SOCIAL ANXIETY

CLIENT PRESENTATION

Poor Eye Contact (1)¹
1. The client described a pattern of difficulty making eye contact with others.
2. Within the session, the client had limited eye contact, often looking at the floor or purposefully looking away from the clinician.
3. As treatment has progressed, the client has improved his/her pattern of eye contact.
4. The client displays an appropriate level of eye contact.
Reticence to Respond Verbally (1)
1. The client reported a pattern of difficulty responding verbally to social overtures from others.
2. The client reticence to respond verbally was apparent in the session.
3. As treatment has progressed, the client reports an increased ability to verbally respond to others.
4. The client displays much better patterns of verbal involvement with others.
Avoidance of Unfamiliar People (2)
1. The client has consistently avoided contact with unfamiliar people.
2. The client expressed feelings of anxiety about interacting with unfamiliar people.
3. The client has started to initiate more conversations with unfamiliar people.
4. The client has initiated social contacts with unfamiliar people on a consistent basis.
Social Isolation/Withdrawal (3)
1. The client described a persistent pattern of withdrawing or isolating himself/herself from most social situations.
2. The client acknowledged that his/her social withdrawal interferes with his/her ability to establish and maintain friendships.
3. The client has gradually started to socialize with a wider circle of peers.
4. The client has become more outgoing and interacts with his/her peers on a regular, consistent basis.
Excessive Isolated Activities (3)
1. The client has spent an excessive or inordinate amount of time involved in isolated activities instead of socializing with peers.
2. The client verbalized an understanding of how his/her excessive involvement in isolated activities interferes with his/her chances of establishing friendships.
3. The client reported spending less time in isolated activities and has started to seek out interactions with his/her peers.
4. The client has achieved a healthy balance between time spent in isolated activities and social interactions with others.
No Close Friendships (4)
1. The client described a history of having few or no close friendships.
2. The client does not have any close friends at the present time.
3. The client expressed feelings of sadness and loneliness about not having any close friends.
4. The client has begun to take steps (e.g., greeting others, complimenting others, making positive self-statements) to try to establish close friendships.
5. The client has now established close friendships at school and/or in the community.
Hypersensitivity to Criticism/Rejection (5)
1. The client has been very hesitant to become involved with others for fear of being met by criticism, disapproval, or perceived signs of rejection.
2. The client described a history of experiencing excessive or undue criticism, disapproval, and rejection from parental figures.
3. The client acknowledged that he/she tends to overreact to the slightest sign of criticism, rebuff, or rejection and subsequently withdraws from other people.
4. The client has begun to tolerate criticism or rebuff from others more effectively.
5. The client has continued to interact with others even in the face of criticism, disapproval, or perceived slights from others.
Excessive Need for Reassurance (6)
1. The client reported an excessive need for reassurance of being liked by others before demonstrating a willingness to get involved with them.
2. The parents reflected that the client frequently avoids getting involved with others in social situations without excessive need for reassurance.
3. As treatment has progressed, the client has been able to demonstrate a willingness to get involved with others without excessive reassurance.
Reluctance to Take Risks (7)
1. The client has been reluctant to engage in new activities or take personal risks because of the potential for embarrassment or humiliation.
2. The client verbalized a desire to engage in new activities or take healthy risks to help improve his/her self-esteem and develop friendships.
3. The client has started to take healthy risks in order to find enjoyment, build self-esteem, and establish friendships.
4. The client has engaged in new activities and assumed healthy risks without excessive fear of embarrassment or humiliation.
Self-Disparaging Remarks (8)
1. The client's deep sense of inferiority was reflected in frequent self-disparaging remarks about his/her appearance, worth, and abilities.
2. The lack of any eye contact on the client's part and negative remarks about self are evidence of how little the client thinks of himself/herself.
3. The client reported feeling inferior to others and generally believes that he/she is a loser.
4. The client has stopped making self-critical remarks and has even begun to acknowledge some positive traits and successes.
Lack of Assertiveness (9)
1. The client indicated that he/she rarely asserts himself/herself because of a fear of being met with criticism, disapproval or rejection.
2. The client indicated that he/she rarely says no to others out of fear of not being liked.
3. The client identified the paralyzing fear that he/she experiences when trying to assert himself/herself with others.
4. The client has gradually become more assertive, and is willing to say no to others and to be more true to his/her real beliefs, values, feelings, or thoughts.
Physiological Distress (10)
1. The client's social anxiety has been manifested in his/her heightened physiological distress (e.g., increased heart rate, profuse sweating, dry mouth, muscular tension, trembling).
2. The client was visibly anxious (e.g., trembling, shaking, sweating, appearing tense and rigid) when talking about his/her social relationships.
3. The client reported that he/she has recently experienced less physiological distress when interacting with others.
4. The client has been able to consistently interact with other people in a variety of social settings without experiencing physiological distress.

INTERVENTIONS IMPLEMENTED

Build Trust (1)²
1. Today's therapy session focused on building the level of trust with the client through consistent eye contact, active listening, unconditional positive regard, and warm acceptance.
2. Unconditional positive regard and warm acceptance helped the client increase his/her ability to identify and express feelings.
3. The therapy session was helpful in building the level of trust with the client, and he/she became more open and relaxed.
4. The session was not helpful in building the level of trust with the client, who remained quiet and reserved in his/her interactions.
Assess Nature of Social Discomfort Symptoms (2)
1. The client was asked about the frequency, intensity, duration, and history of his/her social discomfort symptoms, fear, and avoidance.
2. The client was asked about the focus of his/her fear, types of avoidance, development of the fear, and the impact on his/her daily life
3. The Anxiety Disorders Interview Schedule for Children—Parent Version or Child Version (Silverman and Albano) was used to assess the client's social discomfort symptoms.
4. The assessment of the client's social discomfort symptoms indicated that his/her symptoms are extreme and severely interfere with his/her life.
5. The assessment of the client's social discomfort symptoms indicates that these symptoms are moderate and occasionally interfere with his/her daily functioning.
6. The results of the assessment of the client's social discomfort symptoms indicate that these symptoms are mild and rarely interfere with his/her daily functioning.
7. The results of the assessment of the client's social discomfort symptoms were reviewed with the client.
Explore Social Discomfort Stimulus Situations (3)
1. The client was assisted in identifying specific stimulus situations that precipitate social discomfort symptoms.
2. The client could not identify any specific stimulus situations that produce social discomfort; he/she was helped to identify that they occur unexpectedly and without any pattern.
3. The client was helped to identify that his/her social discomfort symptoms occur when he/she is expected to perform basic social interaction expectations.
Administer Social Anxiety Assessment (4)
1. The client was administered a measure of social anxiety to further assess the depth and breadth of his/her social fears and avoidance.
2. The client was administered The Social Phobia and Anxiety Inventory for Children (Beidel et al.).
3. The result of the assessment of social anxiety indicated a high level of social fears and avoidance; this was reflected to the client.
4. The result of the assessment of social anxiety indicated a medium level of social fears and avoidance; this was reflected to the client.
5. The result of the assessment of social anxiety indicated a low level of social fears and avoidance; this was reflected to the client.
6. The client declined to participate in an assessment of social anxiety; the focus of treatment was turned to this resistance.
Refer/Conduct Substance Abuse Evaluation (5)
1. The client was referred for a substance abuse evaluation to assess the extent of his/her drug/alcohol usage and determine the need for treatment.
2. The findings from the substance abuse evaluation revealed the presence of a substance abuse problem and the need for treatment.
3. The findings from the substance abuse evaluation revealed the presence of a substance abuse problem that appears to be contributing to the client's behavior control problems.
4. The evaluation findings did not reveal the presence of a substance abuse problem or the need for treatment in this area.
Assess Level of Insight (6)
1. The client's level of insight toward the presenting problems was assessed.
2. The client was assessed in regard to the syntonic versus dystonic nature of his/her insight about the presenting problems.
3. The client was noted to demonstrate good insight into the problematic nature of the behavior and symptoms.
4. The client was noted to be in agreement with others' concerns and is motivated to work on change.
5. The client was noted to be ambivalent regarding the problems described and is reluctant to address the issues as a concern.
6. The client was noted to be resistant regarding acknowledgment of the problem areas, is not concerned about them, and has no motivation to make changes.
Assess for Correlated Disorders (7)
1. The client was assessed for evidence of research-based correlated disorders.
2. The client was assessed in regard to his/her level of vulnerability to suicide.
3. The client was identified as having a comorbid disorder, and treatment was adjusted to account for these concerns.
4. The client has been assessed for any correlated disorders, but none were found.
Assess for Culturally Based Confounding Issues (8)
1. The client was assessed for age-related issues that could help to better understand his/her clinical presentation.
2. The client was assessed for gender-related issues that could help to better understand his/her clinical presentation.
3. The client was assessed for cultural syndromes, cultural idioms of distress, or culturally based perceived causes that could help to better understand his/her clinical presentation.
4. Alternative factors have been identified as contributing to the client's currently defined “problem behavior,” and these were taken into account in regard to his/her treatment.
5. Culturally based factors that could help to account for the client's currently defined “problem behavior” were investigated, but no significant factors were identified.
Assess Severity of Impairment (9)
1. The severity of the client's impairment was assessed to determine the appropriate level of care.
2. The client was assessed in regard to his/her impairment in social, relational, vocational, and occupational endeavors.
3. It was reflected to the client that his/her impairment appears to create mild to moderate effects on the client's functioning.
4. It was reflected to the client that his/her impairment appears to create severe to very severe effects on the client's functioning.
5. The client was continuously assessed for the severity of impairment, as well as the efficacy and appropriateness of treatment.
Assess for Pathogenic Care (10)
1. The home, school, and community of the client were assessed for pathogenic care and concerns.
2. The client's various environments were assessed for the persistent disregard of the child's needs, repeated changes in caregivers, limited opportunities for stable attachment, harsh discipline, or other grossly inept care.
3. Pathogenic care was identified and the treatment plan included strategies for managing or correcting these concerns and protecting the child.
4. No pathogenic care was identified and this was reflected to the client and caregivers.
Refer for Medication Evaluation (11)
1. Arrangements were made for the client to have a physician's evaluation for the purpose of considering psychotropic medication to alleviate social discomfort symptoms.
2. The client has followed through with seeing a physician for an evaluation of any organic causes for the anxiety and the need for psychotropic medication to control the anxiety response.
3. The client has not cooperated with the referral to a physician for a medication evaluation and was encouraged to do so.
Monitor Medication Compliance (12)
1. The client reported that he/she has taken the prescribed medication consistently and that it has helped to control the anxiety; this was relayed to the prescribing clinician.
2. The client reported that he/she has not taken the prescribed medication consistently and was encouraged to do so.
3. The client reported taking the prescribed medication and stated that he/she has not noted any beneficial effect from it; this was reflected to the prescribing clinician.
4. The client was evaluated but was not prescribed any psychotropic medication by the physician.
Refer to Group Therapy (13)
1. The client was referred to a small (closed-enrollment) group for social anxiety.
2. The client was enrolled in a social anxiety group as defined in Cognitive-Behavioral Therapy for Social Phobia in Adolescents (Albano and DiBartolo).
3. The client was enrolled in a social anxiety group as defined in Social Effectiveness Therapy for Children and Adolescents (Beidel, Turner, and Morris).
4. The client has participated in group therapy for social anxiety; his/her experience was reviewed and processed.
5. The client has not been involved in group therapy for social anxiety concerns, and he/she was redirected to do so.
6. The client and parents were urged to read portions of Stand Up, Speak Out Workbook (Albano and DiBartolo) as a way to supplement the client's progress.
7. The client's involvement in a social anxiety treatment group has resulted in increased social interactions on the client's part in daily living situations.
Teach Modeling of Social Skills (14)
1. The parents were taught to use the same positive and confident social skills that the client is learning in order to approach and manage their own fears and worries.
2. The client's parents were encouraged to use calming techniques when approaching their own social anxiety.
3. The parents were taught techniques described in Helping Your Anxious Child (Rapee et al.).
4. The parents were taught techniques described in Nurturing Your Shy Child: Practical Help for Raising Confident and Socially Skilled Kids and Teens (Markway and Markway).
5. The parents were reinforced for their consistent use of social skills.
6. The parents have not regularly used prescribed social skills, and they were redirected to do so.
Discuss Cognitive Biases (15)
1. The cognitive-behavioral model of social anxiety and its treatment were conveyed to the client and parents.
2. A discussion was held regarding how social anxiety derives from cognitive biases that overestimate negative evaluation by others, undervalue the self, increase distress, and often lead to unnecessary avoidance.
3. The client was provided with examples of cognitive biases that support social anxiety symptoms.
4. The client was reinforced as he/she identified his/her own cognitive biases.
5. The client was unable to identify any cognitive biases that support his/her anxiety symptoms, and he/she was provided with tentative examples in this area.
Discuss Benefits of Exposure (16)
1. A discussion was held about how exposure serves as an arena to desensitize learned fear, build social skills, and make one feel safer by building a new history of success experiences.
2. The client displayed a clear understanding of how exposure serves to desensitize learned fear, build confidence, and make one feel safer by building a new history of success experiences; his/her insight was reinforced.
3. Despite specific information about how exposure serves to desensitize learned fear, build confidence, and make one feel safer by building a new history of success experiences, the client displayed a poor understanding of these issues; he/she was provided with remedial information in this area.
Assign Information on Social Anxiety, Avoidance, and Treatment (17)
1. The client was assigned to read information on social anxiety that explains the cycle of social anxiety and avoidance, and provides a rationale for treatment.
2. The client was assigned information about social anxiety, avoidance, and treatment from The Shyness and Social Anxiety Workbook (Antony and Swinson).
3. The client was assigned information about social anxiety, avoidance, and treatment from Say Goodbye to Being Shy (Brozovich and Chase).
4. The client was assigned information about social anxiety, avoidance, and treatment from Managing Social Anxiety—Workbook: A Cognitive-Behavioral Therapy Approach (Hope, Heimberg, and Turk).
5. The client was assigned information about social anxiety, avoidance, and treatment from The Mindful Path through Shyness (Flowers).
6. The client has read the information on social anxiety, avoidance, and treatment, and key concepts were reviewed.
7. The client has not read the assigned material on social anxiety, avoidance, and treatment, and he/she was redirected to do so.
Teach Anxiety Management Skills (18)
1. The client was taught anxiety management and relaxation skills.
2. The client was taught about staying focused on behavioral goals and riding the wave of anxiety.
3. Techniques for muscular relaxation and paced diaphragmatic breathing were taught to the client.
4. The client and parents were assigned information about relaxation from the Relaxation and Stress Reduction Workbook for Kids (Shapiro and Sprague).
5. The client and parents were directed to utilize the Audio CD Applied Relaxation Training (Fanning and McKay).
6. The client was reinforced for his/her clear understanding and use of anxiety management skills.
7. The client has not used his/her new anxiety management skills and was redirected to do so.
Identify Distorted Thoughts (19)
1. The client was assisted in identifying the distorted schemas and related automatic thoughts that mediate social anxiety responses.
2. The client was taught the role of distorted thinking in precipitating emotional responses.
3. The client was assigned portions of The Shyness and Social Anxiety Workbook (Antony and Swinson).
4. The client was reinforced as he/she verbalized an understanding of the cognitive beliefs and messages that mediate his/her anxiety responses.
5. The client was assisted in replacing distorted messages with positive, realistic cognitions.
6. The client failed to identify his/her distorted thoughts and cognitions and was provided with tentative examples in this area.
Assign Exercises on Self-Talk (20)
1. The client was assigned homework exercises in which he/she identifies fearful self-talk and creates reality-based alternatives.
2. The client was assigned “Restoring Socialization Comfort” from the Adult Psychotherapy Homework Planner (Jongsma).
3. The client's replacement of fearful self-talk with reality-based alternatives was critiqued.
4. The client was reinforced for his/her successes at replacing fearful self-talk with reality-based alternatives.
5. The client was provided with corrective feedback for his/her failures to replace fearful self-talk with reality-based alternatives.
6. The client has not completed his/her assigned homework regarding fearful self-talk and was redirected to do so.
Build Social and Communication Skills (21)
1. Instruction, modeling, and role-playing were used to build the client's general social and communication skills.
2. Techniques from Social Effectiveness Therapy for Children and Adolescents (Beidel, Turner, and Morris) were used to teach social and communication skills.
3. The client was assigned the “Observe Positive Social Behaviors” exercise from the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, and McInnis).
4. Positive feedback was provided to the client for his/her use of increased use of social and communication skills.
5. Despite the instruction, modeling, and role-playing about social and communication skills, the client continues to struggle with these techniques and was provided with additional feedback in this area.
Teach Social Problem-Solving Skills (22)
1. The client was taught age-appropriate social problem-solving skills tailored to his/her situation.
2. The client was taught calming skills, including both cognitive and somatic calming skills.
3. The client was taught problem-solving skills, including how to specify the problem, generating options, listing pros and cons to each option, selecting an option, implementing an option, and refining the choices.
4. The client was encouraged to implement social problem-solving skills in his daily life.
5. The client was assigned the “Progressive Muscle Relaxation Exercise” from the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, and McInnis).
6. The client was assigned the “Problem-Solving Exercise” from the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, and McInnis).
7. The client's use of social problem-solving skills was reviewed, with support for success and redirection.
Teach Conflict Resolution Skills (23)
1. The client was taught conflict resolution skills through modeling, role-playing, and behavioral rehearsal.
2. The client was taught about empathy and active listening.
3. The client was taught about “I messages,” respectful communication, assertiveness without aggression, and compromise.
4. The client was assigned the exercise “Becoming Assertive” from the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, and McInnis).
5. The client was reinforced for his/her clear understanding of the conflict resolution skills.
6. The client displayed a poor understanding of the conflict resolution skills and was provided with remedial feedback.
Assign Practice of Skills (24)
1. The client was assigned to practice assertion, problem-solving, and conflict resolution skills.
2. Positive reinforcement was used to reinforce the client's use of coping skills.
3. The client has not regularly practiced his/her coping skills, and he/she was redirected to do so.
Construct Anxiety Stimuli Hierarchy (25)
1. The client was assisted in constructing a hierarchy of anxiety-producing situations associated with his/her phobic fear.
2. It was difficult for the client to develop a hierarchy of stimulus situations, as the causes of his/her fear remain quite vague; he/she was assisted in completing the hierarchy.
3. The client was successful at completing a focused hierarchy of specific stimulus situations that provoke anxiety in a gradually increasing manner; this hierarchy was reviewed.
Select Exposures That Are Likely to Succeed (26)
1. Initial in vivo or role-played exposures were selected, with a bias toward those that have a high likelihood of being a successful experience for the client.
2. Cognitive restructuring was done within and after the exposure using behavioral strategies (e.g., modeling, rehearsal, social reinforcement).
3. A review was conducted with the client about his/her use of in vivo or role-played exposure.
4. The client was provided with positive feedback regarding his/her use of exposures.
5. The client has not used in vivo or role-played exposures and was redirected to do so.
Assign Homework on Exposure (27)
1. The client was assigned homework exercises to perform sensation exposure and record his/her experience.
2. The client was assigned “Gradual Exposure to Fear” from the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, and McInnis).
3. The client's use of sensation exposure techniques was reviewed and reinforced.
4. The client has struggled in his/her implementation of sensation exposure techniques and was provided with corrective feedback.
5. The client has not attempted to use the sensation exposure techniques and was redirected to do so.
Foster Generalization of Skills (28)
1. The generalization and strengthening of new personal and interpersonal skills was fostered by encouraging the client to participate in extracurricular or positive peer group activities.
2. The client was assigned “Greeting Peers” from the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, and McInnis).
3. The client was assigned exercises from the Shyness and Social Anxiety Workbook for Teens by Shannon.
4. The client's ongoing use of new personal and interpersonal skills was supported and reinforced.
5. The client was provided with redirection when he/she has not used new personal and interpersonal skills.
Encourage Structured Social Activities (29)
1. The client was encouraged to build his/her interactional skills by increasing participation in structured social activities.
2. The client was assisted in listing his/her preferred social activities, such as inviting friends home or going to a school sporting event together.
3. The client was assigned “Developing Conversational Skills” from the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, and McInnis).
4. The client was assisted in reviewing his/her use of one-to-one interactional skills with a focus on building on successes and problem-solving obstacles.
Consult with School Officials (30)
1. School officials were consulted about ways to increase the client's socialization.
2. The client was assisted in developing his/her preferred ways to increase socialization at school.
3. The client was provided with examples of ways to increase socialization in school, such as tutoring a more popular peer, pairing the client with a popular peer in classroom assignments, and so forth.
Differentiate between Lapse and Relapse (31)
1. A discussion was held with the client regarding the distinction between a lapse and a relapse.
2. A lapse was associated with an initial and reversible return of symptoms, fear, or urges to avoid.
3. A relapse was associated with the decision to return to fearful and avoidant patterns.
4. The client was provided with support and encouragement as he/she displayed an understanding of the difference between a lapse and a relapse.
5. The client struggled to understand the difference between a lapse and a relapse, and he/she was provided with remedial feedback in this area.
Discuss Management of Lapse Risk Situations (32)
1. The client was assisted in identifying future situations or circumstances in which lapses could occur.
2. The session focused on rehearsing the management of future situations or circumstances in which lapses could occur.
3. The client was reinforced for his/her appropriate use of lapse management skills.
4. The client was redirected in regard to his/her poor use of lapse management skills.
Encourage Routine Use of Strategies (33)
1. The client was instructed to routinely use the strategies that he/she has learned in therapy (e.g., cognitive restructuring, exposure).
2. The client was urged to find ways to build his/her new strategies into his/her life as much as possible.
3. The client was reinforced as he/she reported ways in which he/she has incorporated coping strategies into his/her life and routine.
4. The client was redirected about ways to incorporate his/her new strategies into his/her routine and life.
Develop a “Coping Card” (34)
1. The client was provided with a coping card on which specific coping strategies were listed.
2. The client was assisted in developing his/her coping card in order to list his/her helpful coping strategies.
3. The client was encouraged to use his/her coping card when struggling with anxiety-producing situations.
Teach Family about Treatment Goals and Support (35)
1. A family session was held in which the family was taught the treatment goals for the subject's social phobia/shyness problems.
2. The family was taught how to provide support to the client as he/she faces his/her fears.
3. A discussion was held about how to prevent reinforcing the client's fear and avoidance.
4. The family was assisted in ways that they can support and reinforce the client's activation of courageous behavior.
5. The family was provided with encouragement, support, and redirection.
6. Positive feedback was provided, as the family has been able to provide support to the client.
7. The family continues to interact with the client in a manner that reinforces the client's fear and avoidance; redirection was provided to the family about this pattern.
Teach Family Problem-Solving (36)
1. The family was taught problem-solving skills.
2. Conflict resolution skills were taught to the family.
3. The family was urged to use problem-solving and conflict resolution skills to manage problems within the family unit.
4. The family was reinforced for their successful negotiation of problem areas.
5. The family continues to have a great deal of turmoil and was redirected to the problem-solving and conflict resolution skills.
Encourage Family Modeling of Constructive Skills (37)
1. The family was urged to model constructive skills that they have learned for dealing with social shyness.
2. The family was encouraged to model the therapeutic skills that the client is learning (e.g., calming, cognitive restructuring, nonavoidance of unrealistic fears).
3. The client reported that he/she has received constructive examples of how to use therapeutic skills.
Conduct Cognitive-Behavioral Group Therapy (38)
1. Group therapy was conducted in accordance with the concepts espoused by Flannery-Schroeder and Kendall in Cognitive-Behavioral Therapy for Anxious Children or the FRIENDS Program for Youth (Barrett et al.).
2. Cognitive-behavioral group therapy was conducted in which the client was taught about the cognitive, behavioral, and emotional components of anxiety.
3. Cognitive-behavioral group therapy was conducted in which the client learned and implemented skills for coping with anxiety and practiced new skills in several anxiety provoking situations.
4. The client has actively participated in cognitive-behavioral group therapy and benefits of this were reviewed.
5. The client has not actively participated in cognitive-behavioral group therapy and was reminded to do so.
6. The client and parents were encouraged to read information about social anxiety in children.
Inquire about Similarities to Peers (39)
1. The client was asked to list how he/she is like his/her peers.
2. The client was urged to increase contact with peers who share interests and abilities.
3. The client was assigned the exercise “Greeting Peers” from the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, and McInnis).
4. The client has increased his/her involvement with likeminded peers, and was provided with positive reinforcement for this.
5. The client has not engaged in increased involvement with likeminded peers and was reminded to do so.
Utilize Strengths (40)
1. The client was assisted in identifying 5 to 10 of his/her strengths or interests.
2. The client was instructed to utilize three strengths or interests in the upcoming week in order to initiate social contact or develop peer friendships.
3. The client was assigned the exercise “Show Your Strengths” from the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, and McInnis).
4. The client was assisted in reviewing his/her use of personal strengths and interests to increase peer activities, and successes were built upon, and struggles were refocused.
Use ACT Approach (41)
1. The use of acceptance and commitment therapy was applied.
2. The client was encouraged to accept and openly experience anxious thoughts and feelings, without being overly impacted by them.
3. The client was encouraged to commit his/her time and effort to activities that are consistent with identified personally meaningful values.
4. The client has engaged well in the Acceptance and Commitment Therapy (ACT) approach and applied these concepts to his/her symptoms and lifestyle.
5. The client has not engaged well in the ACT approach and remedial efforts were applied.
Explore History of Traumas (42)
1. The client's background was explored for a history of rejection experiences, harsh criticism, abandonment, or trauma that may have contributed to the client's low self-esteem and social anxiety.
2. The client was assisted in developing a time line in which he/she identified significant historical events, both positive and negative, that have occurred in his/her background.
3. The client identified a history of abandonment and/or traumatic experiences that coincided with the onset of his/her feelings of low self-esteem and social anxiety, and this connection was highlighted.
4. Exploration of the client's background did not reveal any significant rejection or traumatic experiences that contributed to the onset of his/her social anxiety.
Encourage Expression and Clarification of Feelings (43)
1. The client was encouraged and supported as he/she verbally expressed and clarified feelings associated with past rejection experiences.
2. The client was provided with support as he/she processed his/her experience of harsh criticism, abandonment, and trauma.
3. The client was assisted in making decisions about how to express his/her emotions to others.
Identify Defense Mechanisms (44)
1. The client was assisted in identifying the defense mechanisms that he/she uses to avoid close relationships.
2. The client was assisted in reducing his/her defensiveness so as to be able to build social relationships and not alienate himself/herself from others.