Cognitive Interventions for Anxiety 197
ing whether subtle forms of avoidance and safety seeking have an effect on her anxiety
level. A client with OCD could be asked to try hard to suppress an anxious obsession on
one day and then relinquish control efforts on an alternative day and record the effects
of trying to control anxiety. A person with panic disorder could be asked to record the
effects of thinking about a heart attack when his chest feels tight versus thinking that it
is muscle strain. Notice that all of these assignments focus more on highlighting some
aspect of the cognitive model in the client’s experience of anxiety rather than directly
modifying thoughts or behavior.
Bibliotherapy is an important method of educating the client into the cognitive
model. We are currently in the process of writing a client workbook based on the pres-
ent volume that will provide explanations and case examples useful for educating clients
into the cognitive therapy perspective on anxiety. A number of other excellent self-help
manuals have been published as well on cognitive therapy or CBT for anxiety disorders
that can be given to clients as assigned reading. Appendix 6.1 presents a selected list of
self-help manuals that are consistent with the cognitive model. Often clients are even
more accepting of cognitive therapy after reading published accounts because it provides
external validation that cognitive therapy is a well established and widely recognized
treatment for anxiety.
Clinician Guideline 6.7
In the initial sessions of cognitive therapy, focus on educating the client into the cognitive
model of anxiety and providing a rationale for treatment. Describe clinical anxiety as an
automatic affective response to inappropriate fear activation that overtakes one’s mental
operating system. The goal of cognitive therapy is to deactivate, or “turn off,” the fear pro-
gram through deliberate and effortful changes in how we think and respond to anxiety. Edu-
cate clients into the cognitive model not by minilectures but by emphasizing its applicability
to their personal experience of anxiety.Self- Monitoring and the Identification of Anxious Thoughts
Teaching clients how to catch their anxious thoughts has been a central ingredient in
cognitive therapy for anxiety since its inception (Beck et al., 1985). And yet this is one of
the hardest skills for clients to master. The reason is that anxious thinking can be very
difficult to recall when the person is in a nonanxious state. However, when individuals
are highly anxious, they can be so overwhelmed with anxiety that any attempt to record
anxious thinking is practically impossible. Moreover, it is during periods of intense
anxiety that the person is most likely to exhibit the exaggerated estimates of threat
probability and severity that are the core cognitive basis of anxiety (Rachman, 2006).
Thus in cognitive therapy for anxiety considerable effort is focused on training in self-
monitoring automatic anxious thoughts. Rachman (2006) also notes that it is important
to identify the current threat that maintains anxiety. Daily diaries and self- monitoring
of anxiety will play a critical role in identifying the perceived threat in everyday life.
There are two ways to introduce anxious clients to thought recording. First, have cli-
ents focus on writing down anxiety- provoking situations, rating their anxiety level, and
noting any primary physical symptoms and any behavioral responses. These aspects of