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This program, developed by the Center for School Mental Health, offers relaxation techniques for managing anxiety. It includes deep breathing, mental imagery, progressive muscle relaxation, and cognitive coping strategies.
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ANXIETY 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
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 anxiety-provoking situations • 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 anxiety-provoking conditions. 1. 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