14 0 ASSESSMENT AND INTERVENTION STRATEGIES
Elements of a Complete Situational Analysis
A thorough situational analysis should consist of the following elements:
••Detailed description of multiple situations or triggers
••Intensity of associated anxiety
••Frequency and duration of exposure to situation/trigger
••Presence of escape, avoidance responses
••Specific eliciting cuesA detailed description of each situation or trigger is needed. Subtle changes in con-
text can alter the intensity of anxiety. For example, a patient with panic disorder might
report little anxiety driving to work on a very familiar route. However, vary the route
by one new street, and anxiety level might change dramatically. The proximity of a
safety signal will also influence anxiety (e.g., presence of a trusted friend or distance
from a medical facility). It may be that a particular situation (e.g., interacting with
work colleagues) needs to be broken down into finer gradients in order to understand
its anxiety- eliciting properties. The cognitive therapist should have enough detail about
each anxiety- provoking situation or trigger so that accurate exposure assignments can
be constructed.
It is important to know the intensity of anxiety felt in each situation since the thera-
pist should have a range of situations or triggers that elicit mild to severe anxiety states.
Some clients require considerable practice using the 0–100 rating scale to gauge their
anxiety level, especially if they tend to engage in dichotomous thinking (e.g., they feel
intensely anxious or not anxious at all). These ratings, however, are needed to develop
an effective treatment plan.
The therapist must determine how often the person experiences an anxiety-
provoking situation and the duration of his or her exposure to the situation. Anxiety-
provoking situations that occur regularly in the person’s daily life will be more helpful
for treatment than rare or exceptional occasions. For example, daily social interactions
with work colleagues that trigger anxiety in someone with social phobia will be much
more important to treatment than a situation such as giving a speech that may rarely
occur in the person’s life. Also, does the provoking situation involve brief or prolonged
exposure when the person encounters the circumstance? Again anxiety- provoking situ-
ations that involve longer exposure intervals (e.g., using a public washroom) will be
more useful in treatment planning than triggers involving brief exposure (e.g., touching
a public telephone as you walk by it).
The cognitive therapist should also obtain information on the extent that each situ-
ation is associated with escape or avoidance. Clients should be asked if they always try
to avoid the situation or escape from the situation as quickly as possible. At this assess-
ment stage the therapist should have a good understanding of how well the client toler-
ates anxiety in each provoking situation. If the situation is avoided on some occasions
but not others, what determines the presence or absence of avoidance? Does this depend
on the person’s mood state or some subtle characteristic of the situation? Information on
escape and avoidance will be critical in planning an exposure hierarchy.
Finally, the cognitive therapist should determine whether there are specific cues or
stimuli in a situation that are first noticed by the anxious individual. For example, when