Cognitive Assessment and Case Formulation 155
gated this possibility. An assessment of intentional thought suppression and emotional
inhibition should be included in the case formulation. Appendix 5.9 presents a cognitive
coping checklist that includes emotion inhibition along with a number of other inten-
tional thought control strategies that may exacerbate the anxious state.
The Cognitive Responses to Anxiety Checklist (Appendix 5.9) can be assigned as
a homework exercise. However, most anxious clients are probably not aware of their
thought control strategies because these responses can become quite habitual over time.
Thus some training and education will be required to teach clients how they may engage
in maladaptive thought control strategies that only make anxious thoughts more salient.
One might be able to review a recent anxious episode and use the checklist to determine
which of the 10 strategies occurred and to what extent they contributed to anxiety
reduction. Alternatively, a state of anxiety could be induced in the therapy session (or
observed in a naturalistic setting) and clients could be asked whether they use any of the
checklist strategies to control their anxious thoughts or worries.
Another way to highlight the nature of thought control in clients’ experience of
anxiety is to conduct a modified thought suppression experiment. This is illustrated in
the following example.
Th e r a p i sT: Lorraine, I would like to take a closer look at your anxiety about having a
panic attack. You’ve indicated that often you feel your chest tighten and your first
apprehensive thoughts are “I must be getting anxious. I really need to calm down.
If I don’t I could have another of those terrible panic attacks.”
Lo r r a i n e: Yes, that is exactly how I feel. I really hate those feelings and would do any-
thing to get rid of them.
Th e r a p i sT: Okay, what I would like to do is a little exercise with you right here in the
office. First, I would like to see if you could focus on your anxious thoughts right
now. Maybe you could bring these thoughts to your mind by tightening your chest
muscles or imagining you are in a recent anxious situation. It doesn’t matter how
you do it, but I would like you to think about feeling anxious and the possibility of
having a panic attack.
Lo r r a i n e: I’m not sure I want to do this. I’m afraid I could trigger a panic attack.
Already I’m beginning to feel anxious.
Th e r a p i sT: I understand your concern. We can stop the exercise at any time. I simply
want you to bring the anxious thoughts to your full attention. If you are beginning
to feel anxious, then maybe you can focus on these anxious thoughts right now
even without tightening your chest muscles.
Lo r r a i n e: Oh, I have no trouble thinking about my anxiety right now and the possibil-
ity of a panic attack.
Th e r a p i sT: Okay, Lorraine, please close your eyes and focus your attention on thoughts
of being anxious right now. Think about how you are feeling and the last time you
had a panic attack. I am going to ask you to hold that thought for 30 seconds....
[pause] Now stop thinking about your anxiety. I am going to give you another 30
seconds to stop thinking about your anxiety and the possibility of panic. You can
do this anyway you choose.... Okay, stop [pause]. Were you able to stop yourself
from thinking about your anxiety and the possibility of a panic attack?