Behavioral Interventions 255
Develop Alternative Coping Responses
The adaptive alternative that is promoted in cognitive therapy is continued exposure to
the fear stimulus. Any coping responses that encourage the client to wait for anxiety
to dissipate naturally is considered an adaptive approach. For example, a client with a
long- standing panic disorder was very terrified of panic attacks. The core belief was she
might lose control and eventually go insane. Any signs of anxiety, especially trembling,
shaking, or crying, were misinterpreted as loss of control. She responded by tensing her
muscles, distracting herself, and trying to suppress her anxious feelings. To counter these
futile attempts at anxiety control, a form of paradoxical response prevention was for-
mulated. Whenever she noticed the first signs of anxiety, she was to go to her bedroom,
stand before a full- length mirror, and purposefully shake and cry as hard as possible.
She was to watch herself do this in the mirror until her anxiety level dropped signifi-
cantly. This plan for coping with anxious episodes served several functions. It encour-
aged direct exposure to the physical symptoms that frightened her. It also blocked her
maladaptive coping responses and it usually ended with a good laugh, which initiated
an emotional state contrary to anxiety. In sum, effective response prevention should not
only specify the safety- seeking responses that should be blocked or suppressed, but also
alternative ways of responding that promote adaptive exposure.
Challenge Problematic Cognitions
The cognitive therapist is always attentive to any faulty thoughts or beliefs that might
lead to continued reliance on safety- seeking responses and undermine response preven-
tion. This can be done by questioning clients on their automatic thoughts about per-
ceived need to avoid or control anxiety as well as by examining self- monitoring records
for maladaptive safety- seeking cognitions that occurred during exposure assignments.
Once such thinking is identified, cognitive restructuring can be employed to modify the
anxious appraisals and beliefs (see Chapter 6).
Certain themes are common in the automatic thoughts and beliefs that maintain
safety seeking and interfere with response prevention. These include an intolerance of
anxiety and uncertainty, a need to maintain control, the importance of minimizing risk,
and the maintenance of safety and security. Individuals with anxiety will often express
beliefs like “I can’t stand the anxiety,” “I need to be certain that I haven’t left the stove
burners on and could cause a fire,” “If I don’t maintain strict control over my emotions,
people will notice there is something wrong with me,” “I can’t stand to take risks; it’s
better to be safe than sorry,” “The more I feel peace and comfort the better my physical
and mental health,” or “If I look perfect, I can avoid the negative evaluation of familiar
people [Maria].” In many cases response prevention of maladaptive coping and safety
seeking will not be accepted as long as the anxious person endorses this way of think-
ing. Thus the cognitive therapist should probe for problematic cognitions whenever cli-
ents fail to follow through on response prevention.
Record and Evaluate
As with any intervention, it is essential that clients maintain some record of their response
prevention efforts between sessions. The Response Prevention Record in Appendix 7.3