432 TREATMENT OF SPECIFIC ANXIETY DISORDERS
worry and its images as hypothetical possibilities rather than as realistic representations
of actual threats to well-being (Rygh & Sanderson, 2004). Appendix 10.2 provides a
Worry Exposure Form that can be used when individuals engage in worry exposure
homework.
Individuals are given instructions in worry expression prior to its assignment as
homework. Clients are instructed to set aside the same 30-minute period in a specified
location of their home and to engage in a prolonged period of imagining the worst out-
come (i.e., catastrophe) to a single primary worry theme. They should keep their atten-
tion focused on the catastrophe “and to think about it or imagine it with as much detail
and vividness as possible.” They should not try to problem-solve or decatastrophize the
worry but simply concentrate on it as fully as possible. If their mind wonders off the
worry topic, try to pull it back to the worry as quickly as possible. Clients are encouraged
to use the catastrophe script to help them focus on the worry. After each worry exposure,
the Worry Exposure Form (Appendix 10.2) should be completed. Particular attention
should be given to recording the quality of the catastrophe exposure and any anxious
thoughts about engaging in the worry exercise. The client should write down challenges
to the anxious thoughts that will encourage more repetition of the worry sessions. If
worry occurs during some other time of the day, individuals are to postpone the worry
until the worry exposure session. This can be accomplished by writing down the worry
content on the Worry Self- Monitoring Form B (Appendix 10.1) as a reminder for the
worry exposure session and then focus attention on some aspect of their present- moment
experience. Individuals with GAD must be told that it will take daily practice sessions of
worry exposure over 2 to 3 weeks before the benefits of this intervention may be felt.
Clinician Guideline 10.21
Repeated exposure to the catastrophic worry outcome is an important behavioral experi-
ment in cognitive therapy of GAD. It challenges individuals’ maladaptive beliefs about the
dangers and uncontrollability of worry and prevents the use of ineffective worry control
strategies.Safety Cue Processing
Chronic worriers become so focused on threat and uncertainty during the worry pro-
cess that they often fail to process positive, safe, or benign aspects of a worry situation.
Thus the cognitive therapist takes every opportunity while assessing aspects of worry or
employing cognitive restructuring to explore the positive or safety aspects of situations.
Individuals are encouraged to write down aspects of a worry situation that are positive
or safe as a counter to their automatic threat and danger interpretations. The purpose of
this intervention is to help individuals develop a more balanced, realistic perspective on
the worry. Sometimes there may be one or two primary safety cues associated with the
worry, whereas at other times there may be multiple indicators of safety that are evident
throughout the worry process.
In our previous example Clare had suffered from chronic worry about cancer. After
generating the catastrophic scenario, the cognitive therapist helped Clare think about
the possible positive or safety aspects of her cancer worry.