Manual 2day Anxiety Certification Course

Rehab Kids
2-Day Anxiety
Certification Course
Kimberly Morrow, LCSW
Elizabeth DuPont Spencer, M.S.W., LCSW
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2-Day Anxiety
Certification Course
Elizabeth DuPont Spencer, M.S.W., LCSW
Rehab Kids
ZNM054525
6/23
Copyright © 2023
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112pp
6/23
Rehab Kids
MATERIALS PROVIDED BY
Kimberly Morrow, LCSW, is a licensed clinical social worker

in private practice in Erie, Pennsylvania. Graduating from
Memphis State University with a Master’s in psychology and
the University of Wisconsin-Milwaukee with a Master’s in social
work, Kimberly is a compassionate therapist, an anxiety expert,
and a national speaker. She has been specializing in treating
people with anxiety and OCD for over 25 years and teaching
other professionals how to treat anxiety for over 15 years.
Elizabeth DuPont Spencer, M.S.W., LCSW-C, is a licensed clinical

social worker and board approved supervisor. Trained as a
cognitive behavioral therapist using exposure and response
prevention for anxiety disorders, obsessive compulsive disorder
and depression, she has been in private practice for 25 years,
working with children, adolescents and adults. Elizabeth is a
member of the International Obsessive Compulsive Foundation
(IOCDF), the National Association of Social Workers (NASW) and
of the Anxiety and Depression Association of America (ADAA).
For speaker disclosures, please see the faculty biography in activity advertising.
Materials that are included in this course may include interventions and modalities that are beyond the
authorized practice of mental health professionals. As a licensed professional, you are responsible for
reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of
practice in accordance with and in compliance with your professions standards.
As required by several accrediting boards, speaker and
activity planning committee conflicts of interest
(including financial relationships with ineligible
organizations) were disclosed prior to the start of this
activity. To view disclosure information, please see
activity advertising.
CBT for Anxiety and OCD
KI MBERLY MORROW, LCSW
ELI ZABETH DUPONT SPENCER, LCSW-C
CBT for Anxiety and OCD
Suggested Items To Enhance

Participation
Warhead-extreme sour candy
Notebook
Puppets or 2 stuffed animals
Pillow case
Gummy bears or sticky candy
Straw
Finger Trap
Ball
We invite you to lean into participating in our many exercises, or
joining us in a demonstration – and you can get a reward video
from us! More about this later this morning.
1
Disclaimer
Materials that are included in this course
may include interventions and modalities
that are beyond the authorized practice
of mental health professionals. As a
licensed professional, you are responsible
for reviewing the scope of practice,
including activities that are defined in law
as beyond the boundaries of practice in
accordance with and in compliance with
your professions standards.
Speaker Disclosure:
Elizabeth DuPont Spencer, LCSW-C
• Financial: The speakers are in private practice.

They receive a speaking honorarium and
royalties on their book from PESI, Inc.
• Nonfinancial: The speakers are members of
the National Association of Social Workers, the
Anxiety and Depression Association of
America, and the International Obsessive
Compulsive Foundation
Risks and Limitations

•While CBT with ERP is 60 - 90% effective, not everyone gets well
•Treatment is too hard for some people who have limited support
without first stabilizing living and /or social supports
•Have a plan for clients who do not get well
• Go back to basics
• Send for a physical to rule out hidden medical problems
• Try complementary treatments
• Send for medicine review
• Consider residential treatment
•CBT research often does not include clients with complex MH or
cognitive/learning issues
•CBT is present oriented and client oriented. It often does not delve into
issues from the past or address system issues
2
Keys to
Effective CBT for Anxiety:
1. Structure sessions to focus on the most important work
2. Include psycho-education to empower clients to be their
own expert and friends or family to be coaches as we
work ourselves out of a job
3. Teach clients that thoughts, actions and feelings are
interconnected and may be changed
4. Focus on exposure and response prevention to change
dysfunctional behaviors and challenge rigid beliefs
5. Require homework between sessions to practice new
skills
Cognitive Behavioral Theory

•Dysfunctional thinking underlies all emotion and
behavior-common to all psychological
disturbances
•Challenge the thoughts and change the behavior
to increase tolerance of emotions
• Acceptance rather than resistance is the key to
improving psychological symptoms
3 Aspects of Anxiety
Cognitive
Feelings Low self
esteem,
unrealistic
Anxiety,Blush, demands for
tremble, sweat, self, beliefs of
dry mouth, inadequacy
Behavioral
No eye contact, avoid,
don’t date, don’t speak
in class
3
You've had a bad day, feel fed up, so go out
shopping. As you walk down the road, someone
you know walks by and, apparently, ignores you.
This starts a cascade of…
UNHELPFUL HELPFUL
Thoughts: He/she looks a bit

Thoughts: He/she ignored me. wrapped up in themselves - I
wonder if there's something
wrong?
Emotions: Anxious and rejected .
Emotions: Concerned for the
other person, positive
Physical: Stomach cramps, low
energy, sick Physical: None, feel
Action: Go home and avoid comfortable
them .
Action: Get in touch to make
sure they're OK
10
Research
11
Goals of CBT
• To provide skills that clients can use
on their own in a variety of different
situations.
• To empower the client to be in
charge of anxiety.
• To work ourselves out of a job.
12
4
CBT is goal oriented and problem
focused.
• Work towards a
mutual
understanding of
problem
• Client develops
goals for therapy
with your help
• Goals are stated in
behavioral terms
13
CBT involves collaboration

and active participation
• Teamwork
• Client decides what
to work on.
• Client identifies their
own cognitive
distortions.
• Client decides on
homework.
14
CBT starts and spends much time

in the present.
• Strong focus on current
specific situations that are
distressing
• Shift to the past for two

reasons:
• If client has a strong
need to and it would
compromise therapy not
to
• When client gets stuck in
dysfunctional thinking
and an understanding of
where their beliefs come
from would be helpful
15
5
CBT includes psycho education-teaching
the client to be their own therapist.
• Have client take

notes in session
and bring home
to review/cue
throughout
week (note
cards, notes on
cell phone or
notebook)
16
CBT is time-limited
• 6-12 sessions is typical for anxiety or
depression (this can be longer)
• Goals:
• provide symptom relief
• facilitate remission of disorder
• help client resolve their most pressing
problems
• relapse prevention
• provide skills/therapeutic attitude for
client to use with future struggles
17
CBT is structured: handout

◦ Maximizes effectiveness and efficiency.
◦ Mood check
◦ Review of week/homework
◦ Setting agenda together
◦ Discussing problems related to agenda
◦ Setting new homework
◦ Summarizing
◦ Feedback
18
6
CBT involves Goal Setting
Have client make a list of goals they would like
to accomplish:
Example: Client with Panic Disorder
◦ Goals:
◦ Drive outside of mile radius from home
◦ Drive with someone other than my spouse
◦ Return to Church
◦ Sit in whatever seat is available in theater
◦ Travel in the state
◦ Travel outside of this state
19
CBT teaches how to challenge

automatic thoughts/beliefs
◦ Socratic questioning (handout) seeks to
get the other person to answer their own
questions
◦ Behavioral experiments to directly test
thoughts
◦ Non Shopping Trip
20
Non Shopping Trip
21
7
CBT uses techniques and
teaches skills
• Changes thinking, mood, and
behavior
◦ Trap of techniques
◦ Importance of therapeutic attitude
◦ Practice skills in session with client
22
CBT involves Changing Behaviors
23
Behavioral experiments
•Creates an opportunity for the client to learn more
about their disorder as well as their automatic thoughts
•Social anxiety example:
◦ Ask questions about their activities and how they are
different than before they were struggling.
◦ Help them connect their automatic thoughts to their
experiences.
◦ Set up behavioral experiments to test their
thoughts/beliefs.
◦ “I can’t enjoy being with friends because of my
anxiety.” (ask how could we test this?)
24
8
CBT Challenges Automatic
Thoughts
•Help client to see the potential fault in their
thinking.
•Set up experiment to test their thinking.
•Ask questions to set experiment up to maximize
success.
• Who would you like to see? Who has recently
contacted you? What could you do?
•Develop a cognitive response for when
experiment does not turn out (friend says no).
What are alternative explanations?
25
CBT Gives Homework

•Essential! Discuss this upfront, educate about
usefulness, explain your boundary for not doing HW.
• Always practice what you have discussed in session
(in vivo exposures, role plays, skill building)
• Develop homework to practice out side of session
• Client decides on homework
• Consider obstacles in doing homework and how to
climb over
• Set up homework to be successful
• Success is in trying, not in doing HW perfectly
26
Homework Assignments
Behavioral Activation: Schedule things for client to do during
the week (depressed client)
Monitoring Automatic Thoughts: Client will ask from 1st
session, “What’s going through my mind?”
Evaluating and Responding to Automatic Thoughts: Help
client modify their inaccurate thoughts and write down their
new way of thinking/responding to trigger situation.
Skill building: Practice in and out of session
Exposure and Response Prevention: Practice facing fears to
change relationship with fear and develop anxiety
tolerance
Bibliotherapy or videos: Noises in your head free video series
27
9
Noise in Your Head
28
CBT May Involve Interrupting

•Use this, gently, if client is long winded, going off
on a tangent, or undirected in their sharing
•Use when identifying problems so that client does
not get into the details of the problem yet
•Use when client is telling anxiety story
•Helps to keep therapy on track and is often
appreciated by client
29
What is not helpful.

•Distraction: NOT USEFUL! Client
needs skill to face and feel
emotions to learn although
they are uncomfortable,
feelings are not dangerous
•Relaxation Techniques: When
and what to use and not to
use
• Intention: Pay attention
•Co-compulsing: Answering the
clients questions to reassure
them or help them feel better
•Figuring out why: Don’t go
down the rabbit hole!
•If a client is not ready
30
10
Incorporate Cultural
Competence into CBT session
• To understand how anxiety has impacted a client’s
life we must consider the cultural context in which
they experience that anxiety
• Consider and acknowledge differences between
you and your client such as: Socioeconomic, racial,
religious, gender, sexual identity; disability status
• Recognize the power imbalance between a
therapist and client and foster a mutually
beneficial and non-paternalistic relationship
31
CBT Prepares for Termination

and Relapse Prevention
Goal of therapy: To have remission of symptoms and skills to
use for future problem solving.
Prepare client early: At first session, socialize client into a
time-limited treatment.
When client begins to feel better, discuss course of recovery:
improvement-plateaus-setbacks.
32
11
CBT Session Structure
 Mood check (scaling, inventories)
 Review of week (successes, struggles, triggers-very

brief)
 Review of Homework (successes and struggles-spend

time understanding obstacles, cognitive and other, to
develop more successful homework)
 Setting agenda together (have client give problems a

title and decide which one is most important to start
with today)
 Discussing problems related to agenda(get into

specifics, use socratic questions to understand
beliefs/rules/assumptions. Have client understand
their thoughts related to triggers. Develop new ways to
think and new behaviors)
 Setting new homework (based on what you just talked

about. Make sure they write it down and you discuss
their obstacles to doing homework. Practice in session
if possible)
 Summarizing (client)
 Feedback (what can you do better?)
12
Socratic Questions
The overall purpose of Socratic questioning is to challenge accuracy and completeness of
thinking in a way that acts to move people towards their ultimate goal.
Conceptual clarification questions

Get them to think more about what exactly they are asking or thinking about. Prove the concepts
behind their argument. Use basic 'tell me more' questions that get them to go deeper.
• Why are you saying that?

• What exactly does this mean?
• How does this relate to what we have been talking about?
• What is the nature of ...?
• What do we already know about this?
• Can you give me an example?
• Are you saying ... or ... ?
• Can you rephrase that, please?
Probing assumptions
Probing their assumptions makes them think about the presuppositions and unquestioned beliefs
on which they are founding their argument. This is shaking the bedrock and should get them
really going!
• What else could we assume?

• You seem to be assuming ... ?
• How did you choose those assumptions?
• Please explain why/how ... ?
• How can you verify or disprove that assumption?
• What would happen if ... ?
• Do you agree or disagree with ... ?
Probing rationale, reasons and evidence

When they give a rationale for their arguments, dig into that reasoning rather than assuming it is
a given. People often use un-thought-through or weakly-understood supports for their arguments.
• Why is that happening?

• How do you know this?
13
• Show me ... ?
• Can you give me an example of that?
• What do you think causes ... ?
• What is the nature of this?
• Are these reasons good enough?
• Would it stand up in court?
• How might it be refuted?
• How can I be sure of what you are saying?
• Why is ... happening?
• Why? (keep asking it -- you'll never get past a few times)
• What evidence is there to support what you are saying?
• On what authority are you basing your argument?
Questioning viewpoints and perspectives

Most arguments are given from a particular position. So attack the position. Show that there are
other, equally valid, viewpoints.
• Another way of looking at this is ..., does this seem reasonable?

• What alternative ways of looking at this are there?
• Why it is ... necessary?
• Who benefits from this?
• What is the difference between... and...?
• Why is it better than ...?
• What are the strengths and weaknesses of...?
• How are ... and ... similar?
• What would ... say about it?
• What if you compared ... and ... ?
• How could you look another way at this?
Probe implications and consequences

The argument that they give may have logical implications that can be forecast. Do these make
sense? Are they desirable?
• Then what would happen?

• What are the consequences of that assumption?
• How could ... be used to ... ?
• What are the implications of ... ?
• How does ... affect ... ?
• How does ... fit with what we learned before?
• Why is ... important?
14
Assessment and Treatment
Planning: Set the Stage for
Successful Treatment
Keys to
skills
Assessment and
Treatment Planning
Set the Stage for Successful Treatment
• Diagnosis – why it’s important

• Key questions to ask at intake
• Assessment forms – where to find them
• Teach your clients to use a notebook
• Using a SUDS scale
15
Build Empathy;
Improve Treatment Outcomes
BARRIERS TO
BRIDGE TO EMPATHY
COMMUNICATION
1. It can be hard to sit with 1. Reflect with your client on
the suffering of our clients bad things are for them
2. It can be hard to 2. Respect that this odd
understand why clients functioning is the best
do what they do your client can do now
3. It can be hard to take a 3. Fear feels terrible
fear seriously whatever the trigger
Diagnosis is an Opportunity
•For psychoeducation (CBT •It doesn’t make the problem
works; brain biology; books; worse
online resources)
•It does not increase suffering
•To select evidence-based
treatment
Intake Forms
ANXIETY QUESTIONNAIRE FREE ASSESSMENTS
1. I worry a lot of the time 1. American Psychiatric Association
psychiatry.org/psychiatrists/practice/dsm/ed
2. I often feel depressed and down ucational-resources/assessment-measures
3. My sleep is a problem
2. Jonathon Grayson’s forms
4. I have panic or anxiety attacks freedomfromocd.com
5. There are places I avoid
6. I experience frequent pain 3. YBOCS and CY-BOCS rating scales and
scoring instructions
7. I am shy and nervous with people
8. My anxiety is embarrassing
9. I have bad/upsetting thoughts
10. I have to do things over and over
11. It is difficult to concentrate at
school or work
12. My family and friends notice my
anxiety
16
Hallmarks of Anxiety Disorders:
Panic Disorder
Specific Phobia
Generalized Anxiety Disorder (GAD)
Social Anxiety Disorder
Selective Mutism
Post Traumatic Stress Disorder
Obsessive Compulsive Disorder (OCD)
Screen for Complications:

•Caffeine
•Alcohol
•Drugs of abuse
•Over the counter medicines
•Thyroid disorder
•PANS evaluation for children with sudden onset
OCD/separation anxiety/tourettes/eating disorder
The Journey with a New Client

Begins
17
Situational Units of Distress
(SUDS) Scale
8-10
Teach your client a new
language to describe the
5-7 suffering and avoidance due
to anxiety or OCD.
0-4
10
Trigger Situations
SUDS TRIGGER
10 Meeting new people
8 Eating in the cafeteria
10 Giving a presentation
7 Going to a party
6 Go to a sporting event
5 Answering the phone
9 Answering a question
in class
11
Set Goals – Dream Big!

Easy
Medium
◦ Go to a sporting event
Hard
◦ Go to school every day
◦ Make a friend
Impossible
◦ Attend college and live in a dorm
12
18
Homework for 1st Session
Have your client write what they are
missing due to anxiety.
Psychoeducation is key: give them a
book/chapter/website link to read
Ask them to keep a record of things
that trigger their anxiety and what
they do (or others do) to help them
feel better
13
First Homework
Observe and record what is happening
14
First Session Highlights:

•The goal is for your client to
leave with a name for their
suffering and a feeling of hope
that they can get well
•Use good empathy building
skills
•Collaboration is key to getting
the right diagnosis
•Help your client set up a
notebook or note page on
phone
•Use intake forms to give your
client permission to talk about
embarrassing problems
15
19
Anxiety, OCD and Depression Screening
Name: ____________________________ Date: __________________

Please circle the response that best describes you. Feel free to change the wording of a
particular question to fit our situation.
0 = Not at all true 1=Somewhat true 2=Moderately true 3=Very true 4=Completely true
1. I worry a lot of the time 0 1 2 3 4
2. I often feel depressed and down 0 1 2 3 4
3. I have panic or anxiety attacks 0 1 2 3 4
4. There are places I avoid 0 1 2 3 4
5. I am shy and nervous with people 0 1 2 3 4
6. My anxiety is embarrassing 0 1 2 3 4
7. I have bad /upsetting thoughts 0 1 2 3 4
8. I have to do things just so or over and over 0 1 2 3 4
9. I experience frequent pain 0 1 2 3 4
10. My sleep is a problem 0 1 2 3 4
11. My difficulties impact work or school 0 1 2 3 4
12. My family and friends notice my difficulty 0 1 2 3 4
What is the main problem you are having?

______________________________________________________________________________
______________________________________________________________________________
________________________________________________________________________
In order to conclude that your treatment was successful, what would you want to achieve?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
20
Evaluating the Anxiety, OCD and Depression Screening
Circle all that are present for this client. Double circle all 3 and 4 answers
1. GAD or phobias
2. Depression
3. Panic disorder
4. Phobia, phobia or OCD
5. Social Anxiety Disorder
6. Social Anxiety Disorder
7. OCD
8. OCD
9. A frequent complication of anxiety, OCD and depression
10. A frequent complication of anxiety, OCD and depression
11. Screen for severity of the impact of anxiety, OCD and depression
12. Screen for severity of the impact of anxiety, OCD and depression
21
PATIENT 22.
NAME_________________________________DATE_________________________
YALE-BROWN OBSESSIVE COMPULSIVE SCALE (Y-BOCS)*
Questions 1 to 5 are about your obsessive thoughts

Obsessions are unwanted ideas, images or impulses that intrude on thinking against your wishes and efforts to resist
them. They usually involve themes of harm, risk and danger. Common obsessions are excessive fears of
contamination; recurring doubts about danger, extreme concern with order, symmetry, or exactness; fear of losing
important things.
Please answer each question by circling the appropriate number.
1. TIME OCCUPIED BY OBSESSIVE THOUGHTS SCORE __________

How much of your time is occupied by obsessive thoughts?
0 = None
1 = Less than 1 hr/day or occasional occurrence
2 = 1 to 3 hrs/day or frequent
3 = Greater than 3 and up to 8 hrs/day or very frequent occurrence
4 = Greater than 8 hrs/day or nearly constant occurrence
2. INTERFERENCE DUE TO OBSESSIVE THOUGHTS SCORE __________

How much do your obsessive thoughts interfere with your work, school, social, or other important role
functioning? Is there anything that you don’t do because of them?
0 = None
1 = Slight interference with social or other activities, but overall performance not
impaired
2 = Definite interference with social or occupational performance,
but still manageable
3 = Causes substantial impairment in social or occupational performance
4 = Incapacitating
3. DISTRESS ASSOCIATED WITH OBSESSIVE THOUGHTS SCORE __________

How much distress do your obsessive thoughts cause you?
0 = None
1 = Not too disturbing
2 = Disturbing, but still manageable
3 = Very disturbing
4 = Near constant and disabling distress
4. RESISTANCE AGAINST OBSESSIONS SCORE __________

How much of an effort do you make to resist the obsessive thoughts? How often do you try to disregard or
turn your attention away from these thoughts as they enter your mind?
0 = Try to resist all the time
1 = Try to resist most of the time
2 = Make some effort to resist
3 = Yield to all obsessions without attempting to control them, but with some
reluctance
4 = Completely and willingly yield to all obsessions
22
23.
5. DEGREE OF CONTROL OVER OBSESSIVE THOUGHTS SCORE __________
How much control do you have over your obsessive thoughts? How successful are you in stopping or diverting
your obsessive thinking? Can you dismiss them?
0 = Complete control
1 = Usually able to stop or divert obsessions with some effort and concentration
2 = Sometimes able to stop or divert obsessions
3 = Rarely successful in stopping or dismissing obsessions, can only divert attention
with difficulty
4 = Obsessions are completely involuntary, rarely able to even momentarily alter
obsessive thinking.
The next several questions are about your compulsive behaviors.

Compulsions are urges that people have to do something to lessen feelings of anxiety or other discomfort. Often
they do repetitive, purposeful, intentional behaviors called rituals. The behavior itself may seem appropriate but it
becomes a ritual when done to excess. Washing, checking, repeating, straightening, hoarding and many other
behaviors can be rituals. Some rituals are mental. For example, thinking or saying things over and over under your
breath.
6. TIME SPENT PERFORMING COMPULSIVE BEHAVIORS SCORE __________

How much time do you spend performing compulsive behaviors? How much longer than most people does it
take to complete routine activities because of your rituals? How frequently do you do rituals?
0 = None
1 = Less than 1 hr/day or occasional performance of compulsive behaviors
2 = From 1 to 3 hrs/day, or frequent performance of compulsive behaviors
3 = More than 3 and up to 8 hrs/day, or very frequent performance of compulsive
behaviors
4 = More than 8 hrs/day, or near constant performance of compulsive behaviors
(too numerous to count)
7. INTERFERENCE DUE TO COMPULSIVE BEHAVIORS SCORE __________

How much do your compulsive behaviors interfere with your work, school, social, or other important role
functioning? Is there anything that you don’t do because of the compulsions?
0 = None
1 = Slight interference with social or other activities, but overall performance
not impaired
2 = Definite interference with social or occupational performance, but still
manageable
3 = Causes substantial impairment in social or occupational performance
4 = Incapacitating
23
24.
8. DISTRESS ASSOCIATED WITH COMPULSIVE BEHAVIOR SCORE __________
How would you feel if prevented from performing your compulsion(s)? How anxious would you become?
0 = None
1 = Only slightly anxious if compulsions prevented
2 = Anxiety would mount but remain manageable if compulsions prevented
3 = Prominent and very disturbing increase in anxiety if compulsions interrupted
4 = Incapacitating anxiety from any intervention aimed at modifying activity
9. RESISTANCE AGAINST COMPULSIONS SCORE __________

How much of an effort do you make to resist the compulsions?
0 = Always try to resist
1 = Try to resist most of the time
2 = Make some effort to resist
3 = Yield to almost all compulsions without attempting to control them, but with
some reluctance
4 = Completely and willingly yield to all compulsions
10. DEGREE OF CONTROL OVER COMPULSIVE BEHAVIOR SCORE __________

How strong is the drive to perform the compulsive behavior? How much control do you have over the
compulsions?
0 = Complete control
1 = Pressure to perform the behavior but usually able to exercise voluntary control
over it
2 = Strong pressure to perform behavior, can control it only with difficulty
3 = Very strong drive to perform behavior, must be carried to completion, can only
delay with difficulty
4 = Drive to perform behavior experienced as completely involuntary and over-
powering, rarely able to even momentarily delay activity.
TOTAL SCORE ______________
24
Y-BOCS Symptom Checklist
Instructions: Generate a Target Symptoms List from the attached Y-BOCS Symptom Checklist by
asking the patient about specific obsessions and compulsions. Chock all that apply. Distinguish between
current and past symptoms. Mark principal symptoms with a "p". These will form the basis
of the Target Symptoms List. Items marked may “*” or may not be an OCD phenomena.
Current Past Current Past
AGGRESSIVE OBSESSIONS
Fear might harm self SOMATIC OBSESSIONS
Fear might harm others Concern with illness or disease*
Violent or horrific images Excessive concern with body part or aspect of
Fear of blurting out obscenities or insults Appearance (eg., dysmorphophobia)*
Fear of doing something else embarrassing* Other
Fear will act on unwanted impulses (e.g., to stab
friend) CLEANING/WASHING COMPULSIONS
Fear will steal things
Fear will harm others because not careful enough Excessive or ritualized handwashing
(e.g. hit/run motor vehicle accident) Excessive or ritualized showering, bathing,
Fear will be responsible for something else terrible toothbrushing grooming, or toilet routine Involves
happening (e.g., fire, burglary cleaning of household items or other inanimate objects
Other measures to prevent or remove contact with
Other:_______________________________ contaminants
CONTAMINATION OBSESSIONS Other
Concerns or disgust w\ with bodily waste or CHECKING COMPULSIONS
secretions (e.g., urine, feces, saliva Concern with dirt
or germs Checking locks, stove, appliances etc.
Excessive concern with environmental contaminants Checking that did rot/will not harm others
(e.g. asbestos, radiation toxic waste) Checking that did not/will not harm self
Excessive concern with household items (e.g., Checking that nothing terrible did/will happen
cleansers solvents)
Checking that did not make mistake
Excessive concern with animals (e.g., insects)
Checking tied to somatic obsessions
Bothered by sticky substances or residues
Other:
Concerned will get ill because of contaminant
Concerned will get others ill by spreading contaminant REPEATING RITUALS
(Aggressive) Rereading or rewriting
No concern with consequences of contamination Need to repeat routine activities jog, in/out door,
other than how it might feel up/down from chair)
Other: Other _____________________________
SEXUAL OBSESSIONS
Forbidden or perverse sexual thoughts. images. or
COUNTING COMPULSIONS
impulses
___________________________________
Content involves children or incest
Content involves homosexuality* ORDERING/ARRANGING COMPULSIONS
Sexual behavior towards others (Aggressive)* ___________________________________
Other:
HOARDING/COLLECTING COMPULSIONS
(distinguish from hobbies and concern with objects of monetary or
HOARDING/SAVING OBSESSIONS sentimental value (e.g., carefully reads junk mail, piles up old newspapers,
(distinguish from hobbies and concern with objects of monetary or sorts through garbage, collects useless objects.)
sentimental value)
___________________________________
RELIGIOUS OBSESSIONS (Scrupulosity)

Concerned with sacrilege and blasphemy
Excess concern with right/wrong, morality MISCELLANEOUS COMPULSIONS
Other: Mental rituals (other than checking/counting)
OBSESSION WITH NEED FOR SYMMETRY OR EXACTNESS Excessive listmaking
Accompanied by magical thinking (e.g., concerned Need to tell, ask, or confess
that another will have accident dent unless less Need to touch, tap, or rub*
things are in the right place) Rituals involving blinking or staring*
Not accompanied by magical thinking
Measures (not checking) to prevent: harm to self -
harm to others terrible consequences
MISCELLANEOUS OBSESSIONS
Need to know or remember Ritualized eating behaviors*
Fear of saying certain things Superstitious behaviors
Fear of not saying just the right thing Trichotillomania *
Fear of losing things Other self-damaging or self-mutilating behaviors*
Intrusive (nonviolent) images Other
Intrusive nonsense sounds, words, or music
Bothered by certain sounds/noises*
Adapted from Goodman, W.K., Price, L.H., Rasmussen, S.A. et al.:
Lucky/unlucky numbers “The Yale-Brown Obsessive Compulsive Scale.”
Colors with special significance Arch Gen Psychiatry 46:1006-1011,1989
3 superstitious fears
Other: 25
Anxiety and the Brain: What
Every Client Needs to Know
KIMBERLY MORROW, LCSW
E L I Z AB E T H D UP O N T S P E N C E R , L C S W- C
Keys to
own expert and friends or family to be coach's as we work
ourselves out of a job
dysfunctional behaviors and challenge ridged beliefs
5. Require homework between sessions to practice new skills
Anxiety and the Brain:

What Every Client Needs to Know
•Why this is a pivotal point of treatment

•Simple ways to teach clients about anxiety and
the brain
•The role of avoidance and safety behaviors
•Medication-what is helpful and what is not
26
Why Are We Talking About
This?
•Psychoeducation is a major part of CBT treatment for

anxiety and OCD
•Understanding the brain helps explain why ERP works
•Recognize that CBT helps re-wire the brain
•Gives your clients a big dose of hope!
Anxiety is Normal and Helpful

•Anxiety helps protect us
•Without Anxiety our species would not have survived
•Anxiety keeps us safe – we don’t touch hot stoves,
walk in dark alleyways or get hit by mac trucks.
•Anxiety helps us focus on what is important – we study
for a test; athletes and actors perform better with
anxiety
When Helpful Anxiety

Becomes an Anxiety Disorder
•Seeing danger when there is
none, or overstating the risk
•Use the reasonable person
standard.
•What would 100 people say
about this?
27
Thalamus
Brain and
Brain and Anxiety
Anxiety
Common Safety Behaviors

•Needing to have a water bottle
•Being with a safe person (parent, teacher, spouse)
•Staying close to home
•Checking pulse
•Always having a throw-up bag
•Reassurance seeking
•Distraction from anxiety-generating thoughts
•Avoiding eye contact/wearing sunglasses
•Being nice/avoiding conflict
•Carrying a cell phone
28
Selective Serotonin /
Norepinephrine Reuptake Inhibitors
SSRI’s SNRI’s
Prozac (fluoxetine) Effexor (venlafazine)
Zoloft (sertraline) Pristiq (desvenlafaxine)
Paxil (paroxetine) Cymbalta (duloxetine)
Celexa (citalopram) Fetzima
(levomilnacipran)
Lexapro
(escitalopram)
Other Categories
of Anti-Depressants:
•Wellbutrin (bupropion)
•Remeron (mirtazapine)
•Desyrel (trazodone)
•Trintellix (vortioxetine)
(Formerly marketed as
Brintellix)
•Avoid Benzodiazepines
Our Brains are Amazing

But they can work against us
29
30
Thoughts about trigger:
What if I turn red
Amygdala
Prefrontal
Cortex
Trigger: Cortisol/Adrenalin-
Giving woosh of fear
presentation Reactivates
danger signal
Automatic Do something to feel
danger better- rehearse , seek
signal reassurance, refuse to
participate, avoid
school that day
31
The Art of Exposure and
Response Prevention
Keys to
skills
The Art of Exposure and

Response Prevention
•The role of the clinician
•Teach clients to ride the wave of anxiety
•Create a fear hierarchy using SUD scales
•How to set up an exposure
•Working with resistance to exposure
•What NOT to do
32
Becoming a Team with Your
Client
•Identify triggers and responses
•Develop a hierarchy
•Agree where to begin with exposures
•Develop exposures- specific to client
•Identify obstacles to exposures
•Practice exposures together
•Discuss exposures beginning of next session
Developing a hierarchy
•Make a list of things that trigger them and their
responses
• Homework after 1st session
•Use SUDS (Subjective Units of Distress Scale) to
identify anxiety levels for each trigger
• 1-10
• 0-100
•Rank order triggers from least anxiety provoking to
most anxiety provoking
•Inhibitory Learning Model-throw triggers in a hat
Fear Hierarchy: Claustrophobia

SUDS TRIGGER
30 Reading about trapped miners
45 Having fingernail polish on with no way to remove it
50 Watching news about someone in jail
60 Having a tight ring on finger
75 Traveling in an elevator with another person
90 Traveling in an elevator alone
95 Driving through a tunnel
100 Being locked in a room
33
Types of Exposures
•Planned
•In Vivo
•Spontaneous
•Scripts
ERP comes in different sizes
Developing Exposures
•Break down into incremental steps-nothing is too small!
•How to develop exposures
• Google ideas
• Google images
• Ask client
• Ask colleagues (consultation with AnxietyTraining.com or
ADAA.org)
•Focus on vulnerability
•Teach how to do a successful exposure: body language,
energy, intention, self talk
•Identify compulsions and educate on healthy response to
trigger
34
Role of Avoidance
10
Ride the wave of anxiety
11
Reassurance
12
35
Distinguishing Information-Seeking
and Reassurance Seeking
Developed at the Anxiety Disorders Center, Saint Louis Behavioral Medicine Institute
AN INFORMATION-SEEKER: A REASSURANCE-SEEKER:
Asks a question once Repeatedly asks the same

question
Asks questions to feel less
Asks questions to be anxious
informed
Responds to an answer by
challenging the answerer,
Accepts the answer arguing, or insisting the answer
provided be repeated or rephrased
Asks people who are Often asks people who are
qualified to answer the unqualified to answer the
question question
13
AN INFORMATION-SEEKER: A REASSURANCE-SEEKER:
Seeks the truth Seeks a desired answer

Accepts relative, qualified, Insists on absolute, definitive
or uncertain answers when answers whether
appropriate appropriate or not
Pursues only the information Indefinitely pursues
necessary information without ever
forming a conclusion or
making a decision
14
Practicing ERP
•In Vivo Exposure- done in session to:
• demonstrate
• understand obstacles
• look for ways client gives fear power
•Homework
• 3 strikes and your out
•What does success look like?
• Success is in the trying
• Look out for perfectionists
• Problem solve when exposure does not result in
anxiety tolerance
15
36
Role Play about fear of vomit with
my niece, Colleen, who is an
actor
16
Rewards
•Small:
• More screen time
• Frappuccino
• Sleep over with friend
• Medium:
• A dollar for every exposure
• Dinner out at restaurant of choice
• Movie at theater
• Large:
• A new tent for camping
• A dog
• A weekend skiing
17
What Not To Do
•Do not connect to the content of the fear
•Do not reassure a client
•Do not engage in psychodynamic
processing
•Do not teach them relaxation
•Do not listen to their anxiety story for any
length of time
18
37
Exposure for Snake Phobia
19
Wins!
Help your client see the successes!
20
38
An information-seeker: A reassurance-seeker:
Asks a question once Repeatedly asks the same question
Asks questions to be informed Asks questions to feel less anxious
Responds to an answer by challenging

Accepts the answer provided the answerer, arguing, or insisting the
answer be repeated or rephrased
Asks people who are qualified to answer Often asks people who are unqualified to
the question answer the question
Asks questions that are answerable Often asks questions that are
unanswerable
Seeks the truth Seeks a desired answer
Accepts relative, qualified, or uncertain Insists on absolute, definitive answers

answers when appropriate whether appropriate or not
Pursues only the information necessary Indefinitely pursues information without

to form a conclusion or make a decision ever forming a conclusion or making a
decision
Developed at the Anxiety Disorders Center, Saint Louis Behavioral Medicine Institute
39
Imaginal Scripts for OCD
Fear: I will be responsible for something bad happening.
Easy
My younger sister asked me to pick out a book for her to read. I suggested one of my favorites,
but I’m worried it will upset her. There is a part at the end that is kind of scary and I forgot that
when I suggested it to her. What if she has nightmares, and is mad at me for giving her that
upsetting book?
Medium
My family chore is stacking the dishwasher after dinner every night and starting it. I am very
slow because I check every plate to make sure I have it cleaned before it goes into the machine.
What if I leave some food on, and someone gets sick? What if I stack a broken cup and someone
gets cut? Tonight, we eat late after swim practice there is not much time to stack the dishwasher
before it is my bedtime. I can’t do it as carefully as I want, and I’m scared I made a mistake and
someone will get hurt or sick because of me.
Hard
I love taking care of animals. My family is currently fostering a dog named Snickers and just
received a phone call that someone wants to adopt him. I am feeling anxious about this. How
will my parents know it's a good family for him? What if the new family hurts him? My parents
agree to meet the family but it’s only a quick meeting because they have to take me to swim
practice. The new family seems okay. I don't want to give up this dog but I know I have to. My
family is only a foster family and we already have a dog of our own. The family comes to pick
Snicker's up the next day and I get this strange feeling in my gut. I am not sure this is the right
family but I have nothing to go on. They take Snickers with them and I feel horrible. I don't sleep
that night worrying that I let this dog go to a family who may harm him. I miss school the next
day because I can't stop crying. How could I be so reckless? I should have made my parents ask
more questions of the adoptive family. I'll never know if they were the right one or if they are
being mean to Snickers.
40
Exposure Ideas
Social Anxiety
Description of exposure In Out of Props needed Other

session? session? children/adults
needed?
Giving a speech X Yes
- Have people whisper

- Have people ask questions
Buy something at the café X Money
Order something alone at the café X Money
Trip in front of people X X
Wear strange makeup and make your X X Makeup X

hair look funny
Go in the elevator X X
Play a game with a new person X X Game X
Have the child find you in a different X

part of the building
Walk around campus X
Have the child walk around with toilet X Toilet paper

papers tuck to their shoe
Treasure hunt: give the child a list of X Various X

people/objects to find and let them go
alone to find these (people have to
initial the paper)
The child takes a test (e.g., WIAT X Test X

subtest) and purposely messes up, has
someone grade it but is not permitted
41
to explain that they made a silly
mistake
Child writes a composition with the X Writing X

wrong hand and lets someone read it
without explanation
Child has a disagreement with someone X X X

and argues his/her point
Therapist and child walk around the X

building or outside looking messy and
unkempt
Therapist and child practice doing X X Various

embarrassing things in front of people
(e.g., bumping into people, asking
obvious questions, looking lost, spilling
things).
Child has to purposely lose an easy X Game X

game to a stranger
Have the child sing, act a scene from a X X X

play or play a game in front of a crowd
Ask people in the building for the time X X X
Say something silly/dumb on purpose in X X X

front of friend
Scavenger hunt - asking questions to X X X

find out info needed
Scavenger hunt (easier version)- items X X various X

that do not require verbally asking
42
Separation Anxiety

needed?
Have parent be late to pick up child X X X
Have mom stay in the car during X X

session
Scavenger hunt with clues placed X Various X

around the building to look for his/her
parents
Hide and seek. Tell the child that there X X X

is a ________ in the building. Go
“hide.” The child then needs to ask
someone where _____is, get directions,
find therapist.
Have parents drop off child alone in X X

front of the building
Talking about mom/dad dying and what X

would happen (e.g., where would you
live, how would you feel, whether
people would support you, etc.)
Write a detailed story of the feared X X

situation gone wrong and have them
read it aloud repeatedly
43
Selective Mutism

needed?
Asking the teacher a question X X X
Ask a friend a question in the classroom X X X
Say “Hi” to someone nonverbally in the X X Various X

classroom
Hide and seek X X X
Talk to a friend in the classroom X X X
Talk to the principal X X Principal X
Ask front desk staff a question X X staff X
Ask random student in hallway for help X X Confederate X
Engage in back and forth conversation X X friend X

with a friend in the classroom
Engage in back and forth conversation X X parents X

with a parent in the classroom
Answer a question out loud in X X Teacher/parent X

classroom with teacher and parent
present
Scavenger hunt - asking questions to X X Random X

find out info needed
Scavenger hunt (easier version)- items X X Random X

that do not require verbally asking
44
Cognitive Therapy: Change
the Way Clients Think About
Their Thoughts
Keys to
skills
Cognitive Therapy: Change the

Way Clients Think about Thinking
•Empower clients to choose how to interpret their thoughts
•Utilize values clarification to motivate change
•Challenge distortions and core beliefs that get in the way of
change
•The role of mindfulness in anxiety treatment
45
Cognitive Therapy :
Challenge the Way You Think
•Thoughts are not facts
•We have choices about how we interpret our thoughts
•Thoughts can have cognitive distortions we are unaware of
•Values clarification can help clients find motivation for
change
•Underlying assumptions and core beliefs can get in the way
of change – rules and assumptions can undermine success
Values Clarification
VALUES SOCIAL ANXIETY DISORDER
o You are stuck with your parents
◦ Family and they are stuck with you.
oYou aren’t good enough for
◦ Socializing anyone to want to be in a
relationship with you.
◦ Self Confidence oYou will never be successful
with how bad you are at talking
◦ Participating in Life to people.
oJust stay at home so you don’t
have to face embarrassment.
Cognitive Strategies
1. Automatic Thoughts
2. Cognitive Distortions
3. Core Fear
4. Bossing Back
5. Acting “As If”
6. Just a Thought
7. Bring it On
8. Anticipatory Anxiety
9. Thought / Action / Feeling
10. Thought Log
46
Automatic Thoughts
What was I just thinking?
Cognitive Distortions
1. All-or-nothing thinking
2. Overgeneralization
3. Minimizing and maximizing
4. Fortune-telling
5. Emotional reasoning
6. Should have’s and Ought to’s
7. Tunnel vision
8. Catastrophizing
Cognitive Restructuring
RECORD DISTORTED DEVELOP RATIONAL/REALISTIC
THOUGHTS ALTERNATIVE STATEMENTS
• If I think I am ugly, I must • Just because I think it,
be ugly doesn’t make it true
• Other people are • I have to pay attention to
disgusted by me what other people say to
• I can’t be seen in public me and how they act to
because people will laugh me to know how they
at me might feel about me
• People might laugh at me,
but I’m willing to take the
risk so that I don’t have to
live like this anymore!
47
Core Fear / Core Belief /
Catastrophic Fear
I’m afraid to fly
What if I pick up
germs?
I might get sick

and vomit
I can’t handle
vomiting
I would go crazy
or die if I vomited
10
Externalizing / Bossing Back
11
Acting “As If”

•Watch body language
•Especially good the first time doing something
•Pretend to have confidence!
12
48
ADAA Master Clinician
Presentation 2019
13
Just a Thought.
Let it come, let it drift away. Don’t add emotion or judgement
14
Bring it On
I hope I get anxious going to

the mall! It will be a great
opportunity to practice
tolerating these feelings and
shopping anyway!
15
49
Anticipatory Anxiety
•The worst is always yet to come!
•Remember the surge of anxiety before exposure or a
triggering event is normal, it’s our brain trying to keep us safe
•Going through the high level of anxiety helps retrain our
brain to know that we can handle it!
•Avoidance fuels higher levels of anxiety
•How do you get into a cool swimming pool when it is warm
out?
16
Situation:
Skipped a day of homework doing exposures to fear of needles
Automatic Thought:
Action/Behavior:
I suck
Everyone else's priorities Inactive
come before mine Didn’t do anything
My therapist is going to Cried
think I failed at my Ate ice cream
homework
Feeling:
Failure I learned that my true self is a failure

Overwhelmed
Hopeless
17
Situation:
Skipped a day of homework doing exposures to fear of needles
Automatic Thought:
Action/Behavior:
I’m tired of avoiding this

and freaking out when I
have to get blood drawn I regularly did exposures
I did actually do most day’s every day
homework
Feeling:
Energetic
More capable
Like I can count on myself
18
50
Thought Log: Giving an Oral
Report
Automatic Distress Supporting Contradicting Rational Distress
Thoughts 0 - 10 Evidence Evidence Thoughts 0 - 10
I’m going to 9 I had a panic I finished that I can 6
have a attack before oral report practice with
panic when I gave even with a panic attacks
attack and an oral panic attack and public
leave the report and I got a speaking.
room good grade Even though
No evidence I don’t like
The other I don’t know giving an
students if they think oral report I
will think I’m smart or can do it and
I’m dumb dumb no one pays
much
attention
19
Mindfulness
20
Integrating
the
Cognitive
and
Behavioral
Collaborate
Build Skills
Not all techniques will

work for every client
Attribute success to
your client at every
session
21
51
Bossing Back OCD
12-year-old with hoarding. Her father lost his job and her family life was stressful. Each item
felt like it was special and never would exist again. She feared she would be losing something
precious if she let it go, so she kept piles of trash in her room, including plates with leftover
food on them from dinner. She refused to go to the school bus one day until she moved the
family trash cans away from the curb so they wouldn’t be collected. She could not do this
Bossing Back exercise before she started on Prozac, so we waited before we work on harder
items. In the meantime, we set family “rules” like no food in bedrooms.
“Worry Bully, you aren’t the boss of me!”

“I can choose to ignore your bad advice.”
“You are my brain tricking me, and I don’t have to fall for your tricks.”
“Holding on to everything is not letting me enjoy anything, so I’m going to wash my plate and
flush the toilet.”
“I’m going to let this egg carton go, try to stop me!”
“I get to choose -- you can’t make me bring things home things that are trash.”
“Make me feel yucky, Worry Bully, I’m throwing out this cup from Chipotle anyway.”
52
Automatic Anxious/ Rational Response

Negative Thought
53
Motivational Letter
OCD has taken my self- esteem, my ability to be happy, and my ability to feel
comfortable around other people. I feel judged so often. OCD has taken away
my ability to contribute to family’s financial needs and to the greater community.
The more power I give you, OCD, the more depressed I get. I feel like I have to
fight two demons and I just want to give up. I wait for support from others but you
keep me focused on how I’ll never succeed and so I give up again. I feel like a
failure and I’m angry so often because I feel alienated from the rest of the world. I
don’t know what my place is or why I’m even here. You have taken this from me
OCD. By not working, I thought I would have more peace, that I could work on
getting better. Instead, it has only brought on different worries that paralyze me as
well. Working or not, I can’t escape the being uncomfortable and anxiety that each
one brings.
I feel confused. I don’t know if I should keep listening to you or take a chance and
see what the other side is like. I may fail. I may disappoint my family. But I have
to try because what if I succeed? I might begin to feel better about myself. I will be
able to better provide for my family. I will be forced into a more structured setting
which may improve my sleep. I won’t have to feel guilty about spending money. I
will be participating in the community and might even develop a friendship. I
know that to accomplish this, it will mean I have to forge through discomfort,
anxiety, doubt, and fears of failure. However, if I don’t try, I’ll never know if I
would have succeeded and I am certain the depression will continue, worsen, and
destroy me. I will walk through this pain. I will return to work!
54
Family Involvement: Teach
Loved Ones to be a Part of the
Solution
Keys to
skills
Family Involvement: Teach Loved

Ones to be a Part of the Solution
•Teaching family and friends to be a part of

the solution
•Learning how to respond without
reassuring
•Challenging loved ones to face their fears
55
Coaching
Psycho education
•Involve family members and friends from
the beginning
•Teach coaching steps
•Practice coaching steps in session
•What to do if there is no support system
Coaching steps
• Do not reassure someone who is anxious or has OCD.
Validate their uncomfortable feelings and help them to
tolerate them without solving the problem.
• Remember that panic and anxiety are normal bodily
reactions and are not harmful.
• Be a cheerleader! Convince them that they can tolerate
the anxiety feelings or OCD thoughts without doing
anything to feel better. You know and they will learn that
the anxiety will eventually decrease.
• Challenge him/her to feel worse. If they can look at a
spider, can they also touch the spider?
56
Coaching
• Teach your anxious person to rate their anxiety level from
0-10. (10 is a panic attack, and 0 is a breeze).
• Have your anxious person stay with this feeling until their
anxiety decreases by 50% then challenge them to feel
worse and tolerate it some more.
• Do not be an enabler or allow the anxiety to rope you in
with whatever the trigger topic is for your anxious person.
Say, “I know this is the anxiety (or OCD) talking, not you.”
Coaching
• Expect and allow the anxiety or OCD to re-appear. The
goal is not to get rid of anxious feelings. The goal is to live
a good life and accept that anxiety will come and go.
• Help them to change the emotion-anger, frustration,
resistance all give anxiety power. Laughter can deflate it!
• Reward their hard work! (use small gifts for young children
and lots of verbal praise for older children, get creative
with adults)
When Family is Not Helpful….
57
One Mother’s Story….
10
Day 1 Key Points:

1. Anxiety is normal and not dangerous
2. We get to choose how we respond to anxiety
3. Avoidance feels good in the moment but it is a trap
4. Find your motivation to face your triggers
5. Set goals – what do you wish you could do?
6. Create a hierarchy of steps to practice facing triggers
7. Relaxation is not necessary to get well and could
become a compulsion
8. Celebrate success at every step of the way
9. Accept that anxiety may come back
11
58
Coaching Someone Through Anxiety/OCD
1. Remember that panic and anxiety are normal bodily reactions, are not
harmful, and will pass on their own if your anxious person does nothing.
2. Do not reassure someone who is anxious or has OCD. Validate their
uncomfortable feelings and help them to tolerate them without solving the
problem. “I know you are feeling anxious and I am confident that you can
handle that feeling and do X.”
3. Be a cheerleader! Convince them that they can tolerate the anxiety feelings
or OCD thoughts without doing anything to feel better. “You can do this!
Remember when you did X even though you were feeling scared? You are
capable of more than you believe!”
4. Challenge them to feel worse. The more they face the less they’ll fear. If
they can look at a spider, can they also touch the spider? If they can delay a
compulsion for 1 min, can they delay for 1 more?
5. Help them to change the emotion -- anger, frustration, and resistance all give
anxiety power. Laughter can deflate it! Other ways to change the emotion:
• Find ways to compete for a prize by doing challenges together.
• Help them make a play list of songs that motivate them to lean into
their fears.
6. Make a list of the ways you accommodate the anxiety and slowly begin to
stop when your child/loved one has learned to handle their anxiety.
7. Do not be an enabler or allow the anxiety to rope you in with whatever the
trigger topic is for your anxious person. “I know this is the anxiety (or
OCD) talking, not you.”
8. Expect and allow the anxiety or OCD to re-appear. The goal is not to get rid
of anxious feelings. The goal is to live a good life and accept that anxiety will
come and go.
9. Reward their hard work! (Use small gifts for young children and lots of verbal
praise for older children, get creative with adults)
59
Today’s Agenda
8:00- 9:30 EST Session 7: Obsessive Compulsive Disorder
• Handouts: Imaginal Script
• Need: sticky candy
9:30-10:30 EST Session 8: Panic Disorder
◦ Handouts: Panic symptoms and Interoceptive exercises
Need: Straw
10:30-10:45 EST Break-write/record a script
10:45-12:00 EST Session 9: Social Anxiety
◦ Handouts: None
12:00-1:10pm EST LUNCH/Dinner/Snack??: Do a comfort zone challenge
1:10-2:00 EST Session 10: Generalized Anxiety Disorder
◦ Handouts: none
2:00-3:10 EST Session 11: Kids with Anxiety
◦ Handouts: Fun ways to Play, Tips for Teachers
3:10-3:25 EST Break-Mindfulness walk
3:25-4:00 EST Session 12: Termination
Speaker Disclosure:
Elizabeth DuPont Spencer, LCSW-C
• Financial: The speakers are in private practice.

They are co-owners of Anxiety Training. They
receive a speaking honorarium and royalties on
their book from PESI, Inc.
• Nonfinancial: The speakers are members of
the National Association of Social Workers,
the Anxiety and Depression Association of
America, and the International Obsessive
Compulsive Foundation
Obsessive
Compulsive Disorder
ELIZABETH DUPONT SPENCER, LCSW-C
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Keys to
own expert. Empower friends or family to be coaches as
we work ourselves out of a job
skills
Agenda
• Diagnosing OCD
• Themes of OCD
• Identify the pattern (it’s always the same no matter the
theme)
• ERP and Inhibitory Learning model for OCD
• Stopping ruminating/mental compulsions
• Identifying OCD’s tricks
• Metacognitive Approaches to treating OCD
Diagnosing OCD
• Obsessions:
1. Recurrent and persistent thoughts, impulses, or images that are
experienced, at some time during the disturbance, as intrusive and
inappropriate and that cause marked anxiety or distress.
2. The thoughts, impulses, or images are not simply excessive worries
about real-life problems.
3. The person attempts to ignore or suppress such thoughts, impulses, or
images or to neutralize them with some other thought or action.
4. . The person recognizes that the obsessional thoughts, impulses, or
images are a product of his or her own mind
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Diagnosing OCD
• Compulsions:
1. Repetitive behaviors (e.g., hand washing, ordering, checking) or
mental acts (e.g., praying, counting, repeating words silently) that the
person feels driven to perform in response to an obsession, or according
to the rules that must be applied rigidly.
2. The behaviors or mental acts are aimed at preventing or reducing
distress or preventing some dreaded event or situation. However, these
behaviors or mental acts either are not connected in a realistic way with
what they are designed to neutralize or prevent or are clearly excessive.
• Assessment: Use the YBOCS or CYBOCS

• OCD vs Obsessive Compulsive Personality Disorder
OCD Themes
• Contamination
• Scrupulosity
• Sexual Orientation
• Harm-other or self
• Relationship
• Need to Know (for sure)
• Just right
• Real Event
• Sensorimotor
• Pedophelia
• And many more….
Identify the pattern

Trigger topic or event or thought
What if?
Feared consequence
Increased anxiety
Compulsion
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Let’s Practice
David has recently begun to feel anxious each time he is
in the car, especially when he gets out of the driveway.
The problem started 2 months ago. He had read about
someone killing a child on the driveway, and shortly after
Dave began to wonder whether something like that
could happen to him. Dave has even begun to avoid
driving his car and now often takes the bus to work. Why
risk ever to be thrown in jail and having to live with killing
a child? Besides, it simply takes too long to even get out
of the driveway. He is jittery and has a sinking feeling in
his stomach. Each time, he would get out of the car, and
check everywhere to make sure he did not hit anyone.
He even checked under the car and behind the wheels,
and still doubted whether he had maybe missed
something.
Clinician’s Handbook for Obsessive-Compulsive Disorder: Inference-Based Therapy, First
Edition. K. O’Connor and F. Aardema. @ 2012 John Wiley & Sons, Ltd. Published 2012 by
John Wiley & Sons, Ltd.
10
ERP for OCD

• Lean into the places they are avoiding
• Change the emotion
• Change their relationship with the fear
• Look for ways to mess with the fear
• Teach them to stop compulsing
• How to use scripts-if you do…
Successful exposures: proactive, consistent, frequent,

intense
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Inhibitory Learning (Craske & Abramowitz)

• Develop the ability to experience and handle the emotional
response that is triggered by these stimuli
(Different than habituation)
• Don’t use hierarchy’s- choose from a menu
• Don’t tune into SUDS-anxiety levels. Tune into willingness.
Anxiety doesn’t have to decrease to teach your brain to see
the trigger differently.
• Increase flexibility to exposure (time of day, anxiety level)
• Tune into what they want their brain to learn from the
exposure experience before the exposure and what they
learned after the exposure
• Violate Expectations-Set up exposure to challenge
expectations rather than decrease anxiety
• “I can’t do it….I can do it”
• “These are just sensations, I am adding the fear”
• “How did I ever believe that thoughts are facts?”
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How to Identify what to expose
to and what responses to
prevent:
What do they avoid? What action when in
contact?
1. Going places near
chemical dump 1. Wash
2. Lawn chemicals 2. Seek reassurance
3. Insect spray 3. Ruminate/try to figure it
out
4. Things in home that I
believe were 4. Remove clothes
contaminated 5. Wash car
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Successful Exposure Practice

• Providing rationale to your clients
• Changing the emotion
• Setting up the exposures
• Following through to the end
• What to do if they refuse
• Don’t abandon an exposure just find a smaller
place to start
• Let’s practice together….
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Changing the Emotion:

Scrupulosity
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64
Identifying triggers: Sexual
Obsessions (never go against
values)
Less Extreme More Extreme
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When and how to use Scripts

(handout)
1. Let OCD do the talking. Use lots of details and reasons as to why this
deserves your attention.
2. Record the script
3. Listen to the script as you go throughout your day to get use to the
background noise without connecting to the content of the story.

What if the people who are adopting Snickers abuse him? Did you review all
of their paperwork? Why didn’t you get references? Remember that time someone
told you that a cat got adopted through a friend of yours, and they found out it was
abused? People do that awful stuff! They might seem like decent people, but with
if they are not? That’s how abusers trick you, by being nice. You are never going
to be ok with what you did. You might be responsible for Snicker’s death because
you did not act in a responsible manner. You will have to live with the
consequences of this the rest of your life if you don’t call them and take Snicker’s
back. At least go ask your husband if he thinks these were bad people.
.
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Stopping Rumination/Mental
Compulsions
1.Trying to figure something out
2.Directing attention/monitoring
3.Keeping their guard up
4.Pushing away thoughts, trying
not to let thoughts enter
awareness.
5.Using bad distraction
6.Engaging in self-talk
Practice together…attention vs
awareness
*Dr. Michael Greenberg blog
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Identifying OCD’s Tricks
• Trick: “This time it’s different”- Show them it’s same monster,
different mask.
• Obsession (What if thought)
• Anxiety (produced by the obsessional story)
• Compulsive / Reassurance Behavior (to reduce the Anxiety)
• Temporary Relief
• Repeat
• Trick: OCD says: “Listen to me, do what I say, and you will feel
better”- Do the OPPOSITE
• Trick: OCD is always hungry for more and insists on getting to a
more perfect place, it wants certainty- Live with uncertainty
• Trick: OCD says, “you will never be able to handle this feeling so do
what I say and you won’t have to feel this way.” –Practice handling
distressing feelings
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Meta-cogntive Approaches
• Mindfulness • Change relationship with
thoughts
• Inference based • Thoughts get sticky
CBT because of the attention
we give them
• ACT- defusion • Understand that content is
unimportant but necessary
• Attention Training at the same time
• Guided journey with client
so they can see what
makes them pay attention
to the story
• It’s not dangerous to leave
thoughts alone
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Emetephobia
• Fear of vomiting
• Can be difficult to treat
• Watch webinar
• Ken Goodman:
https://adaa.org/webinar/
consumer/how-free-
yourself-fear-vomit-and-
reclaim-your-life-healing-
journey-shared
• Banagrams: play with words
• Google pictures
• Vomit recipe: oatmeal, beef
barley soup, cream of
tomato soup, stinky cheese,
egg
• Mix and put in airtight
container for 2-3 days
before session
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Resources
Inhibitory Learning information:
https://jonabram.web.unc.edu/wp-
content/uploads/sites/2968/2012/07/Inhibitory-learning-
OCD-Jacoby-and-Abramowitz-2016.pdf
Metacognitive Approach to OCD Treatment and Self-Help.
IOCDF.org
https://www.youtube.com/watch?v=5lxcZ3L2zQg
Inference Based Cognitive Behavioral Therapy with Carl
Robins. FEAR podcast.
https://fearcastpodcast.com/2022/06/06/ibt-
robbins/?utm_source=rss&utm_medium=rss&utm_campaign
=ibt-robbins
Inference based therapy website:
https://icbt.online
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Imaginal Script for OCD
1. Let OCD do the talking. Use lots of details and reasons as to why
this deserves your attention.
2. Record the script
3. Listen to the script as you go throughout your day to get use to the
background noise without connecting to the content of the story.
What if the people who are adopting Snickers abuse him? Did you
review all of their paperwork? Why didn’t you get references?
Remember that time someone told you that a cat got adopted through a
friend of yours, and they found out it was abused. They might seem like
decent people, but with if they are not? That’s how abusers trick you, by
being nice. You are never going to be ok with what you did. You might
be responsible for Snicker’s death because you did not act in a
responsible manner. You will have to live with the consequences of this
the rest of your life if you don’t call them and take Snicker’s back. At
least go ask your husband if he thinks these were bad people.
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Panic Disorder
Keys to
skills
DSM criteria for Panic Disorder

11 SOMATIC SYMPTOMS 2 COGNITIVE SYMPTOMS
Increased heart rate
Shortness of breath Fear of dying

Chest pain
Fear of losing control
Choking sensation
Trembling
Sweating
Nausea *Need 4 or more of these

Dizziness
symptoms to have the disorder.
Numbness/Tingling
Hot flashes or chills
Depersonalization
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DSM criteria for Panic Disorder
•Recurrent unexpected panic attacks
•Hallmark of Panic Disorder: Fear of having
another panic attack
Agoraphobia
•Anxiety about being in situations related to
perceived inability to escape or get help if a
panic attack occurs
•Situations are avoided or endured with
significant distress
Assessment
•Assessment tools
• Anxiety Sensitivity Index (ASI)
• Panic and Agoraphobia Scale (PAS)
• Panic Disorder Severity Scale (PDSS)
PDSS
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Psycho education
• Brain’s misinterpretation of normal bodily
signals
• Role of Amygdala and Prefrontal Cortex
in Panic
• There often isn’t a trigger
• Potential reasons for panic:
• Neurobiological wiring
• Hormones
• Stress threshold
Psycho education
• Our body’s response to a perceived threat is
appropriate:
• blood sugar level increases
• eyes dilate
• sweat glands perspire
• heart rate increases
• mouth becomes dry
• muscles tense
• blood decreases in arms and legs and pools in head
and trunk
• It’s how WE respond with our thoughts and actions that
is not appropriate
Psycho education (cont)

•Smoke Alarm
•Impartial observer
•Focus outside of body
•A.W.A.R.E.
• Acknowledge & Accept
• Wait & Watch (and maybe, Work)
• Actions (to make myself more comfortable)
• Repeat
• End
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Somatic Management
•Medication: SSRI vs. Benzodiazepine
•Breathing retraining: diaphragmatic breathing
Cognitive Interventions
•Challenging automatic thoughts
•Anticipatory anxiety for panic (what if I can’t
handle it?)
•I can handle it! (jelly beans)
•Ask for more….Cognitive interventions for
Panic
Reid Wilson…
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Situational Exposures
•Fear and avoidance hierarchy: top ten
troubling situations
•Graduated exposures: imaginal and in vivo
•Use reinforcement/rewards
•Client as the teacher
Safety Behaviors
Interoceptive Therapy
•Exposure to sensations of anxiety
•The more you fear the sensation, the more you look for
them, the more you find them
•Symptom induction exercises: Process cognitions
about experience during practice
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Common Interoceptive
Practices
Head rolling – 30 seconds: dizziness, disorientation
Hyperventilation – 1 minute: produces dizziness
lightheadedness, numbness, tingling, hot flushes, visual
distortion
Stair running – a few flights: produces breathlessness, a
pounding heart, heavy legs, trembling
Full body tension – 1 minute: produces trembling, heavy
muscles, numbness
Chair spinning – several times around: produces strong
dizziness, disorientation
Mirror (or hand) staring –1 minute: produces derealization
Relapse Prevention
Bring it on! (panic at work)
Challenge thoughts
Don’t avoid
Seek uncertainty and discomfort
Mindfulness with bodily sensations
Share success with others-talk about
anxiety!
Booster sessions.
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Interoceptive Exercises
Not enough air
Over breathe: Breathe forcefully, fast and deep (1 min)
Breathe through a straw: hold your nose and breathe through the straw (2 min)
Hold your breath (30 sec)
Heart beating
Run quickly on the spot (2 min)
Lift your knees high (2 min)
Step up and down on a stair-hold onto rail for balance (1 min)
Dizziness
Spin while sitting in an office chair (1 min)
As fast as you can Spin around while standing up- Make sure to leave yourself enough
space & have a place to sit after (30 sec)
Head Rush
Put your head between your legs then sit up quickly (1 min)
Lie down & relax for at least then sit up quickly (1 min)
Unreality
Stare at yourself in a mirror (2 min)
Concentrate hard without blinking (2 min)
Stare at a blank wall-concentrate hard without blinking (1 min)
Stare at a fluorescent light and then try to read something (1 min)
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Monkey Mind
Sensation What’s Really Going On
Misinterpretation
Anxiety causes changes in
your breathing so that you
take in more oxygen and
breathe out more carbon
Dizziness, light-headedness What if I faint? dioxide. This mix helps fuel
your big muscles so that you
can outrun or fight a threat. It
also makes you dizzy and
lightheaded—but not faint!
Your heart rate increases so
that it can pump oxygenated
Increased heart rate, heart
blood to your large muscles
palpitations, tightness in What if I am having a heart
so you can outrun or fight a
chest attack?
threat. Your heart is a
powerful muscle doing its
job.
When you are afraid, your
eyes widen and your pupils
Things seem weird and dialate so that you are better
Vision changes unreal. What if I am going able to see danger—even in
crazy? darkness. This causes vision
changes.
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Social Anxiety: Paradoxical
Treatment Interventions that
Get Results
Keys to
dysfunctional behaviors and challenge ridgid beliefs
skills
Diagnosis
• Marked fear or anxiety about one or more social situations in which the
individual is exposed to possible scrutiny by other.
•The social situations almost always provoke fear or anxiety.
•The fear or anxiety is out of proportion to the actual threat posed by the
social situation and to the sociocultural context.
•The social situations are avoided or endured with intense fear or anxiety.
•The fear, anxiety, or avoidance causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning
•The fear, anxiety, or avoidance is persistent, typically lasting for 6
months or more
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Key Components of Treatment
•Values Identification
•Mindfulness Training
•List of Trigger Situations
•Identifying of Safety Behaviors
•Exposure and Response Prevention (comfort zone
challenges)
•Removal of Safety Behaviors
•Cognitive Therapy to challenge thoughts about fears
•Additional approaches: Shame, Positive Psychology
•Social Skills Training, if needed
Values Identification
What is important to me? What does anxiety prevent?
1. Sports 1. Can’t go to events or talk
to others about games
2. Friends
2. No friends
3. Family
3. Messing up family
4. Education
4. Not in school
5. Christian
5. Can’t go to church
Mindfulness Practice
•Thought Defusion: The ability to have a conversation while
treating your thoughts as background noise. “I’m having the
thought that…”
•Curiosity Training: Practice participating in conversations with
an attitude of curiosity rather than judgement-take interest in
the person you are talking to.
• when client slips into focusing on their thoughts or feelings, say:
“curious” “present” “background noise” or connect to their breath.
•Attention Training : The technique consists of actively listening

and focusing attention in the context of simultaneous sounds
presented at different loudness and spatial locations.
Attention Training Technique
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Attention Training
Making a List of Goals/Triggers

1. Going on a date
2. Talking in front of people
3. Maintaining a conversation
4. Going to a coffee shop by myself
5. Eating in front of others
6. Be able to assert myself with a different opinion
Developing a Hierarchy
Trigger Suds level
1.
2.
3.
4.
5.
6.
7.
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Identifying Safety Behaviors
•Cell phones
•Friends
•Sweatshirts with hoods
•Makeup
•Items in hands (water bottles, keys, etc.)
•Hair style
•Don’t initiate conversations
•Stay on sidelines
•Avert eye contact
•Try to script what to say
10
ERP: Paradoxical Exposures

•What is it?
• Practice uncertainty and distress around how
others will judge you
•Paradoxical exposures: Purposely create the
embarrassing situation and develop tolerance
•Examples:
Mall
Waiting room
Elevator
Public
Grocery store
Giving a speech
11
Comfort Zone Challenges

How to become more
confident-Till H. Gross-Tedx
12
80
Till Gross
13
You Tube Exposure: channel

name is … Eli Vandersaul
14
•Before the exposure, ask what their negative
expectations are.
•During the exposure, don’t discuss anxiety levels.
•After the exposure, ask what they learned. Did
their negative expectations come true? How did
they handle difficult places? What would they like
to practice more?
•Help them find ways to talk to their Amygdala
and develop the “I can handle it” muscle
15
81
Challenging Automatic
Thoughts
Getting the (wrong) information:
Situation: Went to the football game with some kids.
Action: Kathy started talking to Jen and I didn’t talk
Automatic Thought: Talking to people sucks. I can’t do
this. I look stupid. They don’t even like me.
Feeling: I feel like an idiot. I shouldn’t have gone.
Challenging Automatic Thoughts: (resistance vs. acceptance)
Rational Thought: I have difficulty talking to people. I did do
this even if it felt bad and wasn’t perfect. I don’t know how I
looked, I only know I felt anxious. I will have to wait to see if they
like me.
Action: I will text them and tell them I had fun with them.
Feeling: Proud I went even though it was hard.
16
Challenging Unhelpful
Thoughts:
Unhelpful thoughts: I’ll appear tense and nervous. People
won’t enjoy talking to me. I’ve got to find a way out of this!
Constructive thoughts: My anxiety isn’t nearly as visible to
others as it feels to me. If I focus with interest on the person
and the conversation and ignore my anxious feelings and
thoughts, we’ll likely have a decent conversation. If
someone doesn’t like me or the conversation, that’s OK. I
don’t like everyone or all conversations, either! Regardless of
how this goes, it will be good practice, and I’ll be proud of
myself for taking a step forward in my life rather than
avoiding
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Challenging Core Beliefs

Unhealthy core beliefs: I’m socially inept. I’m bad at
meeting people and making small talk If people see my
anxiety or other flaws, I’ll make a bad impression and they
wont like me.
Healthy core beliefs: My social skills are decent when I’m

calm and focusing mindfully. I can build skills as needed with
practice. Like all people, I have strengths and weaknesses.
People don’t expect perfection among the people they
like, any more than I do! If someone doesn’t like me, it’s just
a matter of subjective taste, not a judgment of my worth.
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Head Held High Assertions
•The ability to own your struggles without
shame.
•Write down your fears in social situations
•Practice what you would say if those fears
came true
•Practice self compassion
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Shame
•Apainful feeling of humiliation or distress caused
by the consciousness of wrong or foolish behavior
that makes us feel bad about ourselves
•Always be on the look out for it
• Resources: Ted Talks and Podcasts
• Brene Brown- (Ted Talk-Listening to Shame)
• Kristen Neff- (Ted Talk- The Space Between Self
Esteem and Self compassion)
• Mike Heady-Understanding Shame (Kimberley
Quinlan: Your Anxiety Toolkit)
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Benefits of Positive Psychology

•Develop a gratitude journal and/or practice of
identifying aspects of social life and situations you are
grateful for
•Identify daily social goals and put effort towards using
your strengths
•Practice shifting your attention to find at least one
positive sign or aspect of the social situation you are in
•Practice small interpersonal acts of generosity and
kindness, especially following a socially threatening
situation
•Practice being aware of any sign of positive emotion
and being able to identify positive emotions
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Social Skills Training
•Making eye contact
•Smiling
•Initiating conversations
•Noticing others and commenting
•Conversation ping-pong
•Ordering at a restaurant
•Ending conversations
•Answering and making phone calls
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Social Anxiety Experiment
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84
Generalized Anxiety Disorder :
Helping Our Clients Live in the
Present

ELIZABETH DUPONT SPENCER, LCSW-C
WWW.ANXIETYTRAINING.COM
Keys to
skills
3 Aspects of Worry
Cognitive
Physical Belief that worrying
Stomach aches, is helpful. Thinking
headaches, about the future
exhaustion frequently. What if..
Behavioral
Communicating concerns to
others, checking on concerns,
avoidance of triggers
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Diagnosing GAD (DSM V)
1.The presence of excessive anxiety and worry about a
variety of topics, events, or activities. Worry occurs more
often than not for at least six months and is clearly
excessive.
• Excessive worry means worrying even when there is no
specific threat present or in a manner that is
disproportionate to the actual risk.
2.The worry is experienced as very challenging to control.
The worry in both adults and children may easily shift from
one topic to another.
Diagnosing GAD
3. The anxiety and worry are accompanied by at least three
of the following physical or cognitive symptoms (In children,
only one of these symptoms is necessary for a diagnosis of
GAD):
• Edginess or restlessness
• Tiring easily; more fatigued than usual
• Impaired concentration or feeling as though the mind goes
blank
• Irritability (which may or may not be observable to others)
• Increased muscle aches or soreness
• Difficulty sleeping (due to trouble falling asleep or staying
asleep, restlessness at night, or unsatisfying sleep)
Treatment of GAD
1. Psychoeducation
2. False beliefs about thoughts
3. Practicing presence
4. Exposure and Response Prevention
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Psychoeducation:
Helpful vs. Unhelpful Worry
• Worry is the fear of feeling negative
feelings/suffering in the future. It tells us to do
something, get moving, problem-solve, etc.
• When worry is helpful, it’s reminding us to take

action and study for a test or do laundry before the
work week
• Anxious worry is the thing we do (compulsion) that
makes us believe we have some control over the
future-it keeps us ruminating, prevents us from
being present, and wastes our time
Psychoeducation:
Worry tricks people
1. It says horrible what if’s about the future that trigger the
amygdala
2. The chemicals that get released make it feel like it is
important to pay attention and that responding is helpful
problem solving since it gives a moment of relief
3. Like with other anxiety disorders, the feeling of relief
shows that worry is a compulsion/safety behavior
3. The what if’s sound scary except….there are no facts to
support them.
4. We need to help our clients learn to live with uncertainty
and stick to the facts (what is, not what if)
*ADAA public webinars David Carbonell: How to Worry Less
False Beliefs about Thoughts*

• Every thought is worth thinking about
• Every thought has meaning
• I must alert others to potential danger when I
worry
• Not being certain signals danger
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False Beliefs about Thoughts
• Not remembering is dangerous
• I must be free of unwanted thoughts to be happy
• Ignoring thoughts is unhealthy
• Introspection is always healthy
*What To Do With Unwanted, Intrusive Thoughts

by Sally Winston and Martin Seif
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Changing Relationship with

Worry
• Expect the worry
• Welcome the fear-Allow it
to be there without giving it
your attention
• Don’t connect to
content…anything after
“what if”
• Seek it out-I could worry
about that!
• Staying in the doubt-maybe
my fear will happen, maybe
it won’t, but I will handle it.
11
Practicing Presence:
Mindfulness for Worry
1. Learn to get out of their head and into their life
2. Learn to notice- defusion allows them to talk about the
worry rather than believe the worry
◦ ” I notice that I am having worries about starting a new
job”
3. Learn to respond to emotions, compassionately-rather
than avoid them
◦ Practice remembering a time when they felt a strong
emotion-become curious, label the emotion, describe
what it feels like, where do they feel it
12
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Practicing Presence:
Acceptance and Willingness
1. Discuss acceptance and willingness to lean in to
discomfort vs resistance
◦ Teach them to drop the rope in tug-o-war with worry
◦ Explain this increases flexibility and resilience
2. Help them work for something that matters today rather
than fearing tomorrow
◦ “I want my family to be able to share their struggles with
me”
◦ “ I want to be able to find a better job”
3. Practice accepting internal experience rather than
changing it
◦ Consider teaching meditation as a way to practice
noticing thoughts without getting hooked by them
13
Practicing Presence: Labeling

and Grounding
1.Label it…”Just a worry.”
2.Anchor yourself ….”That is about the future, the
only thing that is happening now is that I am driving
to work.”
3.Use your senses….Notice what you can see, hear
and feel in the present moment
4.Get out of your head and into your body…breathe
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ERP for Worry

1. See worry as noise (metaphor)
• Worry has no content and therefore no message
to respond to
2. Look for opportunities to worry-chase after it,
and drop the story that attaches to it
3. Play with worry

• I might fail the test-post it notes everywhere
4. Show Noises in Your Head Free Video Series
15
89
ERP for Worry
5. Face ultimate fear-visualize with tolerance
6. Coping vs. Fear scripts (see handout)
7. Reduce avoidance
8. Do pleasurable activity while allowing worry
9. Decision Making-Choose to be 100% in with a
decision that is not certain
16
Worry Script-see handout

Fear Scenario:
I wake up and feel a sensation in my throat. I begin to touch my neck, looking for something that
explains this lump I feel. I notice a bit of a difference on the side of my neck that feels the lump. I
start to freak out. Do I have cancer? There must be something wrong with me or I wouldn't have
notice this. I can't wait for 8:00am when the doctor's office opens. I think I'm going to have a panic
attack! Maybe I should call the on call doctor. I wake up my husband and tell him something is
terribly wrong.
Coping Scenario:
I wake up and feel a sensation in my throat. I begin to touch my neck and am unsure if I feel
something different. I recognize that my anxiety is increasing. I tell myself that this may or may
not be something to be concerned about but I am not going to anything with it now when I am not
awake and feeling anxious. I take a shower and eat some breakfast. My husband wakes up and I'm
tempted to tell him my worry but decide I won't say anything for 24 hours. When 8:00am arrives, I
want to call my doctor and make an appointment for today. I decide, instead, to wait 3 days before
I make any calls to see how much anxiety is playing a role in this. Once my anxiety calms down,
my body may be able to take care of this on its own. I will let myself doing something about it
only if it doesn't go away in 3 days or gets worse.
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Pitfalls for Therapists

• Correct misinformation one time
• Don’t engage content
• Don’t get caught up in worry stories
• Resource
• Free Consumer Webinar by David Carbonell
• How to Worry Less
• https://adaa.org/webinar/consumer/how-worry-less
18
90
A client’s perspective…
19
91
Worry Script
Fear Scenario:
I wake up and feel a sensation in my throat. I begin to touch my neck,
looking for something that explains this lump I feel. I notice a bit of a
difference on the side of my neck that feels the lump. I start to freak out.
Do I have cancer? There must be something wrong with me or I
wouldn't have notice this. I can't wait for 8:00am when the doctor's
office opens. I think I'm going to have a panic attack! Maybe I should
call the on-call doctor. I wake up my husband and tell him something is
terribly wrong.
Coping Scenario:
I wake up and feel a sensation in my throat. I begin to touch my neck
and am unsure if I feel something different. I recognize that my anxiety
is increasing. I tell myself that this may or may not be something to be
concerned about but I am not going to anything with it now when I am
not awake and feeling anxious. I take a shower and eat some breakfast.
My husband wakes up and I'm tempted to tell him my worry but decide I
won't say anything for 24 hours. When 8:00am arrives, I want to call my
doctor and make an appointment for today. I decide, instead, to wait 3
days before I make any calls to see how much anxiety is playing a role
in this. Once my anxiety calms down, my body may be able to take care
of this on its own. I will let myself doing something about it only if it
doesn't go away in 3 days or gets worse.
92
Kids with Anxiety:
Playing with Fear
WWW.ANXIETYTR AINI NG.CO M
Keys to
skills
Kids with Anxiety

•Special considerations when working with children
•PANS/PANDAS, School refusal, contamination,
bad thoughts
•Adding play to your treatment plan
•Strategies for age appropriate interventions
•Teach kids to talk back to their fears
•How to handle parent resistance/therapy
interference
93
Prevalence of Anxiety
Disorders in Children
•Anxiety disorders are the most common disorders
in childhood
• Prevalence rates up to 25% with anxiety being a
concern for up to 50% of referrals to mental
health services
Increased Anxiety?
•50 % of college students report experiencing severe
anxiety symptoms (#1 mental health crisis in America)
•Possible reasons:
◦ Parents/society who don’t allow suffering
◦ Too many options/decisions increases anxiety
◦ Immediate gratification through technology
◦ FOMO: Fear of Missing Out (social media)
◦ Social media bullying
◦ Video games and decreased social skill building
◦ Increased exposure to fear triggers (breaking news!)
◦ Pressure to do more and do better
Goals
•Help kids develop resilience
•Help kids build their “I CAN HANDLE IT” muscle
94
Special Considerations
•Autism Spectrum:
• Understand function of compulsive behavior
◦ Put it in writing
◦ make it 3rd person
◦ involve something they enjoy (video games,
music)
◦ Go slower
◦ Takes longer
Social Story
•PANS/PANDAS: Pediatric Acute-onset
Neuropsychiatric Syndrome
• Anxiety/OCD/tics/learning difficulties/refusal to
eat that come on quickly and severely after a
viral, strep infection, mold exposure or lyme
• Needs medical attention including anti
inflammatory and antibiotics, sometimes steroids
and IVIG
• May need an SSRI-low doses
• Will need CBT with ERP
• Treatment guidelines: Revised Treatment Guidelines
Released for Pediatric Acute Onset Neuropsychiatric Syndrome
(PANS/PANDAS)
95
•Selective Mutism:
◦ Consistent, ongoing failure to speak in specific
social situations, especially school
◦ Not due to a primary language disorder
◦ Need to decrease stress in classroom and be
patient!
◦ Communication Anxiety Therapy
◦ Selective Mutism Resources: Selectivemutism.org
10
Special Considerations:
•School Refusal:
• Collaborate with parents and school to gather
information
• Teacher Tips (see handout)
• Assess what might be driving school refusal
(anxiety disorder, depression, behavioral issues)
• Accommodations : goal to increase ability to
face trigger situations (see resources)
• Anne Marie Albano and School Refusal
11
School Refusal
•Challenging: The longer kids are out of school the more
difficult it is to get them in school.
•Advanced Training Class through Anxiety Training
Community
•Anxiety in the Schools: Training Bundle for Teachers/staff,
Students, and Parents (see at www.AnxietyTraining.com)
12
96
Parents: Help or Hindrance?
Include parents when working with an anxious
child
• Anxiety will go to the weakest link
• Everyone needs to speak the same language
and have the same goals
• Most parents want to be helpful but don’t have
good information about anxiety
• Provide them the coaching handout
• Eli Lebowitz: SPACE training/ Breaking Free of Child
Anxiety and OCD
• https://anxietyspecialistsofatlanta.com/raising-resilience/
• “ I can see that you are worried about____ and I am
confident that you can handle that worry.”
13
Metaphors to Explain Anxiety
14
Play the game the right way
15
97
Be On The Same Team
16
Teaching Tips (handout)

• Validate the child’s feelings and help them to identify it as anxiety.
• “You are feeling yucky right now, are you worried about something?”
• “It’s normal to feel anxious before a test or speaking in front of the class.”
• Do Not reassure an anxious child.
• “You’ll be fine.”
• “You always do well on a test.”
• “You don’t have anything to worry about.”
• “The day will be over before you know it.”
• Help the child to tolerate his/her uncomfortable feelings.
• “I know you’re feeling pretty bad right now but I wonder if you can sit at your seat while
you’re feeling bad and I’ll check in with you in a few minutes.”
• “You really miss your mom this morning. It will be hard but I bet you can get started with
your work even though you miss her and you might find that working helps those feelings to
quiet down a little.”
• “The storm outside is making you feel very scared. I’m wondering how many of you can
work even though you’re feeling scared.”
• Be a cheerleader for them as they tolerate their anxious feelings.
• “I am so proud of you for finishing your work even though you were feeling anxious!”
• “You did a great job of staying in school today even though you missed your mom!”
• “I really appreciate how hard you must have worked to not ask me questions all day even
though you might have been worried about doing your work correctly.”
• Challenge him/her to go for longer periods of time or to do something that will make them feel worse
(after they begin to feel empowered).
• “You worked really hard at staying in the class for the last fifteen minutes even though you
wanted to go to the nurse’s office. Can you work hard for another fifteen minutes?”
• “You completed that portion of the test even though you felt anxious. I’m wondering if you
can feel anxious and do the next part of the test.”
• Help them to see that when they do something even though they feel anxious, their anxiety eventually
quiets down.
• Reward very anxious children with small tokens, candy, or prizes for completing tasks that make them
feel anxious. (Use lots of praise for older children.)
17
Be Strategic: Develop a Plan

•Give anxiety a name- externalizes
•Help the child practice facing their fears: Choose
to do things that feel scary/difficult
•Teach them how to change how they talk to
anxiety: “Of course I’ll feel anxious, but I’d rather
feel anxious and live a life filled with risks than feel
safe and live a small life filled with fears!”
•Change the way you talk to the child: I hope you
feel anxious today (wink, wink)
•Set them up for success (start small and work up)
•Start session by asking how they were courageous
18
98
Act as though…..
19
Playing with Fear (handout)

https://www.bravepracticeforkids.com/
•Monster stomp- right fears on paper, stomp, and say with
confidence, “I can handle it!”
•Slap Hands – Parent touches contaminated object
•Halloween Candy- put on bathroom floor for kids to get during visit
•Puppets- Practice talking back to anxiety
•Body Drawings- where do they feel the anxiety?
•Bad thoughts Ball- toss back and forth saying bad thoughts
•War Heads- Explains ERP
•Would you rather…
•Matching Game- use words they are afraid to say out loud
•Bravery chart- Documents success
•Dart Game- You can’t win if you don’t play
•Story telling with cards
20
Banana grams
21
99
Talking Back to Anxiety
•Give them permission to talk back to anxiety-it may be
the only time they can do this without getting into
trouble !
• “I’ve heard enough from you, I’m not going to listen
to you!”
• “La, la, la, la, la ,la” –while covering their ears
• “ I know you’re a trick which is why I am NOT scared
of you!”
• “You can come to school with me but you have to
sit on the floor.”
• “That’s Riddikulus!” https://youtu.be/3PWKFyhJ2h4
• Let’s practice….
22
Rewards
•Could be the most
important way to help a
child do ERP
•Have child make a list

of small, medium and
large rewards
•Discuss the importance

of giving rewards
immediately with
parents
23
100
Fun ways to play with Exposure and Response Prevention
Apps:
Mind Shift
Mindful Powers
Contamination Fears:
I have the parent touch the “contaminated” item and then we play slap hands. Where the
child puts their hands on the parents upturned open hands and the parent tries to slap or
hit the child's hands “gently” while the child tries to pull them away quickly to avoid being
hit. Obviously, the child is touching the parent’s hand and so the contamination is being
spread to them - it is fun and a step before the child is ready to touch the item themselves.
Packaged Halloween candy sprinkled on the office bathroom floor and around the
toilet....and near other gross spots (they can eat it if they are willing to pick it up)
Explaining Anxiety and Physical Symptoms
Chinese finger traps to show how fighting the anxiety traps you
When working with kids with anxiety during the psychoeducation phase of treatment
where I'm talking about physical symptoms of anxiety and recognizing the clues our bodies
are giving us that we're starting to feel anxious, I often have kids do body drawings. For
these, we have the child lie down on a huge piece of paper from one of those large rolls of
paper, we trace their body, and then have them draw in how their bodies react when
they're feeling anxious (e.g. drawing butterflies in their stomach or a heart beating
quickly). They can then choose if they would like to hang up their drawing (which doesn't
have any PHI on it) in our hallway leading into the clinic or if they can take it home with
them. It's been a fun way to get kids engaged in thinking about recognizing their physical
symptoms for what they are and not, for example, immediately thinking that their stomach
hurting in the morning before school means they're sick, but rather could be a sign they're
anxious.
"Bad" thoughts
Play Ball!-Say bad thought/word every time you catch the ball (therapist also does this)
That there are three lies that OCD thoughts tell you:
1.This is really important and you must pay attention

2.This means something important about you or reflects what you really feel
3.And you have to do something about this thought now
101
Exposure for teens especially is to aim to agree with the doubt. That does not mean
agreeing with the feared outcome. So you don't have to accept and process being gay if
that's what the bad thought is. It's to be able to say to yourself maybe I'm gay maybe I'm
not and not try and resolve the uncertainty or get an answer.
Naming Anxiety
externalizing the anxiety (as if a person...a bully),
Cognitive Challenges
To help kids understand how thoughts affect how we feel, I tell them there's been a snow
storm, and 3 kids wake up to see it--one is happy, one is angry, and one is worried. I ask
them how can 3 kids feel 3 different ways about the same snow storm? We then discuss
that it's what they're thinking about the snow storm that leads to how they feel--the happy
child is thinking what fun they will have playing in the snow, the angry child is thinking
about their long driveway that their parents are going to make them shovel, and the
worried child is thinking about how their parent will get to work safely with all that
snow. This is something that kids can easily relate to and understand, so it helps them
grasp that situations do not cause feelings but rather thoughts cause feelings.
Jelly bellies-(Bean Boozled) how to act as though they can handle it…. (have parents eat
them and handle it, kid guesses who has the bad one)
Socializing to treatment
dart game- you can't get better if you don't play
Exposure Therapy-starting small

Make cards with different pictures of the object of theme they fear and play a matching
game or let them sort the cards based on different features
Spider: have them draw a dot in the middle of a piece of paper and have them draw 8 legs
out from the dot (discuss what they thought about the dot versus how they felt when they
added the legs)
Becoming Brave
Bravery Chart: Specifically, I start each week with a review of the past week through the
lens of asking them what they did this week that was brave, challenging, or that they were
proud of. Usually I encourage any ‘incidental exposures’ to be documented here. For
younger children (and some of my older teens who like it), I let them choose a sticker to
represent each brave activity, and then have them write what it stands for. This provides a
102
more structured way to handle the between session update, it frames for child (and
sometimes parent) the importance of celebrating doing hard things rather than feeling
demoralized about all the challenges that have come up, and it subtly reinforces doing
unplanned exposures. And, it is a really nice memento to take home at the end of treatment.
Patients often like looking back at old stickers they have earned and marveling about how
surprised they are that some situation used to be difficult. It doesn’t resonate with every
child, but actually works for more than I originally expected.
103
Anxiety in the School: Tips for Teachers
1. Validate the child’s feelings and help them to identify it as anxiety.

“You are feeling yucky right now, are you worried about something?”
“It’s normal to feel anxious before a test or speaking in front of the class.”
2. Do Not reassure an anxious child.
“You’ll be fine.”
“You always do well on a test.”
“You don’t have anything to worry about.”
“The day will be over before you know it.”
3. Help the child to tolerate his/her uncomfortable feelings.
“I know you’re feeling pretty bad right now but I wonder if you can sit at your seat
while you’re feeling bad and I’ll check in with you in a few minutes.”
“You really miss your mom this morning. It will be hard but I bet you can get started
with your work even though you miss her and you might find that working helps
those feelings to quiet down a little.”
“The storm outside is making you feel very scared. I’m wondering how many of you
can work even though you’re feeling scared.”
4. Be a cheerleader for them as they tolerate their anxious feelings.
“I am so proud of you for finishing your work even though you were feeling
anxious!”
“You did a great job of staying in school today even though you missed your mom!”
“I really appreciate how hard you must have worked to not ask me questions all day
even though you might have been worried about doing your work correctly.”
5. Challenge him/her to go for longer periods of time or to do something that will make
them feel worse (after they begin to feel empowered).
“You worked really hard at staying in the class for the last fifteen minutes even
though you wanted to go to the nurse’s office. Can you work hard for another fifteen
minutes?”
“You completed that portion of the test even though you felt anxious. I’m wondering
if you can feel anxious and do the next part of the test.”
6. Help them to see that when they do something even though they feel anxious, their
anxiety eventually quiets down.
7. Reward very anxious children with small tokens, candy, or prizes for completing
tasks that make them feel anxious. (Use lots of praise for older children.)
Remember, children will not learn to tolerate anxiety if they do not

practice the skill. They need your encouragement to sit with the bad
feelings and work anyway. If you reassure them or send them to the
nurses office, they will only learn that they can’t tolerate these
feelings and the anxiety will worsen.
104
Termination and
Relapse Prevention
Keys to
5. Require homework between sessions to practice new skills
Success!!!
•Live a rich, full life
•Able to take lessons learned
and apply them to new
challenges in life
•Look for opportunities for ERP /
being brave as a regular part of
life
105
Does Recovery From an Anxiety
Disorder or OCD Mean No More
Symptoms?
NO!
Relapse
Prevention
Must
Include
Recognizing
that
Symptoms
May Return
Wellness
•Healthy eating
•Exercise
•Mindfulness / relaxation
•Good relationships
•Hobbies
•Job/volunteer activity
•Spirituality
106
Typical Red Flags –
Customize for Each Client
•Avoidance of old trigger situations

•Avoidance of NEW trigger situations
•Increased reassurance seeking
•Missing school or work
•Missing optional or fun activities
•Family or coach notices symptoms return
Help Your Client Make a Plan

if Anxiety / OCD Returns
RED FLAGS STEPS TO GET HELP
•If my OCD became stuck on •ERP every day

one obsession for more than 1
week •Go for a run every day
•If I stop taking my medicine •Practice mindfulness daily
•If my wife says I am worse •Listen to self-compassion

recording
•If I stop doing my ERP daily
•Call my therapist for an
•If I have to take time off work appointment
due to OCD or depression
•Call my psychiatrist
My Worry Bully
107
Helpful ways to live will with
anxiety
1. Keep working at it
2. Love yourself
Treat yourself
Show yourself the mercy that you show others
Practice loving kindness meditation
Forgive yourself
Hand over heart: "Even though I am struggling, I love
myself"
3. Meditate
Headspace
Buddhify
10% happier
Meditation chimer app
4. Accept the suffering: welcome it and wait for it to pass
5. Positive self talk: "you've been here before. You know your
brain lies to you. It's ok to feel this way. "
More ways to live well with

anxiety….
6. Remember Danger vs. Discomfort (what would 100
other people do or think about this?)
7. Say it out loud to someone so you can check if it's
fact or fear
8. It's just a thought-let it pass or throw it in the fire
9. Try not to engage in safety behaviors, they only
prolong the suffering
10. Build your "I can handle it!" muscle
11. Remember you are developing resilience: What
doesn't kill you makes you stronger 
Enduring Recovery is When

Symptoms Don’t Matter!
108
Resource List for Anxiety Treatment
Cognitive Behavioral Therapy
Using CBT Effectively in Treating Anxiety and Depression. Current

Psychiatry 2014 June;13(6):45-53
Seif, M and Winston, S. (2014) What Every Therapist Needs to Know About Anxiety Disorders.
New York: Routledge.
Exposure and Response Prevention in the Treatment of Obsessive-Compulsive Disorder: Current

Perspectives. Psychology and Behavior Management 2019; 12: 1167–1174
Anxiety- General
Bourne, E. (2011). The Anxiety & Phobia Workbook (p. 481). Oakland, CA: New Harbinger
Publications.
Brantley, J. (2007). Calming your anxious mind:how mindfulness and compassion can free you
from anxiety, fear, and panic (2nd ed.). Oakland, CA: New Harbinger Publications.
Chansky, T. (2004). Freeing your child from anxiety: Powerful, practical strategies to overcome
your child's fears, phobias, and worries. New York: Broadway Books.
Clark, D., Beck, A., (2011) The anxiety and worry workbook: the cognitive behavioral solution.
New York: Guilford Press.
DuPont, C., DuPont Spencer, E., and DuPont R. (2014) (Second Edition). The Anxiety Cure for
Kids: A Guide for Parents and Children. Turner Publishing Company.
Highlights of Changes from DSM-IV to DSM-5. American Psychiatric Association. Web. 1 Oct.
2014 www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf
Jeffers, S. (2007). Feel the fear-- and do it anyway (Ballantine Books trade pbk. ed.). New York:
Ballantine Books.
Morrow, K. (2011) Face It and Feel It: 10 Simple (but not Easy) Ways to Live Well with
Anxiety.
Wilson, R. (2016) Stopping the Noise in Your Head: The New Way to Overcome Anxiety and
Worry. Health Communications, Inc.
Anxiety and Addiction

Melemis, S. (2010). I want to change my life: How to overcome anxiety, depression, &
addiction. Toronto: Modern Therapies.
109
Panic
Carbonell, D. (2021). Panic Attacks Workbook: Second Edition: A Guided Program for Beating
the Panic Trick, Fully Revised and Updated (Panic Attacks 2nd edition)
Wilson, R. (2009). Don't panic: Taking control of anxiety attacks (3rd ed., 1st Collins Living
ed.). New York: Collins Living
Wilson, R. (2003). Facing panic: Self-help for people with panic attacks. Silver Spring, MD:
Anxiety Disorders Association of America.
Obsessive Compulsive Disorder

Baer, L. (2000). Getting control: Overcoming your obsessions and compulsions (Rev. ed.). New
York: Plume
Baer, L. (2002). The imp of the mind: Exploring the silent epidemic of obsessive bad thoughts.
New York, N.Y., U.S.A.: Plume
Ciarrocchi, J. (1995). The doubting disease: Help for scrupulosity and religious compulsions.
New York: Paulist Press
Gravitz, H. (1998). Obsessive compulsive disorder: New help for the family. Santa Barbara, CA:
Healing Visions Press.
Neziroglu, F., Bubrick, J., & Perkins, P. (2004). Overcoming compulsive hoarding: Why you
save & how you can stop. Oakland, Calif.: New Harbinger Publications.
Osborn, I. (1999). Tormenting thoughts and secret rituals: The hidden epidemic of obsessive-
compulsive disorder. New York: Dell
Wagner, A., & Jutton, P. (2004). Up and down the worry hill: A children's book about obsessive-
compulsive disorder and its treatment (2nd ed.). Rochester, NY: Lighthouse Press Book
Body Dysmorphic Disorder

Claiborn, J., & Pedrick, C. (2002). The BDD workbook. Oakland, Calif.: New Harbinger
Phillips, K. (2005). Understanding and treating Body Dysmorphic Disorder (Rev. ed.). Place of
publication not identified: Oxford University Press.
Mindfulness
Broderick, P. (2013). Learning to Breathe, New Harbinger
Burdick, D.(2014). Mindfulness Skills for Kids and Teens, PESI,Inc.
110
Hershfield, J. (2013). The Mindfulness Workbook for OCD: A Guide to Overcoming Obsessions
and Compulsions Using Mindfulness and Cognitive Behavioral Therapy (A New Harbinger Self-
Help Workbook)
Siegel, D. (2013). Brainstorm - The Power and Purpose of the Teenage Brain, Tarcher Perigee
Meta Cognitive Approaches:

Inhibitory learning approaches to exposure therapy: A critical review and translation to
obsessive-compulsive disorder Clinical Psychology Review, 2016; 49: 28-40
The Inference-based Approach to Obsessive-Compulsive Disorder: A Comprehensive Review of

Its Etiological Model, Treatment Efficacy and Model of Change Journal of Affective Disorders,
2016; 202: 187-196
Other Resources:
Anxiety and Depression Association of America. www.adaa.org Web. 30 Sept. 2014
Anxiety Specialists of Atlanta: Raising Resilience: 25 Tips to Parenting Your Child with Anxiety
or OCD https://anxietyspecialistsofatlanta.com/raising-resilience/
Anxiety Training and Case Consultation. www.anxietytraining.com Web. 30 Sept 2016
Altman, Donald. "Mindfulness-Related Links." Welcome to Mindful Practices. Donald Atman,

Web. 29 Sept. 2014. www.mindfulpractices.com/Resources Links.html
"Anxiety Help: Practical, Powerful Solutions for Panic and Anxiety." Anxiety Help: Practical,
Powerful Solutions for Panic and Anxiety. David Carbonell, Web. 20 Sept. 2014.
http://www.anxietycoach.com/
Association for Behavioral & Cognitive Therapies. Web 1 Oct. 2014. www.abct.org/home
Beck Institute for Cognitive Behavior Therapy. Web 1 Oct. 2014. http://www.beckinstitute.org/
Brave Practice for Kids: https://www.bravepracticeforkids.com/
Carbonell, David. How to Worry Less. https://adaa.org/webinar/consumer/how-worry-less
Greenberg, Michael. How to Stop Ruminating. https://drmichaeljgreenberg.com/how-to-stop-

ruminating/
111
Harry Potter Riddikulus excerpt: https://youtu.be/3PWKFyhJ2h4
Inference Based Cognitive Behavioral Therapy with Carl Robins. FEAR podcast.
https://fearcastpodcast.com/?s=CArl+Robbins
International OCD Foundation. Web. 28 Sept. 2014. www.iocdf.org
Metacognitive Approach to OCD Treatment and Self-Help. IOCDF.org

https://www.youtube.com/watch?v=5lxcZ3L2zQg
Trichotillomania Learning Center. Web. 30 Sept. 2014. www.trich.org
Anxieties Disorders Treatment Center, Web. 29 Sept. 2014. www.anxieties.com
Inference-Based Cognitive Behavior Therapy, Web Oct. 2022. https://icbt.online/
National Social Anxiety Center

(https://nationalsocialanxietycenter.com/2017/09/18/developingpositive-managing-social-
anxiety/)
OCD Peers: OCD Support Groups (https://ocdpeers.com/)
Stop Worrying – 6 Episode Video Series (https://anxieties.com/259/noise-in-your-head-
videoseries)
The Anxiety Coach (http://www.anxietycoach.com/)
The OCD Stories (https://theocdstories.com/)
Your Anxiety Toolkit - It's a Beautiful Day to Do Hard Things

(https://kimberleyquinlan.libsyn.com/)
PANS and PANDAS information and resources: https://pandasnetwork.org/
112
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Printed in the United States

Kimberly Morrow, LCSW, is a licensed clinical social worker

Elizabeth DuPont Spencer, M.S.W., LCSW-C, is a licensed clinical

KI MBERLY MORROW, LCSW

ELI ZABETH DUPONT SPENCER, LCSW-C

CBT for Anxiety and OCD

KI MBERLY MORROW, LCSW

ELI ZABETH DUPONT SPENCER, LCSW-C

Suggested Items To Enhance

• Financial: The speakers are in private practice.

Risks and Limitations

Cognitive Behavioral Theory

Thoughts: He/she looks a bit

CBT involves collaboration

CBT starts and spends much time

• Shift to the past for two

• Have client take

CBT is structured: handout

CBT teaches how to challenge

Non Shopping Trip

CBT involves Changing Behaviors

CBT Gives Homework

CBT May Involve Interrupting

What is not helpful.

CBT Prepares for Termination

 Review of week (successes, struggles, triggers-very

 Review of Homework (successes and struggles-spend

 Setting agenda together (have client give problems a

 Discussing problems related to agenda(get into

 Setting new homework (based on what you just talked

 Feedback (what can you do better?)

Conceptual clarification questions

• Why are you saying that?

• What else could we assume?

Probing rationale, reasons and evidence

• Why is that happening?

Questioning viewpoints and perspectives

• Another way of looking at this is ..., does this seem reasonable?

Probe implications and consequences

• Then what would happen?

KI MBERLY MORROW, LCSW

ELI ZABETH DUPONT SPENCER, LCSW-C

• Diagnosis – why it’s important

Screen for Complications:

The Journey with a New Client

Set Goals – Dream Big!

◦ Attend college and live in a dorm

First Session Highlights:

Name: ____________________________ Date: __________________

1. I worry a lot of the time 0 1 2 3 4

2. I often feel depressed and down 0 1 2 3 4

3. I have panic or anxiety attacks 0 1 2 3 4

4. There are places I avoid 0 1 2 3 4

5. I am shy and nervous with people 0 1 2 3 4

7. I have bad /upsetting thoughts 0 1 2 3 4

8. I have to do things just so or over and over 0 1 2 3 4

9. I experience frequent pain 0 1 2 3 4

10. My sleep is a problem 0 1 2 3 4

11. My difficulties impact work or school 0 1 2 3 4

12. My family and friends notice my difficulty 0 1 2 3 4

What is the main problem you are having?

Name: __________ Date: