behavior” and these were taken into account in regard to their treatment.Culturally based factors that could help to account for the client's currently defined “problem behavior” were investigated, but no significant factors were identified.9 Assess Severity of Impairment (9)The severity of the client's impairment was assessed to determine the appropriate level of care.The client was assessed in regard to their impairment in social, relational, vocational, and occupational endeavors.It was reflected to the client that their impairment appears to create mild to moderate effects on the client's functioning.It was reflected to the client that their impairment appears to create severe to very severe effects on the client's functioning.The client was continuously assessed for the severity of impairment, as well as the efficacy and appropriateness of treatment.
10 Refer to a Physician (10)The client was referred to a prescribing clinician for an evaluation for a prescription of psychotropic medications.The client was reinforced for following through on a referral to a prescribing clinician for an assessment for a prescription of psychotropic medications, but none were prescribed.The client has been prescribed psychotropic medications.The client declined evaluation by a physician for a prescription of psychotropic medications and was redirected to cooperate with this referral.
11 Monitor Medications (11)The client was monitored for compliance with the psychotropic medication regimen.The client was provided with positive feedback about regular use of psychotropic medications.The client was monitored for the effectiveness and side effects of the prescribed medications.Concerns about the client's medication effectiveness and side effects were communicated to the prescribing clinician.Although the client was monitored for medication side effects, they reported no concerns in this area.
12 Use Motivational Interviewing (12)Motivational interviewing techniques were used to help the client clarify their stage of motivation to change.Motivational interviewing techniques were used to help move the client to the action stage in which they agree to learn new ways to conceptualize and manage anxiety.The client was assisted in identifying dissatisfaction with the status quo and the benefits of making changes.The client was assisted in identifying level of optimism for making changes.
13 Explore Anxiety/Addiction Making Life Unmanageable (13)The client was presented with the concept that powerlessness over anxiety and addiction makes their life unmanageable.The client was assisted in identifying specific instances wherein they have been powerless over addiction and have experienced anxiety, causing life to be unmanageable.As the client's anxiety has decreased, their life has been noted to be somewhat more manageable.The client denied any concerns in regard to anxiety/addiction making life unmanageable and was provided with feedback about how the clinician sees this occurring.
14 Teach Anxiety/Addiction Relationship (14)The client was taught the relationship between anxiety and addiction, including how substances can be used to treat the anxious symptoms.The client was taught about how more substance abuse becomes necessary to cope with the ongoing anxiety symptoms.The client was assigned “Coping With Stress” from the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma).The client accepted the relationship between anxiety and addiction and was assisted in identifying specific examples from experience that support this pattern.The client reported decreased substance use during anxious situations, and this success was celebrated.It was noted that despite learning about the connection between anxiety and addiction, the client has not decreased substance use during anxious situations.The client has not completed the “Coping With Stress” homework and was redirected to do so.
15 Discuss Anxiety Components (15)The client was taught 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.The client was taught how treatment breaks the anxiety cycle by encouraging positive, corrective experiences.The client was taught information from Mastery of Your Anxiety and Worry: Therapist Guide (Zinbarg, Craske, & Barlow) or Treating Generalized Anxiety Disorder (Rygh & Sanderson) regarding the anxiety pattern.The client was reinforced as they displayed a better understanding of the anxiety cycle of unwarranted fear and avoidance and how treatment breaks the cycle.The client displayed a poor understanding of the anxiety and was provided with remedial feedback in this area.
16 Discuss Target of Treatment (16)A discussion was held about how treatment targets worry, anxiety symptoms, and avoidance to help the client manage worry effectively.The reduction of overarousal and unnecessary avoidance and a reengagement in rewarding activities were emphasized as treatment targets.The client displayed a clear understanding of the target of treatment and was provided with positive feedback in this area.The client struggled to understand the target of treatment and was provided with specific examples in this area.
17 Assign Reading on Anxiety (17)The client was assigned to read psychoeducational chapters of books or treatment manuals on anxiety.The client was assigned information from Mastery of Your Anxiety and Worry: Workbook (Barlow & Craske) or The Anxiety and Worry Workbook (Clark & Beck).The client has read the assigned information on anxiety, and key points were reviewed.The client has not read the assigned information on anxiety and was redirected to do so.
18 Teach Relaxation Skills (18)The client was taught calming/relaxation/mindfulness skills.The client was taught skills such as applied relaxation, progressive muscle relaxation, cue-controlled relaxation, mindful breathing, and biofeedback.The client was taught how to discriminate better between relaxation and tension.The client was assigned “Progressive Muscle Relaxation” in the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, McInnis, & Bruce).The client was taught how to apply relaxation skills to daily life.The client was taught relaxation skills as described in New Directions in Progressive Muscle Relaxation (Bernstein, Borkovec, & Hazlett-Stevens) or The Relaxation and Stress Reduction Workbook (Davis et al.).The client was provided with feedback about use of relaxation skills.
19 Assign Relaxation Homework (19)The client was assigned to do homework exercises in which they practice calming/relaxation/mindfulness skills on a daily basis.The client was assigned “Deep Breathing Exercise” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client has regularly used relaxation exercises, and the helpful benefits of these exercises were reviewed.The client has not regularly used relaxation exercises and was provided with corrective feedback in this area.The client has used some relaxation exercises but does not find these to be helpful; the client was assisted in brainstorming how to modify these exercises to be more helpful.
20 Implement Worry Time (20)The client was taught to implement “worry time”—delaying the worry about various environmental settings until a designated “worry time.”The rationale for using a “worry time” was explained, focusing on trying to limit the association between various environmental settings and the experience of worry.The client was assigned the “Worry Time” exercise in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client and therapist agreed upon a specific “worry time” and the client was urged to implement this process.
21 Teach Techniques to Postpone Until Worry Time (21)The client was taught how to recognize, stop, and postpone worry until the agreed-upon worry time.Skills were taught to the client, including thought-stopping, relaxation, and redirection of attention.The “Making Use of the Thought-Stopping Technique” exercise from the Adult Psychotherapy Homework Planner (Jongsma & Bruce) was assigned.The client was encouraged to use the techniques in daily life.The client's use of recognizing, stopping, and postponing worry techniques was reviewed within the session, with reinforcement for success and corrective feedback toward improvement.
22 Discuss Estimation Errors (22)In today's session, examples were discussed about how unrealistic worry typically overestimates a probability of threats.The client was assigned “Past Successful Anxiety Coping” from the Adult Psychotherapy Homework Planner (Jongsma & Bruce).It was noted that unrealistic worry often underestimates the client's ability to manage realistic demands.The client was assisted in identifying specific examples
