Mastery of Your Anxiety
Mastery of Your Anxiety
Mastery of Your Anxiety
and Worry:
Therapist Guide,
Second Edition
Richard E. Zinbarg
Michelle G. Craske
David H. Barlow
Anne Marie Albano, Ph.D.
Jack M. Gorman, M.D.
Peter E. Nathan, Ph.D.
Bonnie Spring, Ph.D.
Paul Salkovskis, Ph.D.
G. Terence Wilson, Ph.D.
John R. Weisz, Ph.D.
Mastery of Your
Anxiety and Worry
SECOND EDITION
T h e r a p i s t G u i d e
1
1
Oxford University Press, Inc., publishes works that further
Oxford University’s objective of excellence
in research, scholarship, and education.
Stunning developments in health care have taken place over the last sev-
eral years, but many of our widely accepted interventions and strategies
in mental health and behavioral medicine have been brought into ques-
tion by research evidence as not only lacking benefit, but also perhaps
inducing harm. Other strategies have been proven effective using the
best current standards of evidence, resulting in broad-based recommen-
dations to make these practices more available to the public. Several re-
cent developments are behind this revolution. First, we have arrived at a
much deeper understanding of pathology, both psychological and physi-
cal, that has led to the development of new, more precisely targeted inter-
ventions. Second, our research methods have improved substantially, such
that we have reduced threats to internal and external validity, making the
outcomes more directly applicable to clinical situations. Third, govern-
ments around the world, as well as health care systems and policymakers,
have decided that the quality of care should improve, that it should be
evidence-based, and that it is in the public’s interest to ensure that these
changes occur (Barlow, ; Institute of Medicine, ).
Of course, the major stumbling block for clinicians everywhere is the ac-
cessibility of newly developed evidence-based psychological interventions.
Workshops and books can go only so far in acquainting responsible and
conscientious practitioners with the latest practices in behavioral health
care and their applicability to individual patients. This new series, “Treat-
ments That Work™,” is devoted to communicating these exciting new
interventions to clinicians on the frontlines of practice.
This therapist guide and the companion workbook for clients address
the treatment of generalized anxiety disorder (GAD). This disorder oc-
curs in approximately % of the population (about two-thirds of them
female), but is underrecognized and undertreated. With its characteristic
symptoms of uncontrollable, unstoppable worry about upcoming events,
accompanied by chronic tension, fatigue, irritability, and difficulty sleep-
ing, GAD can cause significant impairment. Most people seek treatment
for this condition in primary care medical settings, where cognitive-
behavioral treatments are seldom available.
vi
Contents
References
This program is designed for people who suffer primarily from worry and
tension. It is ideally suited for those who meet the criteria for the diagno-
sis of generalized anxiety disorder (GAD) in the Diagnostic and Statisti-
cal Manual of Mental Disorders, th edition, Text Revision (DSM-IV-TR),
but will also be useful for those individuals who have occasional worries or
tension, but do not meet the severity criteria for GAD. The DSM-IV-TR
criteria for the diagnosis of GAD are given later. The key feature of GAD
in the DSM-IV-TR is excessive and pervasive worry for at least months.
In this context, excessive worry means that the intensity, duration, or fre-
quency of worry exceeds the actual likelihood or negative consequences
of the event that is the object of worry. In addition, the worry has the
1
quality of being uncontrollable; that is, the individual finds it difficult to
keep worries from interfering with his or her concentration on tasks at
hand and has difficulty ending the worry process. The pervasiveness of
worry refers to a generalized focus on minor, everyday events or a focus on
more than one major life circumstance (i.e., job, family, finances); these
foci may shift repeatedly during the -month period. In addition, the
worry is associated with physical symptoms of tension, such as restless-
ness, being easily fatigued, feeling keyed up or on edge, irritability, and
sleep disturbances. This tension is seen as representing a state of motor
readiness to respond to threat.
Although the person may not always identify his or her worries as being
excessive, he or she will report subjective distress due to unceasing worry,
difficulty controlling the worry process, or associated impairment in func-
tioning. In many cases, the therapist can make a judgment about whether
the worry is excessive by thoroughly assessing the person’s life circum-
stances that are relevant to the worry. For example, if one of the person’s
worries is finances, the therapist may need to ask about the person’s in-
come, debts, savings, and other assets. We judged financial worries to be
excessive in one of our clients, a radiologist, who earns several hundred
thousand dollars a year and has large sums of money invested in stocks
and bonds, but we would be hard pressed to do so in a client who had
just lost his job and had meager savings that were not sufficient for pay-
ing his monthly bills. In other cases, the therapist may need to ask the
person to compare his degree of worry relative to others belonging to the
cultural groups the person identifies with. For example, one of our clients
was a devout member of a congregation that believed that homosexual-
ity was immoral, and she worried a great deal about whether her sons
would grow up to be gay. When we asked her to compare her worry
about this issue with that experienced by other mothers of young boys
in her congregation, it became clear that other mothers did not worry
about this possibility nearly as much as our client, even though they
shared her conviction that homosexuality was immoral.
2
DSM–IV-TR Criteria for Generalized Anxiety Disorder
(includes Overanxious Disorder of Childhood)
C. The anxiety and worry are associated with at least three of the
following six symptoms (with at least some symptoms present for
more days than not for the past months). Note: In children, only
one symptom is required.
. Irritability
. Muscle tension
3
hyperthyroidism), and does not occur exclusively during a Mood
Disorder, Psychotic Disorder, or Pervasive Developmental Disorder.
The MAW program would also not be appropriate if the client is not ex-
periencing excessive worry and tension, despite undergoing a major life
stress, such as marital difficulties or financial problems. Similarly, the
MAW program would not be appropriate if the client experiences panic
attacks and worries only about having more panic attacks or is depressed,
without the complication of worry and tension. A different treatment
protocol is used for people suffering from panic attacks and associated
apprehension about panic and agoraphobic avoidance. This is the Mas-
tery of Your Anxiety and Panic (MAP) program, which was developed
at the Albany Center for Stress and Anxiety Disorders and substantially
revised and updated at our Centers at Boston University (directed by
Dr. Barlow) and the University of California at Los Angeles (directed by
Dr. Craske). Information on obtaining the MAP protocol can be found
at www.oup.com/us/ttw.
Mental health professionals may wish to screen patients using the Anxi-
ety Disorders Interview Schedule for DSM-IV (ADIS-IV), which was de-
vised for this purpose. The ADIS-IV generates diagnoses for all DSM-IV
mood and anxiety disorders, and includes a brief screen for psychotic dis-
4
orders and substance abuse. Extensive psychometric studies using earlier
versions of the Anxiety Disorders Interview Schedule (ADIS) indicate
that adequate reliability can be obtained with the ADIS for the diagnosis
of mood and anxiety disorders (Barlow, ; Brown, DiNardo, Lehman,
& Campbell, ). Information on obtaining this interview schedule
can be found at www.oup.com/us/ttw.
Medication
Many people suffering from worry and tension will be referred to mental
health professionals while already taking psychotropic medication, most
often prescribed by primary care physicians. In our experience, over half
of these individuals are taking selective serotonin reuptake inhibitors
(such as paroxetine [Paxil]) or serotonin norepinephrine reuptake inhibi-
tors (such as venlafaxine [Effexor]), while some are taking variety of
other drugs, most commonly, low doses of benzodiazepines, other minor
tranquilizers, or tricyclic antidepressants. We do not recommend that
clients decrease their medication during the course of the MAW pro-
gram. Instead, we suggest that clients continue with whatever dosage of
medication they are currently taking, until they complete the program.
In this way, they will have skills for tension and worry management as
the medications are withdrawn.
5
without any outside urging to do so. Notwithstanding this general ten-
dency, issues of medication withdrawal are discussed in workbook chap-
ter (see chapter ) for those clients who do need some encouragement
to initiate withdrawal. We have found that the MAW program is very
helpful as an aid to discontinuation of medication for clients and pre-
scribing physicians who choose to do so. If withdrawal from benzodi-
azepines is particularly difficult and includes panic, then the MAP pro-
gram may be useful and has often been used with success under similar
circumstances.
The question of who should run the MAW program has not been fully
examined. However, we have attempted to present the program in suffi-
cient detail such that any mental health professional should be able to
supervise its application. The major prerequisite is being conversant with
the nature of anxiety and worry; some of the basic information regard-
ing these topics is presented in chapter . We also believe that it is im-
portant that the therapist have sufficient understanding of the concep-
tual foundations underlying treatment to be able to tailor the various
sessions to best suit the needs of each individual client undergoing the
MAW program. The goal of this therapist guide is to impart this under-
standing. The references listed at the end of this guide provide more de-
tailed and in-depth information on these topics. Finally, we also believe
that it is useful for therapists to have some knowledge of the basic prin-
ciples of cognitive and behavioral intervention.
In our center, the MAW program has been delivered in both individual
and group formats. While we have not yet formally compared these for-
mats, the program seems equally effective in either format. Thus, a de-
cision on whether the program should be administered in a group ver-
sus an individual format should probably be resolved on a site-by-site
basis, according to the preferences of the therapist. Health maintenance
organizations tend to administer this program in groups of six to eight
6
to capitalize on the economies associated with this mode of administra-
tion. On the other hand, private practitioners may not wish to make clients
wait until a group forms, and thus find it more suitable to administer the
program on an individual basis. We customarily limit the number of
clients to no more than six, when administering the program in a group
format. We find that it is difficult to allocate sufficient individual atten-
tion to clients in the course of a -minute group session if the group is
much larger than six. On the other hand, there is no formal research sug-
gesting the optimal number of clients in this treatment program.
Session Style
Example 1
“Spoon-Feeding” Style
7
mild uneasiness to extreme terror and panic, and can vary in frequency
from occasional distress to seemingly constant unease.
“Socratic” Style
T: So, what are your goals for this program? In concrete terms, how will
your life be different months or a year from now, if we are successful
in helping you?
C: Now I see what you’re saying. When I was a student and taking a sub-
ject I was pretty good at, I wouldn’t get too nervous before tests, but I
did get a little bit nervous. Because I was a little nervous, I probably
spent more time studying than I would have otherwise.
8
Example 2
“Spoon-Feeding” Style
“Socratic” Style
T: When you began to feel anxious about friends visiting and you made
your house spotless, what did you think afterward? What did it make
you think about, the fact that your friends didn’t criticize you? Were
you more likely to attribute their lack of criticism to the fact that you
cleaned or to the possibility that they wouldn’t have rejected you, even
if the house wasn’t spotless?
9
Can you think of any reasons why this might not apply to you? Does that
fit with your experience? Therapists should also clearly communicate to
clients that cognitive therapy is not about the power of positive think-
ing; rather, it’s about realistic thinking, or “finding the truth.” Experi-
enced cognitive therapists are also fond of saying that, in cognitive ther-
apy, the therapist never loses. What is meant by this is that almost any
experience that the client has, progress or distress, can fit into the cogni-
tive model. Thus, even if someone has a very intense episode of height-
ened anxiety during treatment, you can always find some way of using
it to demonstrate the importance of one of the factors in the model,
(e.g., threatening misinterpretations, the role of cognitive avoidance or
overcautiousness in maintaining anxiety, hypervigilance).
What is the evidence for that? After the first two or three sessions of cog-
nitive restructuring, the therapist should try to assist the clients to chal-
lenge their own thoughts by asking questions such as the following.
What question or questions could you ask yourself to help you challenge
that automatic thought the next time you have it? If the program is being
implemented in a group format, the therapist might elicit attempts by
the other group members to be cognitive restructuring coaches in the
later sessions through questions such as the following.
10
gets stuck when trying to restructure one of his or her own worries, we
often find it helpful for the therapist to use the “put the shoe on the
other foot” technique. That is, the therapist can ask the client to con-
sider what he or she might say to a good friend or relative, or even the
therapist, if one of these other people were experiencing the worry under
discussion.
We find that one of the most common difficulties that arises when work-
ing with anxious clients is ambivalence or resistance about completing
self-help assignments. The therapist must keep in mind that, when im-
plementing cognitive restructuring and exposure therapy, we are asking
the client to do exactly what he or she is anxious about and has been
avoiding, to some degree. At times when the client does not readily com-
ply with such interventions, we find it useful to asssume that the person
must have some motivation for change, or he or she would not keep
coming to see us. Thus, our task becomes helping the client to articu-
late, and perhaps even strengthen, his or her motivation for change. One
way to do this involves borrowing the approach advocated in Motiva-
tional Interviewing, developed by William R. Miller and his colleagues
and side with the resistance (Miller & Rollnick, ; also see Newman,
). “Siding with the resistance” simply refers to reflecting back to the
client what the therapist understands to be the client’s reasons for main-
taining the status quo and resisting change, with an attitude that con-
veys that these reasons have validity and are understandable (e.g., “It
sounds like you don’t want to heighten your awareness of the automatic
thoughts that might be contributing to your anxiety because you believe
that doing so will make you even more anxious than you already are; it
makes sense to me that you would want to avoid focusing on your au-
tomatic thoughts, given your belief ”). Assuming that the invidual is
ambivalent (i.e., has some motivation for change in addition to motiva-
tion to avoid), siding with the resistance will encourage the client to side
with the motivation for change and growth. What if our assumption of
ambivalence is wrong, and the client does not have any internal motiva-
tion for change? Might siding with the resistance backfire and lead to
premature termination? Our view is that it may well be true that siding
11
with resistance, when there is no internal motivation to change, will lead
to the client deciding that therapy is not right for him or her at the pres-
ent time and terminating the therapy. However, we also believe that
there is a lot of wisdom to the old joke: How many therapists does it take
to change a light bulb? One, but the light bulb has to want to change.
That is, if the client has no internal motivation to change, we don’t be-
lieve that the therapy would have progressed very far anyway, and if we
do side with the resistance, at least the client will feel understood and
may be more willing to return to therapy in the future, if and when some
internal motivation develops.
12
creating an alliance that can more readily withstand such strains, and
may even prevent some strains from occurring.
Frequency of Meetings
The MAW workbook is divided into chapters. All clients should com-
plete chapters through , , and . Workbook chapter (on safety be-
haviors and behavioral overcautiousness, including procrastination and
other subtle patterns of avoidance) and workbook chapter (on dis-
continuing medication) may be completed at the discretion of the thera-
pist. If safety behaviors or behavioral overcautiousness is substantial, chap-
ter may take several sessions to complete.
Ordinarily, the therapist will meet with the client or group once per
week and assign readings from the MAW workbook as well as various ex-
ercises to be practiced during the week. Later sessions may be held bi-
weekly to give the client more practice in applying the skills more inde-
pendently. Some therapists, however, may wish to accelerate treatment
by scheduling two sessions per week or, alternatively, by trying to cover
two lessons during weekly -minute or -minute sessions. Either
way, the duration of the treatment program would be cut approximately
in half. Initial evaluations of the program yielding successful results have
been based on a pattern of administration of one lesson per week for the
first eight weeks, with the last four sessions held on a biweekly basis.
Nevertheless, there is no reason to believe that certain clients could not
achieve equal benefits from the program delivered in a shorter period, if
they are prepared to dedicate the extra time needed to the tasks.
13
minate early because they are feeling better may be prone to higher rates
of relapse than those who carry out the entire program. It should also be
evident that there is a progression in the program, with each chapter
building on the last and adding new information, interventions, and ex-
ercises. Until we become aware of evidence that some parts of the pro-
gram might be superfluous, we will continue to advise that each client
complete all aspects of the program.
14
■ The client may consult the workbook when he or she is confused
or overwhelmed. While many concepts may be readily apparent to
trained therapists, we often lose sight of the fact that clients who
seem to comprehend ideas during a session often get confused
about the same ideas after leaving the session. One of the greatest
benefits of the workbook is the opportunity for clients to reexamine
pertinent conceptualizations, explanations, and instructions be-
tween sessions. This may be especially helpful during episodes of
intense anxiety, when many clients understandably report the
greatest difficulty remembering their newly learned coping skills.
The MAW workbook often becomes the client’s bible during the
course of treatment. Some clients go so far as to take the work-
book, or portions of it, with them everywhere they go, to have it
ready as a handy guidebook. For many of these clients, this has
proved very helpful.
■ Family members and close friends can read the workbook. Re-
search at our center (Barlow, O’Brien, & Last, ; Cerny, Bar-
low, Craske, & Himadi, ) has shown that there is a significant
benefit to having family members, especially spouses, be apprised
of and involved in treatment for at least one type of anxiety
problem, panic disorder with agoraphobia. For example, clients
whose spouses were involved in treatment did much better at
-year follow-up than those whose spouses were not involved.
Recent research by Chambless and Steketee () has shown that
greater levels of hostility expressed toward the client by relatives
(% of whom were spouses) prior to the start of therapy pre-
dicted poorer response to cognitive-behavioral therapy for panic
disorder with agoraphobia and obsessive-compulsive disorder. In
contrast, nonhostile criticism—being critical of specific behaviors,
without devaluing the client—actually predicted better response
to the therapy (Chambless & Steketee, ). We have recently
obtained identical results in a study of the efficacy of the major
components of the MAW program in clients with GAD who were
in committed relationships (Zinbarg, Lee, & Yoon, ).
15
either intentionally or unwittingly, may be prevented if family
members are familiar with the nature of the difficulty and the ra-
tionale underlying the different exercises that the client is perform-
ing. Similarly, it is possible that partners or family members who
are very hostile toward the client might be less so if they had a
greater understanding of the processes maintaining the worries.
Second, family members can be very beneficial in encouraging the
client to conquer some of the overcautiousness in behavior that
often accompanies anxiety problems. Of course, there are some
clients who would prefer that their spouse or family members be
completely uninformed about their problem and the treatment
program. In these cases, we invite the client to consider the poten-
tial benefits of sharing their problems with their spouses and try to
restructure any excessive or unrealistic worries that they may have.
Typically, these worries focus on apprehension that the family will
think that they’re crazy or will be openly antagonistic to their
efforts. In our experience, this very rarely happens. If the worries
are particularly strong, we may bring the spouse into the sessions,
either initially or for all of the sessions. In some of our group
treatment programs, groups typically consist of four to six clients
and their spouses, for a group size of eight to twelve.
■ Clients can consult the workbook at the end of the program. The
MAW program advises clients to be prepared for the occasional
recurrence of intense anxiety under especially stressful circum-
stances. The workbook can be a reservoir of comfort during these
periods, and even may prevent the development of a full-blown
relapse. In fact, for some clients, simply having the workbook
nearby during these times seems to serve an anxiolytic function.
16
Benefits of Standardized Assessment
Some very capable therapists who have been working with the MAW
program since its initial development report a preference for distribut-
ing the workbook chapters in several segments. In this way, they ensure
that clients don’t skip too far ahead and are better able to focus on the
material at hand. These therapists have used loose-leaf binders or simi-
lar mechanisms to put the various segments of the workbook together.
17
this time. The disadvantage of this practice is that individual chapters
are more prone to be lost, so that clients will not have complete MAW
workbooks when the program ends. Obviously, having an incomplete
workbook will make it difficult to consult in the months and years
ahead. In addition, it does not particularly trouble us when clients do
some jumping around. As a generalization, we find that the more time
a client spends reviewing the MAW program, the deeper his or her com-
prehension and the greater his or her improvement. If the client wants
to discuss something or read from a future lesson during a session, we
simply redirect him or her and keep focused on the current assignment.
18
exposure (Zinbarg, Lee, & Yoon, ). Fifty percent of the individuals
who completed the treatment had returned to within one standard de-
viation of the nonclinical mean on at least four of our five outcome mea-
sures at the end of the program, and can therefore be regarded as having
achieved high-end state functioning. Another .% were markedly im-
proved (returning to within one standard deviation of the nonclinical
mean on three of the five outcome measures), and another % were
somewhat improved (returning to within one standard deviation of the
nonclinical mean on two of the five outcome measures). Thus, a total of
.% were at least somewhat improved.
Wetherell, Gatz, and Craske () adapted the MAW program for a
late-life sample (mean age, years) and compared it to a discussion
group pertaining to worry-provoking topics and to a wait-list control.
The MAW program was clearly more effective than the wait-list control
and marginally more effective than the discussion group. Stanley, Beck,
Novy, Averill, Swann, Diefenbach, and Hopko () also conducted a
treatment study among older adults (mean age, . years) in which
they compared a cognitive-behavioral therapy package that included many
of the components of the MAW program with a minimal contact treat-
ment that involved weekly phone calls to assess symptom severity and
provide minimal support. The cognitive-behavioral therapy was clearly
superior to the minimal contact treatment. However, consistent with
other evidence for poorer treatment response in older age groups, the
rates of high end-state functioning were quite low in the reports of both
Wetherell et al. () and Stanley et al. ().
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Chapter 2 The Nature of Anxiety and
Generalized Anxiety Disorder
For a full exposition of this theoretical model, see Barlow () and
Zinbarg (). In brief, interactions among the following factors are
recognized in the genesis of GAD: negative affectivity or neuroticism;
attentional vigilance and narrowing to signals of potential threat; a ten-
dency toward interpreting ambiguous situations as threatening; passive
avoidance, overcautiousness, or procrastination; perceptions of uncon-
trollability and unpredictability; and cognitive avoidance, distraction, or
other active efforts to resist or neutralize worrying.
21
Synergistic Vulnerabilities
Biological Vulnerabilities
Diatheses
Generalized Psychological Vulnerability
Generalized Anxiety
Depression
Figure 2.1
Diatheses–stress model of the development of generalized anxiety and depres-
sion. Redrawn from Barlow (), with permission.
sion that is often associated with anxiety. When the threat of danger is
real, anxiety is crucial to our survival. Seen in this light, it would be sur-
prising if someone were born without the capacity to experience anxiety.
22
No threat potential Preferred mode of safety
and control
Figure 2.2
Relationship of worry, anxious apprehension, and fear (panic). Redrawn from
Craske (), with permission.
23
stantly anxious person. Since the attack, Rick has had difficulty relaxing,
and he feels constantly on edge and vulnerable to ever-present danger in
his surroundings. This is accompanied by a high level of startle reactiv-
ity. Rick feels a need to be on guard, since he attributes the mugging to
a lack of readiness. In other words, he believes that, had he been ready
at the time, he would not have gotten out of his car or he would have
done something to avoid being mugged. Therefore, it remains crucial to
him to be always ready and on guard now, to be prepared for further un-
predictable dangers. What he had once perceived as being a safe world
was upset by this unexpected event, and now his whole sense of safety
and danger has been altered. Clinically, his guardedness was readily ob-
served when he was asked to do relaxation exercises. He reported that,
every time he tried to relax, he would become more anxious. He felt in-
creasingly vulnerable to more bad things happening if he allowed him-
self to relax.
The processes that serve to maintain high levels of anxiety are hyper-
vigilance and cognitive biases favoring the processing of threat at early
stages of processing (e.g., preattentive scanning for threat, favoring threat-
ening interpretations of ambiguous stimuli), avoidance behaviors (that
become more pronounced and observable, depending on the specificity
of the situational cues that set the occasion for anxiety and the extent to
which overt avoidance is possible); and cognitive avoidance at later stages
of procesing, including both distraction and the shift away from imag-
istic processing of threat and toward verbal-linguistic processing that is
characteristic of the process of worry (Borkovec, Shadick, & Hopkins,
24
; figure .). Individuals characterized by preattentive scanning for
threat and a bias toward threatening interpretations of ambiguous events
would be more likely to identify mildly threatening stimuli and to en-
code ambiguous stimuli as threatening. As a result, such individuals would
experience anxiety in response to cues that others do not find threaten-
ing. Moreover, it has been shown that the preattentive scanning for threat
occurs at a relatively early and “automatic” level of information process-
ing, outside of conscious awareness. Hence, the individual may not even
be immediately aware of the triggers of his or her anxiety, experiencing
worry, characterized by a vague sense of dread and apprehension, with-
out even knowing what he or she is worried about! In any event, the au-
tomaticity of this preattentive bias is almost certain to lead to the expe-
rience of worry and anxiety as being intrusive.
25
Evocation of Anxious Propositions
(situation contexts, unexplained
arousal, or other cues)
Figure 2.3
The process of anxious apprehension. Redrawn from Barlow (), with
permission.
26
pression paradoxically increases the accessibility of the unwanted thought,
increasing the likelihood that the individual’s processing resources will
be automatically “recaptured” by the threat cues that initially triggered
the worry episode. This inability to terminate bouts of worry and pro-
vide more than momentary relief, together with the intrusive quality
of the initiation of worry, contribute to the sense of uncontrollability of
worry that appears to distinguish normal worry from worry associated
with GAD.
27
bituation and decatastrophizing processes to operate) or by the formu-
lation of a more or less effective plan for coping with a realistic danger.
Either way, “nonclinical” worriers are able to effectively terminate a bout
of worry.
Tension
Automatic
Trigger threatening Anxiety Dysfunctional
image performance
Verbal
processing
(suppress image)
Distract Worry
Figure 2.4
Model of maintenance of generalized anxiety disorder. Redrawn from Barlow
(), with permission
28
Difficulty in terminating worry or the tendency for tension to heighten
self-focus is likely to interfere with the individual’s ability to concentrate
on other tasks, thereby impairing performance and providing additional
sources of worry. Even when the worry trigger is a realistic danger, the
individual with GAD may not be able to terminate worry long enough
to engage in effective problem-solving. Thus, a third vicious cycle may
begin, as the ineffective problem-solving is taken as further evidence that
stressors are uncontrollable, and as a result, the individual begins to
worry about worrying. In figure ., this aspect of the model is repre-
sented by the step labeled “dysfunctional performance,” which connects
worry back to increases in the experience of negative affect, thereby com-
pleting the last of the three positive feedback loops.
29
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Chapter 3 Outline of the Treatment Procedures and the
Basic Principles Underlying Treatment
There are four primary treatment modules in the MAW workbook. The
first module consists of basic information, instruction, and cognitive re-
structuring. This module is designed to correct faulty information and
misconceptions of the nature, processes, and consequences of anxiety and
worry. Furthermore, cognitive restructuring is designed to foster the recog-
nition and replacement of anxious, negatively skewed styles of thought.
31
overcautiousness and checking and safety behavior are understood to be
motivated principally by the anticipation of a negative outcome or of
levels of anxiety that might impair performance, cognitive restructuring
and relaxation are introduced and practiced before in vivo exposure ex-
ercises and response prevention are conducted.
The first two treatment modules are viewed principally as skills for man-
aging anxiety once it has been elicited. On the other hand, the imagery
exposure, in vivo exposure, and response prevention modules are seen as
the principal vehicles by which control over the initiation of the anxiety
and worry processes is acquired.
Treatment Targets
Individual Variability
The MAW program attempts to apply to the broad range of ways in which
an individual may experience worry, arousal, and avoidance. Given such
large individual differences, not all sections of the program will be en-
tirely appropriate for every client. For example, in vivo exposure to ex-
ternal situations and response prevention of safety behaviors may not be
relevant for everyone. In addition, research at our center and several other
32
centers around the world (Zinbarg, Barlow, Licbowitz, Street, Broadhead,
Katon, Roy-Byrne, Lepine, Teherani, Richards, Brantley, & Kraemer,
), suggested that there may be many individuals who experience
chronic symptoms of anxiety that do not meet the full definitional thresh-
olds for GAD. Some of these individuals primarily experience excessive
worry whereas others primarily experience excessive arousal, even though
their worry is judged to be in proportion to their life circumstances.
Thus, for some sufferers of chronic anxiety, cognitive restructuring may
be less relevant than relaxation, or vice versa. An initial individual re-
sponse profile will be helpful for ascertaining which of the treatment
components will be most useful. Such a profile can be determined by as-
sessing the following areas: excessiveness of worry, degree of arousal and
tension, and patterns of avoidance, including subtle patterns of passive
avoidance of external situations, procrastination, overt or covert safety
or checking behaviors designed to ward off danger, and cognitive avoid-
ance or distraction strategies.
33
person moderates the level of anxiety and, therefore, the most
functional exposure practice would involve gradually working up
toward having the child spend time away from home without
adult supervision. As another example, clients who worry about a
spouse who is late may report much less anxiety when exposed to
their spouse’s coming home minutes late as a planned practice
as opposed to the experience of the same delay that occurs with no
advance notice. Here, the most functional exposure would involve
the client and spouse agreeing to the number of days out of the
week that the spouse will come home late, without the client
knowing which particular days those will be, and gradually in-
creasing how late the spouse will be.
34
entation (cognitive, physiological, and behavioral). Anxiety is
characterized by: () perception or awareness of distant threat,
() chronic tension and hyperarousal, and () cautiousness, pro-
crastination, and interference with performance and the ability
to concentrate on the task at hand. In contrast, fear or panic is
characterized by: () perception or awareness of immediate peril,
() sudden autonomic discharge, and () strong escape or fight-or-
flight urges. Most often, the anxiety experienced by chronic worriers
tends to be focused on various life circumstances, such as family,
health, finances, and role performance. Due to the disruption of
performance that sometimes results from high states of anxiety,
one may worry about becoming anxious. Worry often occurs at a
level of cognitive appraisal associated with awareness, for example,
“I hope my boss doesn’t fire me for not meeting the deadline we
were shooting for,” or “I hope I don’t become so nervous that I’ll
blank out on my lines during the audition,” or at a preattentive
level outside of conscious awareness.
35
Case Example
When she presented for treatment at the center, J was a -year-old mar-
ried woman with two children, aged and years. She reported that
worry and high levels of general anxiety had been a problem for her for
almost as long as she could remember—at least since she left college.
Her two major spheres of excessive worry were concerns about her job
and her family, and she reported having great difficulties controlling her
worry. She described herself as a “perfectionist” and too much of a “people
pleaser.” In the several months just prior to her initial assessment, she had
experienced several stressors, including terminal illness in a close family
member, that contributed to a marked increase in her usual high level of
generalized anxiety. In addition to experiencing long-standing symp-
toms of motor tension, sleep disturbance, and difficulty concentrating,
she reporting experiencing recent physical difficulties, such as irritable
bowel syndrome, temporomandibular joint dysfunction, and possibly, a
spastic bladder. J reported feelings of depression that seemed to come
and go, but did not reach the definitional thresholds for either a major
depressive episode or dysthymia.
Hence, J felt that almost her whole life revolved around the fear of fail-
ure and her attempts to be perfect—the perfect employee, the perfect
mother, the perfect source of comfort and support for her sick relative.
On top of everything else, J was becoming aware of worrying about her
36
high levels of worry! She was worried that she had so much to do that
her worrying would take up too much of her time and prevent her from
accomplishing all that needed to be done.
J underwent our treatment program at the Center for Stress and Anxi-
ety Disorders. Given the initial focus on corrective information, relaxation
training, and cognitive restructuring, J’s initial response was mixed. She
learned the -muscle-group progressive relaxation procedure and ap-
plied it successfully at times to reduce tension at the end of the day and
help her sleep at night. However, she did not always practice the relax-
ation exercises on a regular basis. Thus, she did not progress beyond the
eight-muscle-group procedure to be able to make the relaxation skills
portable enough to use whenever she noticed tension, regardless of where
she was or what she was doing. She did realize that she was vastly exag-
gerating the consequences of not being perfect in many areas of her life.
However, as sometimes occurs, J used this information in a reassuring
way, without fully processing or understanding the role of cognitions.
That is, the information reassured her, but was not adequately incorpo-
rated into her “fear structure.” In fact, she initially found the cognitive
restructuring to be extremely anxiety-provoking as it became apparent
that J had often been accustomed to using distraction from her worries
to cognitively avoid or, in her words, “shut down.” It also became ap-
parent that J employed the safety behavior of overpreparing with respect
to many of her work-related projects. It was not until the imagery expo-
sure and worry prevention phases were implemented that her reactivity
to her worrisome thoughts and their intrusive quality truly diminished.
J’s imagery exposure exercises primarily involved her worries about visit-
ing her dying relative. Her greatest fear in this area was that she would cry
uncontrollably, which would put additional strain and stress on her rela-
tive, worsening his condition and hastening his death. Before beginning
the imagery exposure, even the thought of getting on the train to travel to
his house was almost overwhelming, so we wanted to begin there. In fact,
the thought of doing imagery exposure to the train trip was so anxiety-
provoking that J refused to do the exposure. We took one step further
back and asked her to do imagery exposure to the image of doing im-
agery exposure! Once she got comfortable with the imagery of herself
doing imagery exposure to the train trip and becoming highly distraught
and tearful in front of her therapist, she was willing to expose herself to
37
the imagery of the train trip. After becoming relatively comfortable with
the imagery of the train trip, she progressed to exposing herself to the im-
agery of approaching his house, then entering the house, and finally, en-
tering his room and crying. Her increased tolerance for this worry and
for “holding on to it” rather than distracting herself, or “shutting down,”
allowed her to make great strides in her cognitive restructuring work
with it. As she began to examine her worry content more closely, she was
able to elaborate that, for her, crying uncontrollably meant that she
would cry the entire time she was with him and not be able to talk at all.
Through examination of the evidence, she was able to see that these out-
comes were very unlikely. Identifying the possibility that her relative might
interpret her crying as a sign of how deeply she cared for him helped to
decatastrophize the consequences of crying in his presence. She experi-
enced a decrease in both the frequency of this worry and the anxiety it
elicited as a result of repeatedly practicing the imagery exposures and cog-
nitive restructuring. She eventually came to visit her relative on a regu-
lar basis and felt much better about herself for having done so.
38
of the program, J was reevaluated and found to experience little or no
evidence of the signs and symptoms of GAD.
39
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Chapter 4 The Nature of Generalized Anxiety
41
Session Outline
■ Brief check-in
■ Negotiating an agenda
■ Negotiating homework
Brief Check-in
As the client will not have had any self-help assignments before this ses-
sion, the brief check-in will consist of greetings, a chance for the client
to state how he or she has been feeling recently, and a chance to briefly
review whatever monitoring forms the therapist may have asked the client
to complete prior to this session.
Negotiating an Agenda
For this session, the therapist’s suggestions for agenda items should in-
clude a discussion of the client’s goals for therapy and the client’s expecta-
tions regarding how the therapy will help to achieve his or her goals. The
42
therapist might also suggest that, if time permits, the therapist and the
client can begin to formulate a shared understanding of the factors main-
taining the client’s anxiety, worry, and tension—in other words, a shared
understanding of the processes that they need to target for intervention.
■ The various ways of coping with worry and anxiety, including per-
fectionism, procrastination, and its opposite—putting pressure on
oneself to complete things in unnecessarily short periods—are
43
understandable. However, these approaches tend to diminish one’s
feelings of enjoying life. Moreover, these attempts at coping may
be effective at reducing anxiety in the short run, but often tend to
perpetuate the anxiety and worry in the long run.
44
Negotiating Homework
For this session, the therapist’s suggestions for homework (or self-help,
for those clients who have a negative reaction to the word “homework”)
items should include reading over the appropriate MAW workbook chap-
ter or chapters for the next session and giving more thought to goals for
therapy to add to the goals identified in this session. If the client has al-
ready begun self-monitoring (we typically like to begin self-monitoring
even before the first therapy session, if the logistics can be arranged), an-
other suggestion should be to continue with self-monitoring. Alterna-
tively, if the client has not already begun self-monitoring, but the thera-
pist covers both chapters and from the MAW client workbook in this
session, the suggestion would be to begin self-monitoring.
45
as it contributes to the establishment of a collaborative partnership, shows
openness to discussing problems in the relationship, and demonstrates a
willingness to work through any such problems. In addition, there have
been occasions when our clients have responded to this question with
negative feedback, and we were able to resolve the issue on the spot, if
time permitted, or at the beginning of the following session.
Case Vignettes
Case Vignette 1
T: So, it sounds like you believe that worrying protects you, and you’re
worried about feeling vulnerable by letting down your guard. May I
ask you a couple of questions so that we can look at that belief a little
more closely and evaluate its validity?
C: OK.
T: Have you ever experienced any stressful events that you weren’t able to
foresee and so didn’t worry about in advance?
T: And would you say that you handled any of those situations adequately?
46
C: Not usually, no.
C: Well, there was one time when my boss asked me to make a presenta-
tion at the last minute. Afterward, everyone told me that I did a good
job, and I guess I felt OK about it.
T: Good. And can you think of any times when any member of your
family confronted a stressful situation or a potentially dangerous situa-
tion that you weren’t aware of and didn’t worry about in advance?
C: Yes. Recently, my son took a trip with some of his college friends that I
wasn’t aware of. Usually, I worry a lot before any of my family mem-
bers takes a flight. This time, I didn’t worry because I didn’t even know
he was flying until afterward.
T: So, what do these two examples suggest? Do you always need to worry
in advance for things to turn out OK?
C: No, I guess not. But surely, there must be some times when worrying
helps.
T: I agree that anxiety does serve some adaptive functions. Try to remem-
ber that the goal of this program is not to eliminate any and all anxiety
and worry. Rather, we are going to focus on reducing the anxiety and
worry you experience that is excessive or unnecessary.
Case Vignette 2
47
and usually recedes fairly quickly. Your worry about picking up more
worries, or contagion, is probably related to your current level of anxi-
ety and worry about becoming anxious. As you learn to regulate your
anxious response, the worry of contagion will probably seem less and
less relevant to you.
Case Vignette 3
C: How can such a brief program cure me after I’ve experienced this anxi-
ety and tension for so long? I’ve been a worrier all my life—that’s just
the way I am—so I feel there is no way it can resolve so rapidly.
T: There are a few things to remember here. First, it has often been found
that the duration of an anxiety problem doesn’t necessarily influence the
response to treatment. Instead, it appears that the amount of practice
and involvement you have with the program is most important in
terms of achieving the maximum benefit. Second, this program is
highly skills-oriented, and learning takes place fairly quickly. Third,
and perhaps most important, we don’t expect you to be “cured” at the
end of this short-term program. Rather, I have a different goal in mind
for you, related to the notion that, during this program, you will ac-
quire skills that you can apply on your own. Based on that, can you
imagine what an alternative goal might be, other than that you will be
cured by our last session?
(The therapist appropriately shares some information with the client that the
client is unlikely to have, but also begins to familiarize the client with the
Socratic method and the process of identifying alternatives.)
C: I’m not sure. Maybe that when I finish the program, I’ll know skills
that will allow me to deal with the problems that remain?
48
T: Well, the success rate is very high, but you’re right that not everyone
improves. Do you agree, though, that the high success rate is, in itself,
a reason for you to attempt to carry out the program, or at least to
withhold a final judgment until you have had experience with some of
the exercises and techniques?
Case Vignette 4
T: So, let’s talk some about your goals for our work together. If we’re suc-
cessful, how will your life be different or months from now? Please
try to be as concrete as possible.
C: Well, I think the biggest way in which I hope my life will be different
is that I won’t get so overwhelmed by my anxiety that I get frozen or
stuck. Like now, when I think about what direction to go with my ca-
reer or graduate programs, or when I think about where my relation-
ship with Trevor is heading, or where I should live after my current
lease is up, I just can’t make up my mind. Each direction I think about
gets me worried, and I feel stuck. I even feel frozen when it comes to
cleaning my apartment. The place is so messy that I know I can’t get it
all straightened up in one shot, and that thought gets me so anxious
that I don’t even do any cleaning! I just go and play a video game or
watch TV.
C: Yeah.
T: OK. Are there any other goals, or does that pretty well cover it?
C: Those are the ones that come to mind right now, but maybe I’ll think
of some more later.
T: OK. We can always add to this list as we go. One thing I really like
about what I hear from you is that you are saying that you want to re-
49
duce your anxiety to manageable levels rather than eliminate it entirely.
Some of the people I work with say that they want to get rid of all of
their anxiety, and I have to tell them that, even if that were possible,
we would be doing them a disservice by eliminating all of their anxi-
ety. Can you imagine why I might say that?
(The therapist uses the Socratic method to initiate discussion of the adaptive
functions of anxiety rather than lecturing to the client about something he or
she might already have a good understanding of.)
T: That’s exactly what I’m talking about. In fact, a lot of therapists and
researchers relate anxiety to the functioning of the fight-or-flight re-
sponse. Any ideas what we might mean by that?
Case Vignette 5
C: I can’t think of any times in my life when anxiety was helpful to me.
T: Well, how do you think you would have done on exams if you didn’t
have any anxiety?
T: It sounds like you did experience anxiety that was so high that it dis-
rupted your performance. But I’m not asking you to think about how
you would have done if you had been less anxious; I am asking you to
50
consider how you would have done if you didn’t experience any anxi-
ety whatsoever.
C: I still think I would have done better since I would have been relaxed
while taking the exams.
C: Well, I’m still not sure that I get your point. I was so tense while
studying that I had difficulty concentrating then, too. So I think being
more relaxed while studying would have helped.
T: OK. Let’s try looking at this from a slightly different perspective. Try
to imagine what it would be like for someone else, a student who
doesn’t experience any anxiety at all. Would such a student, a student
who had no concerns about his or her test score, spend a lot of time
studying for tests?
C: OK. He might not have studied much and gotten bad grades. He
might have been playing and loafing off when he should have been
studying.
T: So, is it possible that low levels of anxiety can sometimes help motivate
people to prepare for challenges?
C: Now I think I can see your point. Even though I still can’t think of a
time when my anxiety level wasn’t so high that it got in my way, I
guess that not having any anxiety also would have created some prob-
lems for me. I guess the trick is finding an anxiety level that is some-
where in the middle, huh?
T: Yes, that’s one way of putting it. The implication of this for our work
together is that the overall goal of this program is not to eliminate any
and all anxiety—even if we could do so, we wouldn’t want to. Rather,
our goal is to eliminate excessive anxiety.
Case Vignette 6
C: I don’t think I meet the criteria for the diagnosis of generalized anxiety
disorder. I experience a lot of muscle tension and the other physical
51
symptoms you mentioned, but I don’t really worry all that much. Does
that mean that this program is not right for me?
T: Whether you are a worrier or not, portions of this program are de-
signed to help with the tension and physiological aspects of anxiety
that are troubling you. In addition, you might be experiencing worri-
some thoughts that are so automatic that, ordinarily, you are not even
aware of having them. The program includes techniques designed to
help you identify whether you are experiencing such automatic
thoughts. If you are experiencing automatic anxious thoughts, the
techniques will help you learn a less anxious style of thinking.
Case Vignette 7
C: I definitely worry a lot, but I think my worries are realistic. Does that
mean this program is not right for me?
T: First of all, there are portions of this program that could help you,
even if your worries are not excessive or unrealistic, including methods
to control tension and physiological symptoms of anxiety and tech-
niques for solving real problems. I’d also like to hear more about your
worries. Can you give me an example of one of your biggest worries
that you believe to be realistic?
C: Well, I’ve been very worried about the fact that I’ve been out of work
for the last months. If that isn’t a realistic worry, I don’t know what is!
(The therapist validates the realistic side of the client’s worry and gently probes
further to find out if the worry might be excessive.)
C: I’ve only been able to find temporary office work so far. I worry that
I’ll never find another permanent job.
T: It sounds like your job search has been frustrating so far. And I can
certainly understand how thinking that you’ll never find another per-
52
manent job would make you very anxious. But what evidence do you
have that you’ll never find another permanent job?
(The therapist simultaneously validates the patient’s feelings and gently points
out the link between thoughts and feelings.)
C: I’m not sure, but I think it’s somewhere between and %.
T: And do you know anyone in your field who recently found a job?
C: I heard that someone I used to work with, who was laid off a few
months before me, found something recently.
C: I suppose that’s a possibility. But even if that is the case, I’m not sure
what to do about it.
(The therapist considers it a success to have helped the client acknowledge that
this worry might be excessive, and does not take it further at this time.)
53
count. In addition, a genetic, medical, or chemical explanation is often
seen as being less stigmatizing than a psychological explanation. Conse-
quently, clients initially may be resistant to giving full regard to the in-
formation in the first few sessions, even in the absence of medical evidence
of abnormality. Clients may express the attribution that “I inherited being
high-strung” or attribute their anxiety to a “chemical imbalance” that can-
not be tested.
54
evidence regarding the treatment efficacy of the MAW program
and similar approaches to the treatment of anxiety can be empha-
sized. Examples might also be given of medical problems—such
as stroke and some forms of diabetes—that have known bio-
chemical causes and yet are treated behaviorally.
55
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Chapter 5 Learning to Recognize Your Own Anxiety
■ The need for becoming an observer of one’s own behaviors and re-
sponses to enhance understanding of one’s anxiety and to adapt speci-
fic treatment procedures to one’s personal experience.
Session Outline
■ Brief check-in
■ Negotiating an agenda
■ Discussion of self-monitoring
■ Negotiating homework
57
Brief Check-in
The brief check-in will consist of greetings, a chance for the client to state
how he or she has been feeling recently, a brief review of whatever moni-
toring forms the therapist may have asked the client to complete prior
to this session, and a brief review of how the client made out with any
other homework tasks from the previous session.
Negotiating an Agenda
For this session, the therapist’s suggestions for agenda items should in-
clude a discussion of self-monitoring and negotiation of homework.
Discussion of Self-Monitoring
58
anxiety assists in the development of an awareness of triggers. In
addition, the earlier that clients can identify that their anxiety is
beginning to spiral upward, the more successful they should be in
their efforts to reduce it. A metaphor that might be useful here is
that it is far easier to put out a small brush fire as soon as it starts
rather than waiting until it turns into a raging forest fire.
Negotiating Homework
For this session, the therapist’s suggestions for homework items should
include reading over the appropriate MAW workbook chapter or chap-
ters for the next session, and starting self-monitoring (or continuing doing
so if they have already begun self-monitoring).
Ask the client to summarize any take-home messages or points from this
session that might be helpful. Also, ask the client if he or she had a nega-
tive reaction to anything about the session.
Again, the procedures in this lesson are basically didactic. The notion of
predictability is introduced by suggesting the importance of looking for
precipitants to episodes of anxiety. As chapter in the client workbook
is brief, we typically either combine this chapter with chapter or begin
self-monitoring even before the first treatment session (going over the
points from this chapter at the end of an initial diagnostic assessment and
distributing the relevant forms at that time or discussing them over the
phone prior to the first treatment session and then sending the relevant
monitoring forms through the mail).
59
Case Vignettes
Case Vignette 1
T: For the time being, you may record your level of overall, or average,
anxiety. When you begin to practice confronting situations that you
currently avoid and refraining from the safety-checking behavior in
which you currently engage, you will probably find that episodes of
heightened anxiety will become more frequent. At that point, you can
monitor their decline.
Case Vignette 2
C: Should I record each time I feel anxious? If so, then I’m going to be
filling in the monitoring forms constantly.
T: On the Worry Record, only record those times when you experience a
pronounced increase in anxiety or a change in the major focus of your
worry. Record the degree to which you’re constantly feeling anxious as
part of your average anxiety rating on the Daily Mood Record.
C: But I often start the day feeling really anxious and continue to feel
that way all day long, so I’m still not sure what to do with the Worry
Record.
T: So, do you mean to say that there aren’t some times of the day when
you are more or less anxious than at other times?
C: Well, I guess when I get home from work at the end of the day, I feel
a little more relaxed than at other times. And my anxiety goes up if I
know that my boss is looking for me.
T: So, your anxiety level drops a little when you get home. What about in
the morning? Does your anxiety level rise at any point while you’re get-
ting ready for work?
60
C: Well, I guess when I first wake up, I’m almost too tired to be worried.
It’s usually after I get out of the shower that the anxiety really starts to
build.
T: OK, so on mornings like that, you could begin to fill out a Worry
Record when you get out of the shower. On days when your boss is
looking for you, you could begin to fill out another Worry Record as
soon as you can after your anxiety about that starts to increase.
T: Do you usually try to avoid thinking about how you feel because
you’re worried that thinking about how you’re feeling will raise your
anxiety level?
C: Yes.
Case Vignette 3
T: Certainly, the monitoring will take some time. However, there are a
few things that are important to keep in mind. First, the monitoring,
at this point in the program, should only take a few minutes each day.
Second, excessive anxiety usually creates some inefficiency and inter-
feres with performance. Can you think of any times when this has
been true for you?
61
C: Sure, that’s part of the reason I’m here. I worry so much about getting
a project perfect that I usually take twice as long to complete my work
as my co-workers.
T: In that case, I’d like you to try to remember that the monitoring is es-
sential for change. We can’t change your anxious patterns of respond-
ing if we don’t first understand them and their precipitants. Does that
make sense?
C: Sure.
Case Vignette 4
T: Ok. Let’s take a look at the Daily Mood Record you completed this
week.
62
T: Wow! It looks like you’ve had a very anxious week! You rated most
days a on both overall anxiety and maximum anxiety.
C: Yeah, that’s pretty much how things have been going lately.
T: OK. Well, let me ask you a question about this week. I know it was a
bad week for you, but I am wondering if some days or times might
have been even worse than others?
(The therapist asks about whether there were even worse times rather than
asking about some less anxious moments, as he hypothesizes that the client
may have filled out the Daily Mood Record the way he had to make sure that
the therapist understood how bad off the client was. Therefore, the client
might be reluctant to talk about more relaxed moments right away.)
C: Yeah, Gina and I had a big fight on Monday night, and that night and
most of Tuesday, I was even more anxious than usual, thinking that I
wasn’t being a good husband and that Gina would leave me.
T: I’m sorry to hear about that. Bad fights can be very distressing. Now
what I would like you to do is think about our - to -point scale
such that Monday night and Tuesday would be points. OK?
C: Yeah.
T: Good. Now let’s go back and re-rate the last day or two, keeping in
mind that Monday night and Tuesday, after the big fight with Gina,
were rated as . So, if Monday night was , the maximum anxiety
rating for Monday would be . Since it wasn’t quite that bad earlier
on Monday, what would you now say was your overall anxiety level on
Monday, averaged across the whole day?
C: Well, if you look at it that way, I guess the rest of the day would have
been an , so maybe for the overall rating that day.
T: Good. Now, how about yesterday? If your overall rating for Tuesday
was , what would you now say was your overall anxiety level yester-
day, averaged across the whole day?
C: Well, it was about like Monday was before the fight, so I’d give it an .
63
Daily Mood Record for James
Daily Mood Record
Rate each column at the end of the day, using a number from the - to -point scale below.
Wednesday 60 90 70 70 65
9th
Some clients profess that they have neither the time nor the energy to
complete the monitoring forms. If lack of time or energy is due prima-
rily to lack of motivation, then it would seem reasonable to assume that
the client’s level of motivation for completing the treatment program is
relatively low. If this is the case, then the therapist might try using tech-
niques from Miller and Rollnick’s approach, as described in Motivational
Interviewing (). Thus, the client can be asked to rank a set of values
according to their order of importance. The therapist would then ask
how the client’s anxiety, worry, and avoidance or safety behaviors relate
to the values of greatest importance to the client. The therapist could
64
Worry Record
Worry Recordfor James
Date: Wednesday 9th Time began: 5:00 (../..) Time ended: 5:00 (../..)
Easily fatigued
Irritability
Muscle tension
Sleep disturbance
Anxious thoughts: Too much to do, won’t get everything finished, boss will be mad at me
Anxious behaviors: Tried to watch TV to keep my mind occupied, but I continued to worry
then ask the client to engage in a “decisional balance” exercise. In the de-
cisional balance exercise the client first writes on the left side of a page
all of the reasons for not wanting to participate in the program. Next,
the client writes all of the reasons for wanting to participate in the pro-
gram. When the therapist reflects these motivations back to the client, it
is recommended to begin with the reasons for participating in the pro-
gram and finishing with the reasons for not participating. The idea here
is that, if the client has a “yes, but” style, the buts will tend to be directed
at the points the therapist concluded with, and it is preferable for their
65
“yes, buts” to be directed at the reasons for not participating. If these
techniques do not have the desired effect of building internal motivation
to change and participate in the program, then the therapist might sug-
gest that now is not the best time to undergo this type of time- and
effort-intensive program.
In other cases, as reflected in case vignette , the client may avoid moni-
toring because he or she fears that the process of monitoring will increase
anxiety levels. In response to this worry, the possibility, at least initially,
of becoming more anxious should be acknowledged, but the usual de-
crease in anxiety over time is to be emphasized.
If clients state that they know how they feel and, therefore, regular moni-
toring and recording is unnecessary, it is useful to ask whether there are
any times when the anxiety seems to occur unexpectedly, or without aware-
ness of the triggers. If so, the potential benefit of close monitoring to
identify precipitants should be pointed out. Common examples of such
triggers might be news reports or newspaper articles and comments made
by friends, from which the client later overgeneralizes or makes personal
references. In any case, monitoring records provide systematic and rela-
tively objective evidence for later assessment of change. In addition, the
evidence regarding the extent to which retrospective recall is skewed,
particularly in ways that may enhance the anticipation of future anxiety,
can be repeated.
Finally, some clients may need ongoing corrective feedback and repeated
instruction regarding the method of monitoring, due to lack of under-
standing. For example, on rare occasions, we have worked with some
clients who recorded overall anxiety levels in the Daily Mood Record that
exceeded their corresponding maximum anxiety level ratings. We have
also worked with some clients who recorded scores of for both over-
all anxiety and maximum anxiety every day the first week they used the
Daily Mood Record. In such cases, it can be useful to ask the client whether
there were some times or days that week when he or she felt even more
anxious than at other times or days, as in case vignette . If the client is
able to identify a “worst” time or day, then the therapist would ask the
client to use that day or time as the anchor point for a rating of
points, and then to go back and reevaluate at least some of the other rat-
ings, with that anchor point in mind.
66
Chapter 6 The Purpose and Function of Anxiety
■ Introduction to the idea that anxiety and panic states consist of three
primary response systems: physiological, cognitive, and behavioral.
This is not a description of the etiological factors involved in the de-
velopment of an anxiety disorder. Rather, the focus is on a description
of the phenomenology of anxiety states. The physiological component
is said to be based on central and autonomic nervous system arousal.
The cognitive component consists of thoughts, beliefs, self-statements,
or images associated with perceived danger and uncontrollability. The
behavioral component is manifested as avoidance (including procrasti-
nation), checking and safety behavior, or disruption of performance.
67
■ Description of the ways in which the three response components inter-
act to escalate or reduce anxiety. The interaction of cognition, physiol-
ogy, and behavior is offered as a cause of increased or decreased inten-
sity of any emotion at any given time.
Session Outline
■ Brief check-in
■ Negotiating an agenda
■ Negotiating homework
68
Brief Check-in
The brief check-in will consist of greetings, a chance for the client to state
how he or she has been feeling recently, a brief review of the Worry Record
and Daily Record monitoring forms, and a brief review of how the client
made out with any other homework tasks from the previous session.
Negotiating an Agenda
For this session, the therapist’s suggestions for agenda items should in-
clude a discussion or review of the nature of anxiety and fear, a discus-
sion of the components of anxiety, and negotiation of homework.
69
ety is viewed as a “priming” of the fight-or-flight response in
preparation for future danger. It is assumed that clients can learn
to distinguish between fear and generalized anxiety on the basis of
accurate descriptions of the response components (physiological,
cognitive, and behavioral) that are characteristic of the respective
states.
It is important that the following three points are included in this dis-
cussion.
70
Sequence of Anxiety
Anxiety Components Components for a Recent Episode of Anxiety
for James
Negotiating Homework
For this session, the therapist’s suggestions for homework items should
include reading over the appropriate MAW workbook chapters for the
next session, continuing self-monitoring using the Worry Record and the
Daily Mood Record, and completing an Anxiety Components form
and a Sequence of Anxiety Components for a Recent Episode of Anxi-
71
ety form for every episode of anxiety recorded on a Worry Record (or, at
least, for several episodes).
Ask the client to summarize any take-home messages or points from this
session that might be helpful. Also, ask the client if he or she had a nega-
tive reaction to anything about the session.
72
Case Vignettes
Case Vignette 1
C: Sometimes I worry that I’ll get so anxious that I’ll go crazy. Does that
ever happen to anyone?
T: Many people believe that they are going crazy when they are experienc-
ing high levels of anxiety. They are most likely referring to the severe
class of mental disorders known as the psychoses. Let us look at psy-
chosis to see how likely that is. Psychoses are characterized by such
severe symptoms as disjointed thoughts and speech, sometimes extend-
ing to nonsensical speech; delusions, or strange beliefs; and hallucina-
tions. An example of strange beliefs might be that one’s thoughts are
being controlled by beings from outer space, and an example of hallu-
cinations might be hearing voices when no one else is there.
Psychosis runs strongly in families and has a genetic basis, so only a cer-
tain proportion of people can become psychotic, and in other people, no
amount of stress will cause a psychotic disorder. Another important
point is that people who have schizophrenia, the most common form of
psychosis, usually show some mild symptoms for most of their lives (such
as unusual thoughts or flowery speech). Thus, if you have not shown
these symptoms and there is no history of psychosis in your family, then
it is extremely unlikely that you will become schizophrenic. This is es-
pecially true if you are over years of age since schizophrenia generally
first appears in the late teens to early twenties. Finally, if you have been
through interviews with a psychologist or psychiatrist, then you can be
fairly certain that you would know by now if you are likely to become
schizophrenic.
Case Vignette 2
73
T: Automatic negative thoughts are a characteristic of the kind of prob-
lem that you’re experiencing and may explain why anxiety sometimes
seems to occur, even when you are unaware of being worried. When I
use the term “automatic” when referring to some negative thoughts, do
you have some ideas about what I might mean?
C: What comes to mind for me is that you’re talking about ways of think-
ing that have become a habit for me.
T: That’s part of what I have in mind, yes. At the same time, “automatic,”
to me, also means that you might have a thought, but not be con-
sciously aware of it—perhaps because you have had the same thought
so many times before. For example, when you came into my office,
were you aware of having the thought “Oh, that’s a chair. A chair is for
sitting on. I’ll sit down there.”?
C: No, of course not. I just saw the chair and sat down on it.
T: Exactly, but does that mean that your brain isn’t still analyzing the
situation, recognizing the chair as something for sitting on, and send-
ing the appropriate commands to your legs and muscles? Or might it
be that, because you have seen and sat on so many chairs before, your
brain still assigns meaning to the chair and issues commands to sit, but
this happens automatically, without your awareness, so that you can
devote your attention to thinking about other things, like what you
want to put on the agenda for today’s session?
C: It makes sense that my brain is still working like you said, without me
being aware of it. So, you are saying that sometimes, even when I’m
not aware of being worried about something, I might have had an au-
tomatic worry?
T: Exactly. Over the next few sessions, we’ll discuss automatic thoughts in
more detail. How about if, for now, we go back to concentrating on
understanding the three response components that are usually present
once anxiety has heightened?
74
Case Vignette 3
T: It’s not necessarily the symptoms that are adaptive for survival, but the
processes that underlie the symptoms. One might experience various
sensations or reactions as a by-product of high levels of arousal. Diffi-
culty concentrating is often the by-product of the mind’s tendency to
scan the environment for possible signs of threat, when in an anxious
state, making it difficult to concentrate on the task at hand. Similarly, a
pounding or racing heart may be the by-product of increased activity
in the cardiovascular system, which is pumping blood more efficiently
to the muscles as part of preparation for a threat reaction. Under con-
ditions of real danger, those particular sensations may not be the focus
of attention. For example, imagine that you are deeply engrossed in a
project at work or at home, when you suddenly hear an announcement
on the radio warning of a possible tornado or flood in several hours.
You are not likely to be distressed by the fact that the anxiety you expe-
rienced shifted your attention to thoughts of preparing for the storm
and interrupted your concentration on the project you were working
on. On the other hand, when you experience anxiety in the absence of
real danger, you are likely to be more distressed by and aware of diffi-
culty concentrating on the task at hand. Moreover, by attending to any
symptoms that you find distressing, such as difficulty concentrating,
your anxiety may increase, possibly intensifying the symptoms.
75
worried about. The notion of automatic thoughts is explained in more
detail in workbook chapter . In chapter of this book (which corre-
sponds to workbook chapter ), we also discuss some demonstrations, or
“behavioral experiments,” that a therapist can do with a client to let the
client experience automaticity and the impact of automatic thoughts on
mood. For a client whose doubt about automatic thoughts is so strong
that it threatens to undermine the credibility of the entire program, it
might help to conduct these demonstrations, now rather than waiting
for chapter (workbook chapter ).
Some clients may understand the main points discussed about the com-
ponents of anxiety and the sequence of the components, but get confused
at home and have difficulty completing the Anxiety Components form
or the Sequence of Anxiety Components for a Recent Episode of Anxi-
ety form on their own. To minimize the likelihood of this occurring, we
strongly recommend that the client complete a version of each of these
forms (and all other forms introduced hereafter) in session, with the
therapist serving as a coach.
76
Chapter 7 A Closer Look at Generalized Anxiety Disorder
77
Session Outline
■ Brief check-in
■ Negotiating an agenda
■ Negotiating homework
Brief Check-in
The brief check-in will consist of greetings; a chance for the client to
state how he or she has been feeling recently; a brief review of the Worry
Record and Daily Mood Record monitoring forms; and a brief review of
how the client made out with any other homework tasks from the pre-
vious session.
Negotiating an Agenda
For this session, the therapist’s suggestions for agenda items should in-
clude a discussion of the factors maintaining excessive levels of anxiety
and worry, a discussion of the rationale for the treatment program, and
negotiation of homework.
78
■ The role of inherited traits underlying excessive anxiety and worry.
Some people may have a general physiological sensitivity that is
inborn or hereditary. From the available research literature, it ap-
pears that high levels of physiological arousability or lability may
contribute to the vulnerability to an anxiety disorder.
. The belief that worry always decreases the likelihood that negative
events will occur in the future
79
It is also important that clients understand that each of these factors is
mutable, so that the vicious cycle of anxiety may be broken. In fact, each
of these processes is targeted by one or more of the treatment compo-
nents in the MAW program.
Negotiating Homework
For this session, the therapist’s suggestions for homework items should
include rereading chapter several times, reading over other appropriate
MAW workbook chapter or chapters for the next session, continuing
self-monitoring using the Worry Record and the Daily Mood Record.
Ask the client to summarize any take-home messages or points from this
session that might be helpful. Also, ask the client if he or she had a nega-
tive reaction to anything about the session.
80
experiencing. Thus, this lesson consists of corrective information, but no
specific exercises are introduced at this point.
Case Vignettes
Case Vignette 1
C: Does being physiologically sensitive mean that I’ll always have more
anxiety than other people?
Case Vignette 2
81
disorders may be related to what is learned while growing up in a fam-
ily. In any case, the majority of children with anxious families do not
have anxiety disorders.
Case Vignette 3
C: You know, I can’t remember a time when tension and worry weren’t a
problem for me. I’ve been a worrier all my life. So I can’t say that I can
put my finger on any particular stresses that brought on my problem.
Will I be able to learn to control my excessive anxiety if I can’t figure
out what initially caused it?
Case Vignette 4
C: I don’t understand why you say that distracting myself from negative
images contributes to my anxiety problems. I’ve always felt that dis-
tracting myself is one of the few ways I’m able to give myself some
relief.
82
and said, “Don’t think about a white elephant, or else I’ll pull the
trigger?”
C: Sure. The harder you try not to think about the elephant, the more
likely it is that you will.
T: Right, and the same is true for worries. So, if you try to resist your
worrisome images, it’s as if I’m holding a gun to your head and telling
you not to worry or else I’ll pull the trigger. You might succeed at
distracting yourself temporarily. However, you’ll be even more likely
to experience that image in the future than if you didn’t distract your-
self, and the image is likely to be just as anxiety-provoking in the fu-
ture, since you didn’t evaluate it objectively in the past. Does that
make sense?
Case Vignette 5
C: Maybe I do see the world as it really is. Just look at the news reports,
and you’ll see that there are terrible events every day—and it’s getting
worse.
C: Well, yes, I guess so. My boss recently left a message saying that he
wanted to see me. I thought he was going to chew me out and maybe
even fire me. With all the reports of people being laid off in the news-
papers lately, I was really worried about it. But it turned out that he
just wanted to explain a new project that he wanted me to start work-
ing on.
83
T: So, would you agree that, in that instance, you were seeing more dan-
ger in the situation than was actually there?
C: In that situation, yes, but there have been plenty of times when my
worries proved to be warranted.
T: Then our task is going to be to look very closely at your worries and
evaluate them in an objective manner, to decide which are valid and
which might be excessive and in need of modification. OK?
C: OK.
Sometimes clients report that, because they have worried for so long,
they no longer believe that their worries might come true (e.g., being fired
or being criticized by in-laws or friends for the house being messy). How-
ever, they still feel very tense and anxious. In these cases, it is important
to evaluate whether the clients engage in any behaviors to prevent these
worries from coming true (see workbook chapter and chapter in this
book). If so, questioning what they think might happen if they didn’t
engage in these behaviors often helps to promote recognition of con-
cerns that the worries might come true if they were to relax and let their
guard down.
84
Chapter 8 Learning to Relax
85
The mental component involves concentrating on the sensations that
are experienced as a result of muscle tensing and releasing. Concentrat-
ing on the sensations aids the development of the ability to control
bothersome thoughts. It also allows for a more detailed mental repre-
sentation of the experience of deep relaxation that will be helpful
when implementing the final phase of relaxation training—the recall-
relaxation procedure.
Session Outline
■ Brief check-in
■ Negotiating an agenda
■ Negotiating homework
Brief Check-in
The brief check-in will consist of greetings, a chance for the client to
state how he or she has been feeling recently, a brief review of the Worry
Record and Daily Mood Record monitoring forms a chance to answer
questions and discuss objections to the material covered in chapter ,
and a brief review of how the client made out with any other homework
tasks from the previous session.
86
Negotiating an Agenda
For this session, the therapist’s suggestions for agenda items should in-
clude introducing progressive muscle relaxation training and negotiation
of homework.
■ There are many methods used for relaxation. If the client has al-
ready found an effective technique that is easily portable, he or she
may decide to continue to use that procedure rather than learn the
Jacobsonian procedure presented in the MAW workbook. If he or
she has tried the Jacobsonian technique in the past, without good
results, this does not necessarily mean that the procedure will not
work now. Together with the therapist, the client may be able to
identify aspects of the way the client had been conducting the ex-
ercise that diminished its effectiveness. One example of such a fac-
tor would be implementing the technique with an added sense of
pressure and urgency, such as “I have to relax or else . . .”
87
■ Initially, the relaxation exercises are relatively lengthy, requiring
about or minutes to introduce the -muscle-group proce-
dure in session and about to minutes to implement it there-
after, and for this reason, they would be difficult to apply in many
situations. However, the exercises will be modified gradually to
increase their portability and, hence, their applicability across a
broader range of everyday situations. In addition, in our recent
trial of the major components of the MAW program, we began
with the eight-muscle-group procedure (outlined on p. ‒ of
the MAW workbook) rather than the -muscle-group procedure.
Our goal in doing so was to shorten, by at least a week, the time it
would take to reach the highly portable one-step relaxation proce-
dure. Our plan was to revert to the -muscle-group procedure for
any client who did not obtain an adequate relaxation response to
the initial eight-muscle-group procedure. In fact, only one of
clients reported noticeable tension remaining after the eight-muscle-
group procedure, and that client was instructed to begin practic-
ing the -muscle-group procedure at home, rather than the eight-
muscle-group procedure.
Negotiating Homework
88
session, continuing self-monitoring using the Worry Record and Daily
Mood Record, and practicing the progressive muscle relaxation exercise
(it would be ideal for the client to practice progressive muscle relaxation
twice daily).
Ask the client to summarize any take-home messages or points from this
session that might be helpful. Also, ask the client if he or she had a nega-
tive reaction to anything about the session.
Also, some clients, particularly those who also experience panic, may
find the relaxation exercises anxiety-provoking. This may be the result of
focusing attention on muscular tension or fear of losing control and equat-
ing the release of relaxation with loss of control.
89
Case Vignettes
Case Vignette 1
T: At this time, what’s most important is for you to simply learn how to
do the relaxation exercise. After you gain confidence in your ability to
relax in a relatively brief period of time, then you can begin to apply
relaxation as a technique for managing anxiety-provoking situations.
Case Vignette 2
T: Yes, there are a few common sense precautions. If you wear contact
lenses, it’s best to remove the contacts before beginning the exercise
since it entails squeezing your eyes tightly together. If you have lower
back pain, it’s a good idea to use some kind of support behind your
lumbar region. If you have temporomandibular joint dysfunction, or
pain around the jaw, then it’s best not to tighten those particular
muscles. In other words, it’s important to remember that we don’t
want to induce pain.
Case Vignette 3
T: Try not to struggle against them. Just let them run their course. Try to
imagine that the distracting thoughts are like clouds being blown
across the sky by a breeze, and let them pass at whatever pace the
breeze happens to be blowing them. Once the distracting thoughts
have passed, bring your attention back to the physical sensations you
90
are experiencing. With practice, your ability to concentrate on the ex-
ercise will gradually increase.
Case Vignette 4
T: The tensing component is included for two reasons. First, imagine ten-
sion and relaxation as being on a pendulum. The further you pull the
pendulum one way, the easier or more likely it is that it will go the
other way when you release it. So, releasing tension enables relaxation
to occur more easily. Second, the tensing component helps you to dis-
criminate between states of relaxation and tension. Hence, during your
daily activities, you will become better able to detect more and more
subtle increases in tension throughout your body, for use as a signal to
apply relaxation exercises and the other coping techniques we will in-
troduce. You can think of it as it being easier to put out a brushfire
than a raging forest fire, and we are trying to catch your anxiety se-
quences while they’re still just brushfires.
Sometimes clients find that the relaxation exercises lack credibility, point-
ing out that, if simply telling themselves to relax were effective, then they
would have no need for help from a therapist. Thus, for these clients, the
exercise seems more like a gimmick than a somatic control technique.
Because progressive muscle relaxation exercises have been used with good
results in many cases, clients can be asked to withhold any such judg-
91
ments until they have tried the exercise for themselves. In addition, it
should be emphasized that this technique does not merely involve telling
oneself to relax, but rather involves the acquisition of new skills. Thus,
like any other skilled activity, it requires practice and time to master. Al-
though it should be acknowledged that immediate benefit is not likely,
it should be noted that the potential long-term benefits may justify the
practice required.
Some clients report that, if they schedule a practice just before bedtime,
they fall asleep before completing the exercise. Though this is a good in-
dicator that they are finding the exercise relaxing, these clients should be
encouraged to schedule their last practice at another time of day, when
they are not so tired, to get the benefit of working with each of the muscle
groups included in the procedure.
92
Chapter 9 Controlling Thoughts That Cause Anxiety:
I. Overestimating the Risk
■ Description of the two types of cognitive errors that often occur dur-
ing states of anxiety and that serve to increase anxiety further. The first
of these cognitive styles, probability overestimation, is defined in more
detail in this chapter. Probability overestimation is defined as over-
estimating the likelihood of the occurrence of a negative event. Ex-
amples of probability overestimatations, based on his or her own
experiences, are obtained from the client.
93
■ Methods of questioning probability overestimatations by identifying
alternative predictions or interpretations and using evidence-based
analysis.
Session Outline
■ Brief check-in
■ Negotiating an agenda
■ Negotiating homework
Brief Check-in
The brief check-in will consist of greetings, a chance for the client to
state how he or she has been feeling recently, a brief review of the Worry
Record and Daily Mood Record monitoring forms, a review of progres-
sive muscle relaxation homework, and a brief review of how the client
made out with any other homework tasks from the previous session.
Negotiating an Agenda
For this session, the therapist’s suggestions for agenda items should in-
clude discussion of advancing in the progressive muscle relaxation train-
ing exercises; introduction of cognitive restructuring, with a focus on
probability overestimation; and negotiation of homework.
94
Moving Forward with Progressive Muscle Relaxation Training
If the client has obtained good results from the progressive muscle re-
laxation training practice during the past week, the therapist should in-
struct the client to begin practicing the next phase of the relaxation mod-
ule. If the client began with the -muscle-group procedure, he or she
should begin practicing the eight-muscle-group procedure at home; if the
client began with the eight-muscle-group procedure, he or she should
begin practicing the four-muscle-group procedure at home. If the client
was not achieving good results from the practice during the past week,
he or she should continue to practice the same procedure for the com-
ing week.
95
feel that they do not have evidence that their feared catastrophes
are unlikely, given that they have often engaged in behavior that
they believe is responsible for preventing the catastrophes. It is im-
portant to question the actual need for these protective behaviors,
rather than viewing these past experiences as an indication of the
value of the protective behavior. That is, clients are helped to
understand that their worry would not have come true, even if
they had not engaged in the protective behavior.
Negotiating Homework
For this session, the therapist’s suggestions for homework items should
include reading over the appropriate MAW workbook chapter or chapters
for the next session, continuing self-monitoring using the Worry Record—
96
Real Odds form and the Daily Mood Record, practicing the progressive
muscle relaxation exercise (it would be ideal for the client to practice pro-
gressive muscle relaxation twice daily), and using the Worry Record—
Real Odds form and the Pie Chart form to practice cognitive restruc-
turing as often as possible when anxious episodes occur.
Date: Tuesday 22nd Time began: 3:30 (../..) Time ended: 8:00 (../..)
Easily fatigued
Irritability
Muscle tension
Sleep disturbance
Alternative possibilities: I usually get things done & even if I don’t get it finished, chances are low that I
Anxious behaviors: Irritable, called home and told husband I would be late
97
Others may There is no absolute
like the choice right or wrong
I made choice
I will make
Others are
the wrong choice;
unlikely to judge me
I will be viewed
as being dumb just because
as being dumb
of the car I buy
Others may have no
Others won’t be as
opinions of
concerned about what
significance about
car I buy as I am
cars
Ask the client to summarize any take-home messages or points from this
session that might be helpful. Also, ask the client if he or she had a nega-
tive reaction to anything about the session.
98
suring information. For instance, therapists should ask clients what their
most recent job evaluation revealed, instead of simply telling them that
they will not be fired. Likewise, therapists should ask clients how many
times other people have commented on how crazy they look or how
often their family members have been involved in driving accidents, in-
stead of telling them that no one thinks that they’re crazy or that their
family members will not have accidents. Contrasting statements can also
be useful to accentuate the principle of probability overestimation. For
instance, therapists may respond to clients’ statements that their chil-
dren will be kidnapped the next time they are playing outside, by saying,
“So, your children must have been kidnapped several times already?” If
a strong alliance has not already been established or if the client does not
have much of a sense of humor about himself or herself, the therapist
might respond by saying, “So, what evidence do you have that this will
happen?” By modeling the method of asking relevant questions, thera-
pists begin to teach clients how to question evidence appropriately.
When cognitive restructuring is first introduced, the therapist will prob-
ably need to be quite active, not only asking relevant questions, but also
sometimes supplying alternative, balanced thoughts or sources of evi-
dence when the client draws a blank or overlooks important sources of
evidence. Over the course of the remaining sessions, however, the thera-
pist should gradually reduce his or her contributions to the restructur-
ing and explicitly encourage the client to internalize the skills. For ex-
ample, over time, the therapist can begin to ask, “Can you imagine what
questions I might ask you to consider about this?” rather than “What is
the evidence for that?” or “What is an alternative to that thought that is
more balanced?”
99
tions. This is an important implication to communicate to minimize the
likelihood that the client will perceive the therapist as labeling him or
her as “irrational” or “crazy.”
Over the years, we have also found that it is best to pick a topic to re-
structure together in session, for an initial demonstration of the tech-
niques that will heighten the client’s anxiety, if he or she focuses on it.
Of course, if the client will become anxious again when focusing on the
worries from a past anxious episode, then it will work just fine in this re-
gard. The important point to keep in mind is first to ask the client if he
or she is likely to become anxious again when focusing on a particular
past anxious episode. There are at least three advantages to working with
a “hot” topic rather than applying the technique to an anxiety episode
that happened in the past and is no longer “hot.” First, given the state
dependency principle discussed earlier, automatic thoughts can some-
times be difficult to access when they are “cold.” Second, the client gets
some practice in taking a more balanced perspective, even when anxious,
making it more likely that he or she will be able to break out of the neg-
ative bias associated with anxiety and be able to consider disconfirming
evidence and alternative thoughts when applying the techniques outside
of the session. Finally, if the therapist gets a subjective units of distress
rating, both before and after applying the cognitive restructuring tools,
then there will be an opportunity to see if the techniques were at all
helpful to the client. This opportunity is obviously lost if the restruc-
turing is applied to a worry that does not arouse anxiety during the ses-
sion, as it will be difficult to observe anxiety reduction due to a low ini-
tial subjective units of distress rating.
100
Case Vignettes
Case Vignette 1
C: It’s simple to ask myself these questions now, but I don’t have a chance
of thinking rationally when I’m feeling really nervous.
T: As with the other skills we’ve practiced, or any skill, for that matter,
modification of your self-statements takes practice to become effective
as a tool. Initially, it may be difficult for you to apply this strategy at
the height of anxiety, but with practice and rehearsal, it will become
more natural and easier to apply. Also, I think the forms, like the
Worry Record—Real Odds form and the Pie Chart form we filled out
today, contain some helpful reminders of the questions. Consequently,
at least in the beginning, I strongly encourage you to actually fill out
the forms when you’re trying to apply the skills when you feel anxious.
Once you’ve mastered the skills and the questions start to become sec-
ond nature, you’ll probably be able to do the cognitive restructuring in
your head, without having to write it all down.
Case Vignette 2
C: You say that I should put my worries that my wife will have an acci-
dent on a scale of probability. What exactly do you mean by that?
T: I mean that the next time she’s late coming home and you think she
might have gotten into an accident, I want you to judge the actual
likelihood that she had an accident, given all of the evidence you can
gather, which is rated on a scale of (not at all probable) to (will
definitely occur). What is the actual likelihood that she will be in an
accident?
T: So, that means that, out of every times she’s driven somewhere, she’s
had one accident?
101
C: Well, no. She’s only had one accident in all the years she’s been driving.
Case Vignette 3
C: I didn’t have enough time to practice the relaxation exercises. How im-
portant is it really to practice them regularly?
Case Vignette 4
102
mind wasn’t still issuing those commands to your limbs? No, and if
you wanted to teach someone else how to drive a stick shift, you could
make the process very conscious again. So, what you need to do is to
start paying more attention to what’s going through your mind when
you are feeling anxious. When you first notice an increase in anxiety
or tension, the first thing I want you to ask yourself is, “What am I
thinking about?” Just like any other skill, identifying your automatic
thoughts is something that will improve over time. In the meantime,
when you get stuck and draw a blank, let your imagination run free.
Try to imagine what negative event you might have been predicting,
and try to examine and challenge whatever predictions enter your mind.
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experienced readers, such that the individual does not recognize each of
the f s in the word “of.” If you have some doubts, we encourage you to
try this demonstration on colleagues or friends first.
104
ety. In response to this situation, the therapist should acknowledge the
possibility that identifying automatic thoughts may initially increase anxi-
ety. However, the therapist should also emphasize that identifying the
thought in detail is necessary to challenge it effectively. We have often
found a golf analogy to be helpful in illustrating this point. The identi-
fication of automatic thoughts is analogous to locating the flags in the
holes on a golf course. While successfully locating the flag does not guar-
antee that the golfer will get the ball in the hole, the golfer doesn’t have
a prayer without it. He or she might not even know what direction to
go! Similarly, while identifying an automatic thought does not guaran-
tee anxiety reduction, the client doesn’t have a chance at successful cog-
nitive restructuring without doing so.
105
Three problems sometimes come up during a discussion of probability
overestimation. First, some clients state that, although they know that the
likelihood of a negative event is remote, they are still afraid in the event
that the negative event does happen. Second, clients might state that they
are fully aware that their worry is excessive when they are relatively calm,
but they are convinced that the threat is real when in the midst of an epi-
sode of worry. Third, occasionally, clients have experienced the outcome
about which they are worried, such as losing a job, being rejected, or
feeling embarrassed.
First, if the therapist has not already done so, an attempt should be made
to quantify the client’s estimate of occurrence on a - to -point scale.
As reflected in case vignette , it is possible that the client is still making
a probability overestimate, even though he or she states that the chances
are “slim.” In case vignette , the client estimated that the likelihood of
an accident was %, which might be regarded as slim, even though it is
still an overestimate, based on the actual evidence. If the numerical prob-
ability estimate is still somewhat of an overestimate, an evidence-based
analysis should be used again. On the other hand, the client may not be
overestimating at all, but rather, the emotional response may be prima-
rily the result of catastrophizing about the outcome. In these cases, the
therapist may use decatastrophizing, as discussed in the next chapter. Al-
ternatively, the therapist may suggest that the next chapter will cover an-
other type of anxious cognitive style and restructuring strategies that may
be more relevant for the particular worry in question. When choosing
this strategy, the therapist would then refocus the client on identifying
probability overestimates in other worries, for the time being.
Second, the therapist should explain that the state dependency of cog-
nitions is a very common feature of anxiety. That is, many people are
able to recognize that their worries are irrational, when feeling relatively
calm. However, the interaction among the different response systems is
happening in a way that leads to anxious thinking styles when nervous.
This is why the treatment concentrates on breaking the association be-
tween certain thoughts and thought processes and feeling anxious and
tense. In addition, we have often found it useful to adopt a “Gestalt-like”
approach with clients, and talk with the client about the multiple
“selves,” or aspects, within each one of us. The client’s goal then is to fa-
cilitate communication and debate between his or her “rational self ” and
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“fearful self,” during episodes of heightened anxiety. In doing so, it is
important that the “rational self ” does not simply tell the “fearful self ”
to shut up and stop being silly. To emphasize this point, the therapist
may ask the client to consider what would happen if he or she told his
or her frightened children to shut up and stop being silly—they might
stop talking about the fear, but begin to cower under their bed! In a simi-
lar manner, telling oneself to stop being silly when anxious may suppress
conscious awareness of threatening thoughts, but does not diminish their
ability to provoke anxiety. Rather, the client should be encouraged to
draw on his or her rational side, during times of heightened anxiety, to
reason and debate with the more fearful and irrational side. In addition,
concern about being convinced that the threat is real when anxious might
also involve a component of doubt that the client will be capable of re-
structuring and adopting more balanced perspectives when anxious. This
can be prevented or addressed, when it does arise, by following our ear-
lier recommendation to identify a hot topic in session that raises the client’s
anxiety, and then restructure to it to provide evidence and hope that the
techniques can work when anxious.
Finally, on occasion, a client will report that his or her worst worry has
come true in the past—he or she has lost a job or felt rejected by a ro-
mantic interest. In these cases, the therapist may try to help lead the
client to the realization that the chances of that event happening again
are small (e.g., “Of all the times you have worried that you would be fired,
how many times has it actually happened?”). Alternatively, if the client ap-
pears to be catastrophizing about the event, the therapist may want to
use decatastrophizing strategies or suggest that they reprocess the worry
during the next sessions when they will be discussing decatastrophizing
in detail.
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Chapter 10 Controlling Thoughts That Cause Anxiety:
II. Thinking the Worst
Session Outline
■ Brief check-in
■ Negotiating an agenda
109
■ Moving forward with progressive muscle relaxation training
■ Negotiating homework
Brief Check-in
The brief check-in will consist of greetings; a chance for the client to
state how he or she has been feeling recently; a brief review of the Worry
Record—Real Odds, Pie Chart, and Daily Mood Record forms; a re-
view of the progressive muscle relaxation homework; and a brief review
of how the client made out with any other homework tasks from the
previous session.
Negotiating an Agenda
For this session, the therapist’s suggestions for agenda items should in-
clude discussion of advancing in the progressive muscle relaxation training
exercises, continuing with cognitive restructuring, with a focus on cata-
strophic thinking; and negotiation of homework.
If the client has obtained good results from the progressive muscle re-
laxation training practice during the past week, the therapist should in-
struct the client to begin practicing the next phase of the relaxation mod-
ule. Clients who were practicing the eight-muscle-group procedure should
begin practicing the four-muscle-group procedure at home; those who
were practicing the four-muscle-group procedure should begin practicing
the four-muscle-group recall-relaxation procedure at home. Clients who
were not achieving good results from the practice during the past week
should continue to practice the same procedure for the coming week.
110
Cognitive Restructuring Continued: Catastrophic Thinking
. Clients are helped to recognize that they already possess the ability
to cope, even in uncomfortable situations, as would be the case if
they actually were fired or lost a loved one, or if others actually
noticed that the client looked extremely anxious.
Negotiating Homework
For this session, the therapist’s suggestions for homework items should
include reading over the appropriate MAW workbook chapter or chapters
for the next session; continuing self-monitoring using the Worry Record—
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Real Odds & Coping form and the Daily Mood Record; practicing the
progressive muscle relaxation exercise (it would be ideal for the client to
practice progressive muscle relaxation twice daily); and using the Worry
Record—Real Odds & Coping form and the Pie Chart form to practice
cognitive restructuring as often as possible when anxious episodes occur.
Worry Record—Real
Worry Record—Real OddsOdds & Coping
& Coping Example
Date: Friday 15th Time began: 10:00 (../..) Time ended: 11:30 (../..)
--------------------------------------------------
Easily fatigued
Irritability
Muscle tension
Sleep disturbance
Triggering events: Daughter went out with her friends and has not called
Anxious thoughts: She was in a car accident and is injured and disoriented
Alternative possibilities: She is having fun with her friends, she forgot to call, she will call later
Figure 10.1 Example of worry record/real odds and coping completed by patient.
112
Session Summary and Feedback
Ask the client to summarize any take-home messages or points from this
session that might be helpful. Also, ask the client if he or she had a nega-
tive reaction to anything about the session.
As in the previous lesson, the therapist should serve as a coach for iden-
tifying catastrophic thinking and developing methods of challenging these
thoughts. By modeling the method of asking relevant questions, thera-
pists begin to teach clients how to look for alternative ways of interpret-
ing a given situation, as well as to evaluate situations in terms of their
ability to cope rather than the distress experienced. For example, if a
client views a public experience of embarrassment as disastrous, the thera-
pist may ask whether someone else could view an episode of embarrass-
ment as a relatively minor event. In this way, the client begins to perceive
the power of viewing a situation in different ways. Asking clients to imag-
ine the worst possible thing that they believe could happen is a helpful
way of identifying catastrophic predictions and beliefs. Just as with
probability overestimation, we do not assume that the person’s style of
thinking is catastrophic across all situations. Instead, catastrophizing is
viewed as a learned cognitive style that is most likely to emerge during
states of heightened anxiety.
Case Vignettes
Case Vignette 1
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be less worried doesn’t really change any of the underlying mechanisms
that promote worry. It’s important to identify specific predictions that
you’re making and then to challenge those predictions. So, when you
first notice yourself becoming anxious, ask yourself questions like:
What am I predicting or imagining will happen? What is the evidence
for and against that? What’s the worst thing that could happen if my
prediction did come true? Let’s practice using some of these tools with
one of your worries. Tell me about about something that will make
you anxious if we focus on it now.
C: Maybe I’ll look really weird to other people. I can imagine being in a
crowd of people, with everyone staring at me and thinking I’m crazy.
T: So, if these strangers were thinking “there’s a crazy guy,” what would
happen?
Case Vignette 2
T: What do you mean by the “best” worry? What do you think will hap-
pen if we don’t talk about the “best” one?
C: I’m afraid that I won’t make any progress and I’ll finish the program
feeling just as bad as when I started, or maybe worse.
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C: Well, I suppose that the most important thing might be that I learn a
skill that I could then apply to any worry I wanted. So, maybe it
doesn’t matter which worry I talk about.
T: Good. So, maybe even restructuring your worry about which worry to
talk about is helpful? Now, what evidence do you have or could you
get to evaluate those alternatives?
Case Vignette 3
C: Sure. I can tell myself that the chance that I’ll get fired for making a
mistake is small. I tell myself that all the time. But what if I do get
fired? It’s that one-in-a-hundred chance that frightens me.
T: Well, that’s a good question. What would happen if you get fired?
C: I guess I would start to feel a little better. But what if I never find an-
other job?
T: And what is the probability that you will never find another job?
Case Vignette 4
C: I worry that I’ll “blank out” when I get anxious and forget what I was
saying. Since this happens to me a lot, I don’t see how I can use the
self-statements to challenge this worry.
T: Do you worry about that with everyone, regardless of how well they
know you, or just with people you don’t know well?
115
C: Just with people I don’t know well. I’m pretty sure that most of my
good friends wouldn’t think that of me.
T: Then let’s focus on the people you don’t know so well. What evidence
do you have regarding whether an acquaintance or a stranger would
think you were a moron because you blanked out during a conversa-
tion? What else might they think about you? How terrible would it be
if a stranger or an acquaintance did think you were a moron? What
impact would it have on your life?
Case Vignette 5
C: I’ve been trying to restructure one of my worries all week, and it just
doesn’t seem to help.
C: I’ve examined the evidence both for and against the possibility. The
fact is that she lives in a very bad neighborhood. There have been sev-
eral muggings and rapes reported right on her block. I know that it’s
not guaranteed that I will be attacked, but since I would be going by
myself at night, the actual chances seem fairly high.
T: In that case, I’m glad that you’re feeling worried about going to have
dinner at her apartment. Can you imagine why I might say that?
T: And why would I want you to experience that realistic anxiety in this
situation?
T: Exactly. Later on, in a few sessions, we’ll talk about some techniques
for solving realistic problems that may be helpful to you in working
116
out a way that you can get together with your friend in a way that isn’t
so dangerous for you. In the meantime, you’ve learned that the tech-
niques for restructuring probability overestimates can also help us to
distinguish realistic from unrealistic worries. To the extent that the evi-
dence suggests that a worry is realistic, problem-solving skills will be
more effective than cognitive restructuring because our predictions and
interpretations are accurate.
Case Vignette 6
T: So far, we’ve only focused on the chances that you will become de-
pressed again, like you did years ago. How about if we now focus a
bit on what you worry will happen if you do experience another epi-
sode of depression?
(Rather than assuming that he knows what would be so awful about the epi-
sode of depression, the therapist explores the meaning for the client.)
T: How so?
T: Totally dysfunctional? Can you tell me more about what you mean
by that?
C: Well, for about or weeks, I just couldn’t get out of bed. I couldn’t
do anything. I’m not even sure if I showered more than once during
that whole time. I didn’t do my laundry or clean my apartment. I ate
some, but mostly junk food, because I couldn’t even prepare a decent
meal for myself.
T: When you say you couldn’t get out of bed or do anything else, like
shower or prepare a meal, how do you know that you couldn’t do those
things?
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C: I’m not sure that I follow you. What do you mean?
T: Well, it seems clear to me that, when you were depressed, you had the
belief that you couldn’t do those things. I’m wondering if you ever
tested that belief.
C: Tested it how?
T: For example, with the thought that you couldn’t get out of bed and get
in the shower, are you telling me that, if you had taken it one step at a
time, and first told yourself to swing your legs over the side of the bed,
they would not have moved? And then, if you’d told yourself to stand
up, you would not have been able to? And then, if you had told your-
self to put one foot in front of the other and walk toward the shower,
your feet wouldn’t have been able to move? And then, once you got to
the shower, if you had told yourself to turn on the water, you wouldn’t
have been able to do that? Do you get the idea now?
C: Well, when you put it that way, I guess I could have done those things.
T: Good! So, if you do become depressed again to the point where you’re
having the thought that you can’t get out of bed and do your usual ac-
tivities, what can you do differently?
118
tic if the evidence suggests that the predicted event is indeed highly
likely and the event’s consequences are not being blown out of propor-
tion. In such cases, we have found it useful to adopt an intervention that
might be labeled as paradoxical. For instance, as in case vignette , we
might say something like: I’m glad you’re feeling anxious about that. As-
suming that I’m not sadistic, can you imagine why I might say that? Of
course, the techniques for coping with realistic problems that are dis-
cussed in chapter can be helpful, and the therapist may decide either
to initiate them now or simply to tell the client that such techniques will
be covered in chapter , and then refocus on an example of excessive
worry.
Some clients report that their anxiety levels actually increase when they
begin focusing on their negative thoughts. Our preferred response to this
problem illustrates the adage that “the cognitive therapist never loses.”
We try to reframe this feeling of worsening so that it may be viewed posi-
tively, or at least so that the client can see a positive aspect to this feel-
ing. A golf course analogy may be helpful here: The increase in anxiety
functions like the flag in a hole on a golf course. Alternatively, a driving
metaphor might be helpful: Anxiety functions like a road sign on a high-
way that we have never been on before. It lets us know that we are on the
right track, that cognitions indeed have powerful effects on our mood, and
that we have identified some relevant cognitions. Thus, we are headed in
the right direction and are working on the things we need to work on.
119
she did in fact have great difficulty coping and experienced a great deal
of functional impairment. In these cases, the therapist should help the
client explore what might be different if the feared outcome does recur
or how the client might cope with it differently the next time.
One of the most common mistakes that we have seen our student thera-
pists make, when attempting to implement cognitive restructuring, is to
challenge an automatic thought prematurely, before being sure that they
fully understand what the meaning of the feared outcome is to the client
and what it is that the client finds most threatening about it. For ex-
ample, in case vignette , when the client says that it would be awful to
experience another depressive episode, some therapists might have as-
sumed that the client was worried that the next episode would go on for-
ever. Based on this assumption, they might have begun to ask questions
about what evidence the client has that the episode would go on forever
and what steps she could take to keep it from going on forever. If so,
clearly, this line of questioning would have been off target and would
likely be experienced by the client as not being very helpful. Thus, in-
stead of assuming that one knows what the client is finding most threat-
ening, it is always better to ask or to check out one’s assumption with the
client (e.g., “So, when you worry about becoming depressed again, are
you concerned that the depression would never end?”), before beginning
the process of actively challenging the thought.
Finally, we have found that some of our clients have worries about the
treatment process. That is, clients occasionally worry about whether they
have applied a particular exercise in perfect fashion, or whether, as re-
flected in case vignette , they are applying their exercises to the “right”
worry. Given that excessive worry is at the core of GAD, this should not
be too surprising. In our experience, the best strategy for dealing with
these worries is to target them for intervention, as with any other worry
that the client might have. In fact, these worries may be more effectively
treated, as they tend to be “hot”—that is, the client is experiencing the
anxiety in session, and the negative predictions are relatively easily ac-
cessible. So, if a client is troubled by perfectionistic concerns about the
treatment, the therapist should follow the affect, try to identify the auto-
matic thought behind the perfectionism (such as “I won’t get any bene-
fit from this exercise unless I do it perfectly”), and then challenge it, as
illustrated in case vignette .
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Chapter 11 Getting to the Heart of Worrying:
Facing Your Fears
Session Outline
■ Brief check-in
■ Negotiating an agenda
121
■ Introducing worry imagery exposure
■ Negotiating homework
Brief Check-in
The brief check-in will consist of greetings; a chance for the client to
state how he or she has been feeling recently; a brief review of the Worry
Record—Real Odds & Coping, Pie Chart, and Daily Mood Record forms;
a review of progressive muscle relaxation homework; and a brief review
of how the client made out with any other homework tasks from the
previous session.
Negotiating an Agenda
For this session, the therapist’s suggestions for agenda items should in-
clude discussion of advancing in the progressive muscle relaxation train-
ing exercises, an introduction to worry imagery exposure, and negotia-
tion of homework.
If the client has obtained good results from the progressive muscle re-
laxation training practice during the past week, the therapist should in-
struct the client to begin practicing the next phase of the relaxation mod-
ule. Clients who were practicing the four-muscle-group recall-relaxation
procedure should begin practicing the one-step relaxation procedure at
home; those who were practicing the four-muscle-group procedure should
begin practicing the four-muscle-group recall-relaxation procedure at
home. If the client was not achieving good results from the practice dur-
ing the past week, he or she should continue to practice the same proce-
dure for the coming week.
122
Introducing Imagery Exposure
123
on the physical and emotional sensations involved in each sce-
nario. Remember the suggestion, cited in chapters and of this
book, that the process of worry itself suppresses imagery, includ-
ing those aspects that encode efferent commands to the autonomic
system. This suggestion implies that it is important to include
physiological response elements in imagery exposure.
Negotiating Homework
For this session, the therapist’s suggestions for homework items should
include reading over the appropriate MAW workbook chapter or chap-
ters for the next session, continuing self-monitoring using the Worry
Record—Real Odds & Coping form and the Daily Mood Record, prac-
ticing the progressive muscle relaxation exercise (it would be ideal for
the client to practice progressive muscle relaxation twice daily), using the
Worry Record—Real Odds & Coping form and the Pie Chart form to
practice cognitive restructuring as often as possible when anxious epi-
sodes occur, and practicing imagery exposure at home (ideally, on a daily
basis, with a minimum of three times during the week).
Ask the client to summarize any take-home messages or points from this
session that might be helpful. Also, ask the client if he or she had a nega-
tive reaction to anything about the session.
124
Principles and Points to Consider
125
Please also note that our suggestions for therapist-assisted imagery ex-
posure differ somewhat from the instructions given in the MAW client
workbook. We felt that the instructions for how we do the exposure in
a session with a therapist would be too complicated for the client to keep
in mind if doing the exposure on his or her own and also that there
would be too much potential for the client to fail to continue beyond
the point of the most catastrophic scene or to sustain the imagery on his
or her own. Thus, the instructions in the MAW client workbook were
written for clients who work through the program entirely on their own,
without a therapist. Therapists should tell their clients this, and explain
that they will be implementing the procedure a bit differently than how
it is described in the client workbook.
Case Vignettes
Case Vignette 1
C: You said that it was important not to distract myself when I start to
feel anxious while I concentrate on and imagine my worry. Should I
concentrate on how awful I feel?
Case Vignette 2
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pull his or her hair. But when I try to concentrate on that worry now
for exposure, it doesn’t do anything for me. What can I do to practice?
T: Well, there are several possible reasons why this might be the case.
First, we might have to make more use of your imagination so that
you can picture yourself in that situation now. For example, you want
to imagine that you are in the play group now. Imagine the outfit your
daughter has on, how she feels in your arms as you are carrying her,
and how she smells. What colors are the other children wearing? Hear
the noises the children are making while they are playing. What colors
are the other mothers wearing? Hear their voices as they are talking
to you. Hear the sounds of the other child crying and screaming as
your daughter pulls his or her hair. Feel the tension in your muscles
increase and your breathing rate quicken as you experience the urge to
run over to her. Were you trying to put yourself in the middle of the
scene like that?
C: No, I was just repeating the thought to myself. When I tried to imagine
the scene as you were just talking, I did start to become more anxious.
T: Good. Try to hold on to that scene now, and continue to keep your-
self in the middle of it, as if it were happening now. Let’s see what
happens next.
Case Vignette 3
T: Well, the rate of habituation differs from one person to the next, and
sometimes even within the same person, for different worries. Some
people require more prolonged exposure to begin to experience habitua-
tion, which is why we recommend that people start with about
127
minutes of exposure. However, some people require even more than that
for some of their worries. Why don’t we focus on that worry now and
see if there is a change in your anxiety level over the next minutes?
Case Vignette 4
T: So, we are going to expose you to your worry that your father will
pull out a knife and cut himself during a fight with your mother. On
a scale from to , what is your anxiety level right now?
C: About .
T: OK. Start the movie wherever you would like. Remember, I want you
to imagine it as if it were happening right now, describing to me what
you see, feel, and hear. Close your eyes, if that will help you see it in
your mind’s eye.
C: I hear the phone ringing. I pick it up, and I hear it’s my mother’s voice.
She sounds very agitated. She tells me that they’re having another fight,
and I can hear my father screaming in the background. My mother
asks me to come over as soon as I can to stop the fight. She tells me
that Dad has pulled a large knife out of a drawer, and then she hangs
up. I tell Steve that they’re at it again, and I have to go over there, or
else Dad is going to hurt himself or Mom. I grab my car keys and jump
in the car. I’m driving as fast as I can, and I can’t get the image of him,
with a knife in his hand, out of my head.
T: What are you feeling, and where are you feeling it?
T: You’re doing great. Hold that scene for a bit. (The therapist is then silent for
a minute or two.) Where is your anxiety level now, on a scale of to ?
C: It’s .
C: I pull up in their driveway and hop out of the car. Now I’m running
up their driveway, and I can hear my mother. She sounds hysterical,
but it’s really weird ’cause I don’t hear Dad at all. When I come in the
128
front door, I see him. He is lying on the floor, and I see that his wrist
and his neck are cut. There is blood all around him. My mother is sob-
bing uncontrollably. I ask her if she has called an ambulance, and she
shakes her head no, so I grab the phone and call an ambulance. A few
minutes goes by before the ambulance gets there, and as I’m waiting, I
start to cry, too, and I’m thinking that this is my fault. If I had driven
even faster, I could have gotten here before he cut himself. (Client is
now crying in session.) Now I hear the sirens of the ambulance, and the
medics come inside. They immediately get him on a stretcher, and
they ask if one of us is going to ride with him in the ambulance. My
mother is still hysterical, so I go.
T: Now hold that scene. (Silence for a minute or two.) And where is your
anxiety level now?
T: You’re really doing great. Stay with it now. What happens next?
C: We get to the hospital and they immediately rush him to the ER. The
nurse asks me to wait outside, in the waiting area. I’m sitting there,
praying that he’s going to make it and feeling just awful that I didn’t
get there sooner. I call Steve and ask him to come to the hospital, and
then I start crying again and wishing that he were there already. Then
the nurse comes out and tells me that she’s very sorry, but they couldn’t
save my father, that he’d lost too much blood. Then Steve finally gets
there, and I’m crying like a baby in his arms.
T: Now hold that scene. (Silence for a minute or two.) And what is your
anxiety level now?
C: Well, I’m at his funeral. I see all of our relatives and my parents’
friends. We are gathered around his gravesite, and my brother, Steve,
my uncle, and one of my cousins lower Dad’s coffin into the grave. I
take my turn shoveling some dirt on top of his coffin. I start to cry,
and I keep seeing the image of him lying in that pool of blood. I feel
really, really sad, and kind of empty inside.
129
T: Now hold that scene. (Silence for a minute or two.) And what is your
anxiety level now?
C: Still .
T: You’re doing great. Let’s stay with it a bit more. Let’s fast-forward
about a week or so. What’s happening now?
C: It’s my first day back at work. I’ve been crying off and on all week
long. I’m still thinking about my father just about all the time. I’m
having a hard time concentrating on my work, but I struggle through
and do get a little bit done.
C: Well, I’m am still thinking about Dad a lot, and I still see the picture
in my head of him lying in that pool of blood. But it isn’t all the time
now, and when I’m talking to a client, I can pay attention to what he is
saying. When I think about Dad, my eyes do tear up, but I am not
sobbing like I was.
C: Well, when I’m busy—at work or doing something with Steve on the
weekends—I’m fine. When I go to visit my mother and brother, or when
I’m alone at home though, I start thinking about Dad, and I get pretty sad.
130
Case Vignette 5
T: You can use any word you like as a cue, like “calm” or “good.” Just
keep using the same word each time you practice so that it becomes
associated with the feelings of relaxation.
Perhaps the most common problem with the imagery exposure proce-
dure, as with other forms of exposure, is getting the client started. This
is likely to be particularly true for individuals who use cognitive avoid-
ance (in other words, distraction) frequently as an attempt to control
their worry. This difficulty is most often associated with worry about
worrying. We have found it most useful to treat this worry like any other
worry that a client may have. Thus, the therapist might suggest that such
clients begin the exposure with the worry about conducting imagery ex-
posure. That is, the clients would imagine what they fear would happen
if they were to expose themselves to one of their other worries (such as
losing a job or having an accident). Alternatively, the therapist may help
the client to cognitively restructure worry about imagery exposure. Here,
the therapist would encourage the client to engage in an evidence-based
analysis, (e.g., “What is the evidence that exposing yourself to your worry
about losing your job would lead to ?”) and to apply the “so
what” technique (e.g., “So what if you do experience a temporary increase
in your anxiety as a result of exposing yourself to your worry about los-
ing your job?”).
Perhaps the next most common problem with the exposure procedure is
the client wanting to flee from the image as the most catastrophic scene
approaches or is encountered. Here, there are two principles to keep in
mind. The first is for therapists to give their clients praise throughout the
procedure and to express confidence in their clients’ ability to cope with
the anxiety aroused by the most catastrophic scene. The second is for
therapists to keep in mind that, if the client does break off the exposure
131
before or immediately after experiencing the most catastrophic scene,
the therapist should encourage the client to return to the exposure as
soon as he or she feels more composed and ready (using some relaxation
work or cognitive restructuring to help the client recover more quickly, if
it seems that it would be useful).
Other problems that occasionally arise with imagery exposure are dis-
cussed at the end of workbook chapter .
132
Chapter 12 From Fears to Behaviors
This chapter, dealing with avoidance and safety behaviors, obviously needs
to be applied only if these problems are present. If avoidance and safety
behaviors are not a problem, the therapist can focus this session on re-
laxation training and imagery exposure only, or the client may simply
skip to workbook chapter . On the other hand, when these problems
are present, the therapist may wish to spend several sessions dealing with
them, depending on the pervasiveness of the problem and the client’s
rate of progress.
133
■ Instruction in the method of repeated exposure to the hierarchy items,
starting with the least anxiety-provoking exercise in the hierarchy.
Session Outline
■ Brief check-in
■ Negotiating an agenda
■ Negotiating homework
Brief Check-in
The brief check-in will consist of greetings; a chance for the client to
state how he or she has been feeling recently; a brief review of the Worry
Record—Real Odds & Coping, Pie Chart, and Daily Mood Record
forms; a review of progressive muscle relaxation homework and imagery
exposure homework; and a brief review of how the client made out with
any other homework tasks from the previous session.
Negotiating an Agenda
For this session, the therapist’s suggestions for agenda items should in-
clude discussion of advancing in the progressive muscle relaxation train-
ing exercises, continuing with imagery exposure, introducing in vivo ex-
posure and response prevention, and negotiation of homework.
134
Moving Forward with Progressive Muscle Relaxation Training
135
woman dividing her experiences into successes versus learning
experiences, with far more catergorized as learning experiences).
Negotiating Homework
For this session, the therapist’s suggestions for homework items should
include reading over the appropriate MAW workbook chapter or chapters
for the next session, continuing self-monitoring using the Worry Record—
Real Odds & Coping form and the Daily Mood Record; practicing
the one-step progressive muscle relaxation exercise (it would be ideal for
the client to practice progressive muscle relaxation twice daily); using the
Worry Record—Real Odds & Coping form and the Pie Chart form to
practice cognitive restructuring as often as possible when anxious epi-
sodes occur; practicing imagery exposure at home (a minimum of three
times a week); and beginning to conduct in vivo exposure with response
prevention, if relevant (also a minimum of three times a week).
Ask the client to summarize any take-home messages or points from this
session that might be helpful. Also, ask the client if he or she had a nega-
tive reaction to anything about the session.
136
escape or avoidance. At this point in the program, clients should be gen-
erating their own tasks or goals and developing a sense of their own
method for achieving mastery.
Many clients tend to view courage as the absence of fear, and so see
themselves as cowardly and weak people. However, as noted by Stanley
Rachman () in Fear and Courage, there is an alternative definition of
courage. Within this view, courage is seen as action despite fear. Seen in
this light, clients are displaying or creating courage whenever they en-
gage in an exposure practice. If the client can be led to recognize this al-
ternative perspective on bravery, then exposure practices can be used to
foster the restructuring of the self-image from cowardice and weakness
to courage and inner strength.
To begin to prepare the client for termination, we start to spread the ses-
sions out after this session. Until this point, sessions are typically sched-
uled week apart. From this point forward, we usually schedule sessions
on a biweekly basis to give the clients more practice in applying the skills
on their own.
Case Vignettes
Case Vignette 1
C: I really would rather not do these exercises because I’m sure that I’ll
feel very anxious. I haven’t said “no” when a friend has asked me for a
favor or made requests of other people for a long time, and now you’re
asking me to do it.
T: Of course, you should expect to feel anxious the first several times you
attempt to do the things you’ve been avoiding or putting off. But the
other side of the coin is that, through repeated practices, it will get eas-
ier. That long-term payoff is important to remember. Also, you have
developed a new set of coping skills and strengthened old ones, which
you can use to help yourself when you begin to feel anxious about
being assertive. Finally, remember our stepladder, or one-step-at-a-time,
approach. You can break down some of the more difficult exposure
tasks into a series of smaller steps. You can then perform each of these
137
smaller steps a number of times to feel more comfortable, before pro-
ceeding to the next one. For example, you can start out with very small
requests and gradually work your way to more involved ones. Alterna-
tively, you can start out making requests from people you feel more
comfortable with and gradually progress to people you are currently
less comfortable with.
Case Vignette 2
Case Vignette 3
138
checking in once every hours, you could go to just once a day, and so
on. Also, it’s important for you to examine realistically what you’re say-
ing to yourself about the worry interfering with your work. You said
that you wouldn’t be able to function. Do you mean to say that you
wouldn’t be able to get any work done? If so, what is the evidence for
that? If not, then you need to ask yourself just how much your work
performance actually will suffer and how terrible that would be.
Case Vignette 4
C: I worry that, when I get anxious, I’ll blank out and forget what I was
saying or what someone else was saying to me. How can I practice that?
T: Exactly. That way, you could have more control over the practice. For
example, if there are certain people with whom you feel more comfort-
able doing this, then you could start with them. You could then pro-
gressively challenge yourself more over time.
Given that the majority of this section of the MAW program is self-
directed, compliance with practice assignments can become problem-
atic. The therapist’s role, at this point, is to emphasize the value of prac-
tice and the extent to which further improvement depends on such
practice. Occasionally, as clients make changes in their typical daily pat-
terns, family members may be affected. Discussion of ways to inform
significant others is useful, under such conditions.
139
his or her tendency to arrive at appointments minutes ahead of time.
If the client found it too overwhelming to practice arriving a few min-
utes late, or right about on time, the therapist could suggest starting with
a practice of leaving , , or minutes later than usual. After this ini-
tial practice has been mastered, the client could then gradually make the
practices more challenging by leaving at progressively later times.
140
us know that we are on the right track and working on the exposure
practices that we need to work on.
Sometimes, clients report that their level of anxiety does not decrease
across repeated exposure trials. In most cases, this is caused by continued
subtle patterns of avoidance, safety behaviors, or cognitive avoidance.
141
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Chapter 13 Dealing with Real Problems: Time Management,
Goal Setting, and Problem-Solving
143
involves setting priorities among planned activities and scheduling
tasks in accordance with their priority.
Session Outline
■ Brief check-in
■ Negotiating an agenda
■ Negotiating homework
Brief Check-in
The brief check-in will consist of greetings; a chance for the client to
state how he or she has been feeling recently; a brief review of the Worry
Record—Real Odds & Coping, Pie Chart, and Daily Mood Record forms:
a review of progressive muscle relaxation, imagery exposure, and in vivo
exposure homework; and a brief review of how the client made out with
any other homework tasks from the previous session.
144
Negotiating an Agenda
For this session, the therapist’s suggestions for agenda items should in-
clude discussion of advancing in the progressive muscle relaxation train-
ing exercises, continuing with imagery exposure, introducing time man-
agement and brainstorming, and negotiation of homework.
The therapist and client should discuss whether the client feels ready to
progress to doing an exposure to a more anxiety-provoking worry than
previously practiced. If time management and brainstorming are rele-
vant for the client and will be covered this session, there will probably
not be time for imagery exposure, so this should be practiced at home.
If time managment and brainstorming are not relevant for the client and
will be skipped, there should be sufficient time to conduct therapist-
assisted imagery exposure in session.
If in vivo exposure is relevant for the client and he or she began practic-
ing in vivo exposure between the last session and this one, the therapist
and client should discuss whether the client feels ready to progress to
doing an exposure to a more anxiety-provoking worry than previously
practiced.
145
Introducing Time Management and Brainstorming
Negotiating Homework
For this session, the therapist’s suggestions for homework items should
include reading over the appropriate MAW workbook chapter or chap-
ters for the next session; continuing self-monitoring using the Worry
Record—Real Odds & Coping form and the Daily Mood Record; ap-
plying the one-step progressive muscle relaxation procedure whenever
an increase in tension is noticed; using the Worry Record—Real Odds
& Coping form and the Pie Chart form to practice cognitive restructur-
146
ing as often as possible when anxious episodes occur; practicing imagery
exposure at home (a minimum of three times a week); practicing in vivo
exposure with response prevention, if relevant (also a minimum of three
times a week); and using the time management strategies on a daily basis
and applying the brainstorming technique to one recent real-life prob-
lem or crisis, if relevant.
Ask the client to summarize any take-home messages or points from this
session that might be helpful. Also, ask the client if he or she had a nega-
tive reaction to anything about the session.
Case Vignettes
Case Vignette 1
C: I thought I was doing so well, and then this week I had a couple of
days of very high anxiety. Now, I feel like I am right back at square one.
C: The same old things. My daughter was being aggressive with the other
infants in her play group, and I was worried that the other mothers
would think that I was a bad mother.
T: Do you see the processes that account for why you became anxious at
that particular moment?
147
C: Yes, I can understand it now much more readily than before. I felt em-
barrassed and immediately thought that the others must be thinking
that I’m a failure. I questioned the evidence, but then I dismissed the
facts and thought that it really could happen.
C: Yes.
T: How about if we do a pie chart relating to the thought that you’re back
at square one? Maybe you are back at square one, but maybe there are
other ways to look at this. What is an alternative perspective?
C: Well, maybe I never was beyond square one, and I was fooling myself
when I thought I had made progress.
C: Maybe I have made progress, but I’m always going to have some slips?
T: Good. Write that one down on the pie chart, next to the original
thought. Any others?
C: How about that I need to practice more to be able to apply the skills
more consistently?
T: Now, let’s look at the evidence. What evidence do you have that you’re
back at square one?
C: I did have those days this past week when I was overestimating the
likelihood of bad things happening.
T: Anything else?
T: OK. Let’s look at the other side. What evidence do you have that you’ve
made progress and either need to practice more or are just continuing
to experience some flare-ups, but that, overall, you are doing better?
148
C: I’m pretty sure that, if I looked at my monitoring forms, I’d see that,
when I first started, I was having days like these almost every day, and
now, they occur only on rare occasions.
Case Vignette 2
C: I know that I’m busier than I need to be, but I’m worried that if I start
saying “no” to my friends when they ask me to do favors for them,
they won’t want to be my friends anymore.
T: It sounds like some of the other skills you’ve learned might help you in
dealing with that worry so you can manage your time more efficiently.
How could you apply the skills you’ve already learned to this situation?
C: I can remind myself that just because I’m thinking that they will reject
me doesn’t necessarily mean that they will actually reject me. Then I
could examine the evidence to evaluate how likely it really is.
T: Good. Is there anything else you can do to help yourself with this
worry?
C: Well, I could practice saying “no” to people, but I think I might be too
nervous to start.
T: Do you have some friends whom you believe would be more under-
standing than others?
C: My best friend knows how hectic things are for me. I think she would
probably understand. Maybe I could start with her and build my way
up to other people.
Case Vignette 3
149
T: Calling the police was a very good start. What other possible solutions
are there?
C: I don’t know. I can’t think of anything else that seems like it would re-
ally work or be feasible.
T: That’s OK. Let’s get all of the possible ideas out on the table first, and
then we’ll evaluate them only after we’ve identified a number of them.
C: Well, I suppose I could park a few blocks away and just have a longer
walk.
T: And is there good access to public transportation near where you live?
C: Yes, there is a bus that stops right near my house. I could take the bus
back and forth between my house and a parking space further from my
neighborhood. You know, for that matter, I suppose one possibility
would be to sell my car and just use public transportation. I’m not
crazy about the idea, but I guess it is at least worth thinking about.
150
rejection from a close friend or relative, it is important to evaluate whether
a probability overestimate is being made. When the client is predicting
rejection from an acquaintance, decatastrophizing will probably be most
appropriate (i.e., “How often do you see this person?” “What impact will
it have on your life if he or she does think negatively about you?”).
151
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Chapter 14 Drugs for Anxiety and Their
Relation to This Program
Session Outline
■ Brief check-in
■ Negotiating an agenda
■ Negotiating homework
153
Brief Check-in
The brief check-in will consist of greetings, a chance for the client to state
how he or she has been feeling recently, and a brief review of the client’s
self-monitoring and homework tasks negotiated during the previous
session.
Negotiate Agenda
For this session, the therapist’s suggestions for agenda items should in-
clude continuing with imagery exposure, continuing with in vivo ex-
posure and response prevention (if applicable), discussion of medica-
tion issues (if applicable), preparing for termination, and negotiation of
homework.
The therapist and client should discuss whether the client feels ready to
progress to doing an exposure to a more anxiety-provoking worry than
previously practiced. Therapist-assisted imagery exposure should be con-
ducted in session, if time permits; otherwise, imagery exposure should
be practiced at home.
If in vivo exposure is relevant for the client, the therapist and client should
discuss whether the client feels ready to progress to doing an exposure to
a more anxiety-provoking worry than previously practiced.
154
Discussing Medication Issues
155
Preparing for Termination
Negotiating Homework
For this session, the therapist’s suggestions for homework items should
include the same menu of choices as listed in the previous chapter.
Ask the client to summarize any take-home messages or points from this
session that might be helpful. Also, ask the client if he or she had a nega-
tive reaction to anything about the session.
156
Case Vignettes
Case Vignette 1
Case Vignette 2
T: Tell me, why do you think you’d experience a lot of anxiety during
withdrawal?
T: How would you respond to those feelings now if you experienced them?
T: And what would that actually involve? What exactly would you do?
157
would think of the worst that could actually happen and whether I
could cope with that or not.
Case Vignette 3
C: I really feel like I’m not ready to finish the program now. I still have
some worries that I haven’t worked on yet and some situations that I’m
avoiding.
T: OK. Let’s deal with the worries first. How would you approach each of
these worries? What techniques would you use to confront them?
C: I would start by deciding which one I’m going to do first. If I need to,
I can break any that seem overwhelming into smaller tasks. Then I
would practice doing each task enough times until I feel comfortable,
before moving on to the next one.
T: So, you know which techniques and principles to use and how to work
toward the goals of learning to be less worried and avoidant?
C: Yes, but I’m still a little nervous about the program’s ending.
T: Well, it’s only natural for you to feel some anxiety about ending. But
you have successfully learned the principles of this program. It’s up to
you now to continue to apply them for the amount of time necessary
to process the worries that are causing the difficulty.
158
under the supervision of the prescribing physician), weaning from psycho-
logical dependence can be aided by progressively removing the medica-
tion bottle. By way of illustration, clients may practice by giving their
medication to a friend accompanying them, then leaving the medication
in the glove compartment of their car, then leaving it at home, and so
on. Fortunately, the prescription of benzodiazepines for GAD appears to
be on the decrease as the SSRIs and SNRIs have been gaining widespread
acceptance as the first-choice medications for this condition.
159
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Chapter 15 Your Accomplishments and Your Future
Session Outline
■ Brief check-in
■ Negotiating an agenda
■ Discussing termination
Brief Check-in
The brief check-in will consist of greetings, a chance for the client to state
how he or she has been feeling recently, and a brief review of the home-
work tasks the client committed to complete during the last session.
161
Negotiating an Agenda
For this session, the therapist’s suggestions for agenda items should in-
clude discussion of termination.
Discussing Termination
162
. A major concept in this chapter is that the MAW program has not
suppressed an underlying problem, but is designed to intervene in
a maladaptive cycle such that the cycle is eliminated. This does not
mean that the experience of anxiety is eliminated, since it is essen-
tial to survival. The maladaptive cycle refers to the expression of
anxiety at times when it is not warranted. The approach taken is
one of learning to control or remove the excessive anxiety associ-
ated with that specific target, as opposed to covering up an under-
lying pathology.
Because this is the final session of this program, the main focus is on
evaluating the client’s progress and planning for the future. Termination
concerns frequently arise in this session, and it’s important to emphasize
again that, while the treatment was designed to provide clients with the
necessary skills with which to manage anxiety, these skills must be prac-
ticed regularly. To reinforce this point, we often use a dental health anal-
ogy. That is, we ask clients if they can imagine ever reaching a point when
their dentist will tell them that their teeth and gums are so clean and
healthy that they no longer need to brush and floss. We ask clients to
consider whether a similar principle applies to emotional health: might
it be that the maintenance of good emotional health and manageable
levels of anxiety and tension similarly requires regular practice of good
emotional hygiene?
163
Some therapists choose to continue with “booster” sessions scheduled
once a month. Each therapist will have to decide, on a case-by-case basis,
whether the potential benefits of such booster sessions outweigh the po-
tential cost of fostering overdependency on the therapist.
Case Vignettes
Case Vignette 1
C: Even though I’m doing most of the things I used to avoid and have
stopped most of my safety behaviors, even the thought of not having
the house perfectly clean when my in-laws come over still makes me
anxious. Trying to be the perfect daughter-in-law was always one of
my biggest problems, and it looks like I’ll never get over it now.
T: It sounds like you’re separating keeping the house perfectly clean for
your in-laws from all of the other items in your hierarchy, just because
it’s the top item. You’ve already learned how to work through the other
situations, so can you think of how you might make the idea of your
in-laws seeing your house when it’s not perfect more manageable to
work on?
C: No.
C: Well, I guess some of the others did seem overwhelming at first, and I
broke them down into smaller steps. But I’m not sure how I can break
this situation down into smaller steps.
T: Are there some rooms that they don’t spend much time in? Perhaps
you could start with them?
164
T: Excellent. But just to play devil’s advocate, let me ask you to imagine
that you feel overwhelmed when you are ready to go on to another
room, like the living room. What could you do then?
C: I guess I could start by leaving just one ashtray unemptied, and then
work up gradually from there. I guess it’s really not that different from
the other situations, after all. I just need to give it some more thought
and be creative.
Case Vignette 2
T: The self-evaluation is a way to identify specific areas that are still prob-
lematic for you. Remember, the goal of these sessions was to teach you
the skills necessary to overcome these problems, rather than to remove
all of your symptoms by the last session. Since you now have a good
understanding of these skills, it’s a matter of focusing on each area that
still poses a concern and continuing to practice and apply the skills.
Case Vignette 3
C: I thought I’d be cured by the end of treatment, but here it is—the last
session—and I’m not. How much longer will it take before I’m cured?
165
Atypical and Problematic Responses
Clients sometimes feel troubled at this point because they still experi-
ence excessive anxiety, are overly cautious, or engage in safety behaviors
on occasion. Frequently, these clients discount the progress that they
have made, while exaggerating the problems that they continue to expe-
rience. In these cases, it’s helpful to review the client’s experiences re-
corded at the beginning of treatment so that clients may more accurately
evaluate their progress. Pointing out instances where the client mini-
mizes progress in favor of obsessing on the negative may be helpful (e.g.,
“While I haven’t been worrying about my wife as much these days, I still
worry a lot about my kids, so I’m not really any better off ” or “Although
I’m not having trouble sleeping every night anymore, I’ve had a few bad
nights recently”). The therapist can emphasize to clients that, even though
there is still room for improvement, they have made great strides so far
and have worked very hard to achieve their gains. It should be commu-
nicated to clients that it is important that they allow themselves to feel
proud of their accomplishments.
When major life crises occur toward the end of treatment, clients may
regress a bit and feel that they are back to square one. In these cases, it
can be acknowledged that, yes, they have had a setback, but that does
not mean that all progress is lost. Reviewing records kept throughout treat-
ment can be encouraging. By reviewing these records together, therapists
can help clients to recognize that they made progress before and realize
that they can certainly do so again.
Finally, some clients say that they are not yet ready to end treatment, or
that they are unsure of their abilities to continue on their own. Clients
must be helped to realize that they do not need the crutch of a therapist
to continue making progress. Once they have an understanding of the
treatment principles and have learned the requisite skills, all that is left
is to continue practicing and applying these skills so that they become
second nature, and nobody can do this work for the client. At this point,
future benefit is almost entirely dependent on the client’s motivation to
continue working on problem areas.
166
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About the Authors
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Group Subcommittee for revision of the diagnostic criteria for panic dis-
order and specific phobia. Dr. Craske has given invited keynote addresses
at many international conferences and frequently is invited to present
training workshops on the most recent advances in cognitive-behavioral
treatment of anxiety disorders. She is currently Professor, Department
of Psychology and Department of Psychiatry and Biobehavioral Sci-
ences, University of California, Los Angeles (UCLA), and Director of
the UCLA Anxiety Disorders Behavioral Research Program.
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Connecticut; the First Graduate Alumni Scholar Award from the Gradu-
ate College, the University of Vermont; the Masters and Johnson Award
from the Society for Sex Therapy and Research; G. Stanley Hall Lec-
tureship, APA; a certificate of appreciation for contributions to women
in clinical psychology from Section IV of Division of the APA, the
Clinical Psychology of Women; and a MERIT award from the National
Institute of Mental Health for long-term contributions to the clinical re-
search effort. He is past President of the Society of Clinical Psychology
of the APA and the Association for the Advancement of Behavior Ther-
apy, past Editor of the journals Behavior Therapy, Journal of Applied Be-
havior Analysis, and Clinical Psychology: Science and Practice, and currently
Editor-in-Chief of the “Treatments that Worktm” series for Oxford Uni-
versity Press.
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