150 ASSESSMENT AND INTERVENTION STRATEGIES
••“What would happen to your anxiety if you did not engage in this safety activity?
[e.g., What would happen to your anxiety if you didn’t carry your medication
with you?]”
••“How important is this activity to your way of dealing with or managing your
anxiety? Is it something you do deliberately or is it more automatic, like a habit
that you are hardly aware of doing?”Once the client’s primary safety- seeking responses have been identified, it is impor-
tant to also specify the cognitions and physical sensations associated with safety seeking
(i.e., Salkovskis, Clark, et al., 1999). This might be quite obvious from the cognitive-
behavioral responses recorded on the self- monitoring forms or on occasion the cognitive
therapist might have to assess more specifically. The following fictitious clinical excerpt
illustrates the type of inquiry that could be used to identify safety- seeking cognitions.
Th e r a p i sT: I notice from the checklist that you indicated you always carry your Ativan
with you at all times. Could you tell me why this is so important for you?
cL i e nT: Well, I just feel better knowing that I have the medication if I ever need it. I
haven’t used the Ativan in months but knowing that it is there makes me feel bet-
ter.
Th e r a p i sT: What would happen if you forgot to take the medication bottle with you?
cL i e nT: I know that I would feel a lot more anxious if I realized I didn’t have it. The
Ativan is so effective in relieving my anxiety. If I have it with me, I know that I
could always take a pill if the anxiety gets too severe. Even though I haven’t used the
medication in months, just knowing that the anxiety can’t get out of hand because
I could always take an Ativan seems to help.
Th e r a p i sT: Is there anything you feel or experience when in an anxious situation that is
somehow better just knowing you have the medication?
cL i e nT: Well as you know I get really afraid of having another panic attack when I
notice that I’m becoming more anxious. The worst thing is feeling like I am losing
control. Knowing that I could take an Ativan and be calmer and in control within a
few minutes makes me feel a lot better; it makes me feel more confident.
A number of cognitions are evidently associated with this client’s medication- related
safety- seeking behavior. She believes just having access to the medication gives her more
confidence and makes her feel safer, more secure. More importantly, there is a direct
functional relationship between the catastrophic thought “of losing control” and being
able to take the medication. This belief that the medication is an important source of
regaining control and thwarting overwhelming anxiety will become a target in treat-
ment. If the cognitive basis of safety seeking cannot be determined by interview or
review of the self- monitoring forms, direct observation of the client’s anxiety either by
accompanying the person into an anxious situation or conducting an anxiety- induction
exercise in the session might be necessary. In all anxiety cases identifying the primary
safety- seeking behaviors and their cognitive basis is an important part of the case for-
mulation for anxiety.