Cognitive Assessment and Case Formulation 151
Clinician Guideline 5.10
Identify the primary intentional safety- seeking behaviors by reviewing the client’s Behavioral
Responses to Anxiety Checklist (Appendix 5.7) and determine the functional significance
and cognitive basis of the responses. Also reconsider the safety- seeking function that may be
associated with the more automatic, inhibitory reactions noted in Guideline 5.7. This should
result in a clear specification of the subtle, more automatic and more conscious, deliberate
safety- seeking behaviors that characterize the client’s anxiety.Constructive Mode
An important part of the secondary phase of anxiety is the activation of a more con-
structive, problem- oriented approach to the threatening situation. It must be recog-
nized that all treatment- seeking individuals will have some capacity to respond to their
anxiety in a more constructive manner. It is important to identify these strengths in the
case formulation so this can be incorporated into the treatment plan. What behavioral
responses to anxiety does the client already exhibit that indicates a more constructive
approach? Is the person able to engage in adaptive problem- solving? Are there any cog-
nitive strategies that lead to a reduction in the perceived level of threat? It is useful to
assess the constructive mode when the person is in a nonanxious state. How do they
perceive threat and their personal vulnerability when not anxious? How well can they
bring this more realistic, adaptive perspective to bear when they are anxious? How dif-
ficult is it to believe the constructive perspective when anxious?
Very often individuals who seek cognitive therapy for anxiety have had previous
treatment or read cognitively oriented self-help books on anxiety. Thus it is very likely
that some constructive response to their anxiety is already present. Table 5.3 presents
various types of constructive responses to anxiety and sample clinical questions that can
be used to assess constructive mode activation when anxious.
Assessment of clients’ “spontaneous” use of various constructive approaches to
anxiety is important for two reasons. First, it provides some indication of the clients’
strengths around which a treatment plan can be formulated. And second, it may be that
a particular constructive approach has not been employed effectively and so the client
has negative expectations about its success. It would be important for the therapist to
know this before assigning this strategy as homework. In sum, assessment of construc-
tive mode activation is an important part of the case formulation.
Clinician Guideline 5.11
Identify adaptive coping strategies that are present in the client’s repertoire and the extent to
which these responses are utilized during periods of anxiety. Evaluation of the constructive
mode should also include an assessment of the client’s ability to engage in a more realistic
appraisal of his or her anxious concerns when not anxious and whether this more realistic
perspective is available during anxious episodes.