198 ASSESSMENT AND INTERVENTION STRATEGIES
anxiety are often readily available to individuals, and will give them practice in tracking
and dissecting their anxiety episodes. Second, it is important that the first introduction
to anxious thinking be done in the therapy session (Beck et al., 1985). Since clients are
often not anxious while in session, some form of mild anxiety induction exercise may
be needed to elicit anxious thinking. For example, a panic induction exercise such as 2
minutes of overbreathing or spinning in a chair could be used to induce panic-like physi-
cal sensations. The client could be asked to verbalize any thoughts related to the exercise
such as fear of heart attack, fainting, losing control, or the like. A person with PTSD
could be asked to recall aspects of a past trauma and then verbalize his present thoughts
about his recollected memories. A mild fear of contamination or doubt could be induced
with someone suffering from OCD to elicit her appraisals about the threat. In each case
the therapist would ask probing questions about the client’s immediate thoughts. “What
went through your mind as you were breathing harder and harder?,” “What were your
thoughts focused on?”, “What were your main concerns?”, “What was the worst that
could happen?”, “Did it feel like the worst outcome was likely to happen?”, “Did you
have any competing thoughts, such as maybe it wasn’t so bad after all?”
Once the client has demonstrated some rudimentary skills at identifying his ini-
tial apprehensive (automatic) thoughts and appraisals in the therapy session, the thera-
pist should assign a self- monitoring homework task. The Apprehensive Thoughts Self-
Monitoring Form (Appendix 5.4) will be especially useful in this regard. Most clients
need extended practice in self- monitoring their anxious thoughts between sessions. In
fact self- monitoring of anxious thoughts and symptoms will continue throughout the
course of treatment. Cognitive restructuring and empirical hypothesis testing can not be
successfully employed until clients have become capable of identifying their automatic
threat- related thinking.
It is important that the self- monitoring component of treatment increase the anx-
ious person’s awareness of two primary characteristics of anxious thinking:
••Overestimated probability appraisals—“Am I exaggerating the likelihood that
some threat or danger will happen?”
••Exaggerated severity appraisals—“Am I overly focused on the worst possible out-
come? Am I exaggerating the severity of a negative outcome?”Sensitizing clients to their evaluations of threat is important in shifting their focus from
threatening content (e.g., “What if the medical tests indicate cancer?”) to how their
appraisals contribute to anxiety (e.g., “Am I exaggerating the probability that the test
will be positive and lead to the worst possible outcome?, If so, what effect is this hav-
ing on my anxiety?”). Individuals will need repeated practice in identifying their initial
apprehensive thoughts in order to improve their ability to catch the exaggerated threat
appraisals. When reviewing self- monitoring homework, the cognitive therapist probes
for exaggerated likelihood and severity of threat appraisals in order to reinforce the
importance of this thinking in the persistence of anxiety.
Homework Compliance
Homework compliance is an important issue in cognitive therapy for anxiety and often
it will be felt most keenly at the early phase of treatment when first assigning self-