DESCRIPTION OF THE STRATEGY

Anxiety management training (AMT) is a form of coping skills training that teaches applied
relaxation as a means of anxiety control. AMT was first designed for the treatment of
generalized anxiety disorder in adults and has been conceptualized as a treatment for any
problem in which anxiety plays a central role. Although AMT was initially developed for
adults, researchers have also suggested a modified set of AMT procedures for children. AMT
alone does not appear to be the current treatment of choice for childhood anxiety disorders;
however, components of AMT seem to be incorporated into a number of well-accepted
treatment protocols for childhood anxiety.
In AMT, clients are taught to identify and respond to both physiological and cognitive signals
of anxiety with a specific coping behavior. More specifically, clients learn to respond to their
anxiety symptoms through the implementation of a relaxation response. As sessions progress,
clients are instructed in how to recognize physiological and cognitive cues that signal the
onset of anxiety. This enables the client to prevent even higher levels of anxiety from
developing by responding to early anxiety cues with the execution of relaxation behaviors.
There are several subtle distinctions that differentiate AMT from other behavioral treatments
for anxiety, such as systematic desensitization or flooding techniques. In AMT, the clients take
an active role in their anxiety reduction by selectively applying a coping skill (i.e., relaxation
training) to reduce anxiety symptoms evoked during imaginal exposure exercises. During
systematic desensitization, relaxation training and exposure are also employed, although the
usage of such skills differs from AMT procedures, as a relaxed state is optimally maintained
from the start of a systematic desensitization session and imaginal exposure episodes are
typically brief and terminated by the therapist before high levels of fear or anxiety fully
disrupt the client's relaxed state. In addition, AMT uses only two levels of anxiety (moderate
and high) for exposure tasks, whereas systematic desensitization utilizes a gradual, stepwise
hierarchy of stimuli intensity that induces a range of anticipated responding spanning from
very low levels of anxiety to much higher levels of anxiety. Flooding procedures, unlike
AMT, do not include active coping skills training, such as the learning of relaxation exercises.
In flooding, adaptation to feared stimuli is more of a passive process that focuses on
habituation to such stimuli, whereby clients are usually exposed to highly feared stimuli
without any previous, incremental presentation of less fear-evoking stimuli.
AMT treatment protocols usually consist of five structured sessions. However, more than five
sessions are often implemented, as particular sessions may be repeated. The sessions typically
take place once a week for approximately 1 hour at a time. The therapist begins the first
session with an overview of the treatment structure and rationale. The reason for this
overview is that client understanding of the therapeutic process is considered an important
component of AMT. Therapy is described to clients as a type of skill acquisition, learned
primarily through extensive practice. Furthermore, AMT is discussed as a method to train
clients in the early identification of anxiety and the elimination of anxiety through relaxation.
The therapist also emphasizes the importance of active involvement on the part of the clients
during the course of their AMT treatment. The therapist may also describe how relaxation will
be taught, and clients are informed that imagery will be used as a way for the clients to induce
anxiety in session.
In addition to an overview of the treatment rationale, the client also begins relaxation training
during the first session. A relaxation scene to be used during this session is constructed with

the assistance of the client. The relaxation scene should be an event that the client has actually
experienced, should contain as many concrete details as possible, and should include as many
sensory cues as possible. The therapist typically explains that relaxation is a skill that needs to
be practiced outside of session for generalization of such skills to occur. For this reason, the
importance of homework is emphasized. During the first session, this homework consists of
practicing relaxation skills on a daily basis and monitoring the level of tension experienced
before and after relaxation sessions. During homework, the degree of relaxation obtained may
be monitored on a scale of 1100 (where low scores indicate a relaxed state, middle numbers
indicate moderate levels of anxiety, and higher numbers indicate more intense levels of
anxiety).
Notably, the original procedures for relaxation training in AMT were designed for adults, and
these procedures may be difficult for children to follow. Clinicians using AMT in their work
with children should be mindful regarding the possible selection of alternative relaxation
procedures that have been especially developed for use with this population. These alternative
relaxation procedures may include imagery and fantasy strategies that facilitate learning about
how to relax particular muscle groups. For instance, the child can visualize squeezing an
orange as a way to learn to tense and relax muscles in the arm. When working with children
using AMT, it is recommended that relaxation training be limited to 15-minute intervals, using
a maximum of three muscle groups per interval.
The second AMT session begins with identification of an anxiety-evoking scene of moderate
intensity (i.e., a rating of 60 on a scale of 1100). Through use of imagery, exposure to the
anxiety-evoking scene is then induced in session, with the goal of making the imagined
situation as vivid as possible. Once the anxiety-evoking scene is introduced, the therapist
instructs the client to begin relaxation. After a relaxed state has been achieved, anxietyevoking imagery is used in order to obtain another anxious state. When the client reports that
he or she feels sufficiently anxious, imaginal exposure is terminated, and the therapist signals
for the client to begin the relaxation procedure again. This process teaches the client to
quickly respond to an anxious state with induction of a relaxation response. Therefore, this
same procedure of anxiety induction, followed by implementation of the relaxation procedure,
is practiced a number of times throughout the second session. As homework, the client is
instructed to practice using relaxation skills in a number of locations. For example, the client
may be instructed to practice the training while riding on the school bus or before attending a
social gathering.
In the third session, the therapist begins to give increased responsibility for the initiation of
relaxation to the client. Procedurally, an anxiety-evoking scene of moderate intensity (i.e.,
level 60) is presented and the client is asked to pay particular attention to any early symptoms
indicative of an anxious response. The scene is then terminated, and the client is instructed to
implement the relaxation process. This cycle is repeated several times throughout the session
in order to facilitate improved identification of anxiety-related cues. As homework, the client
continues to practice relaxation independently, with the specific instruction of implementing
the procedure in response to a novel situation that produces mild anxiety.
In the fourth AMT session, the intensity of the anxiety-evoking scene utilized in session is
increased through the use of an imaginal scene with a discomfort level of 90 or above. The
cycle of anxiety induction followed by implementation of relaxation is repeated several times
throughout the session, with the level of scene intensity varied between scenes that produce
moderate levels of anxiety and those that produce higher levels of anxiety. In addition, the

therapist continues to give increased responsibility for initiation of relaxation to the client.
Homework includes practicing detection of early anxiety signals and independently
responding to such cues with relaxation strategies.
In the fifth session, the client has most of the responsibility for induction of relaxation
procedures. The therapist helps to present a highly anxiety-evoking scene; however, all other
activities are controlled by the client. Once anxiety is induced, the client responds to the
anxiety elicited by self-initiating the relaxation procedure. In this session, relaxation is
initiated without termination of the anxiety scene. Once the client obtains a stable state of
relaxation, moderate and high intensity scenes are presented in alternating orders, with each
scene followed by client initiation of the relaxation procedure.

RESEARCH BASIS
AMT has been systematically researched over the last 30 years. Originally, AMT was used to
treat manifestations of generalized anxiety disorder in adults; however, AMT also appears
effective for the treatment of several other problems among adults, including test anxiety,
social anxiety, and anger difficulties. AMT may decrease symptoms associated with a number
of medical conditions, including hypertension, diabetes, ulcers, and asthma. AMT was not
developed as a treatment for child anxiety, and limited research has been forwarded to
examine the implementation of AMT as a specific intervention for child populations. One
reason for this limited amount of research on the effectiveness of AMT in child and
adolescent populations may be that components and variations of AMT appear to be
embedded in current research-based treatment protocols for child and adolescent anxiety
disorders. As a result, AMT is not generally used as an intervention, independent of other
treatment components, with child and adolescent populations.
Support exists for the efficacy of approaches similar to AMT in the treatment of childhood
fears and phobias. Researchers have suggested that AMT, with the incorporation of cognitive
restructuring and other behavior management skills, may be effective in the treatment of
children and adolescents with generalized anxiety disorder, social phobia, and separation
anxiety disorder. AMT is also a component of a manualized treatment for obsessivecompulsive disorder (OCD). In this empirically supported treatment procedure, AMT is used
in conjunction with exposure and response prevention (Ex/RP) techniques. Although AMT is
often used concurrently with Ex/RP, at least one research study has found that Ex/RP
treatment components are more effective than AMT alone in the treatment of childhood OCD.

RELEVANT TARGET POPULATIONS AND

EXCEPTIONS
As noted, components and variations of AMT are found within a number of current treatment
protocols for child anxiety, such as a treatment protocol for OCD. In the course of this
treatment for OCD, AMT is defined by the combination of relaxation training, breathing
exercises, and cognitive restructuring skills that can be used during implementation of Ex/RP
tasks. Research on the use of AMT within treatment protocols for OCD has indicated that
AMT may be effective in making exposure more predictable and controllable by decreasing
the level of anxiety related to exposure activities and by targeting co-occurring anxiety
disorders that may interfere with the treatment of OCD.

As noted, treatment components similar to those in AMT also appear within an empirically
supported treatment designed to treat a variety of childhood anxiety disorders including social
phobia, generalized anxiety disorder, and separation anxiety disorder. Components of this
treatment that seem consistent with AMT include teaching children to recognize internal cues
associated with anxiety, relaxation training, and self-monitoring.

COMPLICATIONS
There are a number of potential complications when conducting AMT or related treatment
strategies with children. For instance, researchers have noted that clinicians should pay
particular attention to the motivation level and cognitive capability of children and
adolescents when asking them to self-monitor. The age and developmental level of certain
childhood populations may also limit the utility of AMT and related cognitive-behavioral
strategies. In particular, recognition of cognitive or physiological cues signaling anxiety, a
necessary feature of AMT and many related cognitive-behavioral strategies, may require a
degree of insight or cognitive skill on the part of the child that may not be fully developed
among all children. Consequently, most of the anxiety-focused interventions for children are
targeted at school-aged children (ages 712), as younger children may be relatively limited in
their ability to understand themselves, self-monitor, and regulate their own behavior. A child's
cognitive ability and level of metacognition may also be important regarding the ability to
adequately comprehend terminology associated with AMT or similar treatment strategies.
The anxiety-evoking exposure exercises typical of AMT and other behavioral treatments for
anxiety disorders may be inherently stressful to the child. Therefore, a child may be reluctant
to participate in exposure activities or may use alternative cognitive strategies in order to
prevent arousal from occurring in the session, such as distraction. As a result, it is important to
clearly articulate the rationale of this treatment to the child and to seek the child's
collaboration in treatment procedures. To whatever degree possible, it is also important to
make sure that the child is actually experiencing sufficient anxiety during imaginal exposure
exercises. At the same time, the clinician must take careful steps to make sure that exposure is
presented in such a way that the child does not endure extremely high levels of anxiety in
session. If exposure progresses too quickly or if it leads to the induction of overly intense
anxiety symptoms, the clinician runs the risk of the child experiencing some trauma in
session. For many of the same reasons, it is also important to make sure that when imaginal
exposure is conducted within the session, anxiety is fully reduced before the session is
terminated.

CASE ILLUSTRATION
Jared was an 11-year-old male who presented to a community mental health clinic,
accompanied by his parents, due to difficulties with swallowing pills, both at home and at
school, that were prescribed by his psychiatrist for the treatment of attentiondeficit/hyperactivity disorder (ADHD). Upon consultation, Jared's psychiatrist indicated no
medical etiology for this problem and reported his belief that the cause of Jared's swallowing
difficulties was anxiety-related in nature. During initial assessment, Jared and his parents
completed several questionnaire measures assessing a range of internalizing and externalizing
difficulties, in addition to a detailed history of the problem behavior and a semistructured
interview to assess for diagnostically relevant symptomatology. Jared's school nurse (who
administered medications to him in that environment) also completed a questionnaire measure

regarding his behavior, and Jared's parents were instructed to keep a frequency count of his
compliance with swallowing medications during the week following the initial assessment.
Results of this assessment indicated that while Jared had no prior history of swallowing
difficulties during infancy or childhood, his tolerance of psychostimulant medications was
poor from the start of its usage, 2 months ago, resulting in recurrent feelings of nausea,
headache, and sleeplessness, though his mother and psychiatrist believed that these side
effects seemed to steadily improve throughout the 1st week of treatment. Nonetheless, during
the 2nd week of treatment, Jared began refusing to take his pills either at home or at school.
Changes in the type and dosing of psychostimulant medication failed to remediate his
medication compliance problems. Jared reported that he felt embarrassed about taking
psychostimulant medications, especially at school, and further indicated a particular concern
that he would throw up in front of family or peers after swallowing his pill. Jared failed to
meet full diagnostic criteria for any clinical disorder, other than ADHD. However, he did
report mild to moderate symptoms of social anxiety, oppositional defiant disorder, and
specific phobia (vomiting) that appeared consistent with his medication compliance issues.
AMT was administered to Jared over six treatment sessions. During an initial assessment
feedback session in which the antecedent and consequent conditions that seemed to be
associated with Jared's current swallowing difficulties were reviewed, commitment was
obtained to participate in a brief course of AMT. In the first AMT session, the rationale for
this treatment approach was extensively reviewed with Jared and his family members, a
method for identifying Jared's level of anxiety in session (using Subjective Units of
Discomfort [SUDS] levels) was introduced, and Jared helped to design his relaxation
paradigm. Jared then assisted in teaching his parents the relaxation paradigm he created, and
the family practiced relaxation skills together. In Session 2, a moderately anxiety-evoking
situation was identified (swallowing a psychostimulant pill and feeling nauseous) and
imaginal exposure was utilized to induce anxiety at a SUDS level of 60. Upon attainment of
this SUDS level, Jared was instructed to begin his relaxation paradigm. This exposurerelaxation cycle was then repeated several times in session. At the start of Session 3, Jared's
parents reported a significant increase in his medication compliance, up from compliance
during 7 of 21 administration attempts during Week 1 of treatment, to 15 of 21 administration
attempts at the start of Week 3, with increasing compliance observed throughout the previous
week. Jared also reported that he was feeling a little less anxious about potentially vomiting
after taking his medication. In Session 3, Jared was encouraged to report how his body felt
and any negative self-talk that occurred each time his SUDS levels increased during imaginal
exposure to his moderately intense anxiety-evoking situation. Discussion of how to use the
physiological and cognitive cues that Jared reported during exposure activities to prompt
relaxation use was also conducted. For homework, Jared indicated that he would try to use his
relaxation skills when he noticed any of these anxiety-related cues following medication
usage at school.
Session 4's content was virtually identical to Session 3's, with a more specific focus on
alternately imagining a slightly expanded scene that involved Jared taking his medication in
school and feeling nauseous afterward, as this situation continued to present difficulty to him,
and his regular moderately intense scene. In Session 5, the therapist discussed induction of
Jared's high-intensity anxiety-evoking situation (taking his psychostimulant medication in
school and vomiting in the classroom) and the possible side effects of reviewing such highly
emotional imagery with him and his family. Jared strongly indicated that he was ready for
the imaginal presentation of this situation but agreed to allow his mother to remain in the

room during initial exposure to this imagery, in case of any adverse effects. Jared repeatedly
and successfully induced anxiety at a SUDS level of approximately 80 during this session to
his high-intensity scene (with alternating presentation of his moderately anxiety-evoking
scene), and appropriate use of relaxation in session. At the start of Session 6, Jared's parents
reported that he appeared to no longer exhibit problems with medication compliance and had
not refused to take his medication at any point during the previous week. Jared proudly selfinitiated both imaginal exposure and relaxation to his high-intensity situation and announced
to the therapist that he was ready to discontinue treatment. A follow-up phone call from
Jared's psychiatrist indicated that he continued to evidence full compliance with swallowing
medications 3 months after AMT was completed.
Jill T. Ehrenreich and Brian J. Fisak Jr.
Further Reading

Entry Citation:
Ehrenreich, Jill T., and Brian J. Fisak Jr. "Anxiety Management." Encyclopedia of Behavior
Modification and Cognitive Behavior Therapy. 2007. SAGE Publications. 15 Apr. 2008.
<http://sage-ereference.com/cbt/Article_n2003.html>.