Cognitive Therapy of Anxiety Disorders

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192 ASSESSMENT AND INTERVENTION STRATEGIES


Adaptive Value of Fear


Most individuals suffering from an anxiety disorder have forgotten about the important
role that fear plays in our survival. The therapist should discuss the universal nature
of fear and its survival function. Clients can be asked about times when being afraid
“saved their life” by mobilizing them to deal with a potential threat or danger. Beck et
al. (1985, 2005) noted that it is often helpful to discuss with clients the “fight-or- flight”
response that characterizes fear.
In the same way mild to moderate levels of subjective anxiety (nervousness) can be
adaptive if it is not too intense or prolonged. Being nervous about an impending exam
or job interview might motivate a person to be better prepared. Performers acknowledge
that some degree of nervousness is both expected and beneficial before going on stage.
Again the therapist can solicit past experiences from the client when anxiety was actu-
ally functional.
The reason for including a discussion on the positive function and adaptive value
of fear and anxiety is to emphasize that these states are not abnormal. The problem
in anxiety disorders is not the experience of fear or anxiety, but the fact that the fear
program is inappropriately activated or turned on. Thus the goal of therapy is not to
eliminate all anxiety but rather to reduce anxiety that is inappropriate or maladaptive.
Another reason for emphasizing the survival value of fear is to normalize clients’ anxi-
ety so they view it as an exaggeration or misapplication of normal emotion. This should
bolster a great sense of hope and optimism in treatment since they are not as different
from “normal people” as they may have been thinking.


Cognitive Explanation for Inappropriate Activation of Anxiety


The preceding discussion on the normality of fear and anxiety will naturally lead into
the issue of why the client’s anxiety is so much more intense, persistent, and triggered by
things that don’t bother most people. This is the crux of the educational phase because
it is critically important to the success of therapy that clients realize that their apprais-
als of threat are the primary determinants of their clinical anxiety. A copy of Figure
6.1 can be given to clients in order to facilitate an explanation of the cognitive model of
a n x iet y.
Education into the cognitive model will occur after the assessment so the therapist
can draw on the cognitive case conceptualization to obtain examples of the client’s typi-
cal responses when anxious. The therapist should go through each step in Figure 6.1
and elicit from the client examples of typical situations, automatic thoughts, anxious
symptoms, search for safety and avoidance, worry and preoccupation with anxiety and
helplessness, and failed attempts to control anxiety. These experiences could be written
down on Figure 6.1 as a record for the client on how the cognitive model explains inap-
propriate fear activation and the persistence of her clinical anxiety. Any questions or
doubts concerning the applicability of the cognitive explanation for the client’s anxiety
should be addressed using the guided discovery in which the therapist questions the cli-
ent in a manner that will encourage her to reevaluate her misgivings about the cognitive
explanation (Beck et al., 1979). In most cases it is helpful to assign a homework assign-
ment such as having the person fill in Figure 6.1 immediately after an anxiety episode.
This will help consolidate a better understanding and acceptance of a cognitive explana-
tion for the clinical anxiety state.

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