Generalized Anxiety Disorder 437
argue that a present- moment focus of attention is an effective antidote to worry. Since
anxiety is always anticipatory, there can be no anxiety in the present moment.
Learning to live in the present moment is a challenging task for individuals who
are chronically stuck in the threatening, hypothetical (i.e., “what if”) future. Bork-
ovec et al. (2004) propose a three-stage approach. First, clients are educated that their
negative predictions about the future are usually inaccurate and they practice replac-
ing these predictions with more realistic alternatives. Next, individuals are taught that
no prediction can accurately predict the future and individuals are encouraged to live
an “expectancy-free life.” After clients have become more focused on the present, the
final stage involves teaching them how to construct meaning of the present moment.
This involves focusing on special features of the moment with particular emphasis on
how this connects to the client’s values and happiness in the moment. This elaborative
processing of the present is similar to more recent developments in mindfulness-based
cognitive therapy which emphasize meditative focus on a present activity such as the
breath, observing one’s negative thoughts in a passive, nonjudgmental manner, and
developing acceptance of all thoughts as “just thoughts” and not facts or some aspect
of reality (Segal et al., 2002; Williams, Teasdale, Segal, & Kabat-Zinn, 2007). Whether
interventions for chronic worry place greater emphasis on cognitive restructuring of
worry beliefs and appraisals, or mindfulness-based cognitive therapy, the goal of all
treatment should be to redirect the individual with GAD from a preoccupation with
controlling hypothetical future threats to a greater focus on and appreciation for one’s
present experience.
Clinician Guideline 10.26
An important outcome in cognitive therapy of GAD is to redirect the client’s preoccupation
with possible future- oriented threats to greater appreciation of the present moment in daily
living.Relaxation Training (Optional)
Many cognitive- behavioral programs for GAD still emphasize that training in applied
relaxation is an important intervention for GAD (e.g., Borkovec et al., 2004; Craske
& Barlow, 2006; Rygh & Sanderson, 2004). However, relaxation training is only used
occasionally in cognitive therapy of GAD. It might be offered to individuals who expe-
rience unusually intense somatic anxiety or those who find it difficult to focus on their
cognitions because of heightened anxiety. In this case a course of applied relaxation
might be offered before undertaking direct interventions for pathological worry. Chap-
ter 7 provides a detailed description and implementation for progressive muscle relax-
ation (see Table 7.5) and the applied relaxation treatment protocol (see Table 7.6). More-
over, there is evidence that applied relaxation is an effective treatment for GAD in its
own right (e.g., Arntz, 2003; Borkovec et al., 2002; Öst & Breitholtz, 2000), although
there is considerable variability across studies (Fisher, 2006). Also, there is little evi-
dence that relaxation therapy is effective because it reduces muscle tension (Conrad &
Roth, 2007). Nevertheless, applied relaxation is a credible treatment option available to
the cognitive therapist.