14 6 ASSESSMENT AND INTERVENTION STRATEGIES
Immediate Inhibitory Responses
Immediate, defensive responses such as escape, avoidance, freezing, or fainting (Beck et
al., 1985, 2005) are part of an automatic inhibitory strategy to reduce fear. An impor-
tant part of any cognitive assessment of anxiety is to identify these fear- inhibiting
responses and yet their detection can be difficult because they are so automatic, with
the individual having little conscious awareness of their presence. However, it is impor-
tant to determine the presence of these responses because they should be targeted for
change given their capacity to reinforce the anxious state and undermine treatment
effectiveness. As an example, a number of years ago one of us treated a woman with
driving fear after having been rear-ended in a motor vehicle accident. Upon assessment
it was discovered that while in traffic she anxiously kept her eye on the rearview mirror,
checking to ensure that the car behind her was not too close. This checking behavior
was done quite automatically as a defensive response. However, it meant that she was
not attending as closely as she should to the traffic in front of her, thus increasing the
likelihood of another accident.
Once again a detailed clinical interview, self- monitoring, and behavioral observa-
tion during heightened anxiety are the primary assessment approaches for identifying
immediate defensive behaviors. There are a number of subtle defensive reactions that the
clinician should be aware could occur as an immediate inhibitory response.
••Avoids eye contact to threatening stimulus (e.g., socially anxious person fails to
make eye contact when conversing with others).
••Cognitive avoidance in which attention is shifted away from a disturbing thought
or image (e.g., in PTSD a trauma- related intrusion might trigger a state of dis-
sociation).
••Immediate escape (flight) behavior (e.g., a person with fear of contamination
quickens her pace as she walks past a park bench where homeless people sit).
••Behavioral avoidance (e.g., a person with mild agoraphobia automatically chooses
a less crowded store aisle).
••Reassurance seeking (e.g., a person keeps reciting the phrase “There is nothing
to fear”).
••Compulsive response (e.g., a person automatically pulls the car door handle
repeatedly to make sure it is locked).
••Defensive physiological reflex response (e.g., a person anxious about swallowing
food starts to gag when attempting to swallow; a person with driving fear stiffens
body or is generally tense whenever he is a passenger in a car).
••Tonic immobility (freezing) (e.g., during a brutal assault a person may feel para-
lyzed, feeling like she is unable to move [see Barlow, 2002]).
••Fainting (e.g., a person experiences a sudden drop in heart rate and blood pres-
sure at the sight of human blood or mutilated bodies).
••Automatic safety behaviors (e.g., a person automatically clutches an object to
avoid falling or losing balance).Given the automatic, rapid nature of these defensive responses, it is likely that some
form of behavioral observation will be necessary to accurately assess their presence. It
would be preferable if the cognitive therapist accompanied the client into anxious situ-