The Adult Psychotherapy Progress Notes Planner. David J. Berghuis

on anxiety and key points were reviewed.The client has not read the assigned information on anxiety and was redirected to do so.

      15 Teach Calming/Relaxation/Mindfulness Skills (15)The client was taught calming, relaxation, and mindfulness skills.The client was taught techniques such as applied relaxation, progressive muscle relaxation, cue-controlled relaxation, mindful breathing, and biofeedbackThe client was taught how to discriminate better between relaxation and tension.The client was taught how to apply relaxation skills to his/her/their daily life.The client was taught relaxation skills as described in New Directions in Progressive Muscle Relaxation (Bernstein, Borkovec, and Hazlett-Stevens).The client was taught relaxation skills as described in The Relaxation and Stress Reduction Workbook (Davis et al.).The client was provided with feedback about his/her/their use of relaxation skills.

      16 Assign Relaxation Homework (16)The client was assigned to do homework exercises in which he/she/they practice relaxation on a daily basis.The client was assigned “Deep Breathing Exercise” in the Adult Psychotherapy Homework Planner (Jongsma).The client has regularly used relaxation exercises, and the helpful benefits of these exercises were reviewed.The client has not regularly used relaxation exercises and was provided with corrective feedback in this area.The client has used some relaxation exercises but does not find these to be helpful; he/she/they were assisted in brainstorming how to modify these exercises to be more helpful.

      17 Implement Worry Time (17)The client was taught to implement “worry time”—delaying the worry about various environmental settings until a designated “worry time.”The rationale for using a “worry time” was explained, focusing on trying to limit the association between various environmental settings and the experience of worry.The client and therapist agreed upon a specific “worry time” and the client was urged to implement this process.

      18 Teach Techniques to Postpone Until Worry Time (18)The client was taught how to recognize, stop, and postpone worry until the agreed upon worry time.Skills were taught to the client, including thought stopping, relaxation, and redirection of attention.The “Making Use of the Thought-Stopping Technique” exercise from the Adult Psychotherapy Homework Planner (Jongsma) was assigned.The client was assigned the “Worry Time” homework exercise from the Adult Psychotherapy Homework Planner (Jongsma).The client was encouraged to use the techniques in his/her/their daily life.The client's use of recognizing, stopping, and postponing worry techniques was reviewed within the session with reinforcement for success and corrective feedback toward improvement.

      19 Discuss Estimation Errors (19)In today's session, examples were discussed about how unrealistic worry typically overestimates a probability of threats.The client was assigned “Past Successful Anxiety Coping” from the Adult Psychotherapy Homework Planner (Jongsma).It was noted that unrealistic worry often underestimates the client's ability to manage realistic demands.The client was assisted in identifying specific examples of how his/her/their unrealistic worry involves estimation errors.The client was reinforced for his/her/their insightful identification of unrealistic worry and inappropriate estimation.The client has struggled to identify estimation errors in regard to his/her/their unrealistic worry and was gently offered examples in this area.

      20 Analyze Fears Logically (20)The client's fears were analyzed by examining the probability of his/her/their negative expectation becoming a reality, the consequences of the expectation if it occurred, his/her/their ability to control the outcome, the worst possible result if the expectation occurred, and his/her/their ability to cope if the expectation occurred.The client was assigned “Analyze the Probability of a Feared Event” from the Adult Psychotherapy Homework Planner (Jongsma).The client's ability to control the outcome of circumstances was examined, and the effectiveness of his/her/their worry on that outcome was also examined.Cognitive therapy techniques have been effective at helping the client understand his/her/their beliefs and distorted messages that produce worry and anxiety.As the client has increased his/her/their understanding of distorted, anxiety-producing cognitions, his/her/their anxiety level has been noted to be decreasing.Despite the client's increased understanding of distorted messages that produce worry and anxiety, his/her/their anxiety level has not diminished.

      21 Develop Insight into Worry as Avoidance (21)The client was assisted in gaining insight into how worry is a form of avoidance of a feared problem and how it creates chronic tension.The client was reinforced for his/her/their insightful understanding about how his/her/their worry creates avoidance and tension.The client struggled to understand the nature of worry as a form of avoidance and was provided with remedial information in this area.

      22 Identify Distorted Thoughts (22)The client was assisted in identifying the distorted schemas and related automatic thoughts that mediate anxiety responses.The client was assisted in challenging and changing biases.The client was reinforced as he/she/they verbalized an understanding of the cognitive beliefs and messages that mediate his/her/their anxiety responses.The client was assisted in replacing distorted messages with positive, realistic cognitions.The client failed to identify his/her/their distorted thoughts and cognitions and was gently offered examples in this area.

      23 Assign Exercises on Self-Talk (23)The client was assigned homework exercises in which he/she/they identify fearful self-talk and create reality-based alternatives.The client was assigned the homework exercise “Negative Thoughts Trigger Negative Feelings” from the Adult Psychotherapy Homework Planner (Jongsma).The client's replacement of fearful self-talk with reality-based alternatives was critiqued.The client was reinforced for his/her/their successes at replacing fearful self-talk with reality-based alternatives.The client was provided with corrective feedback for his/her/their failures to replace fearful self-talk with reality-based alternatives.The client has not completed his/her/their assigned homework regarding fearful self-talk and was redirected to do so.

      24 Construct Anxiety Stimuli Hierarchy (24)The client was assisted in constructing a hierarchy of anxiety-producing situations associated with two or three spheres of worry.It was difficult for the client to develop a hierarchy of stimulus situations, as the causes of his/her/their anxiety remain quite vague; he/she/they were assisted in completing the hierarchy.The client was successful at creating a focused hierarchy of specific stimulus situations that provoke anxiety in a gradually increasing manner; this hierarchy was reviewed.

      25 Select Initial Exposures (25)Initial exposures were selected from the hierarchy of anxiety-producing situations, with a bias toward likelihood of being successful.A plan was developed with the client for managing the symptoms that may occur during the initial exposure.The client was assisted in rehearsing the plan for managing the exposure-related symptoms within his/her/their imagination.Positive feedback was provided for the client's helpful use of symptom management techniques.The client was redirected for ways to improve his/her/their symptom management techniques.

      26 Assign Imagination Exercises (26)The client was asked to vividly imagine worst-case consequences of worries, holding them in mind until the anxiety associated with them weakens.The client was asked to imagine consequences of his/her/their worries as described in Mastery of Your Anxiety and Worry—Therapist Guide (Craske, Barlow, and O'Leary).The client was supported as he/she/they have maintained a focus on the worst-case consequences of his/her/their worry until the anxiety weakened.The client was assisted in generating reality-based alternatives to the worst-case scenarios, and these were processed within the session.

      27 Conduct Exposure In Vivo (27)The client was assisted in engaging in activities usually avoided due to unrealistic worry.The client was assisted in removing any unnecessary, anxiety-driven safety behaviors as described in Mastery of Your Anxiety and Worry—Therapist Guide (Craske, Barlow, and O'Leary).The client was supported as he/she/they engaged in difficulty activities until his/her/their anxiety weakened.

      28 Assign Homework on Situational Exposures (28)The client was assigned homework exercises to perform worry exposures and record his/her/their experience.The client was assigned situational exposures homework from Mastery of Your Anxiety and Worry—Client Guide (Zinbarg, Craske, Barlow, and O'Leary).The client was assigned situational exposures homework from Generalized Anxiety Disorder (Brown, O'Leary, and Barlow).The client's use of worry exposure techniques was reviewed and reinforced.The client has struggled in his/her/their implementation of worry exposure techniques and was provided with corrective feedback.The client has not attempted to use the worry exposure techniques and was