200 ASSESSMENT AND INTERVENTION STRATEGIES
At the beginning of each session I will review last week’s homework with you. You
can expect that each week we’ll spend at least 10–15 minutes of the session review-
ing the outcome of the homework and any problems you may have encountered. Do
you have any questions at this point?
“You may be wondering, do I really have to do homework? I always hated
homework in school. Besides I’m too busy for this sort of thing. You can think of
cognitive therapy like ‘mental exercise.’ In any physical training program, you need
to run, walk, or go to the gym three to five times a week in order to gain strength or
lose weight. You wouldn’t expect to meet your physical goals just by meeting with
the trainer once a week. The same thing happens in cognitive therapy. You are devel-
oping a different mental approach to your anxiety that involves learning to respond
to anxiety in ways that are not natural to you. You need lots of practice in using this
alternative approach to override the automatic anxiety program. Switching off the
anxiety program takes repeated practice and it won’t happen just by meeting with
the therapist once a week. The best way to overcome anxiety is through repeated
practice in your daily life so that gradually the new way of responding becomes
second nature to you. Just like in physical exercise, we’ve found in our research that
cognitive therapy is most effective for people who do homework. Very often when
clients do not benefit from treatment one of the main reasons is that they have not
been doing homework. How do you feel about this aspect of therapy? Are you able
to make a commitment to engage in homework at this time?”Clinician Guideline 6.8
One of the first skills taught in cognitive therapy is the ability to identify and record the
automatic apprehensive thoughts, images, and appraisals that characterize anxious epi-
sodes. In addition clients write down their observations of the physical and behavioral
symptoms of anxiety. Self- monitoring anxious thoughts is a prerequisite skill for cognitive
restructuring. It may be necessary to deal with homework noncompliance at this point in
therapy.Cognitive Restructuring
The goal of cognitive restructuring is to modify or literally “restructure” a person’s anx-
ious beliefs and appraisals about threat. It is an integral part of treatment for deactivat-
ing the anxiety program. The focus is on “current threat,” that is, what is perceived as
dangerous or threatening at this moment. Also the cognitive restructuring interventions
are directed at the appraisals of threat rather than at threat content. The central ques-
tion is “Am I exaggerating the probability and severity of threat and underestimating my
ability to cope?” and not whether a threat could happen or not. For example, in panic
disorder cognitive structuring would focus on whether the client is relying on exagger-
ated and biased appraisals of bodily sensations. The therapist would avoid any debate
on whether or not the client could have a heart attack. The same is true for social phobia
where the focus is on probability and severity appraisals of perceived negative evaluation
from others and not on whether some people may be having negative thoughts about
them. In this section we describe six cognitive intervention strategies: evidence gath-