The enclosed techniques and procedures were developed with materials from a workbook of cognitive behavior techniques titled “Thoughts & Feelings and written by Matthew McKay, Martha Davis, and Patrick Fanning. The workbook was published by New Harbinger Publications, Inc in 1997.
Clinical Prompt
The child will need to develop specific self-instructional coping statements to:
- help physically relax,
- remind themselves of the action plan should they encounter problems during exposure,
- cope with anxious arousal and fight-or-flight symptoms,
- cope with catastrophic thoughts,
- accept anxious feelings as temporary and learn to float past them and, finally,
- distract themselves, if necessary, from frightening thoughts.
There are two options to the coping scripts: memorization or recording.
Step 1: Relaxation – Review Technique #04
Step 2: Action Plan
- identify anxiety levels
- identify safe zone
- identify return policy
- develop anticipation
Step 3: Coping with arousal
- symptom explanation
- coping thoughts
Step 4: Catastrophic Thoughts
- visualize experience
- Coping Thoughts Worksheet [what ifs]
- rating anxiety
- evidence for/against
Key Questions to ask the child:
- What would the likely outcome be if the problem you worry about occurred? Is it as bad as you imagine?
- What are the realistic odds that the problem you worry about will occur?
- Are there things that make the problem I worry about unlikely to happen?
- What past experience do I have that suggests the problem is unlikely to occur?
- What is most likely to happen while I’m in the exposure situation? What could I realistically expect”
- How could I cope if the problem I worry about occurred? Have I ever coped with this before or known anyone who successfully coped with this problem? How did I or they handle it?
- Could others help me if the problem I worry about occurred?
- Are there other resources I have or could bring to the situation that would make me feel safer?
- Is there anything about the situation that might, if I thought about it, increase my feelings of confidence or safety?
Step 5: Accepting & Floating
- mantras
- Float past, do not listen
- Accept, do not fight
Step 6: Distraction
- This is an optional component
- Focus attention on a mental task
- Making a Script: Have the child assemble the components of the coping plan into a powerful resource s/he can use during exposure.
Forms & Charts
Bourne Anxiety Scale CBM#10-006 (preparing for upload)
Symptom Explanation Chart CBM#08-001
Catastrophic Thoughts Worksheet CBM#11-001
Download Available | CBMT 11 Supplemental Docs
Introduction
Full recovery from any phobia depends on successfully exposing the client in real life to core elements of their fear. If the child has developed a hierarchy of feared situations and visualized scenes from that hierarchy while relaxing the body and using helpful coping thoughts, s/he may now continue work on his/her phobia through in vivo exposure to the actual scenes and situations. To handle the inevitable anxiety that will come up during exposure, the child will need a coping script to help respond effectively to anxious arousal.
The use of self-instructional coping statements was first introduced by Donald Meichenbaum (1974) when he proposed a method for people to talk themselves through stressful events. In his research with children, Meichenbaum observed that children use self instruction while undertaking new or difficult tasks. They softly talk themselves through the process, reminding themselves of steps in the sequence. While adolescents and adults have forgotten how to do this, Meichenbaum found that he could train them to do what had once been natural – to use subvocal reminders of coping techniques.
McKay, Fanning and Davis have adapted Meichenbaum’s ideas into a coping script that can be used while learning to face feared situations. The child will need to develop specific self-instructions to:
- help physically relax,
- remind themselves of the action plan should they encounter problems during exposure,
- cope with anxious arousal and fight-or-flight symptoms,
- cope with catastrophic thoughts,
- accept anxious feelings as temporary and learn to float past them and, finally,
- distract themselves, if necessary, from frightening thoughts.
There are two options for how to use a coping script. The first is to memorize key elements of the script and use them as needed during exposure. The second is to record the script on tape and then listen to it on a portable cassette player while entering a feared situation. The one advantage of a portable cassette player is that it will remind the child of coping strategies even if anxiety is making it hard to think and remember what s/he wanted to do.
Symptom Effectiveness
The use of coping scripts has been studied as a part of stress inoculation training (Meichenbaum 1977). Coping scripts used in imagery desensitization have been shown effective in the treatment of phobias.
Time for Mastery
The client can develop his/her own individualized coping script in one to three hours. Once you’ve written it on a file card or recorded it, it can be used immediately to help cope during exposure.
Instructions
Step 1: Relaxing
The key element in the coping script is reminding the child to use the relaxation skills. The most effective stress control techniques during exposure are deep breathing and cue-controlled relaxation in combination.
Deep-breathing skills should be overlearned so that the client can take a deep, diaphragmatic breath without a lot of thought or effort. See Technique #04 for relaxation instructions if the child has not fully mastered this skill.
Be sure that the child has selected a cue word or phrase, and learned how to relax the whole body while taking deep breaths and repeating the cue.
With mastery of deep breathing and cue-controlled relaxation, the child should be able to relax the major areas of tension in his/her body in less than a minute. The speed with which the child achieves cue-controlled relaxation is important because real-life stressful situations require a rapid response. The longer the child feels tense, the more likely s/he is to experience anxiety.
Now the child can write the first component of a coping script. This is a sentence or phrase that will remind him/her to use deep breathing and cue-controlled relaxation. Here are some examples:
- Take a deep breath and relax.
- Relax the hot spots.
- Relax and let go.
- Breathe away stress.
- Breathe and let go.
If none of these reminders feels right, have the child write his/her own. Another option is simply to use a cue word or phrase as the instruction to relax.
Step 2: Action Plan
Now it’s time for some contingency planning – planning things that the child will do if they have problems during exposure practice. The first problem to be prepared for is too high a level of anxiety. The Bourne Anxiety Scale [CBT#10-006] allows the child to gauge whether the anxiety is too high during imagery or in vivo exposure. If anxiety is at Level 4 marked anxiety – or above, the child will need a way to retreat from the situation. Remember that marked anxiety means “feeling uncomfortable or spacy; heart beating fast; muscles tight; beginning to wonder about maintaining control.” When the anxiety symptoms reach this point during exposure, the child will need a place to go where they are out of the immediate stressful situation and have the freedom to do relaxation exercises.
The key element of the action plan for retreat is to identify a safe zone that the child can easily reach. Once in the safe zone, the child can focus on muscle relaxation, breathing, and peaceful visualizations to bring the anxiety back down to moderate or mild levels. When the child has reduced the anxiety to Levels 2 or 3 on the Bourne Scale, s/he should return to in vivo exposure. Letting anxiety stop the exposure work altogether only reinforces the phobia. The action plan for retreat allows the child to relax in a safe place, but then s/he must return to finish the practice. It’s not at all unusual to retreat two, three, or even more times before the client is successful with a certain step in exposure work. Don’t let the child be discouraged. Retreating is a necessary part of recovery.
A second element in the action plan is the development of strategies for handling typical problems that may arise in exposure settings. For example, what do you do if the child is attempting exposure practice in a restaurant, but there is a long wait to give the order and service seems extremely slow? You might plan that the child will continue the exposure work at a short-order coffee shop, or order just a single course. Suppose the exposure work involves conversing with strangers in a social situation? You might need to help the child create a plan for dealing with someone who is a bit rejecting or irritated.
By anticipating typical problems and having a pre-established strategy for coping, the child will feel more confidence when approaching exposure work. Include in the coping script a reminder that the action plan is in place. The child might use phrases such as
- I have a plan to cope.
- I know what to do when problems occur.
- I can handle problems; I have a plan.
Step 3: Coping with Arousal
If the child has physiological symptoms of anxiety that worry them during exposure practice, you’ll need to include in the coping script reminders of how harmless these symptoms truly are. You should review with the child the information on coping with panic to get specific medical information [See Symptom Explanation Chart CBT#08-001] on the cause of anxiety symptoms. Armed with clear medical information, you can help the child reinterpret these symptoms as harmless fight-or-flight reactions. Here is a review of recommended coping thoughts for specific anxiety symptoms:
- Racing heart: A healthy heart can go more than 200 beats a minute for weeks without damage. A few minutes, or even a few hours, of rapid heartbeat can’t hurt you.
- Light-headedness/feeling faint: This is due to simple hyperventilation or the normal temporary narrowing of the blood vessels triggered by stress hormones. It can’t hurt you and will pass as soon as the fight-or-flight reaction eases. Fainting comes from low blood pressure; you are not going to faint because anxiety tends to make blood pressure higher.
- Dizziness: This is just a temporary effect of hyperventilation. When you relax, it’ll all go away.
- Feeling depersonalized/not yourself: This is just a symptom of hyperventilation and blood-vessel constriction that comes from the stress hormones. It feels strange, but it can’t hurt you. It will pass as soon as you begin to relax.
- Weakness in legs: This is just the stress hormones making the blood pool in the big leg muscles. The blood is there to give strength to fight or run. You feel shaky and weak, but that’s because you are not running. You are actually stronger than usual right now.
- Shortness of breath: Anxiety makes the diaphragm tighten so it’s harder to take a deep breath. The body will always make sure you get enough air. As you relax the diaphragm with slow, deep breaths, the feeling will go away.
- Fear of acting crazy: You may feel scared and overwhelmed, but you have never acted crazy. Anxious feelings never turn into crazy behavior.
- Feeling hot or cold: Stress hormones are playing havoc with your thermostat. This is normal, it can’t hurt, and it will pass as you relax.
Part of coping with arousal is reminding the child that stress hormones such as adrenaline are released in the body when you anticipate danger. But they are quickly metabolized (in two or three minutes), and the physical symptoms they trigger will pass quickly if you don’t start worrying about them. In other words, elevated heart rate, dizziness, weakness, or shortness of breath is a harmless by-product of stress hormones and the fight or flight reaction. These symptoms cannot hurt you. And they will pass quickly if you focus on relaxation rather than scary thoughts about what they mean and what they might do to you. An important coping thought you might use is: In a few minutes this will all start to pass; the stress hormones and their symptoms will all fade away.
Other coping thoughts shown to be helpful include
- There’s an end to these feelings.
- Relax and these feelings will gradually pass.
- I’ve handled this before; I can get through it.
- When I stop the worry, these feelings will slowly pass.
- These are normal fight-or-flight reactions that can’t hurt me. I’ll ride them out.
- This is just adrenaline; it’ll pass.
- This is just my body’s way of coping. My body does what it needs to do.
Have the child put an asterisk by the key coping statements that seem relevant for them. You and the child can also tailor or rewrite any of the coping thoughts to make them better fit the situation.
Step 4: Coping with Catastrophic Thoughts
Some of the worst anxiety is associated with “what if’s”: “What if I’m so anxious, I lose control of the car?” “What if the elevator stops between floors?” “What if there’s an earthquake when I’m doing exposure work in a high rise?” “What if everyone sees how screwed up I am?” Catastrophic thinking can greatly increase anxiety during exposure. That’s why the coping script needs to include alternative, balanced thoughts in response to the “what if’s.”
On the Catastrophic Thoughts Worksheet [Form CBT#11-001] have the child write down any catastrophic, “what if” thoughts pertaining to the exposure practice that s/he is planning. Don’t include thoughts about the child’s physical symptoms – you’ve already worked with them in the prior technique.
The best way to identify catastrophic thoughts is to have the child visualize him/herself actually doing the exposure work. S/he should try to experience what the scene looks like, what it sounds like, and what it feels like physically. Give them time for the anxiety to begin building. Now ask the child to listen to his/her automatic thoughts. What are they saying to themselves? What’s the worst thing they can imagine happening? How might things really go wrong? What kind of danger do they feel they are in?
When you and the child have identified the key catastrophic thoughts, it’s time to rate them. Have the child rate each thought from 0 to 100 on a scale of anxiety where 0 is feeling completely relaxed and 100 is the worst anxiety s/he can imagine. Circle the thought with the highest rating – this is the distressing thought you’ll examine first. From now on everything on the worksheet will relate to this thought only.
Move to the Evidence For column, and have the child write down anything that would support the possibility that the catastrophe might come true. This column might include things read in the newspaper, things others have said, statistics, and any other information that seems to support the feared outcome.
Now move over to the Evidence Against column. Here the child will list things that tend to weigh against the likelihood of catastrophe. To fill in this column on the worksheet, ask the child the following key questions:
- What would the likely outcome be if the problem you worry about occurred? Is it as bad as you imagine?
- What are the realistic odds that the problem you worry about will occur? How many people in the country have done in the last month what you plan to expose yourself to? In how many of these cases did the thing you worry about happen?
- Are there things that make the problem I worry about unlikely to happen?
- What past experience do I have that suggests the problem is unlikely to occur?
- What is most likely ( to happen while I’m in the exposure situation? What could I realistically expect”
- How could I cope if the problem I worry about occurred? Have I ever coped with this before or known anyone who successfully coped with this problem? How did I or they handle it?
- Could others help me if the problem I worry about occurred?
- Are there other resources I have or could bring to the situation that would make me feel safer?
- Is there anything about the situation that might, if I thought about it, increase my feelings of confidence or safety?
As you read through these questions, probe the child for answers that might be helpful in the Evidence Against column. Write them down and underline the ones that the child feels might be especially helpful.
Having filled in the Evidence For and Evidence Against columns, it’s time for the child to develop Alternative or Balanced Thoughts. Have the child read through the evidence both for and against his/her fear. Make a balanced summary statement that accurately reflects the evidence gathered on both sides of the question. Have the child write an alternative thought in the fourth column. This is the coping statement that s/he will use whenever the distressing thought comes up during exposure.
Step 5: Accepting and Floating Past Anxiety
You can control your thoughts, and you can control your breathing, but you can’t control adrenaline. Once adrenaline gets released into the bloodstream, you’re going to feel anxious and physically uncomfortable for a few minutes. It’s critical that the child learn to accept this feeling and not try to fight it. Remind him/her, that in three minutes or less the adrenaline will be metabolized and the body will begin to calm down. If s/he doesn’t fight the feeling and doesn’t struggle to stop it, it will soon pass.
There are two key mantras (repeated calming phrases) for the child to use during an adrenaline rush to keep him/herself from thrashing, struggling, and scaring yourself further. The first is: Float past, do not listen in.
The first part means that the child should try to detach from the feeling, try to experience it as an observer. S/he should notice but not fight the sensations in his/her body. The second part of the mantra is equally important: Do not listen in. The child will need to learn to stop listening to the catastrophic voice inside that tries to scare him/her with all the awful things that could happen. If s/he can turn his/her attention away from that voice, s/he will likely prevent a second rush of adrenaline and the anxiety will gradually calm down.
A second mantra is: Accept, do not fight.
Here again, the emphasis is on accepting the feelings inside your body, letting them happen. The feeling will pass soon enough if you don’t scare yourself with more catastrophic thoughts. Help the child understand that fighting the feeling won’t help; it only makes you feel more helpless and panicked.
One or both of these ‘acceptance” mantras (developed by Claire Weekes, 1978) should be integrated into the child’s coping script.
Step 6: Distraction
This is an optional component. Some people find distraction more useful than others. The child can distract him/herself from anxious thoughts during exposure sessions by focusing attention on a mental task. Such tasks might include counting backwards by seven from a hundred (100, 93, 86, 79, etc.), counting the number of Buicks, Fords, or any other auto brand seen on the street, estimating people’s heights, counting the number of books owned in your lifetime, and so on. The child can also distract him/herself with a special-place visualization, memories of beautiful places s/he has been, even fantasies of future successes or triumphs.
Making a Script
Next, you should have the child assemble the components of the coping plan into a powerful resource s/he can use during exposure. Remember there are two basic choices: You can condense the script into a file card that the child will carry, or record the script to play on a portable cassette player during exposure sessions. If the child is using a file card, s/he will need to put:
- A sentence or a phrase to remind him/her to use deep breathing and cuecontrolled relaxation whenever s/he feels tense.
- A sentence to remind him/her of the action plan in case problems occur.
- One or more coping thoughts to help respond to typical symptoms of arousal (rapid heartbeat, dizziness, shortness of breath, etc.).
- The alternative balanced thoughts from the worksheet.
- The acceptance mantra(s).
- Specific distraction techniques that the child will want to try if you plan to use distraction.
If the child would prefer to record the coping script for use during exposure sessions, simply have him/her read the coping statements into the tape recorder in a calm, slow voice. Start with a reminder to relax (cue-controlled relaxation) and the action plan. Go on to one of the coping thoughts for dealing with physiological arousal, then go back to a relaxation reminder. Move on to the alternative balanced thought s/he developed in response to one of his/her distressing thoughts. Use an acceptance mantra. Then have the child do a relaxation reminder again. Try a different coping thought for physiological arousal. An acceptance mantra. A reminder to relax. And so on. Make sure that the child leaves lots of blank space on the tape between each of the coping suggestions so s/he will have time to let them sink in during exposure. Keep him/her coming back to the relaxation reminder and acceptance mantras. S/he can mix in the other coping thoughts almost randomly.
Make the tape long enough to last the length of one exposure session. By leaving blank spaces between coping thoughts and repeating them as necessary, the child can make a tape of virtually any length. S/he will also need to experiment with the tape to see how it works for him/her. Have the child test it to see if there’s enough space between coping thoughts to let them sink in. Also cause him/her to notice which coping thoughts seem believable and effective, and which ones aren’t helping. S/he needs to be aware of which coping thoughts may need to be repeated more often, and which s/he needs to hear only once or not at all. You and the child may go through several versions of your taped coping script before you feel confident in its effectiveness.
Remember that this script is the major tool in helping the child cope during exposure. While the child may become bored or tired of working on it, it will be a critical factor in his/her success in dealing with the problem situation. Put it aside, if necessary, to be worked on later, but don’t send him/her out to exposure without a script in which both you and the child are confident.