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In-session anxiety: 5 steps to help patients relax

Vol. 4, No. 8 / August 2005

Patients with anxiety disorders often struggle with in-session anxiety. Five simple steps can help you reduce their anxiety and teach them how to manage their fear within minutes.

Step 1: During a session, encourage patients to rate their current anxiety on a scale from 0 to 100 with 100 being the most intense.

Step 2: Ask patients to identify the score at which anxiety is too distressing or impairs functioning. Because patient perception distinguishes grades of anxiety, this activity helps differentiate between mild anxiety they can manage, moderate anxiety that needs immediate, non-pharmacologic intervention, and extreme anxiety that may require medication.

Step 3: Have patients identify which anxiety symptoms are most distressing:

  • physiologic symptoms such as palpitations, tremors, and tachypnea
  • affective symptoms (unpleasant feelings, anxious affect)
  • cognitive symptoms (racing thoughts, impaired concentration, thoughts of impending doom, loss of control).

Knowing which symptoms are most bothersome helps you tailor your intervention. Patients also see how anxiety symptoms are not equally distressing.

Step 4: Choose one of two interventions depending on which symptoms predominate, and tell the patient you are teaching him or her a coping skill.

For cognitive symptoms, ask the patient to look around the room and describe in detail what he sees over the next 3 minutes. If time remains, ask him how he would make the room more presentable. Avoid eye contact during this time so that the patient stays focused on observing the room.

For physiologic and affective symptoms, try the “safe-place technique.” Ask the patient to close his eyes and recall a time when he felt safe and content. During the next 3 minutes, have him describe the situation, people, and positive feelings involved. Don’t let the patient get sidetracked by negative thoughts or attention to the present. Ask him to slowly open his eyes when finished.

Step 5: Ask the patient to rate anxiety symptoms again on the same 0-to-100 scale. This second score often is significantly reduced (usually between 10 and 60 points). If one technique is not effective, try the other if time permits.

These interventions also show patients that they can control their anxiousness. Encourage patients to try other anxiety- or stress-management techniques and rate their effectiveness using the 0-to-100 scale.1 Have them record effective methods in a notebook so they can develop a personalized repertoire of calming activities and techniques.


1. Copeland ME. Wellness Recovery Action Plan. West Dummerston, VT: Peach Press; 2002;62-71.

Dr. Pinninti is associate professor of psychiatry, School of Osteopathic Medicine, University of Medicine and Dentistry of New Jersey, and medical director, Steininger Behavioral Care Services, Camden, NJ.

Dr. Mago is assistant professor of psychiatry, Thomas Jefferson University, Philadelphia, PA.

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