14 4 ASSESSMENT AND INTERVENTION STRATEGIES
a recent anxiety- provoking situation or the therapist and client could role-play the situ-
ation in order to elicit automatic anxious thoughts or images. Throughout, the therapist
probes for a client’s anxious appraisals of the situation and her ability to cope. Naturally
the effectiveness of this assessment approach depends on the client’s imaginative ability
or capacity to engage in role playing.
Induction exercises can also be used to elicit apprehensive thoughts. For example,
various physiological hyperarousal symptoms can be induced and clients encouraged
to verbalize their “stream of thoughts” as they experience these symptoms. A situation
could be created in the therapy session or stimuli introduced to elicit anxiety and clients
could again be asked to verbalize their emerging thoughts. For example, someone with
fear of contamination could be given a dirty cloth to touch and then report on his anx-
ious thoughts.
Finally, the most effective procedure for eliciting the first apprehensive thoughts is
to accompany the client into a naturalistic anxiety- provoking situation. Although the
presence of the therapist might have a safety cue effect, careful probing of clients’ stream
of consciousness should reveal their first apprehensive thoughts. Even generating an
expectation of exposure to an anxiety- provoking situation might be sufficient to elicit
these primary automatic anxious thoughts.
Clinician Guideline 5.5
Obtain an accurate assessment of the client’s first apprehensive thoughts in a variety of
anxiety- provoking situations to determine the underlying threat schema responsible for the
anxious state.Perceived Autonomic Arousal
Individuals are usually very aware of the physical symptoms of anxiety and so can
quite readily report these symptoms in the clinical interview. They should be asked for
examples of recent anxiety episodes and the physical symptoms experienced at these
times. Rather than have clients report on the typical anxiety attack, it is better for
them to report on specific incidents of anxiety and the exact physical symptoms experi-
enced during these episodes. Some variation in the physical symptoms of anxiety can be
expected across different anxiety episodes.
The practitioner will be relying mainly on clients’ self- report of their physiological
responses since use of psychophysiological laboratory-based or ambulatory equipment
for monitoring purposes is rarely feasible in the clinical setting. Self- monitoring forms
should be used for clients to collect “online” data of their physiological responses when
anxious. In most cases the Physical Sensation Self- Monitoring Form (Appendix 5.3) can
be given as a homework assignment and will provide the needed information on the
client’s autonomic arousal profile. In certain cases where physiological arousal plays a
particularly important role in the persistence of anxiety (i.e., panic disorder, hypochon-
driasis), an expanded checklist of bodily sensations can be administered (see Appendix
5.5).
Three questions must be addressed when assessing subjective physiological hyper-
arousal in the immediate fear response phase. First, what is the typical physiological