Generalized Anxiety Disorder 4 31
Th e r a p i sT: That sounds really terrible, but is there anything beyond this that worries
you?
cL a r e: No, that’s bad enough isn’t it?
Th e r a p i sT: Sure is! So for you, Clare, the worst catastrophe you can imagine about can-
cer is that you will end up alone, depressed, and with a disgusting body. Can you
actually imagine yourself in that state, can you form a picture of it in your mind?
cL a r e: Yes, I have an actual image of how I would look and feel as a cancer survivor.
The cognitive therapist recorded in detail Clare’s image of herself as a cancer sur-
vivor. He then developed with her a decatastrophized script: how she might more real-
istically cope with breast cancer. This was based on the experiences of two women
Clare knew who had breast cancer. The therapist then had Clare engage in 10 minutes
of worry induction about cancer, ensuring that at least half of the induction time was
spent imagining that she had treatment for breast cancer and was looking at herself in
the mirror. This also included her husband’s negative reaction to the effects of her treat-
ment and her own feelings of despair. This was followed by imagining how she would
realistically cope as a breast cancer survivor using the decatastrophizing script as her
reference.
Clinician Guideline 10.20
To enhance worry control and to decatastrophize worry threat, a worry induction exercise is
employed that utilizes catastrophizing and decatastrophizing scripts to encourage exposure
to individuals’ most feared outcomes.Repeated Worry Expression
Worry exposure (or expression) has become an important component of cognitive
behavioral treatments for GAD (e.g., Borkovec et al., 2004; Craske & Barlow, 2006;
Rygh & Sanderson, 2004; Wells, 1997). The concept is based on a stimulus control
treatment procedure first described by Borkovec, Wilkinson, Folenshire, and Lerman
(1983). Individuals initially identified their worrisome thoughts and then established a
standard 30-minute period each day when they engaged in worry. If individuals caught
themselves worrying any other time of the day, they were to postpone their worrying for
the worry period by attending to their present- moment experience. During the worry
period, individuals were to engage in problem solving to eliminate their worry concerns.
Borkovec et al. (2004) viewed stimulus control treatment as a type of response preven-
tion in which worriers learn to gradually restrict their worry to a more limited range of
discriminative cues (i.e., to worry only during a specified time and location).
Over the years various modifications and refinements have been introduced to
worry exposure. In cognitive therapy repeated worry exposure is a behavioral experi-
ment that (1) challenges metacognitive beliefs that worry is dangerous and uncontrolla-
ble, (2) counters avoidance of the worry catastrophe, (3) prevents suppression and other
ineffective worry control strategies, and (4) increases clients’ confidence in their ability
to deal with worry concerns. The goal of worry exposure is for the client to experience