Cognitive Interventions for Anxiety 181
Pierre developed a number of coping strategies to minimize his anxiety.
Although escape and avoidance were his dominant safety- seeking response
style, he carefully monitored what he ate and drank, would sit at the back of a
gathering and close to an aisle, and he always carried his clonazepam with him
whenever he left home. Pierre’s exaggerated appraisal of threat associated with
nausea was not apparent in other areas of his life. He was an avid ice hockey
player who continued to play goalie on a senior men’s team. Thus he regularly
put himself in harm’s way, stopping pucks and often causing significant injury
or pain to himself. This did not make him the least bit anxious. Instead it was
feeling nausea or abdominal discomfort that was associated with appraisals of
unacceptable threat and danger.
Therapy focused on Pierre’s catastrophic misinterpretation of nausea. In
vivo exposure was of limited value because Pierre was already forcing himself
into anxious situations, although he would often leave whenever he became
concerned with nausea. Interoceptive exposure was not utilized because of the
difficulty in producing nausea sensations in a controlled setting. Instead ther-
apy utilized mainly cognitive intervention strategies that targeted Pierre’s faulty
appraisal of nausea, dysfunctional belief that nausea will lead to panic and vom-
iting, and the belief that escape provided the most effective means of ensuring
safety. Education into the cognitive therapy model of panic, evidence gathering,
generating alternative interpretations, and empirical hypothesis testing were
the primary cognitive intervention strategies employed. After eight sessions,
Pierre reported a significant reduction in panic even with increased exposure
to anxiety- provoking situations. Symptoms of general anxiety showed some
improvement, although to a lesser degree. Therapy continued with a focus on
other issues related to his general level of anxiousness and depressive symptoms
such as low self- confidence and pessimism.In this chapter we describe cognitive therapy for the maladaptive appraisals and
beliefs that contribute to the persistence of anxiety. We begin with the purpose and
main objectives that underlie cognitive interventions. This is followed by a discussion of
how to educate the client into the cognitive model and teach skills in the identification
of automatic anxious thoughts and appraisals. We then describe the use of cognitive
restructuring to modify exaggerated threat and vulnerability appraisals as well as the
need to eliminate intentional thought control responses. Empirical hypothesis testing is
next described as the most potent cognitive intervention strategy for modifying anxious
cognition. The chapter concludes with a brief consideration of some newer cognitive
interventions such as attentional training, metacognitive intervention, imaginal repro-
cessing, mindfulness, and cognitive diffusion that appear promising adjuncts in cogni-
tive therapy of anxiety.
main objeCtives of Cognitive interventionsThe cognitive treatment strategies outlined in this chapter are based on the cognitive
model of anxiety described in Chapter 2 (see Figure 2.1). They are intended to target the
anxious thoughts, appraisals, and beliefs highlighted in the assessment and case concep-
tualization (see Chapter 5). Cognitive interventions seek to shift the client’s perspective
from one of exaggerated danger and personal vulnerability to a perspective of minimal