Cognitive Therapy of Anxiety Disorders

232

From Cognitive Therapy of Anxiety Disorders: Science and Practice by David A. Clark and Aaron T. Beck. Copyright
2010 by The Guilford Press. Permission to photocopy this appendix is granted to purchasers of this book for personal
use only (see copyright page for details).

aPPENDIX 6.6

Chapter 6 Quick Reference Summary: Cognitive Interventions

I. Education Phase (sessions 1–2)

Define anxiety and fear; fear adaptive; cognitive basis of anxiety (handout Fig. 6.1) and use client

examples from assessment; negative consequences of anxiety; role of avoidance and safety seeking (use

client examples); establish treatment goals and CT rationale (turn off, deactivate the “anxiety program”).

II. Identifying the First apprehensive Thoughts (sessions 2–3)

1. Review client’s “Situational Analysis Form” (Appendix 5.2); probe for immediate, automatic, first
   anxious thought. If needed use illustration of “walk alone and hear a noise.”


2. Emphasize the exaggerated probability and severity of threat appraisals in first anxious thinking.


3. Assign “Apprehensive Thoughts Self-Monitoring Form” (Appendix 5.4) as homework.


4. Emphasize importance of homework (see explanation in Chapter 6, pages 199–200) and therapeutic
   benefits of understanding one’s anxiety.

III. Standard Cognitive Interventions (sessions 3 to end)

1. Evidence Gathering—first use “Testing Anxious Appraisals: Looking for Evidence” form (Appendix
   6.2) in session; use client anxiety episode from past week or from “Situational Analysis Form.” Assign
   “Testing Anxious Appraisals” form as homework.


2. Cost–Benefit Analysis—first use “Cost–benefit Form” (Appendix 6.3) in session; list advantages/
   disadvantages of “threat perspective” first and then repeat for “alternative perspective.”


3. Decatastophizing—explore with client his worst outcome; go through preparation, catastrophe
   description, and problem-solving stage; have client imagine the worst possible outcome or write down
   its description.


4. Identify Thinking Errors—provide client handout of “Common Errors and biases in Anxiety”
   (Appendix 5.6) and go over recent anxious thinking for possible errors; assign “Identifying Anxious
   Thinking Errors” as homework.


5. Generating Alternative Explanation—first work on generating alternative thinking to recent anxious
   episode; use “Alternative Interpretations Form” (Appendix 6.4); work on evidence for worst outcome,
   then most desired outcome, and finally most realistic outcome. Assign as homework if another
   anxiety concern is evident.


6. Empirical Hypothesis Testing (homework assignment)—provide rationale; specific statement of threat
   appraisal and its competing alternative; plan the experiment (write down instructions); client uses
   “Empirical Hypothesis-Testing Form” (Appendix 6.5) to record actual experiment (write down threat
   interpretation, alternative, and expected outcome when setting up experiment); explore outcome of
   experiment in following sessions (consolidation phase); write out a summary of conclusions about the
   experiment for client.

IV. alternative Cognitive Interventions (latter part of therapy)

1. Attentional Training Technique (ATT)—counters self-focused attention, rumination, and worry;
   trained attention to three neutral sounds in office, then three sounds outside office, then three sounds
   in distance, use ATT rating scale after each; therapist calls out different sounds to practice alternating
   attention; homework assignment is 10–15 minutes of ATT practice twice daily.


2. Metacognitive Intervention—assess whether client engaged in faulty appraisals and beliefs about
   her thoughts; use standard cognitive interventions to challenge metacognitive appraisals and beliefs;
   encourage cessation of any counterproductive thought control strategies; allow anxious thinking to
   “fade naturally.”
   (cont.)