136 ASSESSMENT AND INTERVENTION STRATEGIES
verbal report of one’s thoughts, images, daydreams, ruminations, evaluations, and the
like. Beck (1967) stated: “The schemas pattern the stream of associations and rumina-
tions as well as the cognitive responses to external stimuli. Hence, the notion of schemas
is utilized to account for the repetitive themes in free associations, daydreams, rumi-
nations, and dreams, as well as in the immediate reactions to environmental events”
(p. 283). If schemas direct conscious thought, then the differential activation and con-
tent of schemas can be inferred from verbal content (see also Kendall & Ingram, 1989).
Furthermore, there is a direct link between automatic and elaborative processes as indi-
cated by evidence that changes in conscious appraisal or meaning can modify automatic
threat biases (see Mansell, 2000) and that an automatic attentional bias can be induced
through an attentional training program that involves both brief and long processing
intervals (e.g., Matthews & MacLeod, 2002; MacLeod et al., 2002). Together these
considerations lead to the following proposition: that the nature and function of auto-
matic threat schema activation during the initial fear response can be determined from
the cognitive, behavioral, and physiological products of this activation.
Three primary questions must be addressed in any case formulation of the immedi-
ate fear response (Phase I).
••What situations, cues, or experiences trigger the immediate fear response?
••What is the core schematic threat or danger to self?
••What is the immediate inhibitory or defensive response to this threat?Although standardized questionnaire and interview data can be helpful in building a
case formulation, the most critical information will be obtained from idiographic mea-
sures. These are self- monitoring forms, rating scales, and diary records that allow the
person to collect critical information when experiencing anxiety. They are tailored to
the particular needs and circumstance of each client so that process- oriented, “online”
data gathering is available that contributes to a more accurate case conceptualization.
Behavioral observation is another assessment approach that can provide important
clinical information on immediate fear response. Some anxiety states like social pho-
bia, OCD, and PTSD can be quite easily elicited in the therapy session by introducing
relevant triggers of anxiety. Other anxiety disorders like panic and GAD require more
ingenuity in order to trigger an immediate fear response. Often the therapist accompa-
nies the client to particular external situations in order to observe an anxious state. In
either case, direct observation of a fear response provides opportunity to gather detailed
information on the nature, severity, and functional characteristics of the immediate fear
response. We believe it is important for the therapist to have at least one opportunity to
observe a client’s acute anxiety state in order to develop an accurate case formulation
and a sensitive individually tailored treatment plan.
Clinician Guideline 5.3
Daily self- monitoring and direct behavioral observation are important assessment strate-
gies that should be a regular feature of any assessment and case formulation of anxiety. Both
strategies are critical for determining the nature of immediate fear activation.