Cognitive Therapy of Anxiety Disorders

Behavioral Interventions 235

check her appearance in the mirror and seek reassurance from family members

on whether she looked neat and tidy. She was convinced that if she looked per-

fect, people would think she was competent and this would make her feel more

confident and less anxious. When she started to feel panicky around others,

Maria would engage in an exaggerated form of controlled breathing that was so

extreme that others could not help but notice an unusual breathing pattern that

bordered on hyperventilation. She was also so internally focused on her anxi-

ety that she had difficulty maintaining a conversation. She engaged in extensive

postevent processing in which she would spend considerable time ruminating

about her performance in a social situation. In the end she performed poorly

in social encounters because of her heightened anxiety, panic, and preoccupa-

tion. This daily battle against anxiety and perceived social incompetence left

Maria feeling hopeless and pessimistic, drained of all self- confidence and sense

of self-worth.

This case provides a good illustration of the importance of behavior change in
alleviating anxiety disorders. Avoidance, compulsive checking, reassurance seeking,
hyperventilation, and social skills deficits were just some of the maladaptive behav-
ioral responses that actually contributed to the persistence of Maria’s social anxiety. It
was clear from the case formulation that an effective cognitive intervention must focus
on behavioral change. Graded exposure, behavioral experimentation, and social skills
training through use of videotaped feedback and role plays would be critical therapeutic
ingredients in her treatment plan.
In this chapter we discuss the role of behavioral interventions in cognitive therapy
for anxiety disorders. We begin by considering the importance of behavioral strate-
gies in cognitive therapy of anxiety and how these interventions are restructured to
facilitate change in anxious thoughts and beliefs. Attention is then turned to exposure
as the single most effective intervention for therapeutic change across the anxiety dis-
orders. General guidelines and procedures for implementing exposure-based treatment
are considered along with its three main areas of focus: situations, imagery, and physi-
cal sensations. We then consider the importance of response prevention in eliminating
maladaptive safety seeking and other forms of ineffective coping responses. Relaxation
and breathing retraining are discussed as possible supplementary elements of cognitive
therapy for anxiety.

importanCe of behavioral intervention

Given the prominence of escape and avoidance responses in most forms of pathologi-
cal anxiety, it is not surprising that behavioral change is a critical aspect of cognitive
therapy for anxiety. Beck et al. (1985, 2005) devoted an entire chapter to behavioral
strategies and behavioral change is emphasized in CBT protocols for specific anxiety
disorders like panic (D. M. Clark, 1997; Craske & Barlow, 2001), social phobia (D. M.
Clark, 2001; Rapee & Heimberg, 1997), OCD (D. A. Clark, 2004; Rachman, 2006;
Salkovskis, 1999; Salkovskis & Wahl, 2003), and PTSD (Ehlers & Clark, 2000; Tay-
lor, 2006). In addition, empirical research indicates that behavioral interventions like
exposure and response prevention have their own direct significant effects on reducing