Cognitive Assessment and Case Formulation 14 3
It is important that the first apprehensive thought be recorded in the person’s own words
and not reflect the therapist’s own suggestions. The therapist might probe for a cer-
tain type of thought content, but its actual expression should reflect the idiosyncratic
concerns of the client. This will ensure that the apprehensive thought content is highly
relevant to the specific anxious concerns of the client.
It is also important to remember that even in the same anxiety- provoking situa-
tion, people will differ in the focus of their apprehension and so it is important for the
therapist to discover each client’s unique anxious apprehension. As an example, a client
reports intense anxiety about going to a meeting with work colleagues. The first appre-
hensive thought could be any of the following possibilities:
••“What if I’m asked a question in the meeting that I can’t answer? Everyone will
think I’m incompetent.” (performance evaluation cognition)
••“What if I have to say something and everyone stares at me? This makes me so
nervous.” (social evaluation cognition)
••“What if my voice trembles when I speak? Everyone will know that I am nervous
and wonder what’s wrong with me.” (social phobia cognition)
••“What if I have a panic attack in the meeting?” (panic disorder cognition)
••“What if I accidentally blurt out an insulting remark?” (OCD cognition)
••“What if I’m not supposed to be at this meeting and everyone wonders why I am
there?” (interpersonal acceptance cognition)
••“What if I feel nauseated in the meeting and have to run out and vomit?” (cogni-
tion about specific fear of vomiting)
••“I never really know what to say in these meetings and how to chit-chat with oth-
ers; I really hate this.” (social skills deficit cognition)As can be seen from this example, there are a large number of possible apprehensive
thoughts triggered by any anxiety- provoking situation. The purpose of the cognitive
assessment is to identify the anxious thought content that is unique to each client.
Self- monitoring homework tasks must be assigned in order to obtain more immedi-
ate and accurate assessment of the first apprehensive thoughts or images. The “imme-
diate anxious thoughts” column of the Situational Analysis Form (Appendix 5.2) can
be used as an initial attempt to collect self- monitoring data on the first apprehensive
thought. Clients must be encouraged to focus on “what is the worst that could happen
in this situation” without considering whether it is probable, realistic, or rational. They
should be encouraged to write down the automatic threat thoughts while they are in
the anxious situation. They can ask themselves “What is so bad about this situation?”,
“What am I thinking is the worst that could happen?,” or “What could harm me in
this situation?”. If a more detailed self- monitoring form is needed, the Apprehensive
Thoughts Self- Monitoring Form can be used (see Appendix 5.4).
Imagery or role plays can be used in the therapy session to determine individu-
als’ apprehensive cognitions in anxious situations. In fact anxious patients often have
conscious fantasies or images of physical or psychosocial harm that can elicit intense
subjective feelings of anxiety (Beck et al., 1974). It is important, then, that the therapist
determine whether the initial apprehension may take the form of an intrusive image
such as reliving a traumatic event. Whatever the case, the client can be asked to imagine