Cognitive Therapy of Anxiety Disorders

Cognitive Assessment and Case Formulation 147

ations and then noted any inhibitory responses. Alternatively, a friend, family member,
or spouse could be given the above list of defensive responses and asked to note whether
any of these responses were observed when accompanying the client in anxious situa-
tions.

Clinician Guideline 5.7

Uncover automatic cognitive and behavioral inhibitory responses through behavioral obser-

vation to identify reactions that could later undermine the effectiveness of exposure.

Cognitive Processing Errors

Cognitive processing during the immediate fear response tends to be highly selective,
with attention narrowly focused on the source of threat and one’s ability (or inability)
to deal with this threat. As a result certain unintended errors will be evident in the cli-
ent’s evaluation of the threat that will not be readily apparent to the individual. These
cognitive errors can be determined from the automatic anxious thoughts and behaviors
that are elicited in anxiety- provoking situations. Appendix 5.6 provides a list of the com-
mon cognitive errors seen in anxiety disorders, followed by a self- monitoring form that
clients can use to become more aware of their anxious processing biases. This should be
introduced after the client has been taught how to identify the first apprehensive thought.
Teaching clients how to identify their cognitive errors will not only provide information
for the case formulation but it is a useful cognitive intervention strategy (see Chapter 6).
Many anxious clients have difficulty identifying the cognitive errors in their anx-
ious thinking. It may take a number of sessions before the client can capture examples
of his own thinking biases. In the meantime the therapist can use the form in Appendix
5.6 to identify some of the thinking errors that are apparent from the clinical interview
and self- monitoring of anxious thoughts. This can be incorporated in the case formula-
tion until more accurate data are available from clients’ own recording of their thinking
errors.

Clinician Guideline 5.8

Use Appendix 5.6, Common Errors and Biases in Anxiety, to train clients to identify the

automatic cognitive errors that occur whenever their anxiety is provoked by certain internal

or external triggers.

seConDary reappraisal: assessment anD formulation

Anxiety is always the result of a two-stage process involving the initial activation of
threat followed by a slower, more reflective processing of the threat in light of one’s cop-
ing resources. For this reason the cognitive therapist also assesses secondary elaborative
processing, focusing on two questions that must be addressed in the case conceptualiza-
tion.