realities such as lack of complete control, imperfections, and uncertainty and tolerate unpleasant emotions and thoughts in order to accomplish value-consistent goals.

Objective:

Utilize a paradoxical intervention technique to reduce the anxiety response.

Intervention:

Develop a paradoxical intervention (see Ordeal Therapy by Haley) in which the client is encouraged to have the problem (e.g., anxiety) and then schedule that anxiety to occur at specific intervals each day (at a time of day/night when the client would be clearly wanting to do something else) in a specific way and for a defined length of time.

Objective:

Complete a Cost Benefit Analysis of maintaining the anxiety.

Interventions:

Ask the client to evaluate the costs and benefits of worries in which he/she lists the advantages and disadvantages of the negative thought, fear, or anxiety; process the completed assignment.

Complete the Cost Benefit Analysis exercise in Ten Days to Self-Esteem! by Burns

Objective:

Identify the major life conflicts from the past and present that form the basis for present anxiety.

Interventions:

Assist the client in becoming aware of key unresolved life conflicts and in starting to work toward their resolution.

Reinforce the client’s insights into the role of his/her past emotional pain and present.

Ask the client to develop and process a list of key past and present life conflicts that continue to cause worry.

Objective:

Maintain involvement in work, family, and social activities.

Intervention:

Support the client in following through with work, family, and social activities rather than escaping or avoiding them to focus on anxiety.

Objective:

Reestablish a consistent sleep­ wake cycle.

Intervention:

Teach and implement sleep hygiene practices to help the client reestablish a consistent sleep-wake cycle; review, reinforce success, and provide corrective feedback toward improvement.