480 TREATMENT OF SPECIFIC ANXIETY DISORDERS
vention can be employed. Clients can be asked to recall a time when they were certain of
an action they took or a decision they made and the amount of extra time and effort that
was required to attain a “feeling of certainty.” Then they can be asked to recall a time
when they took an action or decision even in the face of some uncertainty. Compare the
outcome of each action or decision and examine the costs and benefits of the extra time
expended to reach a higher level of certainty. Was it worth it in the long run? The same
type of cognitive intervention can be used with perfectionism beliefs in which clients can
be asked to rate how perfectly they performed some task, the consequences of their less-
than- perfect performance, and whether the extra resources needed to push performance
that extra 10 or 20% was worth the effort or not. The negative consequences of striving
for perfectionism can also be assigned as homework.
Particular attention should be given to appraisals and beliefs of need to control
the obsession and failure to attain complete control. Clients can be encouraged to
experiment with different levels of effort to control the obsession and record the conse-
quences associated with these varying efforts. “What happens to anxiety and frequency
of obsession if compulsions, neutralization, or other control strategies are delayed or
blocked altogether?” “What are the costs and benefits of expending greater or lesser
effort at control of the obsession?” “What’s the worst that can happen if you let go of
control over the obsession?” One can start with encouraging short periods of “no con-
trol” (delay control efforts for a few minutes) and gradually increase the delay periods
to hours or even days. To maximize the cognitive impact of these exercises, clients are
asked to record the consequences of their efforts. This material is thoroughly examined
in subsequent therapy sessions as support for or against the faulty beliefs about con-
trol of the obsession. A decatastrophizing intervention can be used for the secondary
appraisals of control failure. Clients can be asked to describe the worst possible out-
come they could imagine if they lost complete mental control over the obsession. “What
would their lives be like?” “How could they cope if the obsession never faded from
conscious awareness?” The therapist and client could together develop a contingency
plan if she experienced a complete failure in mental control. The client could also survey
family and friends on their tolerance of mental control failures. In fact the client could
be asked to monitor times of mental control failure with nonobsessional thoughts. Cli-
ents may discover that they have less control than they assumed and are more tolerant
of imperfect mental control when it involves nonobsessional thoughts.
Evidence gathering and cost– benefit analysis were used to challenge a number of
Richard’s beliefs about the significant threat posed by the back rash obsession and the
need to attain better control over the obsession so its anxiety- provoking properties
could be neutralized. For example, Richard was asked to take a photograph of his lower
back and then compare it to pictures of other men’s lower back to see if he exagger-
ated the red spot on his back (i.e., overestimated threat appraisal). In another cognitive
restructuring exercise we compared Richard’s appraisals of threat, importance, and sig-
nificance for the thought “What if someone sees my lower back rash?” (i.e., the anxious
obsession) to the thought “What if someone noticed nasal mucus hanging from my
nose?” (i.e., a nonanxious neutral thought). Even though the latter thought was associ-
ated with a much higher realistic probability of social disgust and embarrassment, it
caused no anxiety because of how it was appraised. Richard was able to see that it was
his faulty appraisals of significance that caused his anxiety and preoccupation with the
rash. Finally, evidence gathering was used to challenge (1) Richard’s imagined danger