186 ASSESSMENT AND INTERVENTION STRATEGIES
als (e.g., Craske & Barlow, 2006; D. A. Clark, 2004; D. M. Clark, 1997; Rachman,
2003; Rygh & Sanderson, 2004; Taylor, 2006). In addition, evidence from the social
experimental literature on emotion regulation indicates that cognitive reappraisal as a
coping strategy is associated with greater positive emotion, less negative emotion, and
better psychological health (John & Gross, 2004). Thus our emphasis on the reappraisal
of threat and vulnerability has broad support in the psychotherapeutic and experimen-
tal literature.
Clinical Guideline 6.3
The primary focus of cognitive interventions is the modification of exaggerated estimates
(appraisals) of the probability and severity of threat as well as evaluations of personal vulner-
ability and lack of safety.Normalize Fear and Anxiety
Normalizing anxiety was first discussed by Beck et al. (1985) in their chapter on modi-
fying the affective component of anxiety. At that time normalizing anxiety was high-
lighted as a way to help clients become less self- absorbed in their anxiety symptoms.
There are three aspects of the normalization of anxiety that must be considered.
- Normalizing in relation to others. The actual situations, thoughts, and sensa-
tions that are associated with anxiety should be normalized. Anxious individuals are
often so focused on their own experience of anxiety that they fail to recognize that these
phenomena are almost universal. For example, how often do people experience chest
pain or breathlessness, a concern that they have made a bad impression on others, doubt
over their actions or decisions, uncertainty about the possibility of some accident or
future calamity, or recollections about some frightening experience? The therapist can
ask clients to consider the “normality of threat” and possibly even collect survey data
on whether nonanxious individuals ever experience the anxious threat. The purpose of
this exercise is to shift individuals’ focus away from threat content as the source of their
anxiety to their appraisal of threat as the main contributor to their anxious state. - Normalizing in relation to past experiences. The therapist should explore cli-
ents’ past experience with the situations, thoughts, or sensations that now trigger their
anxiety. “Was there a time when having tightness in your chest didn’t really bother
you?” “Have you always been so concerned about what others think of you?” “Was
there a time when concern about germs was not such a big deal in your life?” By inquir-
ing about their past, clients will be remembering a time when they coped much better
with the perceived threat. Again this shifts the focus from “I am an anxious person” to
“What am I doing now that has made my anxiety so much worse?” - Normalizing in relation to situations. When assessing the situations that trigger
anxiety, the cognitive therapist can also identify other situations that trigger the same
thoughts or sensations but that do not lead to an anxious episode. For example, when
working with panic disorder it is often helpful to inquire whether the client experiences
physical sensations when exercising or engaging in vigorous activity but does not feel