Cognitive Interventions for Anxiety 213
refute the anxious belief and supports the alternative interpretation. Given the over-
whelming empirical evidence for the effectiveness of exposure in fear reduction (see dis-
cussion in Chapter 7), exposure-based hypothesis- testing exercises are a key interven-
tion in cognitive therapy of anxiety. Behavioral experiments should be introduced early
and continued throughout the course of treatment. Often they play a defining role in the
modification of anxious thinking. In fact it is difficult to imagine an effective cognitive
intervention for anxiety that does not include within- and between- session behavioral
exercises. Behavioral exercises can take the form of fairly spontaneous within- session
demonstrations such as asking the client to suppress thoughts of a white bear in order
to illustrate the negative effects of intentional thought suppression. In the following sec-
tion we discuss the critical steps in developing an effective empirical hypothesis- testing
exercise. (See Rouf et al., 2004, for more detailed discussion of how to construct effec-
tive behavioral experiments.)
Step 1. The Rationale
Any empirical hypothesis- testing exercise should be derived from the primary issue of
the therapy session and it should be consistent with the cognitive case formulation. The
cognitive therapist introduces the exercise by providing a rationale. This can be illus-
trated in the following case example. Jodie was a 22-year-old university student who
developed an incapacitating anxiety about attending large lecture-based classes. Her
primary anxious thought was “Everyone in the class notices me and thinks that I don’t
belong in university.” This led to escape (ie., leaving class early) and avoidance (i.e.,
skipping classes) behaviors that were jeopardizing her academic performance. In this
situation the therapist introduced a behavioral experiment by stating:
“So, Jodie, you are sitting in class and feeling very anxious. You have the thought
‘everyone is probably looking at me and thinking she doesn’t belong in university.’
I wonder if we could come up with an experiment or some sort of exercise to test
the accuracy of this thought. I could ask you to try and remember reasons why
you think this interpretation might be true or false, but the most accurate way to
find out is to collect information on site. The very best way to test out this anxious
thought is to collect information on it while you are in the classroom. We all learn
so much more from our own experiences than we do from listening to teachers or
even therapists for that matter. In fact homework exercises such as this have been
shown to be one of the most important ingredients for reducing anxiety. Not only
does it give you an opportunity to test the anxious thinking, but it also provides
an opportunity for you to directly work on the anxiety. Would you like to work
together on constructing an exercise that would test out this anxious thought?”Step 2. Statement of Threat Appraisal and Its Alternative
Assuming collaboration has been established with the client, the next step is to state the
threat appraisal and its alternative. The Empirical Hypothesis- Testing Form in Appen-
dix 6.5 can be used to formulate the behavioral experiment and collect the outcome
data. A clear, specific statement of the threat interpretation (i.e., anxious thought or
belief) targeted by the exercise is essential for an effective behavioral experiment. The