SPECIFIC PHOBIA

CLIENT PRESENTATION

  1. Persistent and Unreasonable Fear (1)1
    1. An immediate anxiety response has been exhibited by the client each time he/she encounters the phobic stimulus.
    2. The client reported that the strength of his/her phobic response has been increasing in the past several months.
    3. The client described the level of fear he/she experiences in response to the phobic stimulus as paralyzing.
    4. The client indicated that although the phobia is of recent origin, it has quickly become very persistent and unreasonable.
    5. As the client has become engaged in therapy, there has been a decrease in the intensity and frequency of the phobic response.
  2. Avoidance and Endurance of Phobia (2)
    1. The client reported that his/her avoidance of the phobic stimulus has caused major interference in his/her normal daily routines.
    2. The client indicated that the intensity of his/her anxiety in response to the phobic stimulus has resulted in marked personal distress.
    3. The client questioned whether he/she would ever be able to resolve the phobia.
    4. The client has progressed to the point that the phobic stimulus does not create interference in his/her normal daily routines or cause him/her marked distress.
  3. Fear Seen as Unreasonable (3)
    1. The client acknowledged that his/her persistent fear is excessive and unreasonable.
    2. The client's recognition of his/her persistent fear as excessive and unreasonable has provided good motivation for cooperation with treatment and follow-through on attempts to change.
    3. In spite of acknowledging his/her fear as unreasonable, the client's avoidance and escape behaviors remain strong.
  4. Sleep Disturbance (4)
    1. The client reported that his/her sleep has been disturbed by frequent dreams of the feared stimulus.
    2. The client indicated his/her disturbed sleep pattern has started to affect his/her daily functioning.
    3. The client's sleep has improved as he/she has worked toward resolving the feared stimulus.
  5. Dramatic Fear Reaction (5)
    1. At the slightest mention of the phobic stimulus, the client indicated he/she has a dramatic fear reaction.
    2. The client's reaction to the phobic stimulus is so dramatic and overpowering that it is difficult to calm him/her down.
    3. The client reported that his/her reaction to the phobic stimulus is rapidly becoming more and more dramatic.
    4. There has been a marked decrease in the client's dramatic fear reaction to the phobic stimulus since he/she has started to work in therapy sessions.
  6. Parental Reinforcement (6)
    1. The parents have catered to the client's fear and have thus reinforced and increased it.
    2. The parents' own fears seemed to be projected onto and acted out by the client.
    3. The parents have worked to curb their reaction to the client's fears, which has resulted in a marked decrease in the client's level of fear.

INTERVENTIONS IMPLEMENTED

  1. Build Trust (1)2
    1. An initial trust level was established with the client through the use of unconditional positive regard.
    2. Warm acceptance and active-listening techniques were utilized to establish the basis for a trusting relationship.
    3. The client has formed a trust-based relationship and was urged to begin to express his/her fearful thoughts and feelings.
    4. Despite the use of active listening, warm acceptance, and unconditional positive regard, the client remains hesitant to trust and to share his/her thoughts and feelings.
  2. Assess Fear and Avoidance/Administer Fear Survey (2)
    1. An objective fear survey was administered to the client to assess the depth and breadth of his/her phobic fear.
    2. The Anxiety Disorders Interview Schedule for Children—Parent Version or Child Version (Silverman and Albano) was used to assess the level of phobia symptoms.
    3. The fear survey results indicated that the client's phobic fear is extreme and severely interferes with his/her life.
    4. The fear survey results indicate that the client's phobic fear is moderate and occasionally interferes with his/her daily functioning.
    5. The fear survey results indicate that the client's phobic fear is mild and rarely interferes with his/her daily functioning.
    6. The results of the fear survey were reviewed with the client.
  3. Administer Client-Report Measure (3)
    1. A client-report measure was used to further assess the depth and breadth of the client's phobic responses.
    2. Measures for Specific Phobias (Antony) was used to assess the depth and breadth of the client's phobic responses.
    3. The client-report measure indicated that the client's phobic fear is extreme and severely interferes with his/her life.
    4. The client-report measure indicated that the client's phobic fear is moderate and occasionally interferes with his/her life.
    5. The client-report measure indicated that the client's phobic fear is mild and rarely interferes with his/her life.
    6. The client declined to complete the client-report measure, and the focus of treatment was changed to this resistance.
  4. Refer/Conduct Substance Abuse Evaluation (4)
    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.
  5. Assess Level of Insight (5)
    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.
  6. Assess for Correlated Disorders (6)
    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.
  7. Assess for Culturally Based Confounding Issues (7)
    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.
  8. Assess Severity of Impairment (8)
    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.
  9. Assess for Pathogenic Care (9)
    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.
  10. Refer for Medication Evaluation (10)
    1. The client was referred for a physician evaluation for possible psychotropic medications.
    2. The client was asked to commit to following through on all recommendations of the physician evaluation.
    3. Communication was established with the physician pre-and postevaluation.
    4. The client was prescribed psychotropic medication.
    5. The client was assessed but not prescribed psychotropic medication.
  11. Monitor Medication Compliance and Effectiveness (11)
    1. The client was informed about major side effects of the medication and asked to report any that he/she experiences.
    2. The client was monitored for compliance with the prescription, and the effectiveness was also noted.
    3. The client was confronted when he/she reported not taking the medication consistently, and positive aspects of medication were reinforced with the client.
  12. Normalize Phobias (12)
    1. A discussion was held about how phobias are very common.
    2. The client was shown that phobias are a natural but irrational expression of our fight-or-flight response.
    3. It was emphasized to the client that phobias are not a sign of weakness but cause unnecessary distress and disability.
    4. The client was reinforced as he/she displayed a better understanding of the natural facets of phobias.
    5. The client struggled to understand the natural aspects of phobias and was provided with remedial feedback in this area.
  13. Discuss Phobic Cycle (13)
    1. The client was taught how phobic fears are maintained by a cycle of unwarranted fear and avoidance that precludes positive, corrective experiences with the feared object or situation.
    2. The client was taught how treatment breaks the phobic cycle by encouraging positive, corrective experiences.
    3. The client was taught information from Mastering Your Fears and Phobias—Workbook (Antony, Craske, and Barlow) regarding the phobic cycle.
    4. The client was taught about the phobic cycle from information in Helping Your Anxious Child (Rapee et al.).
    5. The client was taught about the phobic cycle from information in Anxiety and Phobia Workbook (Bourne).
    6. The client was reinforced as he/she displayed a better understanding of the phobic cycle of unwarranted fear and avoidance, and how treatment breaks the cycle.
    7. The client displayed a poor understanding of the phobic cycle and was provided with remedial feedback in this area.
  14. Discuss Unrealistic Threats, Physical Fear, and Avoidance (14)
    1. A discussion was held about how phobias involve perceiving unrealistic threats, bodily expressions of fear, and avoidance of what is threatening that interact to maintain the problem.
    2. The client displayed a clear understanding of how unrealistic threats, bodily expression of fear, and avoidance combine to maintain the phobic problem; his/her insight was reinforced.
    3. Despite specific information about factors that interact to maintain the problem, the client displayed a poor understanding of these issues; he/she was provided with remedial information in this area.
  15. Discuss Benefits of Exposure (15)
    1. A discussion was held about how exposure serves as an arena to desensitize learned fear, build confidence, and make one feel safer by building a new history of success experiences.
    2. The client was taught about the benefits of exposure as described in Face Your Fears: A Proven Plan to Beat Anxiety, Panic, Phobias, and Obsessions (Tolin).
    3. The client was taught about the benefits of exposure as described in Helping Your Anxious Child (Rapee et al.).
    4. The client was taught about the benefits of exposure as described in Freeing Your Child from Anxiety (Chansky).
    5. 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.
    6. 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.
  16. Teach Anxiety Management Skills (16)
    1. The client was taught anxiety management skills.
    2. The client was assigned the exercise “Progressive Muscle Relaxation” in the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, and McInnis).
    3. The client was taught about staying focused on behavioral goals and positive self-talk.
    4. Techniques for muscular relaxation and paced diaphragmatic breathing were taught to the client.
    5. The client was reinforced for his/her clear understanding and use of anxiety management skills.
    6. The client has not used new anxiety management skills and was redirected to do so.
  17. Assign Calming Skills Exercises (17)
    1. The client was assigned a homework exercise in which he/she practices daily calming skills.
    2. The parents and the client were directed to read portions of The Relaxation and Stress Reduction Workbook for Kids (Shapiro and Sprague).
    3. The client's use of the exercises for practicing daily calming skills was closely monitored.
    4. The client's success at using daily calming skills was reinforced.
    5. The client was provided with corrective feedback for his/her failures at practicing daily calming skills.
  18. Use EMG Biofeedback (18)
    1. EMG biofeedback techniques were utilized to facilitate the client's relaxation skills.
    2. The client achieved deeper levels of relaxation from the EMG biofeedback experience.
    3. The client did not develop deep relaxation as a result of EMG biofeedback.
  19. Teach Applied Tension Technique (19)
    1. The client was taught the applied tension technique to help prevent fainting during encounters with phobic objects or situations.
    2. The client was taught to tense his/her neck and upper torso muscles to curtail blood flow out of the brain to help prevent fainting during encounters with phobic objects or situations involving blood, injection, or injury.
    3. The client was taught specific applied tension techniques as indicated in “Applied Tension, Exposure In Vivo, and Tension-Only in the Treatment of Blood Phobia” (Ost, Fellenius, and Sterner in Behaviour Research and Therapy).
    4. The client was provided with positive feedback for his/her use of the applied tension technique.
    5. The client has struggled to appropriately use the applied tension technique and was provided with remedial feedback in this area.
  20. Assign Daily Applied Tension Practice (20)
    1. The client was assigned a homework exercise in which he/she practices daily use of the applied tension skills.
    2. The client's daily use of the applied tension technique was reviewed.
    3. The client was reinforced for his/her success at using daily applied tension skills.
    4. The client was provided with corrective feedback for his/her failure to appropriately use daily applied tension skills.
  21. Identify Distorted Thoughts (21)
    1. The client was assisted in identifying the distorted schemas and related automatic thoughts that mediate anxiety responses.
    2. The client was taught the role of distorted thinking in precipitating emotional responses.
    3. The client was reinforced as he/she verbalized an understanding of the cognitive beliefs and messages that mediate his/her anxiety responses.
    4. The client was assisted in replacing distorted messages with positive, realistic cognitions.
    5. The client failed to identify his/her distorted thoughts and cognitions and was provided with tentative examples in this area.
  22. Assign Homework on Self-Talk (22)
    1. The client was assigned homework exercises to identify fearful self-talk, create reality-based alternatives, and record his/her experience.
    2. The client was assigned “Journal and Replace Self-Defeating Thoughts” from the Adult Psychotherapy Homework Planner (Jongsma).
    3. The client's use of self-talk techniques was reviewed and reinforced.
    4. The client has struggled in his/her implementation of self-talk techniques and was provided with corrective feedback.
    5. The client has not attempted to use the self-talk techniques and was redirected to do so.
  23. Model/Rehearse Self-Talk (23)
    1. Modeling and behavioral rehearsal were used to train the client in positive self-talk that reassured him/her of the ability to work through and endure anxiety symptoms without serious consequences.
    2. The client was assigned “Positive Self-Talk” from the Adult Psychotherapy Homework Planner (Jongsma).
    3. The client has implemented positive self-talk to reassure himself/herself of the ability to endure anxiety without serious consequences; he/she was reinforced for this progress.
    4. The client has not used positive self-talk to help endure anxiety and was provided with additional direction in this area.
  24. Construct Anxiety Hierarchy (24)
    1. The client was directed and assisted in constructing a hierarchy of anxiety-producing situations.
    2. The client was successful in identifying a range of stimulus situations that produced increasingly greater amounts of anxiety, and this hierarchy was reviewed.
    3. The client found it difficult to identify a range of stimulus situations that produce increasingly greater amounts of anxiety and was provided with assistance in this area.
    4. The client and parents were assisted in developing a list of rewards for successes in overcoming anxiety-producing situations
  25. Develop Contingency Contract (25)
    1. The adolescent and parents were assisted in developing a contingency contact that details the child's exposure tasks and rewards.
    2. The steps in the hierarchy were used to identify the gradual exposure tasks.
    3. The parents were consulted in regard to approval of rewards for the successful completion of each exposure task.
  26. Teach Strategies to Facilitate Exposure (26)
    1. The parents were taught strategies to facilitate the child's exposure or approach behavior toward feared objects or situations.
    2. The parents were taught about positive reinforcement, shaping, extinction, following through, and consistency.
    3. The parents were reinforced for their use of strategies to facilitate the child's exposure or approach behavior.
    4. The parents have not embraced their role in facilitating the child's exposure or approach behavior, and were redirected to do so.
  27. Assign Reading about Situational Exposure (27)
    1. The parents were assigned to read about situational exposure in books or treatment manuals on specific phobia.
    2. The parents were assigned to read Helping Your Anxious Child (Rapee et al.).
    3. The parents have read the assigned material on cognitive restructuring, and important concepts were reviewed within the session.
    4. The parents have not read the assigned material on cognitive restructuring and were redirected to do so.
  28. Select Initial Exposures (28)
    1. Initial exposures were selected from the hierarchy of anxiety-producing situations, with a bias toward likelihood of being successful.
    2. The client was assigned the exercise “Gradual Exposure to Fear” in the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, and McInnis).
    3. A plan was developed with the client for managing the symptoms that may occur during the initial exposure.
    4. The client was assisted in rehearsing the plan for managing the exposure-related symptoms within his/her imagination.
    5. Positive feedback was provided for the client's helpful use of symptom management techniques.
    6. The client was redirected for ways to improve his/her symptom management techniques.
  29. Conduct Graduated Exposure (29)
    1. The client was assisted in conducting exposures to his/her feared stimuli.
    2. Modeling was used to help the client cope within the exposure situation.
    3. The client was reinforced for his/her success in the exposure situation.
    4. The client's level of exposure was gradually increased.
    5. The client was congratulated on his/her ability to function within the exposure situation without any assistance.
  30. Assign Homework on Situational Exposures (30)
    1. The client was assigned homework exercises to perform situational exposures and record his/her experience.
    2. The client was assigned situational exposure homework from Mastery of Your Specific Phobia—Client Manual (Antony, Craske, and Barlow).
    3. The client's use of situational exposure techniques was reviewed and reinforced.
    4. The client has struggled in his/her implementation of situational exposure techniques and was provided with corrective feedback.
    5. The client has not attempted to use the situational exposure techniques and was redirected to do so.
  31. Conduct Cognitive-Behavioral Family Therapy (31)
    1. Cognitive-behavioral family therapy was conducted in accordance with the concepts espoused by Howard et al. in Cognitive-Behavioral Family Therapy for Anxious Children and the FRIENDS Program for Youth (Barrett et al.).
    2. Cognitive-behavioral family therapy was conducted in which family members were taught about the cognitive, behavioral, and emotional components of anxiety.
    3. Cognitive-behavioral family therapy was conducted in which family members learned implemented skills for coping with anxiety, practiced the new skills, and parents learned parenting skills to facilitate therapeutic progress.
  32. Overcome Pattern of Reinforcing Phobia (32)
    1. The family was assisted in identifying situations in which they tend to reinforce the client's phobia through avoidance.
    2. The family was assisted in developing techniques for overcoming the pattern of reinforcement of the client's phobia through avoidance.
    3. As the client's phobia has decreased, the family was taught constructive ways to reward the client's progress.
  33. Teach Family Skills (33)
    1. Family members were taught anxiety management, problem-solving, and communication skills.
    2. The family members were directed to use the skills to reduce family conflict and assist the client's progress.
  34. AssignReading about Family Reactions to Phobia Resolution (34)
    1. The parents were assigned to read about family reactions to phobias and their resolution.
    2. The parents were assigned to read excerpts from Helping Your Anxious Child (Rapee et al.).
    3. The information that the parents have read was reviewed and processed within the session.
    4. The parents have not read the assigned information and were redirected to do so.
  35. Consolidate Strategies (35)
    1. The client was asked to list strategies that he/she has learned in therapy to reduce his/her phobic fear and minimize his/her avoidance.
    2. The client was assigned “Finding a Strategy to Minimize My Fear” from the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, and McInnis).
    3. The client was reinforced for his/her clear understanding of multiple useful techniques for managing his/her phobic fear.
  36. Differentiate between Lapse and Relapse (36)
    1. A discussion was held with the client regarding the distinction between a lapse and a relapse.
    2. A lapse was associated with a temporary 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.
  37. Discuss Management of Lapse Risk Situations (37)
    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.
  38. Encourage Routine Use of Strategies (38)
    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.
  39. Develop a “Coping Card” (39)
    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.
  40. Employ Stimulus Desensitization Interventions (40)
    1. A session was conducted with the client in which he/she was surrounded with pleasant pictures, readings, and storytelling related to the phobic stimulus situation.
    2. The client remained calm and relaxed while the phobic stimulus situation was depicted in pictures, informational material, and storytelling.
    3. The client's ability to face the phobic fear was affirmed, and his/her ability to cope was reinforced.
    4. The client had an extreme reaction to the pictures, reading, and storytelling related to the phobic situation and was provided with support for his/her use of coping techniques during this anxiety.
  41. Interject Use of Humor (41)
    1. Situational humor, jokes, riddles, and stories about the phobic stimulus were used to decrease the client's tension and seriousness regarding the fear.
    2. The client was asked to start each day by telling the parents a joke, riddle, or silly story about the phobic stimulus.
    3. A humorous side was pointed out for each issue/fear the client raised.
  42. Explore Symbolic Meanings of Phobic Situation (42)
    1. The possible symbolic meaning of the client's phobic stimulus was probed and discussed.
    2. Selected interpretations of the phobic stimulus were offered to the client, and each was processed with him/her.
  43. Clarify and Differentiate Present Fears from Past Pains (43)
    1. The client was asked to list his/her present fears and also past emotionally painful experiences that may be related to the current fear.
    2. The client was assisted in clarifying and separating his/her present irrational fears from past emotionally painful experiences.
    3. It was noted that since the client was successful in separating past emotionally painful experiences from the present, he/she has reduced his/her level of phobic fear.
  44. Encourage the Expression of Feelings (44)
    1. The positive value of expressing feelings was emphasized with the client.
    2. Using active-listening and unconditional positive regard techniques, the client was encouraged to express his/her feelings regarding the past painful experiences.
    3. Gentle questioning was used with the client to help him/her start sharing feelings from the past.
    4. Feelings that were shared regarding past painful experiences were affirmed and supported.
  45. Link Past Pain with Present Anxiety (45)
    1. The connection the client was making between his/her past emotional pain and present anxiety was pointed out.
    2. When talking about his/her present fear the client was reminded of how he/she connected it to his/her past emotional pain.
    3. It was noted that since the client was successful in separating past emotionally painful experiences from the present, he/she has reduced his/her level of phobic fear.