| SHORT-TERM OBJECTIVES | THERAPEUTIC INTERVENTIONS |
| Work cooperatively with the therapist toward agreed-upon therapeutic goals while being as open and honest as comfort and trust allow. (1, 2) | Establish rapport with the client toward building a strong therapeutic alliance; convey caring, support, warmth, and empathy; provide nonjudgmental support and develop a level of trust with the client toward him/her/their feeling safe to discuss his/her/their generalized anxiety and its impact on his/her/their life. |
| | Strengthen powerful relationship factors within the therapy process and foster the therapy alliance through paying special attention to these empirically supported factors: work collaboratively with the client in the treatment process; reach agreement on the goals and expectations of therapy; demonstrate consistent empathy toward the client's feelings and struggles; verbalize positive regard toward and affirmation of the client; and collect and deliver client feedback as to the client's perception of his/her/their progress in therapy (see Psychotherapy Relationships That Work: Vol. 1 by Norcross & Lambert and Psychotherapy Relationships That Work: Vol. 2 by Norcross & Wampold). |
| Describe situations, thoughts, feelings, and actions associated with anxieties and worries, their impact on functioning, and attempts to resolve them. (3) | Ask the client to describe his/her/their 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/their anxiety symptoms (consider using a structured interview such as the Anxiety and Related Disorders Interview Schedule for the DSM-5). |
| Complete psychological tests designed to assess worry and anxiety symptoms. (4) | Administer psychological tests or objective measures to help assess the nature and degree of the client's worry and anxiety and their impact on functioning (e.g. The Penn State Worry Questionnaire; OQ-45.2; the Symptom Checklist-90-R). |
| Cooperate with and complete a medical evaluation. (5) | Arrange for a medical evaluation to rule out nonpsychiatric medical and substance-induced etiologies (e.g. hyperthyroidism, stimulant use). |
| 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. (6, 7, 8, 9) | Assess the client's level of insight (syntonic versus dystonic) toward the presenting problems (e.g. 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.g. 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). |
| Cooperate with a medication evaluation by a prescriber. (10, 11) | Refer the client to a prescriber for a medication evaluation. |
| | Monitor the client's medication adherence, side effects, and effectiveness; consult with the prescriber, as needed. |
| Discuss ambivalence about changing current worry patterns toward deciding on whether to make changes. (12) | Use Motivational Interviewing techniques to assess the client's current stage of change and willingness to take action steps toward change (see Motivational Interviewing by Miller & Rollnick). |
| Acknowledge the powerlessness and unmanageability caused by excessive anxiety and addiction. (13, 14) | Help the client understand how anxiety and powerlessness over addiction have made his/her/their life unmanageable. |
| | Teach the client about the relationship between anxiety and addiction (e.g. how the substance was used to treat the anxious symptoms, why more substance use became necessary; or supplement with “Coping with Stress” in the Addiction Treatment Homework Planner by Lenz, Finley, & Jongsma). |
| Verbalize an understanding of the cognitive, physiological, and behavioral components of anxiety and its treatment. (15, 16, 17) | Discuss how anxiety typically involves excessive worry about unrealistically appraised threats, various bodily expressions of overarousal, hypervigilance, and avoidance of what is threatening that interact to maintain the problem (see Mastery of Your Anxiety and Worry: Therapist Guide by Zinbarg, Craske, & Barlow; Treating Generalized Anxiety Disorder by Rygh & Sanderson). |
| | Discuss how treatment targets worry, anxiety symptoms, and avoidance to help the client manage worry effectively, reduce overarousal, eliminate unnecessary avoidance, and reengage in rewarding activities. |
| | Assign the client to read psychoeducational materials as a bibliotherapy adjunct to in-session work (e.g. Mastery of Your Anxiety and Worry: Workbook by Craske & Barlow; The Anxiety and Worry Workbook by Clark & Beck). |
| Learn and implement calming skills to reduce overall anxiety and manage anxiety. (18, 19) | Teach the client calming/relaxation/mindfulness skills such as applied relaxation, progressive muscle relaxation, cue controlled relaxation, mindful breathing, and biofeedback as well as how to discriminate better between relaxation and tension (or supplement with “Progressive Muscle Relaxation” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, McInnis, & Bruce); teach the client how to apply these skills to his/her/their daily life (see New Directions in Progressive Muscle Relaxation by Bernstein, Borkovec, & Hazlett-Stevens; or supplement with The Relaxation and Stress Reduction Workbook by Davis, et al.). |
| | Assign the client homework in which he/she/they practice calming/ relaxation/mindfulness skills daily, gradually applying them progressively from non-anxiety-provoking to anxiety-provoking situations; review and reinforce success; problem-solve obstacles toward sustained implementation (or supplement with “Deep Breathing Exercise” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce). |
| Learn and implement a strategy to limit the association between various environmental settings and worry, delaying the worry until a designated “worry time.” (20, 21) | Explain the rationale and teach a worry time intervention in which the client postpones interacting with worries until a designated time and place (or supplement with “Worry Time” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce); use worry time for exposure (repeating worry toward extinction) and/or the application of problem-solving skills to address worries; 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 (or supplement with “Making Use of the Thought-Stopping Technique” to assist in skill development); encourage use in daily life; review and reinforce success; problem-solve obstacles toward sustained implementation. |
| Verbalize an understanding of the role that thinking plays in worry, anxiety, and avoidance. (22, 23, 24) | Discuss examples that demonstrate how unproductive worry typically overestimates the probability of threats and underestimates or overlooks the client's ability to manage realistic demands (or supplement with “Past Successful Anxiety Coping” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce). |
| | Assist the client in analyzing his/her/their worries by examining potential biases such as the probability of the negative expectation occurring, the real consequences of it occurring, his/her/their ability to control the outcome, the worst possible outcome, and his/her/their ability to accept it (or supplement with “Analyze the Probability of a Feared Event” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce; Cognitive Therapy of Anxiety Disorders by Clark & Beck). |
| | Convey how worry creates acute and/or chronic anxious apprehension, leading to avoidance that precludes finding solutions to problems, thus maintaining them and the worry-avoidance cycle. |
| Identify, challenge, and replace biased, fearful self-talk with positive, realistic, and empowering self-talk. (25, 26) | Using techniques from cognitive behavioral therapies including Intolerance of Uncertainty and Metacognitive therapies, explore the client's self-talk, underlying assumptions, schema, or metacognition that mediate his/her/their anxiety; assist him/her/them in challenging and changing biases; conduct behavioral experiments to test biased versus unbiased predictions toward dispelling unproductive worry and increasing self-confidence in addressing the subject of worry (see Cognitive Therapy of Anxiety Disorders by Clark & Beck; Metacognitive Therapy for Anxiety and Depression by Wells). |
| | Assign the client a homework exercise in which he/she/they identify fearful self-talk, identify biases in the self-talk, generate alternatives, and test through behavioral experiments (or supplement with “Negative Thoughts Trigger Negative Feelings” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce); review and reinforce success, providing corrective feedback toward improvement. |
| Participate in gradual imaginal and/or live exposure to the feared negative consequences predicted by worries and develop alternative reality-based predictions. (27, 28, 29, 30, 31) | Direct and assist the client in constructing a hierarchy of feared and avoided activities such as travel, medical procedures or conditions, or social events (or supplement with “Gradually Reducing Your Phobic Fear” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce). |
| | Select initial exposures that have a high likelihood of being a successful experience for the client; develop a plan for managing the emotion(s) engendered by exposure; mentally rehearse the procedure. |
| | Conduct worry exposure by asking the client to vividly imagine worst-case consequences of worries, holding them in mind until anxiety associated with them decreases (up to 30 minutes); generate reality-based alternatives to that worst case and process them (see Mastery of Your Anxiety and Worry: Therapist Guide by Zinbarg, Craske, & Barlow). |
| | Conduct exposure in vivo to activities that the client avoids due to unrealistic worry, gradually targeting the removal of any unnecessary, anxiety-driven safety behaviors (see Mastery of Your Anxiety and Worry: Therapist Guide by Zinbarg, Craske, & Barlow). |
| | Assign the client a homework exercise in which he/she/they do worry exposures and record responses (see Mastery of Your Anxiety and Worry: Workbook by Craske & Barlow); review, reinforce success, and provide corrective feedback toward improvement. |
| Learn and implement problem-solving strategies for realistically addressing worries. (32, 33) | Teach the client problem-solving/solution-finding strategies to replace unproductive worry and/or avoidance involving specifically defining a problem, generating options for addressing it, evaluating the pros and cons of each option, selecting and implementing an action plan, and reevaluating and refining the action. |
| | Assign the client a homework exercise in which he/she/they problem-solve a current problem about which he/she/they worry (or supplement with “Applying Problem Solving to Interpersonal Conflict” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce; see Mastery of Your Anxiety and Worry: Workbook by Craske & Barlow); review, reinforce success, and problem-solve obstacles toward sustained implementation. |
| Identify and engage in rewarding activities on a daily basis. (34) | 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 (or supplement with “Identify and Schedule Pleasant Activities” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce); use behavioral techniques such as instruction, rehearsal, role-playing, role reversal as needed to assist adoption into the client's daily life; reinforce success; problem-solve obstacles toward sustained implementation. |
| Learn and implement personal and interpersonal skills to reduce anxiety and improve interpersonal relationships. (35, 36) | 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/they implement social skills into his/her/their daily life (or supplement with “Restoring Socialization Comfort” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce); review, reinforce success, and problem-solve obstacles toward sustained implementation. |
| Learn a nonjudgmental, accepting approach to worries, overcoming avoidance, and engaging in action toward personally meaningful goals. (37) | Use techniques from acceptance-based therapies including psychoeducation about worry, mindfulness, cue detection, monitoring and decentering, relaxation, and mindful action toward expanding present-moment awareness; encourage acceptance rather than judgment and avoidance of internal experiences; and promote action in areas of importance to the individual (see An Acceptance-Based Behavioral Therapy for Generalized Anxiety Disorder by Roemer & Orsillo; and/or supplement by asking the client to read The Mindful Way Through Anxiety by Orsillo & Roemer as an adjunct to the therapy). |
| Learn and implement relapse prevention strategies for preventing or managing possible setbacks. (38, 39, 40, 41, 42) | Discuss with the client the distinction between a lapse and relapse, associating a lapse with an initial, potentially temporary, and reversible return of worry, anxiety symptoms, or urges to avoid, and relapse with the decision to return to previous fearful and avoidant patterns in a more sustained manner. |
| | Identify and rehearse with the client the management of future situations or circumstances in which lapses could occur (i.e. high-risk times). |
| | Instruct the client to continue using his/her/their new and effective 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” or other reminder on which new and effective worry management skills and other important information (e.g. “Breathe deeply and relax,” “Challenge unrealistic worries,” “Use problem solving”) are available to the client for later use. |
| | Schedule periodic “maintenance” sessions to help the client maintain therapeutic gains. |
| Identify the fears that were learned in the family of origin and relate these fears to current anxiety levels. (43, 44) | Probe the client's family-of-origin experiences for fear-producing situations; help him/her/them relate these past events to current anxious thoughts, feelings, and behaviors; encourage and support the client's verbal expression and clarification of his/her/their feelings that are associated with past rejection experiences, harsh criticism, abandonment, or trauma. |
| | Assign the client to read books on resolving painful early family experiences (e.g. Healing the Shame That Binds You by Bradshaw or Facing Shame by Fossum & Mason); process key concepts learned from the reading. |
| Write a specific plan to follow when anxious and subsequently craving substance use. (45, 46, 47) | Assist the client in developing a list of 10 positive statements to read to oneself several times per day, particularly when feeling anxious (or supplement with “Positive Self-Talk” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce). |
| | Using a 12-step program's Step 3 exercise, show the client how to turn over problems, worries, and anxieties to a higher power and to trust that the higher power is going to help him/her/them resolve the situation. |
| | Help the client develop an alternative constructive plan of action (e.g. relaxation exercises, physical exercise, calling a sponsor, going to a meeting, calling the counselor, talking to someone) when feeling anxious and craving substance use (or supplement with “Coping with Stress” in the Addiction Treatment Homework Planner by Lenz, Finley, & Jongsma). |
| Write an autobiography, detailing those behaviors in the past that are related to current anxiety or guilt, and the subsequent abuse of substances as a means of escape. (48, 49) | Probe the client's family-of-origin experiences for fear-producing situations; help him/her/them relate these past events to current anxious thoughts, feelings, and behaviors, and discuss alternative approaches to relating to them. |
| | Using a 12-step program's Step 4 exercise, have the client write an autobiography detailing the exact nature of his/her/their mistakes; teach the client how to begin to forgive himself/herself and others (or assign the client to complete the Step 4 exercise from The Alcoholism and Drug Abuse Client Workbook by Perkinson). |
| Develop a program of recovery that includes regularly helping others at recovery group meetings. (50) | Help the client develop a structured program of recovery that includes regularly helping others at 12-step program recovery groups (or supplement with “Aftercare Plan Components” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce). |
| Family members verbalize an understanding of anxiety and addiction and discuss the ways they and the client can facilitate the recovery process. (51, 52) | Provide the family members with information about anxiety and addiction and the tools that are used to assist the client in recovery. |
| | Assist each family member in developing a list of three things that he/she/they can do to assist the client in recovery; hold a family session to facilitate communication of the actions on the list. |
| Complete a survey to assess the degree of satisfaction with treatment. (53) | Administer a survey to assess the client's degree of satisfaction with treatment. |
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