14 2 ASSESSMENT AND INTERVENTION STRATEGIES
So how can the cognitive therapist gain access to this fleeting cognitive content?
It is important to introduce the topic of first apprehensive thoughts in a collaborative,
exploratory manner. A description of the first apprehensive thoughts should be provided
and the client should be warned that it is often difficult to identify these thoughts in
the anxiety cycle. Explain that when entering an anxious situation, most people are so
focused on how they feel and the details of the situation, that their first apprehensive
thoughts are often lost to them. The following example can be used to introduce clients
to the concept of the first apprehensive thoughts.
“Imagine for a moment that you are walking down a deserted street or country
road by yourself and it is getting dark. Suddenly you hear a noise behind you. You
immediately stiffen, your heart beats quickly, and you quicken your pace. Why this
sudden surge of adrenalin? No doubt you instantly interpret the noise as a danger-
ous possibility: ‘Could someone be approaching from behind who could cause me
harm?’ You turn around and there is no one there. Quickly you think to yourself
‘No one is there, it must have been the wind, a squirrel, or my imagination.’ It is
this secondary thought, this reevaluation of the situation, that sticks in your mind.
If later I asked you about your walk, you would remember a momentary twinge
of fear and the later realization that ‘nothing was there.’ That first apprehensive
thought that triggered the fear ‘Is there an attacker behind me?’ is lost to recall,
instead replaced by your reasoned response to the situation.
“In the last couple of sessions you have described a number of situations that
cause you considerable anxiety. In these situations you would have had some initial
apprehensive thoughts or images that fueled your fear or anxiety. It may be that
now you can’t remember what they are because you don’t feel threatened at the
moment and you are not in an anxiety- provoking situation. However, it is impor-
tant to our treatment that we discover the first apprehensive thoughts. We want to
know what ‘kick- starts’ the anxiety. Together, by carefully going over each situa-
tion and collecting some further information, we may discover the types of appre-
hensive thoughts or images that define your anxious experiences.”The first assessment strategy for identifying the initial apprehensive thoughts is the
clinical interview. Although individuals often don’t remember their initial automatic
anxious thoughts, a few specific, well- phrased questions can provide some initial clues
to these thoughts. Here are some examples of clinical questions:
••“You indicated that in situation X you feel intensely anxious. For you what would
be the worst thing that could happen in this situation? What would be the worst
possible outcome? Try to think about the worst consequence without considering
whether or not you think it is likely to happen.”
••“Is there anything specific about the situation or about how you are feeling that
concerns you? What is not quite right for you? What is different from your nor-
mal self?”
••“How could the situation change so you feel less concern, less uneasy?”
••“What do you tell yourself to ease your anxiety, to reassure yourself that every-
thing will be fine?”