Cognitive Therapy of Anxiety Disorders

272

From Cognitive Therapy of Anxiety Disorders: Science and Practice by David A. Clark and Aaron T. Beck. Copyright
2010 by The Guilford Press. Permission to photocopy this appendix is granted to purchasers of this book for personal
use only (see copyright page for details).

aPPENDIX 7.5

Chapter 7 Quick Reference Summary: Behavioral Interventions

I. adopt a Cognitive Perspective

1. Rationale—based on Figure 6.1 (client handout of cognitive therapy model), explain use of behavioral
   assignment to examine validity of anxious thoughts and their alternatives.


2. Identify Target Thought—write down the anxious thought challenged by the behavioral exercise.


3. Behavioral Prescription—write out specific instructions on how to do exercise, what thoughts are
   evaluated, and the outcome criteria.


4. Self-Monitoring—client records how the exercise was conducted, its outcome, anxiety level,
   automatic thoughts, evidence for and against target thoughts.


5. Evaluation—extensive evaluation of outcome of exercise; review self-monitoring form; conclusions
   reached about target thought (belief) and its alternative; write out a summary of exercise in form of a
   “coping card.”

II. Graded Exposure

1. For situational exposure, review the Situational Analysis Form (Appendix 5.2) and hierarchically
   arrange anxiety-provoking situations from mildly to intensely anxious.


2. begin with moderately anxious situation; initially demonstrate exposure within session.


3. obtain 0–100 anxiety ratings before exposure, every 10 minutes during exposure, and finally at
   conclusion of the exercise.


4. Assign exposure as homework, at least 30–60 minutes daily. Use Exposure Practice Record
   (Appendix 7.2) to record outcome.


5. Imaginal exposure begins with development of a fear script, within-session demonstration, and then
   30 minutes of daily homework. Audio habituation training should be considered when cognitive
   avoidance is present.


6. Exposure to bodily sensations involves extensive within-session demonstration prior to homework
   assignment. Table 8.8 (panic disorder chapter) provides a description of various interoceptive
   exercises.

III. Response Prevention

1. Identify maladaptive cognitive and behavioral coping strategies or other forms of neutralization
   (see behavioral Responses to Anxiety Checklist, Appendix 5.7, and Cognitive Responses to Anxiety
   Checklist, Appendix 5.9).


2. Provide treatment rationale for response prevention.


3. Instruct client on “blocking strategies” (e.g., self-instructional coping statements, competing
   responses, paradoxical intention, encouragement).


4. Develop alternative coping strategies for anxiety.


5. Challenge problematic cognitions.


6. Record and evaluate success of intervention using the Response Prevention Record (Appendix 7.3).

Iv. Other Behavioral Interventions

1. Direct behavioral change involves teaching specific behaviors that improve personal effectiveness
   through methods of didactic instruction, modeling, behavioral rehearsal, reinforcement, and self-
   monitoring.


2. Relaxation training can be progressive muscle or applied relaxation training; most useful for gAD. A
   rationale for PMR can be found in Chapter 7, pages 260–262. Instructions for 10-muscle PMR are in
   Table 7.5 and an outline for AR is described in Table 7.6. Assign PMR as homework and record daily
   practice on the Weekly Progressive Muscle Relaxation Record (Appendix 7.4).


3. Breathing retraining—Table 8.9 on page 324 (panic disorder chapter) contains diaphragmatic
   breathing retraining protocol.