196 ASSESSMENT AND INTERVENTION STRATEGIES
ance, safety- seeking behavior, and other cognitive or behavioral responses employed by
clients in an effort to control their anxiety are targeted for change. Alternative ways of
responding to anxiety are introduced and clients are encouraged to evaluate the utility
of these approaches through use of behavioral exercises.
A final ingredient of cognitive therapy for anxiety involves graduated and repeated
exposure to anxiety- provoking situations and a phasing out of escape, avoidance, safety
seeking, or other forms of neutralizing responses (e.g., compulsive rituals in OCD).
When introducing the concept of fear exposure, it must be realized that this can be ter-
rifying to anxious individuals. Many anxious clients refuse to continue with treatment
at the mere mention of exposure because they can not imagine dealing with the intense
anxiety they expect to experience in highly fearful situations. To counter the client’s
negative expectations, the therapist should emphasize that exposure to fear situations
is the most potent intervention for achieving lasting fear reduction. Exposure exercises
will be introduced later in therapy in a very gradual fashion starting with experiences
with a low to moderate level of anxiety in order to elicit core cognitions that underlie
anxious feelings. All assignments will be discussed in a collaborative fashion with the
client having the final say on what is expected at any point in therapy. The therapist
should also reassure clients that an exposure task that seems too difficult can always
be broken down or modified to reduce the level of anxiety. Finally, the therapist should
explain the benefits of exposure to anxious situations. It reduces anxiety by providing
evidence against threat- related “hot” cognitions and beliefs, it bolsters self- confidence,
and it provides opportunity to practice more adaptive ways of coping with anxiety.
Other Approaches to Anxiety
Often clients will inquire whether medication, meditation, herbal remedies, and the
like can be used while having a course of cognitive therapy for anxiety. However, these
approaches are somewhat counterproductive to cognitive therapy because they all empha-
size the short-term reduction and avoidance of anxious symptoms without concomi-
tant change in cognition. For many individuals these interventions may have become an
important part of their coping strategy for anxiety. Thus any withdrawal of these inter-
ventions should be done gradually, commensurate with a reduction in the client’s anxiety
level with progress through cognitive therapy. Naturally no change in medication should
be recommended unless prescribed by the client’s medical practitioner.
Methods of Educating the Client
Although a certain amount of verbal teaching is an evitable part of the educational pro-
cess, it should not be the sole means of communicating the cognitive model and treat-
ment rationale. The therapist should be asking clients about their personal experiences
and using guided discovery to emphasize key aspects of the cognitive model that can be
identified in these experiences. Clients are much more likely to accept the model if it has
immediate relevance to their own experiences with anxiety.
The therapist can also assign self- monitoring homework to encourage the client to
explore whether different aspects of the cognitive model are relevant to his anxiety. For
example, a client with social phobia could be asked to experiment with the effects of giv-
ing eye contact versus avoiding eye contact in social interactions as a way of determin-