424 TREATMENT OF SPECIFIC ANXIETY DISORDERS
her personality and something she could not change: “She had always been a shy person,
an introvert” (vulnerability belief). When she received no response on how she handled
a difficult employee situation, she would seek out feedback from her assistant managers,
believing that she could not stand the uncertainty of not knowing whether she was too
assertive or too passive (intolerance of uncertainty belief). On the one hand, she believed
the worry was detrimental to her work performance because she was always trying to
“second guess herself,” but on the other hand, she felt that the heightened vigilance
prevented her from getting into nasty arguments with employees (metacognitive beliefs).
Obviously the primary goal of cognitive therapy for GAD is to modify these core dys-
functional beliefs that underlie the pathological worry process.
Clinician Guideline 10.16
A cognitive case conceptualization of GAD will include the following elements: (1) descrip-
tion of the primary worry concerns, (2) specification of current life goals and personal striv-
ings, (3) list of internal and external triggers of worry, (4) identification of metacognitive
appraisals of each worry concern, (5) description of the idiosyncratic worry control pro-
file, (6) extent of safety search and negative problem orientation, and (7) formulation of the
underlying schematic organization responsible for chronic worry and generalized anxiety.DesCription of Cognitive therapy for gaDThe overarching goal of cognitive therapy for GAD is reduction in the frequency, inten-
sity, and duration of worry episodes that would lead to an associated decrease in auto-
matic anxious intrusive thoughts and generalized anxiety. This will be achieved by
modifying the dysfunctional appraisals and beliefs as well as the maladaptive control
strategies that are responsible for chronic worry. A successful trial of cognitive therapy
would transform worry from a pathological avoidant coping strategy to a more con-
trolled, problem- oriented constructive process in which the anxious person is more tol-
erant and accepting of risk and uncertainty. The cognitive perspective is expressed by a
number of specific treatment goals that are presented in Table 10.4.
To achieve the stated goals of cognitive therapy for GAD, a typical course of therapy
will include a number of intervention strategies that will be variably employed depend-
ing on the individual case. Table 10.5 summarizes the treatment components of cogni-
tive therapy.
Education Phase
The objective of the first session is to introduce clients to the cognitive model of GAD as
well as the treatment rationale. Most individuals with GAD have suffered with excessive
worry for many years. As a result they will enter therapy with their own beliefs about
why they struggle with pathological worry and possibly some ideas on how it should
be treated. The cognitive therapist should start by asking, “Why do you think you have
struggled so with worry?” Individuals with GAD might give a variety of answers such as
“It’s my personality, I’ve always been a worrier,” “Worry runs in my family,” “I have a