428 TREATMENT OF SPECIFIC ANXIETY DISORDERS
for her store. She managed a highly successful store and consistently made her monthly
sales goals. However, this could change quickly with fluctuations in the economy and
yet Rebecca rarely worried about her sales figures. On the other hand, she did worry
excessively about whether her employees considered her a competent and resourceful
manager or whether they considered her weak and easy to manipulate. This latter worry
met most of the criteria of pathological worry and so became the focus of our therapy
sessions.
Clinician Guideline 10.18
Within the first couple of sessions teach individuals with GAD how to distinguish their real-
istic or productive worry from chronic, excessive, and pathological worry.Cognitive Restructuring of Threat Appraisals
Cognitive restructuring is an important therapeutic element of cognitive therapy for
GAD. The cognitive therapist begins by identifying the threat- related thoughts and
beliefs represented in the primary worry concern. Ratings are made on the perceived
likelihood that the threat (i.e., worst possible outcome) could actually occur in real life.
The therapist uses evidence gathering to determine whether the client’s threat estimation
is realistic or exaggerated (see Chapter 6). Appendix 6.2, Testing Anxious Appraisals:
Looking for Evidence, can be employed to facilitate the evidence- gathering exercise. It is
important to focus on gathering evidence that the client is exaggerating threat when she
worries rather than on trying to prove that the worry threat could never happen. The
latter is a misguided focus on worry content that will only fail to produce therapeutic
effects. After completing evidence gathering, the client is asked to generate an alterna-
tive view on the worry topic that represents a more realistic probable outcome. The
therapist can follow this with a cost– benefit analysis (see Appendix 6.3) to reinforce the
advantages of the alternative interpretation.
Naturally, it is important to follow cognitive restructuring with a homework assign-
ment. For example, whenever the client started to worry, he could record his estimate of
the worst outcome and the more realistic alternative outcome. He could then generate
a list of reasons why thinking the worst is an exaggerated and unrealistic estimate of
threat and reasons why the alternative outcome is a more likely outcome. An empirical
hypothesis- testing exercise could also be assigned to determine if “thinking the worst”
is an exaggeration of threat. The client could be asked to intentionally seek out evidence
that refutes his worry- related automatic threat estimate. When treating worry, the focus
of cognitive restructuring must be on the threat appraisal and not the worry content.
The objective is teach individuals with GAD how to catch themselves exaggerating the
threat (“thinking that the worst is likely to happen”) and to replace it with a less exag-
gerated negative outcome that is more realistic.
Cognitive restructuring of worry- related threat estimation was employed with
Rebecca. The catastrophic outcome associated with her primary work- related worry
was “I haven’t been assertive enough with my staff when problems arise. They will loose
respect for me and then I will fail as store manager.” She rated the likelihood of this out-
come as high, 85/100. There was very little evidence for this feared outcome except that