Generalized Anxiety Disorder 429
a senior assistant manager had complained that she was too soft on the employees. The
other main evidence was every time she had to confront a human resource problem she
experienced hesitation, self-doubt, and anxiety, which Rebecca thought made her look
indecisive. On the hand, there was plenty of evidence that she was exaggerating the like-
lihood of the worst outcome. She recently had an employee situation that she handled
well and it had a good outcome. Ironically, she had to deal with another situation in
which some employees complained that the senior assistant manager, who thought she
was too soft, was actually too aggressive and unreasonable with the employees under
his supervision. Furthermore, she had received positive evaluations from the district
manager on her human resource skills. An alternative interpretation was developed,
“One can never know for sure what people think of you. Therefore, I need to judge the
effectiveness of my human resource skills in terms of more objective outcomes such as
whether employees change their behavior after I intervene. My natural tendency to be
sympathetic and less intimidating when confronting employees might cause them to have
more respect for me rather than if I attacked them in a verbally aggressive manner.” A
follow-up homework assignment involved Rebecca collecting evidence that her less con-
frontational style might actually result in more respect from her employees rather than
less respect. She learned from this that when she worried about human resource issues,
she was exaggerating the probability of the worst outcome and forgetting the more
probable, realistic alternative. She was encouraged to repeatedly practice the cognitive
restructuring of threat exercise whenever she started to worry about employee issues.
Clinician Guideline 10.19
In cognitive therapy for GAD cognitive restructuring is employed to modify individuals’
tendency to engage in automatic exaggerated threat interpretations for future negative events
during their worry episodes.Worry Induction and Decatastrophizing
By the third or fourth session the cognitive therapist should introduce the concept of
worry induction. This involves instructing the client to intentionally worry about a par-
ticular concern for 5–10 minutes in the therapy session. The individual is encouraged
to verbalize the worry process aloud so the therapist is able to assess the quality of the
worry. Before beginning the worry induction, the client is asked to provide two ratings
on a scale from 0 to 100: “If I asked you to worry about X [a primary worry topic] right
now for 10 minutes, how anxious would this make you feel? How uncontrollable would
the worry be?” The client is then instructed to start worrying and try to worry as com-
pletely as possible. That is, the worry exercise should continue until the client is totally
focused on thoughts or images of the worst possible outcome represented in the worry
topic. If the client has difficulty initiating a worry episode, the therapist can help start
the induction by asking the client “What is it about [the worry situation or concern] that
worries you?” If the client has difficulty progressing to his catastrophic outcome, the
cognitive therapist can prime this using the downward arrow technique: “What would
be so bad or worrying about that outcome?” and so on. This worry induction exercise
should be practiced three or four times in the therapy session before it is assigned as a