Cognitive Interventions for Anxiety 225
3-month follow-up. Twohig, Hayes, and Masuda (2006) utilized a multiple- baseline,
across- participant research design involving eight weekly 1-hour sessions of ACT to
demonstrate treatment effectiveness in four individuals with OCD. However, a recent
meta- analysis of various “third wave” therapies, including ACT, concluded that their
mean effect sizes were only moderate, the outcome studies lacked the methodological
rigor seen in CBT, and so they fail to meet criteria for empirically supported treatments
(Öst, 2008). It may be that a greater focus on training the anxious person to adopt a
nonevaluative, benign acceptance and distancing perspective on anxious thinking has
clinical utility in the treatment of the anxiety disorders, but this conclusion must await
the results of more rigorous treatment outcome research.
Clinician Guideline 6.15
Attentional training may be used to interrupt heightened self- focused attention, whereas
cognitive restructuring strategies can be redirected toward modification of faulty metacog-
nitive processes and thought control strategies. Imaginal reprocessing and expressive writ-
ing may be helpful in modifying memories of past traumatic experiences or imagined future
catastrophes, whereas mindfulness and cognitive diffusion derived from ACT may be used
to teach clients a more detached, nonevaluative approach to anxious cognitions. Although
promising, these approaches lack the strong clinical and empirical base of standard cogni-
tive interventions for anxiety.summary anD ConClusionModification of the exaggerated appraisals of threat, vulnerability, and safety seeking is
the primary objective of cognitive therapy for anxiety disorders. This chapter presented
the main cognitive strategies that comprise cognitive treatment protocols developed for
the specific anxiety disorders. These strategies are entirely consistent with the cognitive
model of anxiety (see Figure 2.1) and they target the aberrant cognitions identified in
the case formulation.
The goal of any cognitive intervention is deactivation of the hypervalent threat
schemas and heightened activation of more adaptive and realistic beliefs about threat
and perceived ability to cope with one’s anxious concerns. This is achieved by shifting
the client’s focus away from threat content and onto the faulty appraisals and beliefs
that are the basis of the anxious state. Exaggerated appraisals of the probability and
seriousness of threat are targeted as well as the heightened evaluations of personal vul-
nerability and need to seek safety. Cognitive interventions also seek to increase personal
self- efficacy for dealing with anxiety by normalizing the fear response and fostering a
more adaptive perspective on the balance between risk and safety.
A detailed description was provided on how to implement the main cognitive strate-
gies that define this treatment approach to anxiety. Educating the client into the cogni-
tive model of anxiety is an important first step in establishing therapeutic collaboration
and compliance with treatment. Teaching self- monitoring skills in the identification of
automatic anxious thoughts and appraisals, though critical to the success of cognitive