128 ASSESSMENT AND INTERVENTION STRATEGIES
Assessment and case formulation stand as a bridge between cognitive theory and
treatment. Since its earliest inception cognitive therapy has emphasized the importance
of theory- guided assessment as the foundation for effective psychotherapy. In the first
published cognitive therapy manual, Beck, Rush, Shaw, and Emery (1979) emphasized
that diagnostic formulation, establishing treatment goals, educating the client into the
cognitive model, and selecting target symptoms were critical elements in treatment for
depression.
The tools of assessment and case formulation that are now available to the cogni-
tive therapist are much more precise than those available in the early years of cognitive
therapy. For example J. S. Beck (1995, 2005) developed a more detailed and refined
cognitive case conceptualization scheme that can be applied to the anxiety disorders.
She argues for the importance of conceptualization as a guide for focusing therapy on
the critical problems and processes that underlie a psychological disturbance. Often
treatment failure in difficult cases can be traced to a misguided or incomplete case
conceptualization (J. S. Beck, 2005). Persons and colleagues (Persons, 1989; Persons
& Davidson, 2001) provided one of the most comprehensive models for case formula-
tion, emphasizing its individualized, theory- driven, and hypothesis- generating nature.
Cognitive- behavioral treatment protocols for specific anxiety disorders like panic (S.
Taylor, 2000), social phobia (Elting & Hope, 1995), GAD (Turk, Heimberg, & Mennin,
2004; Wells, 1997) and OCD (D. A. Clark, 2004) again emphasize the important role
played by cognitive assessment and case formulation.
In this chapter we present a case formulation scheme for anxiety based on the cog-
nitive model (see Figure 2.1). A general framework for cognitive case conceptualization
is described that can be applied to all anxiety disorders. Precise applications of this case
conceptualization scheme will be considered within the disorder- specific chapters. The
first section of the chapter reviews diagnostic and general anxiety symptom measures
that are an important assessment tool in cognitive therapy of anxiety. This will be fol-
lowed by a discussion of the assessment of immediate fear activation (Phase I) and its
sequelae. A third section focuses on assessment of secondary, elaborative processes that
lead to a reappraisal of threat and personal vulnerability. The chapter concludes with a
case illustration of cognitive formulation of anxiety and a consideration of difficulties
that can arise at this stage of treatment.
DiagnostiC anD symptom assessmentThe first two or three contact sessions should focus on assessment that leads to a pre-
liminary case formulation. Figure 5.1 illustrates a three- pronged approach to assessment
that will be present during the initial phase of cognitive therapy for anxiety.
Diagnostic Interviews
The diagnostic interview has always played an important role in cognitive therapy. Beck
et al. (1979) argued that a complete diagnostic evaluation is essential for establishing
symptom targets and treatment planning. Although clinicians are divided on the impor-
tance of differential diagnosis in psychotherapy, there is no debate that critical clinical