Cognitive Therapy of Anxiety Disorders

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Behavioral Interventions 237


I was manic,” and “If my physical appearance is perfect, people will think I am more
competent and in control.”


Behavioral Prescription


The client is always provided specific information on how to perform a behavioral exer-
cise, something analogous to a behavioral prescription. A schedule indicating when to
do the exercise, where, and for how long should be worked out. It should be clearly
spelled out whether there are restrictions on the use of safety cues (e.g., a person with
agoraphobia can take a trusted friend to the shopping mall but must spend 30 minutes
in the mall alone). Moreover, the therapist should discuss with the client what cop-
ing responses are considered healthy when performing the behavioral task and what
responses would undermine the success of the intervention (see section on planning
behavioral experiments in previous chapter).


Self- Monitoring


Clients should record the outcome of any behavioral exercise performed as a homework
assignment. Specific self- monitoring forms should be used such as the assessment or
thought record forms reproduced in the appendices of Chapters 5 and 6 or the behav-
ioral forms that can be found later in this chapter. Although some clients insist on
keeping less formal, more open-ended records of their homework, it is important that
sufficient information is recorded to allow an evaluation of the behavioral assignment
(see previous chapter on recording in behavioral experiments).


Evaluation


The postintervention follow-up is perhaps the most critical component of the behav-
ioral exercise in cognitive therapy. The therapist should review in detail the information
recorded on the self- monitoring form. It is critical to highlight how the client’s experi-
ence with the behavioral intervention disconfirmed the anxious appraisal and supported
an alternative interpretation. This could even be written down on a “coping card” that
clients use to counter their anxious thoughts in subsequent anxious episodes.
In our case example Maria was asked to accompany a friend to a café and sit with
her for at least 20 minutes while they had a drink and chatted about their daily lives.
Maria was asked to self- monitor her anxiety level throughout the behavioral assign-
ment, taking particular notice of her automatic thoughts and any social cues that she
picked up from those around her. She made two important observations. First, her
anxiety escalated even further as she became more and more preoccupied with her inter-
nal anxious state and worried that others noticed that she looked uncomfortable. And
second, there was no objective evidence that anyone even noticed her in the café. No
one was looking at her or showed the least interest in her presence. Thus the behavioral
experiment disconfirmed her maladaptive belief that her anxiety was due to others look-
ing at her, of being the “center of their attention,” and supported the alternative expla-
nation that her anxiety was due to heightened self- focused attention on her internal
state. Based on the results of this assignment, therapy then focused on various cognitive

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