Cognitive Interventions for Anxiety 183
tive in cognitive therapy, then, is to shift the client’s focus from threat content to how
they appraise or evaluate threat. For cognitive therapy to be effective, the client must
accept the cognitive model (i.e., treatment rationale) that their anxiety arises from their
faulty thoughts, beliefs, and appraisals of threat rather than from the threat content
itself.
This approach to anxiety recognizes that individuals with an anxiety disorder often
fail to adopt a rational, realistic appraisal of the dangers related to their anxious con-
cerns, especially during anxious states. In fact anxious individuals often recognize that
a danger is highly unlikely, or even impossible. However, the problem is that they will
appraise even a remote danger (1/1,000,000,000) as an unacceptable risk. Thus the
cognitive therapist must focus on the thoughts, appraisals, and beliefs about threat (e.g.,
feelings of nausea) and vulnerability rather than threat content per se. The following is a
clinical vignette that illustrates how this shift in therapeutic orientation can be achieved
with a person suffering from social phobia:
Th e r a p i sT: Looking over your diary, I see that you were especially anxious in a meeting
you had with work colleagues last week.
cL i e nT: Yes, the anxiety was really intense. I was so scared someone would ask me a
question.
Th e r a p i sT: What would be so bad about that?
cL i e nT: I’m afraid I would say something stupid and everyone would think I’m an
idiot.
Th e r a p i sT: What do you think was making you anxious about the meeting?
cL i e nT: Well I was anxious because I could be asked a question and then I would say
something stupid and everyone would think badly of me. [focus on threat content]
Th e r a p i sT: It sounds like you certainly had anxious thoughts like “what if I’m asked a
question” and “what if I say something stupid.” Do you suppose other people who
do not have social anxiety also have these same thoughts from time to time?
cL i e nT: Well, I suppose they do but I feel so anxious and they don’t.
Th e r a p i sT: True, that is an important difference. But I wonder if this difference is
caused by how you evaluate these thoughts when you have them and how a nonanx-
ious person evaluates the thoughts when she has them about a work meeting.
cL i e nT: I’m not sure I understand what you mean.
Th e r a p i sT: When you think “I could be asked a question” and “I could say something
stupid,” how likely do you think this is and what do you think could be a conse-
quence or outcome?
cL i e nT: When I’m anxious I tend to be entirely convinced I’m going to say something
stupid and that everyone will think I’m an idiot.
Th e r a p i sT: So when you have these anxious thoughts you evaluate the probability that
it will happen as very high (“you will say something stupid”) and that terrible conse-
quences will result (“everyone will think I’m an idiot”). Do you suppose this might
be the source of your anxiety, that it is these appraisals of high probability and seri-
ous consequences that are making you anxious? [focus on appraisals of threat]