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Clinical Prompt

Step 1 Relaxation [ See Technique #04]

  • Daily full progressive muscle relaxation procedure
  • Five [05] times daily cue-controlled relaxation routine

Step 2 Risk Assessment Procedure

  • estimating probability
  • predicting outcome

Step 3 Worry Exposure Procedure

  • list worries
  • rank worries
  • relax
  • visualize a worry
  • rate a peak anxiety 0 – 100
  • imagine alternative outcomes
  • re-rate anxiety 0 – 100
  • repeat

Step 4 Worry Behavior Prevention Procedure

  • record worry behavior
  • pick easiest behavior to stop
  • replace with new behavior
  • assess anxiety before and after
  • repeat with next easiest behavior

Forms & Charts

  • Risk Assessment Form CBT#05-001

Download Available | Risk Assessment Form


Worry is a natural response to anticipated future problems. But when worry gets out of hand, it can become an almost full-time preoccupation. Your client has a serious problem with worry if s/he:

  • is chronically anxious about future dangers or threats.
  • consistently makes negative predictions about the future.
  • often overestimates the probability or seriousness of bad things happening.
  • can’t stop repeating the same worries over and over.
  • escapes worry by distracting him/herself or avoiding certain situations.
  • finds it difficult to use worry constructively to produce solutions to problems.

This technique will teach your clients control worry in four ways.

  1. practice regularly the relaxation techniques.
  2. conduct, accurate risk assessments to counter any tendency to overestimate future danger.
  3. practice worry exposure, scheduling a thirty-minute period each day for full-scale, concentrated, organized worrying.
  4. use worry behavior prevention, for controlling the ineffective strategies used now.

Symptom Effectiveness

Relaxation, risk assessment, and worry exposure have been found to be effective in reducing the excessive worry that is the chief feature of Generalized Anxiety Disorder (O’Leary et al. 1992). Worry behavior prevention has also been found to be helpful in curbing ritual, preventive, and corrective behaviors that tend to perpetuate worry.

Studies to date show cognitive behavioral techniques to work only about as well as other interventions to control or diminish worry (Brown et al. 1992). This may be because clinicians haven’t hit upon just the right combination of techniques, because of unclear diagnostic categories and treatment protocols in some early studies, or because we simply don’t understand what makes worry so persistent.

Time for Mastery

It will take one or two weeks for your client to learn to relax using deep breathing, pleasant imagery, and cue-controlled relaxation. At the same time, they can begin the process of assessing risks. Then you can begin teaching worry exposure and should notice improvements by the second or third exposure session.

Worry prevention takes only an hour or two to put into practice, and its benefits can be felt immediately. All told, you can expect to see positive progress in about a month.


Worry is not just a mental process. When you worry, you enter into a cyclical pattern that involves your thoughts, your body, and your behavior. On the following page is a diagram of the worry system.

An event starts worry thoughts going, and the child starts feeling anxious.

The heart starts beating faster, breathing quickens, the skin gets sweaty, the muscles tense, and the child may have other physical symptoms associated with the flight-or-fight response.

On the behavioral level, the child may take action to avoid the upsetting situation or place. Or the child may begin “checking” behavior, such as calling to see if a loved one is all right or proofreading a report for the fifth time.

To control worry, the child will need to approach it on all these levels. The first step is to deal with physical stress reactions by practicing relaxation exercises. To address the cognitive features of worry, s/he will need to take two more steps: risk assessment and worry exposure. Then s/he will get the behavioral problems under control with the fourth and last step, worry behavior prevention.

Step 1. Relaxation

The Child should master progressive muscle relaxation and cue-controlled relaxation first. Chronic worry creates chronic muscular tension. By practicing relaxation daily, s/he can provide crucial breaks in the cycle of flight/fight reactions that worry causes.

The child will need to take the time once a day to perform the full progressive muscle relaxation procedure. You can help by setting aside an inviolate time each day when, no matter what else is going on, the child will do the relaxation exercise. It’s important that s/he practice daily and doesn’t skip or shorten the practice sessions. Reaching a profound level of deep relaxation once a day is an important part of worry control that cannot be postponed or “made up” the next day if it is skipped today.

Five times a day, at more or less regular intervals, have the child do a quick cue-controlled relaxation. This only takes a moment and s/he can do it anywhere. Frequent relaxing moments will keep their overall level of physical stress under control.

It may be necessary, depending upon the time per day which you are assigned with the child and the other expectations placed upon that time, to arrange for the parents or teachers to learn the Relaxation Technique and monitor its use by the child. This should be arranged through the Clinical Supervisor.

Step 2. Risk Assessment

If worry is a problem for the child, s/he probably has not learned the skill and art of risk assessment. No one can escape risk in life. The trick is to know which risks can be avoided, which can be prepared for, and which simply don’t have to worried about.

Estimating Probability

People who worry a lot consistently overestimate risk. Some think that there is a high chance of a traffic accident every time they get in a car. Others worry excessively about making a mistake at school, even though they have seldom or never made a big mistake.

Overestimation happens because of some combination of experience and belief: how much weight to give to personal experience, and the beliefs about the function of worry.

1. Experience There are two ways that the child’s own personal history can influence his/her worry. First, they may ignore historical evidence. Nothing too bad has ever happened, but that doesn’t stop them from worrying about forgetting something important or losing an important relationship. People who think this way, see every day that passes without disaster as increasing the odds of bad things happening.

The other way is if something bad did happen to him/her once. In this case, the child may give this historical evidence too much weight. s/he figures that anything that happened once is likely to happen again – that lightning not only strikes twice, but actually likes to strike the same spot over and over.

2. Belief There are two ways that deeply held, unexamined beliefs can make worry worse. First, the child might believe in the predictive power of worry. If s/he worries about it, this is a sign that it is going to happen. The second way belief is supported is that the child believes in the preventive power of worry. In this case, the child unconsciously assumes that bad things have not happened because s/he worries about them happening. S/he feels like a sentry on guard, ever vigilant, keeping trouble at bay.

The problem with these ways of overestimating risk is that they subtly increase the worry until it becomes a bigger problem than the danger the child worries about. The way out of this trap is for the child to learn accurate risk assessment.

Predicting Outcomes

Even if the worries come to pass, will the outcome be as catastrophic as feared? Most people who worry a lot consistently predict unreasonably catastrophic outcomes. This is “catastrophizing.”

When you worry, your anxiety makes you forget that people routinely cope with even the most serious disasters. You forget that you and your family and friends will probably find a way to cope with whatever happens.

You can teach the child to use the Risk Assessment Form [CBT#05-001] to make accurate risk assessments by lowering anxiety, estimating accurate probabilities, and making reasonable outcome predictions. On the first line, the child should record one of their worries in the form of a feared event. Have the child write down, or write down for them, the worst possible version of the worry s/he can think of. For example, if s/he worries about going out at night, have them imagine the worst: a head-on collision of drunk teens and a big truck, everybody dead on impact or dying in the emergency room after suffering horribly.

On the second line, have the child write the automatic thoughts that typically come up: I’ll die … bloody pain … Things will never be the same … awful … can’t stand it . ..” Have them jot down whatever comes to mind, even if it is just an image or a fleeting word.

Next, have the child rate the anxiety when considering this worst-case scenario. Use 0 for no anxiety and 100 for the worst fear they have ever experienced. Then have the child rate the probability of this worst-case scenario coming to pass—from 0% for no likelihood at all to 100% for absolute inevitability. You may need to dispute this rating, if you find it unreasonable. Use examples or questions to influence the child to see the likelihood more reasonably. But this must be the child’s rating, you cannot have them change simply to please you. What they believe is what they believe, and unless you can present convincing evidence or help them think through the issue in a way that they arrive at a different conclusion, they should use the rating they have.

The next four questions on the form deal with catastrophic thinking. Assuming that the worst did happen, have the child predict the consequences s/he most fears. Then spend some time figuring out what they would tell themselves and what they would do in order to cope with the catastrophe. When they have a clear picture of possible coping strategies, have them make a revised prediction of the consequences. After these predictions, have them re-rate the anxiety and see if it has diminished.

The next two questions on the form address the issue of overestimation. Have the child list the evidence against the very worst outcome happening. S/he should figure the odds as realistically as s/he can.You may want them to go to the library and find out how often such accidents happen and what percentage of teenagers are involved. [Also, remember the Book Innumeracy] Then have them list all the alternative outcomes they can think of. Finally, have them re-rate the anxiety and the probability of the event. The child should find that both the anxiety and probability ratings have declined as the result of making a full and objective risk assessment.

The client should fill out the Risk Assessment Form each time they are confronted by a significant worry, or whenever they return to a worry more than once. It’s important to have him/her do this exercise consistently. Each risk assessment helps them change old habits of catastrophic thinking.

When the child has completed a risk assessment, s/he should keep the form. S/he may wish to refer to it again when confronting a similar worry.

Step 3. Worry Exposure

When practicing worry exposure, the child will expose him/herself to minor worries first, experiencing them for thirty minutes at a time. When minor worries no longer cause painful anxiety, s/he will move on to more distressing worries. Gradually, the child will learn to take on major worries with little or no anxiety.

Worry exposure is similar to flooding, a technique that “floods” the imagination with fearful images until you grow tired of them. Given enough time and focused attention, even the most upsetting material becomes overly familiar and boring, making it less upsetting the next time it is encountered. This effect doesn’t happen when the child simply worries on his/her own because s/he doesn’t spend enough time dwelling on only the worst possible outcome. When you do “free form” worrying, without a structure, you try to distract yourself, argue with yourself, escape into another topic, perform ritual checking or avoiding behaviors, and so on, gaining none of the benefits of structured worry exposure.

Worry exposure also works well because it concentrates the worrying time. When the child knows that s/he will be worrying intensely during the daily exposure session, it’s easier to clear his/her mind of worry during the rest of the day.

Worry exposure consists of eight simple steps:
  1. List the Worries. Have the child write a list [Risk Assessment Form # CBT#05-001] of the things s/he worries about. Include worries about success and failure, relationships, performance at school or work, physical danger, health, making mistakes, rejection, shame over past events, and so on.
  2. Rank the Worries. Have the child pick the least anxiety-provoking item on the list of worries and write it at the top of a new list. Then put down the next least distressing worry. Continue until the child has reordered all of his/her worries, ranking them into a hierarchy that runs from the least to the most anxiety provoking.
  3. Relax. The child is now ready to work with the first worry on the list. Have him/her get into a comfortable position, breathe deeply, and begin cue-controlled relaxation. Let tension drain out of the body.
  4. Visualize a Worry. The child should vividly imagine the item from the hierarchy of worries. S/he should try to see the worst coming to pass, over and over again. S/he should stick with the worst possible outcome and focus on the sights, the sounds, the tastes, the smells, and the sensations as if it were really happening. Don’t just see the scene from an outside vantage point, as if s/he were watching a movie. Rather, s/he should imagine that s/he is an active participant, in the middle of the action.The child should try not to imagine any alternative scenarios. S/he should stick with the worst alternative and not allow the mind to wander and escape into distraction. Have the child do this for twenty-five minutes. Have him/her set a kitchen timer to keep track of the time. S/he should be sure that s/he doesn’t stop early, even if the anxiety is high, even if s/he’s bored.

    If you find that the child’s anxiety level is low, nowhere near the anxiety s/he feels during a “real” worry session, s/he may be having trouble creating sufficiently vivid images. Have the child try switching from the visual sense to another sense. Most people imagine with visual images. But some do better with sounds, textures, or smells.

  5. Rate the Peak Anxiety from 0-100. While the child is visualizing, s/he should rate highest anxiety level. S/he can jot down numbers on a piece of scrap paper without even opening his/her eyes. Use a rating of 0 for no anxiety, and a rating of 100 for the worst s/he has ever experienced.
  6. Imagine Alternative Outcomes. Now you can allow the child to visualize alternative, less stressful outcomes. This can be started after a full twenty-five minutes of visualizing the worst possible outcome. Don’t start it early. Have the child spend just five minutes imagining an outcome that is not as bad as his/her worst scenario.
  7. Re-rate Anxiety from 0-100. After the five minutes of alternative outcomes, have the child re-rate the anxiety. It will probably be notably lower than the previous rating.
  8. Repeat. Repeat steps D through G with the same worry until peak anxiety is 25 or less. Then go on and do the procedure with the next worry on your hierarchy. Do at least one session a day. If you have time and the child can tolerate it, you can do several sessions a day. By the time the child has worked through the hierarchy, s/he should find that worry is significantly reduced.

Step 4. Worry Behavior Prevention

The child may habitually perform or avoid certain behaviors to keep bad things from happening. Close examination will show that these ritual or preventive behaviors [knocking on wood] are actually perpetuating the worry and have no power to prevent bad things from happening.

You can prevent worry behavior by following these simple steps:

  1. Record Worry Behavior.Have the child write down the things s/he does to prevent the disasters s/he worries about from happening.
  2. Pick the Easiest Behavior to Stop and Predict Consequences of Stopping It.Have the child pick the worry behavior that would be easiest to stop and write it down. Then have him/her write down the predicted consequences.
  3. Stop the Easiest Behavior and/or Replace It With a New Behavior.This is the hard part. In order to find out if the child’s prediction will come true, s/he will need to conduct a scientific experiment. S/he will need to resolve to refrain from the behavior the next time they start worrying.

    If the worry behavior is a form of avoidance, such as not walking past the cemetery or never reading the obituaries, it’s hard to stop doing it. The child will have to start doing what s/he has been avoiding. The child should resolve to walk past the cemetery every morning on the way to school, or read the obituaries at breakfast.

    Sometimes even the “easiest” behavior to stop is not so easy. In that case, the child will need to create a hierarchy of replacement behaviors that allows him/her to taper off from the worry behavior.

  4. Assess Anxiety Before and After.When the child felt like performing the old behavior and knew s/he was not going to do it, how anxious was s/he? Have him/her rate anxiety from 0-100, with 0 standing for no anxiety. Now, after performing the new behavior or the cut-down version of the old behavior, how anxious is s/he? Have him/her rate the anxiety again from 0-100. Has the anxiety diminished?

    Also assess the consequences. What actually happened as a result of the reduced or new behavior? Did the dire predictions come true?

  5. Repeat Steps B through D With the Next-Easiest Behavior.From the initial list, pick the worry behavior that is the next easiest to stop, and repeat the steps: Predict the consequences of stopping the behavior; stop it and replace it with a new behavior if appropriate; then assess your anxiety level before and after the experiment.