Mastery of Your Anxiety

and Worry:
Therapist Guide,
Second Edition
Richard E. Zinbarg
Michelle G. Craske
David H. Barlow
OXFORD UNIVERSITY PRESS
Mas t er y of Your Anx i et y and Wor r y
ioiroi-ix-cuiii
David H. Barlow, Ph.D.
sciixriiic
aoivisoi\ noaio
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
S E C O N D E D I T I O N
T h e r a p i s t G u i d e
Richard E. Zinbarg Michelle G. Craske
David H. Barlow
1
:cco
1
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Library of Congress Cataloging-in-Publishing Data
Zinbarg, Richard E.
Mastery of your anxiety and worry : therapist guide / Richard E. Zinbarg,
Michelle G. Craske, David H. Barlow.:nd ed.
p. cm.
Rev. ed. of: Mastery of your anxiety and worry / Michelle G. Craske. :,,:
Includes bibliographical references.
ISBN-:, ,;-c-:,-,,ccc:- (pbk.)
ISBN c-:,-,,ccc:-, (pbk.)
:. AnxietyTreatment. :. WorryTreatment. ,. Stress management.
. Self-help techniques. I. Craske, Michelle Genevieve
II. Barlow, David H. III. Title
[DNLM: :. Anxiety Disorderstherapy. :. Stress, Psychological therapy.
,. Psychotherapymethods. WM :;: Z;;m :cco]
RC,,:.C;, :cco
o:o.,::,codc:: :cc,c,,;,
, ; o , , : :
Printed in the United States of America
on acid-free paper
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 benet, but also perhaps
inducing harm. Other strategies have been proven eective 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 publics interest to ensure that these
changes occur (Barlow, :cc; Institute of Medicine, :cc:).
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.
The manuals and workbooks in this series contain step-by-step, detailed
procedures for assessing and treating specic problems and diagnoses.
But this series also goes beyond the books and manuals by providing an-
cillary materials that will approximate the supervisory process in assist-
ing practitioners in implementing these procedures in their practice.
In our emerging health care system, the growing consensus is that
evidence-based practice oers the most responsible course of action for
A b o u t Tr e a t me n t s T h a t Wo r k
the mental health professional. All behavioral health care clinicians deeply
desire to provide the best possible care for their patients. In this series,
our aim is to close the gap between dissemination and information and
make that possible.
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 diculty sleep-
ing, GAD can cause signicant impairment. Most people seek treatment
for this condition in primary care medical settings, where cognitive-
behavioral treatments are seldom available.
During the past :, years, we have developed increasingly eective treat-
ments for GAD, to the point where these interventions compare favor-
ably with the best psychological treatments for other disorders (Borko-
vec & Ruscio, :cc:). These treatments also have the advantage of proven
durability after treatment ends, with the added benet of allowing either
substantial reduction or elimination of any anxiolytic medications pre-
scribed before this treatment (Barlow, :cc:). The approach in this man-
ual was developed in our Center in the early :,,cs, and has now been
substantially updated with the latest developments. We are gratied that
countless numbers of individuals with GAD, in the hands of skilled
therapists, have reported substantial benet from this program.
David H. Barlow, Editor-in-Chief,
Treatments That Work
Boston, MA
vi
Chapter : Introductory Information for Therapists 1
Chapter : The Nature of Anxiety and Generalized Anxiety
Disorder :1
Chapter , Outline of the Treatment Procedures and the Basic
Principles Underlying Treatment ,1
Chapter The Nature of Generalized Anxiety 1
Chapter , Learning to Recognize Your Own Anxiety ,;
Chapter o The Purpose and Function of Anxiety o;
Chapter ; A Closer Look at Generalized Anxiety Disorder ;;
Chapter Learning to Relax 8,
Chapter , Controlling Thoughts That Cause Anxiety:
I. Overestimating the Risk ,,
Chapter :c Controlling Thoughts That Cause Anxiety:
II. Thinking the Worst 1v,
Chapter :: Getting to the Heart of Worrying:
Facing Your Fears 1:1
Chapter :: From Fears to Behaviors 1,,
Chapter :, Dealing with Real Problems:
Time Management, Goal Setting, and
Problem Solving 1,
Chapter : Drugs for Anxiety and Their Relation
to This Program 1,,
Chapter :, Your Accomplishments and Your Future 1o1
References 1o;
About the Authors 1;1
C o n t e n t s
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The Mastery of Your Anxiety and Worry (MAW) program is designed
to be presented in :c or more separate sessions that may be conducted
either individually or in small groups. If administered individually, each
session should take approximately ,c minutes. Typically, we allocate ,c
minutes for each session when conducting the program in small groups
of six or eight. It is recommended that the therapist: (:) explain the prin-
ciples and practices relevant to each of the lessons described in the MAW
workbook, and (:) ask the clients to read the relevant material from the
MAW workbook and complete the specied practice exercises between
sessions. Beginning in chapter of this therapist guide, the major points
of each session, the primary information that should be covered by the
therapist, and the principles underlying the therapeutic procedures are de-
scribed. Typical questions asked by patients and problems that may arise,
based on our experience, are also included.
Who Will Benet from This Program?
This program is designed for people who suer 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 o 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
Chapter 1 Introductory Information for Therapists
quality of being uncontrollable; that is, the individual nds it dicult to
keep worries from interfering with his or her concentration on tasks at
hand and has diculty 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, nances); these
foci may shift repeatedly during the o-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,
diculty 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 persons life circum-
stances that are relevant to the worry. For example, if one of the persons
worries is nances, the therapist may need to ask about the persons in-
come, debts, savings, and other assets. We judged nancial 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 sucient 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 identies 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
DSMIV-TR Criteria for Generalized Anxiety Disorder
(includes Overanxious Disorder of Childhood)
A. Excessive anxiety and worry (apprehensive expectation), occurring
more days than not for at least o months, about a number of
events or activities (such as work or school performance).
B. The person nds it dicult to control the worry.
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 o months). Note: In children, only
one symptom is required.
:. Restlessness or feeling keyed up or on edge
:. Being easily fatigued
,. Diculty concentrating or mind going blank
. Irritability
,. Muscle tension
o. Sleep disturbance (diculty falling or staying asleep, or
restless, unsatisfying sleep)
D. The focus of the anxiety and worry is not conned to features
of an Axis I disorder, e.g., the anxiety or worry is not about hav-
ing a panic attack (as in panic disorder), being embarrassed in
public (as in social phobia), being contaminated (as in obsessive-
compulsive disorder), being away from home or close relatives
(as in separation anxiety disorder), gaining weight (as in anorexia
nervosa), or having a serious illness (as in hypochondriasis), and
is not part of posttraumatic stress disorder.
E. The anxiety, worry, or physical symptoms cause clinically signi-
cant distress or impairment in social, occupational, or other im-
portant areas of functioning.
F. The worry is not due to the direct eects of a substance (e.g.,
drugs of abuse, medication) or a general medical condition (e.g.,
3
hyperthyroidism), and does not occur exclusively during a Mood
Disorder, Psychotic Disorder, or Pervasive Developmental Disorder.
(From American Psychiatric Association, :,,.)
What if Other Problems (Diagnoses) Are Present?
Among people suering from worry and tension, it is not uncommon to
also present with some depression or with a personality disorder charac-
terized by histrionic, avoidant, dependent, or even schizotypal features.
Treatment with the MAW program is not precluded by any of these prob-
lems as long as they are not the major focus of treatment. Thus, if a client
experiences GAD and is also depressed, it is appropriate to proceed with
the MAW program if GAD is the problem associated with the greatest
impairment in the clients functioning. On the other hand, the depres-
sion should be treated rst if the client presents with a major depressive
episode that is clearly the more severe problem, despite the fact that worry
and tension are present.
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 diculties or nancial 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 dierent treatment
protocol is used for people suering 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, :cc:; Brown, DiNardo, Lehman,
& Campbell, :cc:). Information on obtaining this interview schedule
can be found at www.oup.com/us/ttw.
Medication
Many people suering 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 [Eexor]), 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.
We actively discourage clients from increasing dosages of medications,
particularly benzodiazepines, during the course of treatment with the MAW
program. This policy is based on evidence suggesting that high dosages
of benzodiazepines initiated concurrently with a cognitive-behavioral treat-
ment program for anxiety may interfere with the cognitive-behavioral
program (Lavallee, Lamontagne, Pinard, Annable, & Tetrault, :,;;). In
addition, an increase in the dosage of medication confounds the evalua-
tion of the programs eectiveness for a given individual. However, we
do not require medication reduction or withdrawal if a client comes into
the program who is already taking high dosages of benzodiazepines. Re-
member that any major change in medication must be closely moni-
tored by the prescribing physician.
In our experience, a large proportion of patients successfully completing
the MAW program decide to discontinue medication use on their own,
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 dicult and includes panic, then the MAP pro-
gram may be useful and has often been used with success under similar
circumstances.
Who Should Run the MAW Program?
The question of who should run the MAW program has not been fully
examined. However, we have attempted to present the program in su-
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 sucient 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.
Group versus Individual Sessions
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 eective 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 nd 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 nd that it is dicult to allocate sucient individual atten-
tion to clients in the course of a ,c-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
Given the large amount of information that is disseminated to clients in
this program, it may be dicult to resist the tendency to lecture. How-
ever, it is important that the therapist adopt a Socratic questioning style
whenever possible. There is widespread consensus among leading cogni-
tive therapists around the world regarding the importance of this point,
and there is empirical evidence from the social psychology literature sup-
porting this position. This research shows that people hold onto beliefs
more strongly when the beliefs are self-generated rather than when they
are spoon-fed. Thus, it is important to try to lead clients to various con-
clusions through questioning. The examples below illustrate an undesir-
able spoon-feeding style and a more desirable Socratic style.
Example 1
Anxiety is universal and sometimes adaptive.
Spoon-Feeding Style
T: Anxiety is a natural emotion that is experienced by every single person.
In fact, it is probably the most basic of all emotions, being experienced
in all species of animals, right down to the level of the sea slug. Anxi-
ety is not bad, in and of itself, and in many cases, it is a productive,
driving force. However, anxiety can vary tremendously in severity, from
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 dierent o months or a year from now, if we are successful
in helping you?
C: I hope Ill be able to handle my anxiety better, without becoming over-
whelmed. These days, my anxiety is so strong that sometimes I just feel
frozen and cant make decisions. At my job, I dont like what Im doing
now, but Im too scared to think about doing something else or to
speak up at work to make my situation better. Six months from now, I
hope that I wont be stuck where I am now in my job.
T: I think those goalsreducing or eliminating the times when your
anxiety is so high that it is overwhelming and helping you so you dont
feel stuck in your current jobare excellent and very realistic. One of
the things I like the most about what you said is that you did not
frame your goals in terms of getting rid of any and all anxiety. When I
hear clients state a goal of getting rid of any and all anxiety, I try to
help them see that it is not possible to get rid of all anxiety, and that
even if we could, we would be doing them a disservice if we did. Can
you imagine why I might say that?
C: Im not sure if Im following you.
T: Let me try phrasing my question dierently. Is anxiety always a bad
thing? Can any of you think of any times in your life when anxiety
was helpful to you?
C: Now I see what youre saying. When I was a student and taking a sub-
ject I was pretty good at, I wouldnt 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.
T: Thats a great example. Therapists and researchers who study anxiety
often relate it to the ght-or-ight response. Can you imagine what we
might mean by that?
8
Example 2
Overcautiousness and safety behaviors block the opportunity for learn-
ing that ones negative predictions may not be valid.
Spoon-Feeding Style
T: Avoidance, either cognitive or behavioral, and safety behaviors block
the opportunity for learning that your negative predictions may not
come to pass.
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 didnt criticize you? Were
you more likely to attribute their lack of criticism to the fact that you
cleaned or to the possibility that they wouldnt have rejected you, even
if the house wasnt spotless?
Particularly important general questions that should be used throughout
treatment are: What went through your mind right then? What is the worst
thing that could happen? What do you imagine could have happened?
What do you imagine might have happened if you didnt ? What
do you imagine might have happened if you had let go of your usual
cautiousness in that situation? What do you make of that?
Therapists should constantly try to elicit objections from the clients.
Clients always have what they consider to be evidence for their negative
beliefs. Therefore, it is essential to identify the underlying logic and as-
sumptions, such as Im dierent from everybody else or Ive only sur-
vived up until now because I am always ready and waiting. Without
eliciting the clients objections and his or her evidence supporting the
negative beliefs, these beliefs will persist unchallenged, and may under-
mine the eects of treatment. After eliciting objections, you can apply
the cognitive restructuring techniques to them. The following are help-
ful questions for eliciting objections:
9
Can you think of any reasons why this might not apply to you? Does that
t with your experience? Therapists should also clearly communicate to
clients that cognitive therapy is not about the power of positive think-
ing; rather, its about realistic thinking, or nding 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 t into the cogni-
tive model. Thus, even if someone has a very intense episode of height-
ened anxiety during treatment, you can always nd 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).
As therapy progresses, the therapist should become less direct, to pro-
mote internalization of the coping skills. For example, in the rst few
sessions after cognitive restructuring has been introduced, the therapist
should take an active role in challenging cognitions by asking questions
such as the one that follows.
What is the evidence for that? After the rst 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.
Can anyone think of a question that might be helpful to in
challenging her automatic thought? In our experience, when clients have
more emotional distance from a worry, such as when discussing some-
one elses worry, they have an easier time applying the steps of cognitive
restructuring than when trying to challenge their own automatic thoughts.
Moreover, helping a fellow group member in this way can help the coach
to internalize and master the skills more deeply, thereby increasing the
likelihood that he or she will be able to apply the skills successfully to his
or her own worry in the future. Similarly, in individual therapy, if a client
10
gets stuck when trying to restructure one of his or her own worries, we
often nd 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.
Working with Ambivalence and Resistance
We nd that one of the most common diculties 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 nd 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, :cc:; also see Newman,
:,,). Siding with the resistance simply refers to reecting back to the
client what the therapist understands to be the clients 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 dont 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 backre 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 dont 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.
Strains on the Therapeutic Alliance
Important research by Castonguay and his colleagues (Castonguay, Gold-
fried, Wiser, Raue, & Hayes, :,,o; Castonguay, Schut, Aikins, & Con-
stantino, :cc) suggests that the therapeutic alliance is important, even
when conducting cognitive-behavioral therapy. More specically, Cas-
tonguays work has shown that therapists rigid application of standard
cognitive-behavioral techniques in response to problems in the therapeu-
tic alliance correlates negatively with outcome. When a client expresses
hostility toward the therapist or otherwise expresses negative opinions
about the therapists behavior, it is probably not advisable to try to repair
the strain on the alliance solely, or even initially, by identifying the neg-
ative reactions as evidence of the clients negative thoughts that need to be
challenged. Rather, the work of Castonguay and associates suggests that,
if the client has negative thoughts and interpretations that contributed
to the strain and must be explored, it may be most useful to do so only
after the alliance has been repaired by the therapist demonstrating em-
pathy for the clients emotional reaction and taking at least some re-
sponsibility for contributing to the strain on the alliance. In our experi-
ence, it is useful to end every session not only by asking the client to
summarize important points but also by asking if the client had any nega-
tive reactions to the session (e,g,, Did anything rub you the wrong
way?). We believe that doing so may not only help to catch some strains
that the therapist did not pick up on during the course of the session but
also, and even more importantly, communicates an attitude of openness
to discusssing such reactions. Such an attitude can go a long way toward
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 , :c, 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 ,c-minute or ::c-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
rst 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 benets from the program delivered in a shorter period, if
they are prepared to dedicate the extra time needed to the tasks.
Does Every Person Require the Entire Program?
We strongly suggest that each person complete workbook chapters :
through and ::, even clients who feel greatly improved after several ses-
sions. If behavioral avoidance and safety behaviors are a problem, we
suggest that the individual complete workbook chapter , as well. Simi-
larly, if assertiveness or time management is a problem, we suggest that
the person complete chapter :c. We have observed that people who ter-
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 superuous, we will continue to advise that each client
complete all aspects of the program.
Benets of Using a Workbook
The rst revolution in the development of potent psychosocial treat-
ments during the past decade has been the manualization of these treat-
ments. Since these are structured programs for particular disorders, they
can be written in sucient detail to allow trained therapists to adminis-
ter them in approximately the same fashion that they were proven eec-
tive. This does not imply that therapeutic skills are no longer required.
In fact, psychotherapeutic skills are valuable as the client proceeds with
the program.
The second stage of this revolution is creating a rendition of the struc-
tured program that is appropriate for direct distribution to clients who
are working under therapeutic supervision. The MAW program is one
of a few exemplars of the adaptation of a scientically sound program
that is written at the clients level and can be a valuable adjunct to pro-
grams administered by professionals from a number of disciplines. There
are many advantages to administering the program in this manner, in-
cluding the following:
Because the program is self-paced, the client can proceed at his or
her own rate. It was noted earlier that some therapists or clients
may want to nish the program in half the time by holding ses-
sions twice a week or by trying to cover two workbook chapters in
each weeks visit. There are other clients who, for various reasons,
may choose to proceed through the program at a slower pace.
Having the workbook available for reexamination and study be-
tween irregularly scheduled sessions is of substantial benet.
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
benets 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 diculty remembering their newly learned coping skills.
The MAW workbook often becomes the clients 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, OBrien, & Last, :,; Cerny, Bar-
low, Craske, & Himadi, :,;) has shown that there is a signicant
benet 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 criticismbeing critical of specic behaviors,
without devaluing the clientactually predicted better response
to the therapy (Chambless & Steketee, :,,,). We have recently
obtained identical results in a study of the ecacy of the major
components of the MAW program in clients with GAD who were
in committed relationships (Zinbarg, Lee, & Yoon, :cc,).
There are several possible ways in which family participation may
benet the client. First, any attempts to undermine the program,
15
either intentionally or unwittingly, may be prevented if family
members are familiar with the nature of the diculty and the ra-
tionale underlying the dierent 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 benecial 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 benets 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 theyre crazy or will be openly antagonistic to their
eorts. 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.
Clients can read pertinent material prior to its being covered in
therapeutic sessions. Some of the conceptual material contained in
the MAW workbook will not be altogether understandable to all
clients, despite our best eorts to make it so. Having clients read
some of the chapters in advance may be helpful in fostering full
comprehension of the nature of anxiety and of the directions for
conducting the exercises.
16
Benets of Standardized Assessment
In addition to administering the ADIS-IV prior to beginning therapy to
help determine if the MAW program is the best initial program for a
given client, we also nd it useful to administer a standardized question-
naire battery to our clients on a repeated basis to assess how much they
have beneted from therapy. For assessment of the severity of symptoms
of GAD, we nd two standardized questionnaires to be particularly use-
ful. The rst of these is the Penn State Worry Questionnaire (PSWQ), de-
veloped by Borkovec and colleagues (Meyer, Miller, Metzger, & Borkovec,
:,,c). The second is the Stress subscale from the Depression-Anxiety-
Stress Scales (DASS; Lovibond & Lovibond, :,,,). The DASS-Stress
scale is a good measure of the tension characteristic of generalized anxi-
ety, and research in our Center has shown that it eectively discriminates
patients with GAD from those with other anxiety disorders (Brown,
Chorpita, Korotitsch, & Barlow, :,,;). These two measures are particu-
larly useful for assessing changes associated with the MAW program be-
cause each measures one of the two central diagnostic features of GAD
and there are norms are available for each of them (e.g., Crawford &
Henry, :cc,; Gillis, Haaga, & Ford, :,,,). In our experience, most clients
begin treatment scoring at least two standard deviations above the non-
clinical mean on these and other related measures, but score no more
than one standard deviation above the nonclinical mean on most mea-
sures (i.e., ,: or less on the PSWQ and :: or less on the DASS-Stress
scale) after :: sessions of treatment with the MAW program.
Full Workbook versus Installments
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 dont 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.
On the basis of this feedback, we have carefully thought about supply-
ing the MAW program in such formats, but have decided not to do so at
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 dicult 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 nd 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.
In the nal analysis, there is no empirical evidence that we are aware of
that addresses this issue. Thus, our preference notwithstanding, we cer-
tainly do not dissuade therapists from distributing the MAW workbook
in segments if they prefer to do so.
Fees for the MAW Treatment Program
Typically, the expense of the MAW treatment program materials is in-
corporated into a programs or therapists fee structure in one of two ways.
First, workbooks are procured in bulk by the program or therapist, and
the expense of the materials is incorporated into the costs of the therapy
session or program. Second, some therapists and programs, especially
programs with rather xed fee structures, have clients assume the respon-
sibility and cost of ordering the workbook themselves. Thus, the treat-
ment package, consisting of the Client Workbook, the Monitoring Forms
packet, and the Worry Record pad, may be bought in bulk and resold as
each client begins the program, or ordering information may be given to
clients, with directions to buy the components before they begin their
program.
Efcacy of the MAW Treatment Program
We recently completed a wait-list controlled study in adults ages : to o,
years of the ecacy of the major components of the MAW program, in-
cluding cognitive restructuring, relaxation training, and worry imagery
18
exposure (Zinbarg, Lee, & Yoon, :cc,). 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 ve 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 ve outcome measures), and another :,% were
somewhat improved (returning to within one standard deviation of the
nonclinical mean on two of the ve outcome measures). Thus, a total of
;.,% were at least somewhat improved.
Wetherell, Gatz, and Craske (:cc,) adapted the MAW program for a
late-life sample (mean age, o; 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 eective than the wait-list control
and marginally more eective than the discussion group. Stanley, Beck,
Novy, Averill, Swann, Diefenbach, and Hopko (:cc,) also conducted a
treatment study among older adults (mean age, oo.: 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. (:cc,) and Stanley et al. (:cc,).
19
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The Nature of Anxiety and
Generalized Anxiety Disorder
For a full exposition of this theoretical model, see Barlow (:cc:) and
Zinbarg (:,,). In brief, interactions among the following factors are
recognized in the genesis of GAD: negative aectivity 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 eorts to resist or neutralize worrying.
Conceptualization of the Development of Excessive Worry and Anxiety
A diathesis-stress model is postulated to account for the initial develop-
ment of excessive worry and anxiety (gure :.:). First, it is important to
recognize that anxiety is universal and serves an adaptive function. Anxi-
ety arises from activity in a neuropsychological system whose functions
are to detect signals of danger and to prepare to cope with threat. The
closely related emotion of panic, or fear, implies a discharging of the
fight-or-ight mechanism when threat is imminent. Many of the physio-
logical symptoms of a panic attack may be seen as the activation of the
underlying physiology necessary to support the immediate and strenu-
ous action involved in escape or ghting. Anxiety, on the other hand, is
associated with simultaneous excitation and inhibition of the ght-or-
ight mechanism in response to signals of potential or approaching
threat that is not yet imminent. In other words, anxiety involves a prepa-
ration, or priming, of the ght-or-ight mechanism, making it easier to
activate this mechanism (gure :.:). This priming accounts for the ten-
21
Chapter 2
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.
There is considerable evidence showing that the reactivity, or sensitivity,
of the anxiety system has an inherited component (biological vulnera-
bility). This component, labeled negative aectivity, neuroticism,
emotionality, or behavioral inhibition, appears to correspond to the
level of physiological sensitivity, or arousability, and may be the genetic
diathesis that underlies many, if not all, of the anxiety disorders, and
even depression. This is not to say that GAD is inherited from ones par-
ents. Rather, it is believed that this predispositional variable of physio-
logical arousability interacts with stressful life events to produce intense
anxiety. That is, the tendency to experience anxiety runs in families, and
for reasons not fully understood, some people respond to stress with ex-
cessive worry and tension, whereas others may experience panic attacks,
hypertension, headaches, and so on.
22
Figure 2.1
Diathesesstress model of the development of generalized anxiety and depres-
sion. Redrawn from Barlow (:cc:), with permission.
Synergistic Vulnerabilities
Biological Vulnerabilities
Generalized Psychological Vulnerability
Stress
Generalized Anxiety
Depression
False Alarms
(panic)
D
i
a
t
h
e
s
e
s
Chronic and intense anxiety is particularly likely to develop when an in-
herited strong level of physiological arousability combines with a learning
history that fosters the perception that aversive events are unpredictable
and uncontrollable (psychological vulnerability). For such a person, the
tendencies to perceive threat to be ever-present, or lurking around every
corner, and to be constantly on guard and aroused in preparation for
dealing with danger become understandable. There is also evidence to
suggest that depression can emerge out of chronic anxiety, or as a com-
plication of chronic anxiety, in some people (in gure :.:, this is repre-
sented by the arrow from generalized anxiety to depression).
The case of Rick is a good clinical representation of these constructs. Rick
was a computer programmer who was robbed : years ago in the parking
garage of his condominium complex. The robbery took place at : oclock
in the morning. As he got out of his car, two men attacked him and took
his wallet and briefcase. Prior to the robbery, Rick had been relatively
shy, but did not characterize himself as being a chronic worrier or a con-
23
Figure 2.2
Relationship of worry, anxious apprehension, and fear (panic). Redrawn from
Craske (:,,,), with permission.
No threat potential
Threat potential
Preferred mode of safety
and control
Worry: preparation and
readiness
Approaching threat Anticipatory anxiety:
mobilization and vigilance
Imminent threat Fear and panic: ght
or ight
stantly anxious person. Since the attack, Rick has had diculty 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.
Conceptualization of Worry within Generalized Anxiety Disorder
All of us experience occasional worry and anxiety, especially when under
stress. Moreover, it appears that most of us tend to worry about the same
themes, regardless of whether we have GAD or not. When these worries
occur infrequently and are controllable, they are considered realistic and
normal worries. Research from our Center and elsewhere has suggested
that, phenomenologically, the uncontrollability of worry may be the prime
pathological feature of worry associated with GAD (Borkovec, Shadick,
& Hopkins, :,,:; Craske, Rapee, Jackel, & Barlow, :,,).
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 specicity
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
:,,:; gure :.,). 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 nd 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.
Though avoidance behavior is not as obvious in patients with GAD as it
is in patients with other anxiety disorders, patients with GAD neverthe-
less do engage in subtle patterns of avoidance, including checking and pre-
ventive behaviors, procrastination, and attempts to control worry, such as
cognitive avoidance and distraction (e.g., Brown, Moras, Zinbarg, & Bar-
low, :,,,; Craske, Rapee, Jackel, & Barlow, :,,; Hoyer, Becker, & Roth,
:cc:; Schut, Castonguay, & Borkovec, :cc:; Tallis & de Silva, :,,:).
Behavioral overcautiousness (i.e., preventive behaviors, procrastination, and
subtle avoidance) and the tendency toward cognitive avoidance at later
stages of information processing prevent elaboration and more accurate
evaluation of the anxiety-triggering stimuli. For example, the process of
worry often involves a strong component of planning as to how to avoid
threat. In the extreme, this can be problematic, given that the more re-
sources that are devoted to such planning, the fewer there are to evalu-
ate the realistic likelihood and impact of the threat. Thus, worry and dis-
traction increase the likelihood that the cues triggering unnecessary or
disproportionate anxiety retain their anxiety-provoking properties. Such
cognitive avoidance strategies undoubtedly must be reinforced by the
immediate relief that they might produce. However, this relief is likely
to be short-lived, as there is evidence documenting the diculty of sus-
taining distraction for very long (Wegner, Schneider, Carter, & White,
:,;; Wegner & Erber, :,,:; Wenzla, Wegner, & Roper, :,). This evi-
dence suggests that thought suppression produces an automatic priming
of the unwanted thought (Wegner & Erber, :,,:). Thus, thought sup-
25
26
Figure 2.3
The process of anxious apprehension. Redrawn from Barlow (:cc:), with
permission.
Evocation of Anxious Propositions
(situation contexts, unexplained
arousal, or other cues)
Negative Aect
A sense of uncontrollability and
unpredictability (perceived
inability to inuence personally
salient events and outcomes)
Preparatory coping set accompanied
by supportive physiology and
activation of specic brain circuits
(e.g., CRF system, Grays
behavioral inhibition system)
Attentional Shift
to self-evaluative focus
(on physiological or
other aspects of
responding)
Intensication
Additional Increases
in Arousal
Hypervigilance and
Cognitive Biases
Attentional biases: enhanced
recognition of threat
Attention narrowing on sources of
threat
Interpretative biases
Memory biases
Attempts to Cope Characterized by:
(Possible) Avoidance
of situational context or other
aspects of negative aect (e.g.,
arousal), if feasible
Process of Worry
Heightened verbal and linguistic
capabilities and restricted autonomic
activity to support (often futile) attempts
to plan and problem-solve
Avoidance of core negative aect
Dysfunctional
Performance
and/or lack of
concentration
on task at hand
pression paradoxically increases the accessibility of the unwanted thought,
increasing the likelihood that the individuals 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.
As alluded to earlier, Borkovec and his colleagues (Borkovec, Shadick, &
Hopkins, :,,:) have suggested that the process of worry itself reduces
the generation of imagery, particularly those aspects of imagery that en-
code eerent commands to the autonomic system. They further suggest
that this tendency is strongest among people with GAD (see also Free-
ston, Dugas, & Ladouceur, :,,o). A very recent study has found that
verbal-linguistic processing of threat is associated with subjective reports
of weaker negative aect than imagery-based processing of the same threat
(Holmes & Mathews, in press). Earlier studies have found that worry
also suppresses the physiological component of negative aect (Borko-
vec & Hu, :,,c; Vrana, Cuthbert, & Lang, :,o). Such suppression of
anxious arousal would reinforce and maintain worry (Butler, Wells, &
Dewick, :,,:). It would also prevent the activation of the full memory
structure supporting anxietyincluding its stimulus, meaning, and ef-
ferent componentswhich has been hypothesized to be necessary for
anxiety reduction (Foa & Kozak, :,o; Lang, :,,).
Conceptualization of Generalized Anxiety Disorder
The experience of scanning for threat at a preattentive level, combined
with a tendency to favor threatening interpretations of ambiguous stim-
uli, develops into GAD, when accompanied by an inability to eectively
terminate bouts of worry. It is primarily the later stages of processing
threatening information that appear to dierentiate nonclinical worri-
ers from those who go on to meet the criteria for a disorder (MacLeod
& Hagan, :,,:; Rutherford & MacLeod, :,,c). Nonclinical worriers
appear to be able to respond to the initiation of worry, either with a rela-
tively accurate appraisal of an unrealistic danger (perhaps as a result of
staying with the initial threatening image long enough for natural ha-
27
bituation and decatastrophizing processes to operate) or by the formu-
lation of a more or less eective plan for coping with a realistic danger.
Either way, nonclinical worriers are able to eectively terminate a bout
of worry.
In contrast, the heightened tendency to shift toward verbal-propositional
processing and away from imagery that is characteristic of GAD may be
reinforced by its immediate eect of damping down arousal and nega-
tive aect, but it leads to a failure of habituation in the long run. Thus,
the shift toward verbal-propositional processing and away from imagery
contributes to one of three vicious cycles involved in the maintenance of
GAD. In gure :., this aspect of the model is represented by the step
labeled verbal processing (suppress image) that connects worry back
to the automatic threatening image.
As verbal-propositional processing damps down negative aect, but does
not eliminate it entirely, the individual with GAD also tends toward vo-
litional avoidance of elaborative processing of threat. In turn, eorts to
distract paradoxically serve to increase the accessibility of the threaten-
ing images, and thoughts and thereby create diculty terminating worry.
In gure :., this aspect of the model is represented by the step labeled
distract that completes the second vicious cycle connecting worry back
to automatic threatening images.
28
Figure 2.4
Model of maintenance of generalized anxiety disorder. Redrawn from Barlow
(:cc:), with permission
Tension
Automatic
Trigger threatening Anxiety Dysfunctional
image performance
Verbal
processing
(suppress image)
Distract Worry
Diculty in terminating worry or the tendency for tension to heighten
self-focus is likely to interfere with the individuals 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 eective problem-solving. Thus, a third vicious cycle may
begin, as the ineective problem-solving is taken as further evidence that
stressors are uncontrollable, and as a result, the individual begins to
worry about worrying. In gure :., 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 aect, thereby com-
pleting the last of the three positive feedback loops.
Worry about the recurrence of worry or anxiety decreases as a function
of decreasing sensitivity to worry themes and control over the worry pro-
cess. This is one of the functions of worry control treatment. The treat-
ment targets the maladaptive cycle that maintains states of high anxiety
and worry. (This will be covered in more detail later.)
29
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Outline of the Treatment Procedures and the
Basic Principles Underlying Treatment
There are four primary treatment modules in the MAW workbook. The
rst 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.
The second module consists of somatic control exercises in the form of
progressive muscle relaxation training. Relaxation is included to directly
target the physiological arousal and tension that are a core component
of GAD. Moreover, relaxation has been demonstrated to be quite eec-
tive in terms of treating generalized anxiety.
Third, imagery exposure is used to evoke, in a methodical, controlled fash-
ion, the worrisome images most salient to the individual. Repeated expo-
sure, with increasing control over the worry process, focuses on replacing
cognitive avoidance tendencies with one of cognitive modication through
approach and challenge. The suggestion by Borkovec and colleagues that
the process of worry itself suppresses the generation of imagery, particu-
larly those aspects of imagery that encode eerent commands to the au-
tonomic system, implies that it is important to include physiological
response elements in imagery exposure (Borkovec, Shadick, & Hopkins,
:,,:). Imagery exposure begins with simulation activities, (e.g., recording
images on audiotapes or on paper and then replaying or rereading them)
and progresses to everyday, naturalistic activities (e.g., rereading stories
in newspapers or magazines that trigger worries).
Fourth, in vivo exposure to situations that are being avoided or put o
and response prevention of any safety behaviors are included. Since
31
Chapter 3
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 rst 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
The workbook targets cognitive biases, physiological arousal, and avoid-
ance behaviors. It also introduces time management and problem-solving
skills to speak to other issues that may be, in some cases, pertinent to the
experience of anxiety, such as life stressors (e.g., relationship diculties,
job loss). The workbook does not attempt to directly address additional
problems that often occur with anxiety, such as depression or panic at-
tacks. Consequently, we suggest that, for the duration of time devoted to
implementing the MAW program, the focal point of treatment be lim-
ited to working with worry and generalized anxiety. If other emotional
diculties are primary, or if major life crises take place, we suggest that
they be addressed before an attempt is made to reduce the clients worry
and tension.
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 dierences, 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 denitional 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 suerers of chronic anxiety, cognitive restructuring may
be less relevant than relaxation, or vice versa. An initial individual re-
sponse prole will be helpful for ascertaining which of the treatment
components will be most useful. Such a prole 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 o danger, and cognitive avoid-
ance or distraction strategies.
Principles Underlying the Treatment Procedures
As discussed earlier, the primary features thought to be inuenced by the
treatment package include hyperarousal and tension, vigilance for signals
of threat, misinterpretation of ambiguous stimuli as signals of danger,
apprehension of recurrence of worry and anxiety, cognitive avoidance,
and avoidance behaviors that may be subtle or covert.
:. It is postulated that anxiety is moderated by perceptions of pre-
dictability, controllability, and safety. It is of the utmost impor-
tance to give these variables due regard, particularly when plan-
ning specic practices for clients to carry out. For example, a
client who worries excessively about her childrens well-being may
report very little distress associated with an exposure practice of
letting her ::-year-old child spend an afternoon away from home
with one of the clients friends supervising. In contrast, the client
may have intense anxiety when conducting exposure to letting her
child spend an afternoon away from home with no adult present.
Most likely, the perceived safety of the presence of another trusted
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 spouses coming home :c 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.
Perceptions of lack of safety, unpredictability, and uncontrollability
are presumed to be inuenced by all stages of the treatment pro-
cess: Corrective information is of particular value to perceived
safety and predictability; relaxation is relevant for perceived con-
trollability over tension, worry or in vivo exposure is pertinent to
all three constructs, and problem-solving and time management
are of value to perceived controllability over stressful life events.
:. The survival value of anxiety is stressed throughout the course of
the program, and taps the perceived safety-danger dimension of
the clients beliefs regarding anxiety and worry. In the treatment
program, the cognitive and somatic sensations accompanying
anxiety are related to biological changes that occur as a result of
sympathetic nervous system activation. Moreover, as such activa-
tion is associated with preparation for danger, the sensations are
presented as the byproduct of a mechanism for coping and sur-
vival, and as natural and harmless.
,. The majority of cognitive restructuring focuses on perceiving the
world to be a safer place than is currently estimated by the chronic
worrier. Therefore, it is safe to let go of excessive worry because,
by doing so, the individual is not in reality placing himself or her-
self at greater risk for negative events.
. The state of anxiety is dierentiated from fear or panic, both
theoretically and with respect to their three-response-mode pres-
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 ght-or-
flight urges. Most often, the anxiety experienced by chronic worriers
tends to be focused on various life circumstances, such as family,
health, nances, 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 doesnt re me for not meeting the deadline we
were shooting for, or I hope I dont become so nervous that Ill
blank out on my lines during the audition, or at a preattentive
level outside of conscious awareness.
,. One of the main approaches taken during treatment is graduated
exposure. Thus, the triggers for anxiety may be ordered in terms of
a hierarchy, or stepladder, of intensity. Consequently, imagery
exposure practices may begin with exposure to negative images
that generate relatively manageable levels of worry and anxiety,
and then progress gradually to images that are more troubling.
Similarly, worry prevention (in vivo exposure and response pre-
vention) may begin with situations or tasks that are perceived as
being relatively safe or manageable, and then progress systemati-
cally to practices that are perceived as being more threatening and
challenging (see the following case for an example).
o. Throughout the program, a learning approach is adopted in which
the development of skills is emphasized. The amount of improve-
ment is thought to be related to the extent to which the individual
actually practices the various skills and exercises. Practices are de-
signed to challenge tendencies to avoid and replace them with ap-
proach tendencies.
35
Case Example
Striving for Perfection: The Case of J
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 rememberat 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 diculties 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 diculty concentrating,
she reporting experiencing recent physical diculties, 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 denitional thresholds for either a major
depressive episode or dysthymia.
Her worries and generalized anxiety led to signicant interference with
her life. She continued to function at home and at work in her roles as
mother and teacher. Nevertheless, as a result of her perfectionistic and
people-pleasing tendencies, she was taking on so many projects at work
that it was cutting into her leisure time and she was not enjoying the
little free time she had. In addition, she had been avoiding visiting her
terminally ill family member because she was anxious that she might not
say the right things and might cry, and would worsen his condition as a
result. This created a great deal of conict for her because she felt very
close to this family member and very much wanted to visit him. Thus,
she felt a great deal of shame about not visiting him.
Hence, J felt that almost her whole life revolved around the fear of fail-
ure and her attempts to be perfectthe 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, Js initial response was mixed. She
learned the :o-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.
Js 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 nally, 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.
Much of her worry prevention exercises centered around assertiveness,
initiating social interactions, and saying no to peopleparticularly people
at work. Initially, these exposure practices (or, in her words, reality test-
ing) increased her general anxiety level and the number of episodes of
heightened anxiety that she reported. However, with repeated practice,
her anxiety decreased and she proceeded through the rest of the hierar-
chy relatively smoothly. In fact, at times, she appeared almost gleeful when
thinking about turning down a request to take on a new project at school.
J experienced frequent episodes of heightened anxiety and high levels of
average anxiety through the rst weeks of treatment, when imagery ex-
posure was begun, after which the frequency of her episodes of height-
ened anxiety and her average anxiety ratings declined steadily. By the end
of treatment, J was sleeping much better and only rarely experienced the
gastrointestinal symptoms that had bothered her frequently at the be-
ginning of treatment. She reported that she was socializing more regu-
larly and getting more enjoyment from her leisure and family activities.
She also reported, with some excitement, that she was contemplating the
idea of returning to school for an advanced degree, even though this
change was not directly targeted in treatment. Six months after the end
38
of the program, J was reevaluated and found to experience little or no
evidence of the signs and symptoms of GAD.
Outline of the Therapist Guide
A chapter-by-chapter description of the MAW treatment program is
provided in the remainder of this guide. One chapter is devoted to each
chapter in the MAW program workbook. Each chapter is arranged as
follows:
A suggested agenda for the session, including a point-by-point
summary of information to be discussed
A description of the main concepts imparted to the client in the
chapter
A description of the principles underlying the particular treatment
procedures included in the chapter
Case vignettes that illustrate commonly asked questions arising in
each chapter and examples of therapist responses
A description of atypical or problematic client responses
We strongly recommend that therapists read each chapter in the MAW
workbook before that weeks session, in addition to reading the pertinent
material in this guide. Some therapists prefer that clients read the work-
book chapter before the session so that the therapist can elaborate on is-
sues and tasks, as well as answer questions. Other therapists prefer that
clients read each chapter after the session is over to review and consoli-
date points covered in the session. We usually follow the latter strategy
and assign the relevant MAW workbook chapter after each session.
39
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The Nature of Generalized Anxiety
(Corresponds to chapter 1 of the client workbook)
Summary of Information in Chapter 1 of the MAW Client Workbook
Denition of GAD, including excessive worry and high levels of
physical tension.
Description the of DSM-III-R and DSM-IV criteria for GAD.
Prevalence statistics for GAD in particular and the anxiety disorders in
general.
Distinction between generalized anxiety and normal anxiety, emphasiz-
ing the excessiveness and uncontrollability of the worry process.
Prominence of other types of emotional disorders, within which worry
and anxiety may occur (e.g., depression or panic), as a signal to opt for
a dierent type of treatment.
Complications arising from involvement in more than one psycho-
therapy at a time for the management of anxiety and worry. The limi-
tation to one psychological program at any given time for the treat-
ment of generalized anxiety is recommended.
Combination of medication with the MAW program. Weaning from
medication can be incorporated into the MAW program.
Information regarding treatment ecacy.
Discussion of the relationship between improvement and practice,
since the approach is one of learning; this treatment is most appropri-
ate for individuals who are highly motivated to make changes.
Chapter-by-chapter outline of the MAW program.
41
Chapter 4
Session Outline
Brief check-in
Negotiating an agenda
Discussion of the clients goals for therapy
Discussion of the clients expectations for how therapy will help to
achieve the goals of therapy
Negotiating homework
Session summary and feedback
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 briey
review whatever monitoring forms the therapist may have asked the client
to complete prior to this session.
Negotiating an Agenda
It is important to begin each session by negotiating an agenda. Typically,
the therapist will have several suggestions for agenda items, after which
we encourage the therapist to ask the client if he or she has any suggested
agenda items, either in addition to or instead of any of the therapists
suggestions. This helps to maintain a structure and focus to the session
in a collaborative fashion to ensure that there is time for the therapist to
introduce the various modules of the program, as well as a chance to dis-
cuss topics that the client considers high-priority issues. Whenever pos-
sible, the topics introduced by the client should be addressed in the con-
text of the session topics.
For this session, the therapists suggestions for agenda items should in-
clude a discussion of the clients goals for therapy and the clients 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 clients anxiety, worry, and tensionin other words, a shared
understanding of the processes that they need to target for intervention.
Discussion of the Clients Goals for Therapy
In discussing the clients goals, it is important to keep as concrete a focus
as possible. The more concrete the clients goals at the outset, the easier
it will be to assess whether those goals have been achieved at the end of
the program. We nd it useful to begin with a simple question, such as
If the work we do together is successful, how would your life be dier-
ent, say, o or :: months from now? In the course of the ensuing dis-
cussion, the following is a list of points that the therapist should con-
sider addressing.
The specic clustering of features that distinguishes GAD is su-
ciently prevalent to be recognized and labeled as a specic type of
anxiety problem. That is, the client is helped to understand that
he she is not the only person experiencing these problems. This
intervention targets exaggerated beliefs of abnormality and associ-
ated existential anxiety.
Worry and anxiety are universally experienced and often serve
adaptive functions. Other factors are important in the develop-
ment of a disorder. Hence, the notion that all anxiety is abnormal
and maladaptive is targeted. In addition, this treatment is not de-
signed to remove any and all anxiety. Even if it were possible to
eliminate anxiety entirely, it would not be in the clients best
interests to do so.
Whereas worry and anxiety often serve adaptive functions, they
become problematic when experienced at intensities out of pro-
portion to the level of objective threat in a situation or in situa-
tions in which there is no objective threat whatsoever.
The various ways of coping with worry and anxiety, including per-
fectionism, procrastination, and its oppositeputting pressure on
oneself to complete things in unnecessarily short periodsare
43
understandable. However, these approaches tend to diminish ones
feelings of enjoying life. Moreover, these attempts at coping may
be eective at reducing anxiety in the short run, but often tend to
perpetuate the anxiety and worry in the long run.
Discussion of the Clients Expectations for How Therapy
Will Help Achieve the Goals of Therapy
Because some clients already have realistic expectations at the outset, we
prefer to elicit the clients expectations rather than lecture to them about
points that they already understand. When an expectation is consistent
with our notion of how we work with clients, we quickly provide that feed-
back and focus more intensively on points that the client did not men-
tion and even more so on those expectations that are inconsistent with
how we work with clients. It is crucial that the following two points are
included in this discussion.
:. Practice is essential. Clients wont improve if all they do is read the
manual and attend treatment sessions. Just as with learning any
other new set of skills, the skills introduced in the MAW program
require repeated practice to reach mastery, and even more repeti-
tions are required before the skills begin to feel natural and be-
come second nature.
:. The primary focus will be on maintaining factors in the here and
now. Though, in some cases, it might be useful to discuss child-
hood learning histories (such as when trying to reduce self-criticism
that, for the moment, is focused on how stupid it is to experi-
ence a particular negative automatic thought or belief ), discussion
of such factors is not necessary in most cases, and is not sucient
to produce the full benet of the MAW program. Thus, it can be
very useful to discuss the notion that maintaining factors are often
quite independent of etiologic factors and that, even if we had
perfect understanding of the etiologic factors involved in a particu-
lar case, it is impossible to go back and change those factors (al-
though genetic engineering might someday allow us to change at
least one of those factors, this is not possible today). In contrast,
we can often learn how to gain control over the maintaining factors.
44
Negotiating Homework
At least some problems with compliance with homework can be pre-
vented by making homework something that is truly negotiated and col-
laborative, rather than assigned by the therapist. We nd it useful to
oer the client a menu of homework suggestions and then to ask if the
client can think of any additional suggestions, given what was discussed
in the session. Finally, we ask which of these options the client wants to
commit to doing before the next session. Typically, our clients choose to
commit to completing all of the suggestions, and we believe that they ac-
tually follow through more of the time now than when we assigned home-
work without oering the client any perceived control over the process. On
occasion, a client does refuse to commit to one or more options; how-
ever, we are convinced that they would not have followed through on
these if we had assigned them.
For this session, the therapists 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 identied in this session. If the client has al-
ready begun self-monitoring (we typically like to begin self-monitoring
even before the rst 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.
Session Summary and Feedback
It is important to end every session by asking the client to summarize
any take-home messages or points that might be helpful. This is impor-
tant to assess proper understanding and facilitate consolidation of im-
portant points. We also encourage therapists to ask the client if he or she
had a negative reaction to anything about the session. The vast majority
of the time, our clients tell us that nothing troubled them about the session.
Despite this fact, we believe that ending sessions in this way is helpful,
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.
Principles and Points to Consider
The rst chapter is basically didactic, but remember that it is helpful to
maintain a Socratic style. Chapter : provides corrective information that
assures clients that they are neither crazy nor atypical. Hence, cognitive
modication is begun through the provision of an alternative framework
in which to understand anxiety.
Case Vignettes
Case Vignette 1
C: Im not sure if I want to go through with this treatment program. It
seems that this program is focused on getting me to worry less, but I
nd that worrying helps me to be prepared for what might happen. I
would feel even more anxious if I werent worrying.
T: So, it sounds like you believe that worrying protects you, and youre
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 werent able to
foresee and so didnt worry about in advance?
C: Sure, many times.
T: And would you say that you handled any of those situations adequately?
46
C: Not usually, no.
T: Not even once?
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 werent aware of and didnt worry about in advance?
C: Yes. Recently, my son took a trip with some of his college friends that I
wasnt aware of. Usually, I worry a lot before any of my family mem-
bers takes a ight. This time, I didnt worry because I didnt even know
he was ying until afterward.
T: And how was his ight?
C: No problems. He was ne.
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
C: I was hesitant about starting this kind of therapy program because I
feared hearing about things that would make me feel more anxious. It
sort of feels as if these kinds of worries are contagious.
T: Undoubtedly, as you start to confront the things you are anxious
about, you may very well experience an increase in your anxiety level.
However, confronting your anxieties is an essential part of the treat-
ment process. In addition, the increase in your anxiety is temporary
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 Ive experienced this anxi-
ety and tension for so long? Ive been a worrier all my lifethats just
the way I amso 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 doesnt necessarily inuence 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 benet. Second, this program is
highly skills-oriented, and learning takes place fairly quickly. Third,
and perhaps most important, we dont expect you to be cured at the
end of this short-term program. Rather, I have a dierent 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: Im not sure. Maybe that when I nish the program, Ill know skills
that will allow me to deal with the problems that remain?
T: Exactly. In fact, many people continue to experience further improve-
ments after the program is completed, if they continue to apply the
skills theyve learned. Finally, would you agree that the rate of success
with this type of treatment is relevant evidence to consider about the
odds that you will be helped?
C: Sure, but I bet it doesnt help everyone.
48
T: Well, the success rate is very high, but youre 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 nal judgment until you have had experience with some of
the exercises and techniques?
Case Vignette 4
T: So, lets talk some about your goals for our work together. If were suc-
cessful, how will your life be dierent o 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 dierent
is that I wont 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 cant 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 cant get it
all straightened up in one shot, and that thought gets me so anxious
that I dont even do any cleaning! I just go and play a video game or
watch TV.
T: So, it sounds like an overarching goal is to feel less overwhelmed by
your anxiety. More specic goals are that you would like to make deci-
sions regarding your career path, your relationship with Trevor, and
where to live. Another specic goal is that you would like to stop pro-
crastinating and take some steps toward straightening up your apart-
ment. Does it sound like I got it right?
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 Ill 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.)
C: Sure, when I used to do some acting in college, some anxiety helped to
give me energy during a performance. And being worried that I might
forget my lines during a performance pushed me to go over my lines so
I would remember them.
T: Thats exactly what Im talking about. In fact, a lot of therapists and
researchers relate anxiety to the functioning of the ght-or-ight re-
sponse. Any ideas what we might mean by that?
C: I dont think so. No.
T: OK. Let me explain that to you . . .
Case Vignette 5
C: I cant think of any times in my life when anxiety was helpful to me.
T: How about when you were in school?
C: Im not sure what you mean.
T: Well, how do you think you would have done on exams if you didnt
have any anxiety?
C: I always got so anxious that I couldnt concentrate when taking my
exams. Id get so overwhelmed that I would blank out. So, I think I
would have done better in school had I not been so anxious.
T: It sounds like you did experience anxiety that was so high that it dis-
rupted your performance. But Im 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 didnt experience any anxi-
ety whatsoever.
C: I still think I would have done better since I would have been relaxed
while taking the exams.
T: What about preparing for examsstudying?
C: Well, Im still not sure that I get your point. I was so tense while
studying that I had diculty concentrating then, too. So I think being
more relaxed while studying would have helped.
T: OK. Lets try looking at this from a slightly dierent perspective. Try
to imagine what it would be like for someone else, a student who
doesnt 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 loang o 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 cant think of a
time when my anxiety level wasnt 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 nding an anxiety level that is some-
where in the middle, huh?
T: Yes, thats 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 anxietyeven if we could do so, we wouldnt want to. Rather,
our goal is to eliminate excessive anxiety.
Case Vignette 6
C: I dont 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 dont 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 denitely 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. Id 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, Ive been very worried about the fact that Ive been out of work
for the last months. If that isnt a realistic worry, I dont know what is!
T: I certainly agree that being out of work is a problem that most of us
would worry about to some extent. Can you tell me a little more about
that worry? What specic thoughts go through your mind when youre
worried about being out of work?
(The therapist validates the realistic side of the clients worry and gently probes
further to nd out if the worry might be excessive.)
C: Ive only been able to nd temporary oce work so far. I worry that
Ill never nd another permanent job.
T: It sounds like your job search has been frustrating so far. And I can
certainly understand how thinking that youll never nd another per-
52
manent job would make you very anxious. But what evidence do you
have that youll never nd another permanent job?
(The therapist simultaneously validates the patients feelings and gently points
out the link between thoughts and feelings.)
C: Well, the economy has been lousy lately.
T: OK. Do you have any other evidence?
C: No, its more just based on my feelings, I guess.
T: OK. Do you know what the current rate of unemployment is in your
eld?
C: Im not sure, but I think its somewhere between , and :c%.
T: And do you know anyone in your eld who recently found a job?
C: I heard that someone I used to work with, who was laid o a few
months before me, found something recently.
T: So, what do these bits of evidence tell us about your situation? Is it
possible that youve been overestimating the likelihood that you wont
ever nd another permanent job?
C: I suppose thats a possibility. But even if that is the case, Im not sure
what to do about it.
T: Well, then, that will be a thought that we will want to focus on in
greater detail during the course of our work together. In about ve ses-
sions, I will be introducing you to exercises that will help you change
anxious patterns of thinking. These exercises will help you evaluate
objectively whether your worries are realistic.
(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.)
Atypical and Problematic Responses
Given the physiological sensations accompanying anxiety, a genetic, medi-
cal, or chemical interpretation of anxiety seems more credible to some
clients than an interpretation that takes psychological variables into ac-
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 rst 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.
Generally speaking, as with all treatment approaches, client motivation
to participate actively is vital. In the situations described earlier, however,
low motivation to try the MAW program may result from a specic bias
in attributions for personal experiences. Consequently, an eort to chal-
lenge and explore that attribution is appropriate. Following are several
steps that we recommend.
What evidence does the client have to assume an inherited, medi-
cal, or chemical abnormality? Typically, there is no medical evi-
dence or the anxiety persists, despite control of a medical problem
(e.g., thyroid medication for hyperthyroidism, diet changes for
hypoglycemia). Genetic evidence typically consists of the observa-
tion of anxiety problems running in the family. However, the fact
that ones parents (or other relatives) had anxiety problems is just
as consistent with a learning explanation as it is with a genetic ex-
planation. In fact, in most individual cases, it is impossible to de-
termine the extent to which genetic factors or experiential factors
are involved in the onset of the problem.
The evidence from the research literature does support a genetic
contribution to the experience of anxiety. However, the main
question of why excessive anxiety occurs cannot be answered en-
tirely from a genetic perspective. That is, it seems that what is in-
herited is a predisposition or vulnerability to an anxiety problem,
but other factors come into play in determining whether this
vulnerability results in a disorder.
Even if inherited abnormalities are present and could be shown to
account for the presence of excessive anxiety, this does not neces-
sarily imply that the MAW program will not be ecacious. It is
possible that some of the eects of the MAW program may be
mediated by altering the underlying biochemical processes. The
54
evidence regarding the treatment ecacy of the MAW program
and similar approaches to the treatment of anxiety can be empha-
sized. Examples might also be given of medical problemssuch
as stroke and some forms of diabetesthat have known bio-
chemical causes and yet are treated behaviorally.
Clients may not be able to connect all of their episodes of height-
ened anxiety with discrete and readily identiable triggers. The re-
sultant state that may be experienced as free-oating anxiety
may seem more compatible with a genetic explanation. Recogni-
tion of the following factors is useful: (:) the general impact of
stress on the bodys nervous system, (:) the presence of automatic
thoughts that occur outside of conscious awareness and aect
mood, and (,) how uncertainty about the reasons for anxiety may
increase the level of distress. That is, clients are led to recognize
that there may be triggers for their anxiety that they are not cur-
rently aware of, but that may be discerned through systematic
observation.
A similar problem that may undermine motivation for treatment is that
some clients dont recognize their worries as being excessive (as reected
in case vignette ;). In this situation, the clients worries should be elicited
in as much detail as possible. The realistic aspects of the clients worry
should be acknowledged, but the therapist should also initiate an exami-
nation of the relevant evidence to help the client begin to recognize the
aspects of worry that may be excessive. Discussion of the ability to con-
trol worry versus the tendency for worry to take on a life of its own and
interfere with other activities can also be helpful.
55
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Summary of Information in Chapter 2 of the MAW Client Workbook
The need for becoming an observer of ones own behaviors and re-
sponses to enhance understanding of ones anxiety and to adapt speci-
c treatment procedures to ones personal experience.
The degree to which retrospective recall is skewed by current mood
and may contribute to the perpetuation of anxiety, regular and contin-
uing monitoring and recording is therefore more advantageous and less
detrimental than retrospective recall.
Justication for self-monitoring, which aids in the identication of
subtle or previously unrecognized triggers and episodes of high anxiety,
and helps the client to evaluate progress objectively.
Instruction in how to monitor episodes of heightened anxiety, daily
mood, and progress.
Session Outline
Brief check-in
Negotiating an agenda
Discussion of self-monitoring
Negotiating homework
Session summary and feedback
57
Chapter 5 Learning to Recognize Your Own Anxiety
(Corresponds to chapter : in the client workbook)
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 therapists suggestions for agenda items should in-
clude a discussion of self-monitoring and negotiation of homework.
Discussion of Self-Monitoring
In discussing self-monitoring, the following is a list of points that the
therapist should consider addressing.
The signicance of comprehending processes contributing to the
development and maintenance of episodes of high anxiety, as op-
posed to focusing on symptoms and distress levels. The latter only
serves to maintain anxiety. On the other hand, objective awareness
and understanding of processes is the rst step toward improvement.
The degree to which mood-dependent recall may predominate
and add to current levels of emotional pain, thereby hindering the
acquisition of an objective understanding of the processes. Conse-
quently, the client is led to appreciate that on-the-spot monitoring
may be therapeutic in itself, and much more benecial than retro-
spective recall.
An initial attempt to recognize triggers for heightened anxiety and
early awareness that anxiety is starting to build should be empha-
sized. At this time, it is not necessary to suggest that all episodes of
anxiety are cued. However, there is an eort to encourage clients
to begin to discern precipitants that may be subtle and perhaps
not immediately apparent. Monitoring of oscillations in states of
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 eorts to reduce it. A metaphor that might be useful here is
that it is far easier to put out a small brush re as soon as it starts
rather than waiting until it turns into a raging forest re.
Maintenance of complete records for the duration of the treat-
ment program is a useful means for clients to evaluate their
progress and maintain motivation to make changes.
Negotiating Homework
For this session, the therapists 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).
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.
Principles and Points to Consider
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 rst 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 rst treatment session and then sending the relevant
monitoring forms through the mail).
59
Case Vignettes
Case Vignette 1
C: What should I self-monitor if I dont experience any increases in my
anxiety level because Im avoiding almost all of the situations that in-
crease my anxiety?
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 nd 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 Im going to be
lling 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 youre 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 Im still not sure what to do with the Worry
Record.
T: So, do you mean to say that there arent 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 youre get-
ting ready for work?
60
C: Well, I guess when I rst wake up, Im almost too tired to be worried.
Its 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 ll out a Worry
Record when you get out of the shower. On days when your boss is
looking for you, you could begin to ll out another Worry Record as
soon as you can after your anxiety about that starts to increase.
C: Im worried that monitoring and recording will increase my anxiety
level.
T: Do you usually try to avoid thinking about how you feel because
youre worried that thinking about how youre feeling will raise your
anxiety level?
C: Yes.
T: Well, in that case, monitoring will function as an exposure practice for
you by encouraging you to focus on the things that make you nervous.
As with all exposure practices, you will probably feel uncomfortable at
the start and then gradually feel more comfortable as you continue to
do the monitoring. Monitoring is a benecial strategy, since it involves
recording the objective features of your anxiety. By gaining a deeper
appreciation of the mechanisms of anxiety, you will be in a better posi-
tion to change the processes involved.
Case Vignette 3
C: I am already so busy that the monitoring is just going to add another
burden to my already hectic schedule and make me feel more tense.
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 ineciency and inter-
feres with performance. Can you think of any times when this has
been true for you?
61
C: Sure, thats part of the reason Im 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, Id like you to try to remember that the monitoring is es-
sential for change. We cant change your anxious patterns of respond-
ing if we dont rst understand them and their precipitants. Does that
make sense?
C: Sure.
T: When I was discussing a related issue with one of my former patients,
she shared a metaphor that she got from some reading she had done
that she found useful. In this metaphor, there are two lumberjacks.
The rst is so worried about meeting his quota that, as soon as he cuts
down one tree, he immediately begins work cutting down another. In
contrast, the second lumberjack stops between trees to sharpen and oil
his saw. In the long run, the second lumberjack cuts down at least as
many trees as the rst one. Do you think this metaphor has any rele-
vance for you?
C: Well, sure. Taking the time to monitor is part of my program, so its
like stopping to sharpen and oil my saw, so to speak. In the short run,
it slows me down, but in the long run, it might help me to reduce my
anxiety and work more eciently.
T: Exactly. The short-term cost of putting in a few extra minutes a day
should be associated with the long-term benet of reducing your ex-
cessive anxiety. In the long run, the extra time you put in now should
help you to be more ecient in the future. Finally, because problems
with time pressures are fairly common among people with anxiety
problems, one of the later portions of the program is devoted to
methods of time management.
Case Vignette 4
T: Ok. Lets take a look at the Daily Mood Record you completed this
week.
62
T: Wow! It looks like youve had a very anxious week! You rated most
days a :cc on both overall anxiety and maximum anxiety.
C: Yeah, thats 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 lled out the Daily Mood Record the way he had to make sure that
the therapist understood how bad o 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 ght on Monday night, and that night and
most of Tuesday, I was even more anxious than usual, thinking that I
wasnt being a good husband and that Gina would leave me.
T: Im sorry to hear about that. Bad ghts can be very distressing. Now
what I would like you to do is think about our c- to :cc-point scale
such that Monday night and Tuesday would be :cc points. OK?
C: Yeah.
T: Good. Now lets go back and re-rate the last day or two, keeping in
mind that Monday night and Tuesday, after the big ght with Gina,
were rated as :cc. So, if Monday night was :cc, the maximum anxiety
rating for Monday would be :cc. Since it wasnt 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 c, so maybe ,c for the overall rating that day.
T: Good. Now, how about yesterday? If your overall rating for Tuesday
was :cc, 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 ght, so Id give it an c.
63
Atypical and Problematic Responses
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 clients 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 Rollnicks approach, as described in Motivational
Interviewing (:cc:). 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 clients anxiety, worry, and avoidance or safety behaviors relate
to the values of greatest importance to the client. The therapist could
64
Figure 5.1 Example of Daily Mood Record completed by patient.
Rate each column at the end of the day, using a number from the c- to :cc-point scale below.
c----- :c----- :c----- ,c----- c----- ,c----- oc----- ;c----- c----- ,c----- :cc
None Mild Moderate Strong Extreme
Daily Mood Record for James
Overall Maximum Physical Preoccupation
Date Anxiety Anxiety Tension with Worry Headaches
Monday 100 100 65 75 50
7th
Tuesday 100 100 45 45 10
8th
Wednesday 60 90 70 70 65
9th
Thursday 100 100 20 25 10
10th
Friday 100 100 50 55 30
11th
Saturday 100 100 10 30 15
12th
Sunday 100 100 30 40 20
13th
Daily Mood Record
then ask the client to engage in a decisional balance exercise. In the de-
cisional balance exercise the client rst 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 reects these motivations back to the client, it
is recommended to begin with the reasons for participating in the pro-
gram and nishing 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
Figure 5.2 Example of Worry Record completed by patient.
Date: Time began: (a.x./i.x.) Time ended: (a.x./i.x.)
Maximum level of anxiety (circle a number below):
c----- :c----- :c----- ,c----- c----- ,c----- oc----- ;c----- c----- ,c----- :cc
None Mild Moderate Strong Extreme
Indicate which of the following symptoms you are experiencing:
Restlessness, feeling keyed up or on edge
Easily fatigued
Diculty concentrating or mind going blank
Irritability
Muscle tension
Sleep disturbance
Triggering events:
Anxious thoughts:
Anxious behaviors:
Worry Record for James
Wednesday 9th 5:00 5:00
Sunday nightwork tomorrow
Too much to do, wont get everything finished, boss will be mad at me
Tried to watch TV to keep my mind occupied, but I continued to worry
Worry Record
yes, buts to be directed at the reasons for not participating. If these
techniques do not have the desired eect 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
eort-intensive program.
In other cases, as reected 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 benet 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 :cc for both over-
all anxiety and maximum anxiety every day the rst 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 :cc
points, and then to go back and reevaluate at least some of the other rat-
ings, with that anchor point in mind.
66
Summary of Information in Chapter 3 of the MAW Client Workbook
Description of a dimensional model of anxiety, such that a moderate
level of anxiety is both helpful to performance and adaptive; however,
as anxiety exceeds an optimal level, it can begin to aect performance
negatively.
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.
A model of the physiological basis of anxiety and fear. The functioning
of the sympathetic and parasympathetic nervous systems and the re-
lease of adrenaline and noradrenaline, as well as their eects on bodily
functioning, are described. Particular emphasis is placed on cardiovas-
cular, respiratory, and muscular eects. The discussion of physiological
processes is put in the context of preparation for an alarm reaction.
Preparation is essential and adaptive under conditions of real danger,
as it primes the body for protective action, consisting of either escap-
ing or ghting. While anxiety is associated with preparation for an
alarm reaction, panic is identied with the actual ring of the alarm,
or ght-or-ight, reaction.
67
Chapter 6 The Purpose and Function of Anxiety
(Corresponds to chapter , of the client workbook)
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 oered as a cause of increased or decreased inten-
sity of any emotion at any given time.
Illustrative types of interactions among the three response compo-
nents. For example, worry combined with physical tension, agitation,
and restlessness may interfere with performance at work, which can
lead to further worry and tension. In this example, the three compo-
nents interact in a positive feedback cycle, escalating the overall emo-
tional intensity. On the other hand, the presence of symptoms of
physical tension and arousal in the absence of worrisome thoughts is
much less likely to result in the same intensication of the emotional
state.
Categorization of reactions in the three response systems and their in-
teractions as either anxiety or fear (panic) states. Fear involves percep-
tions of immediate threat, behavioral escape or avoidance tendencies,
and acute physiological arousal. Anxiety involves perceptions of more
distant threat, behavioral interference or avoidance, and a more grad-
ual increase in physiological arousal.
A review of the most common themes of worry: health, loved ones,
work and school, nances, and daily chores.
Session Outline
Brief check-in
Negotiating an agenda
Discussion and review of the nature of anxiety and fear
Discussion of the components of anxiety
Negotiating homework
Session summary and feedback
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 therapists 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.
Discussion and Review of the Nature of Anxiety and Fear
In discussing or reviewing the nature of anxiety and fear, the following
is a list of points that the therapist should consider addressing.
Anxiety is thought of in dimensional as opposed to typological
terms, and can vary from mild to severe. It is important for clients
to realize that the level of anxiety experienced at any given mo-
ment is a function of particular processes that can be controlled.
Consequently, treatment involves identifying these processes and
altering them.
It is of considerable import that clients realize that anxiety is not
all bad. Some moderate level of anxiety is very adaptive and con-
ducive to performance and, in some situations, even necessary for
survival. Therefore, the goal of the treatment program is to reduce
the expression of anxiety at times when it is not warranted or is
out of proportion to the actual threat, as opposed to removing any
and all anxiety. Even if it were possible to remove all anxiety,
doing so would not be in the clients best interests.
The distinction between anxiety and fear (panic) is covered in this
chapter. Fear is thought of as the ght-or-ight response that oc-
curs when threat is perceived as being immediately present. Anxi-
69
ety is viewed as a priming of the ght-or-ight 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.
The physiological sensations accompanying anxious moods are
based on actual physiological processes or changes. It is important
that clients understand that there is a direct connection between
the dierent sensations experienced, their physiological basis, and
their survival value. Hence, perceived safety is introduced.
Discussion of the Components of Anxiety
It is important that the following three points are included in this dis-
cussion.
:. Anxiety is a set of reactions, as opposed to an entity over which
the individual has little or no control (despite the perception of
being out of control). We break anxiety reactions (and all other
emotional reactions) into three components: physiological, cogni-
tive, and behavioral. The client should focus on a recent or particu-
larly memorable episode of anxiety and complete an Anxiety
Components form, with the therapist coaching the client.
:. To reinforce the notion of anxiety as a set of reactions, the ways in
which the dierent components fuel each other are emphasized.
For example, worrisome thoughts can increase physical arousal,
which interferes with behavior. The interference with behavior
(such as diculty concentrating at work) can in turn lead to fur-
ther worry (such as worrying about job performance and evalua-
tion). Therefore, a large part of the program involves learning to
disconnect the response components. That is, learning that ones
worries are unfounded serves to control episodes of heightened
anxiety and tension, and also to reduce the frequency of worry by
reducing the behavioral interference that provides the source of
some worries.
70
,. In keeping with the notion that it will be helpful if clients can
identify increasing anxiety at earlier and earlier points in the anxi-
ety sequence, clients are encouraged not only to break down their
anxiety reactions into the three components, but also to start
thinking about the sequence of these reactions. The Sequence of
Anxiety Components for a Recent Episode of Anxiety form is in-
troduced to systematize the clients thinking about interactions
among the three components and eorts to identify anxiety spirals
at earlier and earlier points in the positive feedback loop. Com-
plete a Sequence of Anxiety Components for a Recent Episode of
Anxiety form together in session, with the client doing the writing
and the therapist coaching the client.
Negotiating Homework
For this session, the therapists 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
Major physical symptoms:
Major thoughts/images:
Major behaviors:
Jittery, tense legs
knot in stomach tension,
especially head & neck
Errors at work, lose job
Not getting things done
Future of family
Irritable with colleagues & family
Procrastinate about starting big jobs
Review my work over and over
Anxiety Components for James Sequence of Anxiety Components for a Recent Episode of Anxiety
Figure 6.1 Example of Anxiety Components form completed by patient.
ety form for every episode of anxiety recorded on a Worry Record (or, at
least, for several episodes).
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.
Principles and Points to Consider
Again, this chapter is principally didactic (but, again, remember to try
to maintain a Socratic approach) and taps the elements of perceived pre-
dictability and perceived controllability. Perceptions of predictability are
targeted by the discussion of the ways in which anxiety can escalate. Per-
ceptions of controllability are targeted by the discussion of ways in which
the three response systems can be dissociated and reduced.
The use of a three-response-system model for a descriptive analysis of
anxiety and fear is based on the work of Peter Lang (:,o) and Stanley
Rachman (:,,c; also see Zinbarg, :,,). The tacit assumption under-
lying the MAW program is the idea that anxiety and fear states can be
elicited by a response in any one of the three components. That is, a net-
work of associations among the three response systems develops over
time, such that the presence of a response in one system may engender
responses in the other systems, to varying degrees.
Clients are asked to record systematically their experiences and to begin
to analyze the course of their anxiety experiences, as they unfold over time.
Similar self-monitoring has been demonstrated to be associated with some
therapeutic benet, in and of itself, although the mechanisms underlying
these eects are unclear. These mechanisms may include reducing biases
in retrospective recall that serve to heighten the anticipation of future
events and enhancing perceptions of controllability and predictability.
72
Case Vignettes
Case Vignette 1
C: Sometimes I worry that Ill get so anxious that Ill 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 ones 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 owery 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
rst 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
C: I can understand how thinking that something bad might happen
would produce an anxious feeling, but why do I feel anxious some-
times, even when Im not thinking of anything?
73
T: Automatic negative thoughts are a characteristic of the kind of prob-
lem that youre 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 youre talking about ways of think-
ing that have become a habit for me.
T: Thats right. And what are the characteristics of a habit?
C: Umm, like doing something, even when I dont want to?
T: Thats 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 itperhaps because you have had the same thought
so many times before. For example, when you came into my oce,
were you aware of having the thought Oh, thats a chair. A chair is for
sitting on. Ill 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 isnt 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 todays 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 Im
not aware of being worried about something, I might have had an au-
tomatic worry?
T: Exactly. Over the next few sessions, well 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
C: If anxiety is an adaptive response, why do I have diculty concentrat-
ing? What is the adaptive value of diculty concentrating?
T: Its 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. Di-
culty concentrating is often the by-product of the minds tendency to
scan the environment for possible signs of threat, when in an anxious
state, making it dicult 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 eciently
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 ood 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 di-
culty concentrating on the task at hand. Moreover, by attending to any
symptoms that you nd distressing, such as diculty concentrating,
your anxiety may increase, possibly intensifying the symptoms.
Atypical and Problematic Responses
Typically, clients comprehend the interaction among the three response
systems, and it seems credible. From time to time, however, it is hard for
clients to apply this model to their own experiences due to the absence
of awareness of specic threat cognitions. In these cases, it may be help-
ful to explain that the interactions among response systems may occur
not only at a very conscious level, but also at a perceptual, or automatic,
level, as in case vignette :. Such automatic eects mean that the individ-
ual may become anxious, without even being aware of what they are
75
worried about. The notion of automatic thoughts is explained in more
detail in workbook chapter o. In chapter , of this book (which corre-
sponds to workbook chapter o), 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 o).
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 diculty 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
Summary of Information in Chapter 4 of the MAW Client Workbook
A model of excessive anxiety and worry, which includes the following
features: an inherited general sensitivity, or emotionality; the tendency
to view the world as a more dangerous place than others do, a set of
beliefs or life experiences that lead one to perceive diminished control
over negative events; and stressors that may act as triggers for the de-
velopment of an anxiety problem at a specic point in time.
A description of some of the factors that serve to maintain a state of
heightened anxiety once it has begun, including the following: high
levels of emotional arousal that interfere with the ability to solve prob-
lems eectively; the belief that worry can somehow lessen the chance
of future negative events; attempts to suppress or distract oneself from
negative images; and behavioral overcautiousness.
The rationale for the training program, including a discussion of how
each of the primary treatment components relates to each of the major
response components. A cognitive component of treatment is designed
to target misinterpretations and negatively skewed thinking styles that
serve to fuel anxiety. A somatic component is designed to reduce levels
of physiological arousal directly. A behavioral exposure component is
designed to prevent avoidant or checking behavior in situations where
danger is predicted. An imagery exposure component is designed to
target distraction, cognitive avoidance, and the tendency for worry to
suppress imagery and full emotional experience. Problem-solving and
time management components are designed to aid in the formulation
of eective plans for coping with realistic stressors that may exacerbate
anxiety.
77
Chapter 7 A Closer Look at Generalized Anxiety Disorder
(Corresponds to chapter of the client workbook)
Session Outline
Brief check-in
Negotiating an agenda
Discussion of factors involved in the etiology of excessive anxiety and
worry
Discussion of factors involved in the maintenance of excessive anxiety
and worry
Discussion of the rationale for the MAW program
Negotiating homework
Session summary and feedback
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 therapists 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.
Discussion of Factors Involved in the Etiology of Excessive Anxiety and Worry
In discussing the etiology of excessive anxiety and worry, the following
is a list of points that the therapist should consider addressing.
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.
In addition to an inherited general physiological sensitivity, three
other main etiological components are considered: (:) a tendency
to view threat as being ever-present; (:) life experiences that create
a sense that the individual does not have control over the negative
events in life; and (,) stressful events.
In addition to several other psychological variables, such as the
quality of social support systems, these four elements are thought
to interact in a way that accounts for the initial onset of excessive
anxiety. Also, it is important that clients understand that the pres-
ence of predispositional variables does not ensure the development
of a full-blown disorder.
Discussion of Factors Involved in the Maintenance of Excessive Anxiety and Worry
In discussing the maintenance of excessive anxiety and worry, the follow-
ing six factors should be considered.
:. Anxiety greater than some optimal level, interfering with perform-
ance and problem-solving
:. Attentional and interpretive biases favoring the processing and en-
coding of threat-related information
,. Chaining of worrythe tendency to shift from one worry to
the next so quickly that objective appraisal of any one worry is
precluded
. Relatively automatic emotion-cognition connections
,. The belief that worry always decreases the likelihood that negative
events will occur in the future
o. Cognitive avoidance or distraction strategies
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.
Discussion of the Rationale for the MAW Program
In discussing the maintenance of excessive anxiety and worry, the thera-
pist should be careful to point out which of the six maintenance factors
discussed earlier is targeted by each part of the MAW program.
Negotiating Homework
For this session, the therapists 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.
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.
Principles and Points to Consider
Chapter is primarily didactic in its orientation (though, once again, re-
member to try to maintain a Socratic approach) and addresses perceived
safety. Information targeting misinterpretations of threat in situations that
others do not nd threatening is provided. Clients are asked to read the
information regarding the excessive anxiety and worry model several times
to integrate it into their own model or representation of what they are
80
experiencing. Thus, this lesson consists of corrective information, but no
specic exercises are introduced at this point.
Case Vignettes
Case Vignette 1
C: Does being physiologically sensitive mean that Ill always have more
anxiety than other people?
T: Try to keep in mind that being physiologically sensitive or labile
should not be equated with anxiety or fear. Anxiety and fear are emo-
tional states that require more than simple arousal to be present. It ap-
pears that the onset of excessive fear or anxiety is related to factors in
addition to arousal, such as certain life experiences and your style of
thinking or processing information. So, physiological sensitivity can
exist without your experiencing anxiety problems. For example, can
you remember a time when you didnt consider anxiety and worry to
be a problem for you? If so, thats obviously dierent from how you
feel now. However, your physiological sensitivity was probably always
present, to some degree.
Case Vignette 2
C: Does the inherited component imply that my children will have an
anxiety disorder?
T: It has been found that anxiety disorders do tend to run in families.
This implies that the likelihood that a child will have an anxiety dis-
order is somewhat increased if his or her parents have experienced an
anxiety disorder. But let me emphasize that having a family member
who experiences an anxiety disorder does not ensure the transmission
of an anxiety problem. Anxiety is not based solely on inherited factors.
In fact, it is only one part of the overall picture. Learning factors play a
prominent role also. Indeed, in some cases, familial patterns of anxiety
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 cant remember a time when tension and worry werent a
problem for me. Ive been a worrier all my life. So I cant say that I can
put my nger on any particular stresses that brought on my problem.
Will I be able to learn to control my excessive anxiety if I cant gure
out what initially caused it?
T: In fact, it is not necessary to know what initially caused your prob-
lems with anxiety to benet from this program. It appears that the fac-
tors that initially trigger excessive anxiety and worry are dierent from
the factors that maintain them. For example, some people rst experi-
ence problems with anxiety and worry while having marital troubles,
yet the excessive anxiety persists, even after the marital diculties are
resolved. Also, there are many other people who have beneted from
this program and similar programs, even though they couldnt identify
the initial cause of their anxiety problems.
Case Vignette 4
C: I dont understand why you say that distracting myself from negative
images contributes to my anxiety problems. Ive always felt that dis-
tracting myself is one of the few ways Im able to give myself some
relief.
T: Undoubtedly, distraction provides some immediate relief from your
anxiety. Its when we look at the long-term eects that I say that dis-
traction ultimately serves to maintain your anxiety. There are at least
two reasons why I say this. First, its impossible to challenge a worri-
some image, and evaluate it in an objective and thorough manner, if
you arent holding it in your mind. Second, it seems that resisting an
image or thought only serves to make it stronger. Maybe youve heard
the old saying about what would happen if I put a gun to your head
82
and said, Dont think about a white elephant, or else Ill 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, its as if Im holding a gun to your head and telling
you not to worry or else Ill pull the trigger. You might succeed at
distracting yourself temporarily. However, youll be even more likely
to experience that image in the future than if you didnt distract your-
self, and the image is likely to be just as anxiety-provoking in the fu-
ture, since you didnt evaluate it objectively in the past. Does that
make sense?
C: I guess so. I hadnt really thought about it that way before.
Case Vignette 5
C: Maybe I do see the world as it really is. Just look at the news reports,
and youll see that there are terrible events every dayand its getting
worse.
T: Certainly, there is no denying that bad things do happen sometimes.
This program is not about the power of positive thinking and telling
ourselves that bad things can never happen to us. Rather, the goal of
this program is realistic thinking. Realistic thinking involves learning
to distinguish realistic and helpful anxiety from excessive and un-
warranted anxiety, and then reducing the excessive anxiety. So, my
question for you is: Have there ever been any times when you pre-
dicted that something bad would happen to you, and it didnt?
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 re me. With all the reports of people being laid o 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 modication. OK?
C: OK.
Atypical and Problematic Responses
Sometimes clients report that, because they have worried for so long,
they no longer believe that their worries might come true (e.g., being red
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 didnt
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.
Though some clients with GAD engage in overt behavioral avoidance,
many do not. Clients who do not engage in overt behavioral avoidance
must be assessed carefully for subtle avoidance or safety behaviors.
84
Summary of Information in Chapter 5 of the MAW Client Workbook
A reminder of the important role of tension in GAD. Generalized ten-
sion and physiological anxiety are produced by anxiety and worry, while
also contributing to them, given the state dependency of cognition and
the automatic mood-cognition associations that develop over time.
The rationale for incorporating relaxation training exercises into the
program. Learning to relax directly targets the generalized tension and
arousal component. In addition, given the state dependency of cogni-
tion and the mood-cognition associations noted earlier, relaxation
should also indirectly reduce the frequency and intensity of worry.
Description of the length of exercises. Relaxation training exercises be-
come shorter as each phase is mastered. Initially, the procedure takes
approximately ,c minutes, but gradually progresses to a one-step pro-
cedure. The one-step procedure can be done almost anywhere, and so
can be applied to interrupt the anxiety process as it is just beginning.
The lengthier, ,c-minute version of the procedure is very eective at
the end of the day for reducing the tension that has built up through-
out the course of the day.
Discussion of the physical and mental components of relaxation train-
ing. The physical component involves rst tensing and then releasing
specied muscle groups. The tensing is believed to ease the relaxation
response by giving it some momentum, like a pendulum. In addition,
it provides an opportunity to learn to better discriminate between the
feelings of tension and relaxation. Learning to detect subtle signs of
tension enhances the ability to interrupt the cycle of anxiety and ten-
sion at an earlier point in the process.
85
Chapter 8 Learning to Relax
(Corresponds to chapter , of the client workbook)
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 nal phase of relaxation trainingthe recall-
relaxation procedure.
Description of a Jacobsonian progressive muscle relaxation procedure,
beginning with :o muscle groups and progressing to eight muscle
groups. The eight-muscle-group procedure is identical to the :o-muscle-
group procedure, except that certain muscle groups are combined.
Specication of exercises for relaxation training.
Session Outline
Brief check-in
Negotiating an agenda
Introduction of progressive muscle relaxation training
Negotiating homework
Session summary and feedback
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 therapists suggestions for agenda items should in-
clude introducing progressive muscle relaxation training and negotiation
of homework.
Introduction of Progressive Muscle Relaxation Training
In introducing the progressive muscle relaxation training module of the
program, the following is a list of points that should be addressed.
Tension plays an important role in the anxiety and worry cycle,
as it represents a state of readiness to cope with stress. Tension is
therefore an important target for intervention.
Relaxation is presented as a skill that requires practice. That is,
clients should not view these exercises as magical cures.
Relaxation training is intended to improve the ability to detect ini-
tial signs of increased tension and to reduce the intensity of physio-
logical arousal and tension. Indirectly, it should also reduce the in-
tensity and frequency of worry. This should especially be the case
if the client takes advantage of his or her improved ability to de-
tect the initial signs of tension and applies both relaxation skills
and cognitive coping skills (introduced in the next chapter) at the
earliest stages of an anxiety episode.
There are many methods used for relaxation. If the client has al-
ready found an eective 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 eectiveness. 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 ,c or c minutes to introduce the :o-muscle-group proce-
dure in session and about :c to ,c minutes to implement it there-
after, and for this reason, they would be dicult to apply in many
situations. However, the exercises will be modied 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. ,;oc of
the MAW workbook) rather than the :o-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 :o-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 :o-muscle-group procedure at home, rather than the eight-
muscle-group procedure.
Initially, it will be helpful to practice the exercises under non-
distracting conditions. The practice conditions will be gradually
made more distracting again, to increase the applicability of the
relaxation exercises across a broader range of everyday situations.
In fact, we have recently begun encouraging our clients to make
the nal stage of practice include not distraction, but pain to in-
crease their ability to focus on the exercises even while distressed
(much as is done in many instructional programs to prepare
mothers for natural childbirth). This can be implemented by hav-
ing a partner, relative, or close friend apply rm pressure to pres-
sure points on the body. Alternatively, the client can implement
this by himself or herself by attaching a clothespin to the ear.
Negotiating Homework
The therapists suggestions for homework items should include reading
over the appropriate MAW workbook chapter or chapters for the next
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).
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.
Principles and Points to Consider
This session contains a combination of didactic presentations and par-
ticipant modeling. The demonstration of somatic control taps the con-
struct of perceived controllability. The procedure of relaxation is designed
to provide anxiety management skills as opposed to direct exposure to wor-
risome thoughts and response prevention of checking or safety behaviors.
It is inevitable that clients will not be able to maintain an exclusive focus
of attention on their sensations of tension and relaxationworries and
other thoughts unrelated to the exercise are likely to occur. This is espe-
cially true during the initial stages of relaxation training. It is important
to prepare clients for this inevitability and to suggest that they simply let
these thoughts pass through their minds, and then refocus on the exer-
cise, rather than struggle to get rid of the worry or thought. Reference
to the well-known example of what happens when someone tries not to
think about a white elephant may be helpful here. That is, the harder the
client tries to get rid of the bothersome thought, the more powerful the
thought becomes.
Also, some clients, particularly those who also experience panic, may
nd 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
C: Should I try to use the relaxation exercise as soon as I begin to feel
anxious?
T: At this time, whats most important is for you to simply learn how to
do the relaxation exercise. After you gain condence 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
C: Are there any warnings I should be aware of when tensing muscles as
part of the relaxation exercise?
T: Yes, there are a few common sense precautions. If you wear contact
lenses, its best to remove the contacts before beginning the exercise
since it entails squeezing your eyes tightly together. If you have lower
back pain, its 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 its best not to tighten those particular
muscles. In other words, its important to remember that we dont
want to induce pain.
Case Vignette 3
C: What should I do if worrisome thoughts keep going through my mind
when Im trying to focus on and attend to relaxing?
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
C: Why should I tense my muscles during the relaxation exercises? I al-
ready know what tension feels like.
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 brushre
than a raging forest re, and we are trying to catch your anxiety se-
quences while theyre still just brushres.
Atypical and Problematic Responses
As noted earlier, perhaps the most common diculty experienced when
practicing progressive muscle relaxation is an initial diculty in main-
taining attention on the sensations of tension and relaxation. Its best to
prepare clients for this eventuality in advance and, as reected in case
vignette ,, to advise clients not to ght against the distracting thoughts.
Rather, they should try to let the distracting thought run its course, and
then refocus attention on the relaxation exercises.
Sometimes clients nd that the relaxation exercises lack credibility, point-
ing out that, if simply telling themselves to relax were eective, 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 benet is not likely,
it should be noted that the potential long-term benets 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 nding 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 benet of working with each of the muscle
groups included in the procedure.
Finally, some clients actually experience increases in their level of anxi-
ety during the relaxation exercises, the relaxation-induced anxiety phe-
nomenon. There are several possible mechanisms that may account for
relaxation-induced anxiety among people who are bothered by chronic
worry or tension. First, clients may perceive relaxation as a letting down
of their guard, leaving themselves vulnerable to unpredictable danger. Sec-
ond, some clients may adopt a perfectionistic attitude in their approach
to relaxation. Finally, some clients may worry that taking time to relax will
create more problems in their lives since their schedules are already so
full. The therapist should help the client to identify whether any of these
mechanisms are present, and then begin to challenge them (see chapters
, and :c in this book regarding cognitive restructuring techniques).
92
Controlling Thoughts That Cause Anxiety:
I. Overestimating the Risk
(Corresponds to chapter o of the client workbook)
Summary of Information in Chapter 6 of the MAW Client Workbook
Instruction to practice the eight-muscle-group relaxation procedure, or
the four-muscle-group relaxation procedure, if the eight-muscle-group
procedure has already been practiced with good results.
Discussion of the techniques of cognitive restructuring, with an
introduction to the notion of automatic thought processes. Anxiety-
provoking thoughts are said to be specic predictions of threat. These
predictions often appear to vary across situations, and can become
automatic on the basis of repetition. Therefore, the identication of
specic predictions, hypotheses, interpretations, or images in any given
situation is a vital rst step in the process of eective cognitive restruc-
turing. After all, one cannot possibly begin to challenge a prediction,
interpretation, or belief that one is not fully aware of.
Description of the two types of cognitive errors that often occur dur-
ing states of anxiety and that serve to increase anxiety further. The rst
of these cognitive styles, probability overestimation, is dened in more
detail in this chapter. Probability overestimation is dened 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.
Reasons for which a particular overestimation of the likelihood of a
negative event persists, despite recurring disconrmation.
93
Chapter 9
Methods of questioning probability overestimatations by identifying
alternative predictions or interpretations and using evidence-based
analysis.
Instructions to attempt to identify and modify overestimations during
the coming week. Furthermore, the client should record his or her at-
tempts at modifying probability overestimatations so that they may be
reviewed in detail during the following session.
Session Outline
Brief check-in
Negotiating an agenda
Moving forward with progressive muscle relaxation training
Introducing cognitive restructuring: probability overestimation
Negotiating homework
Session summary and feedback
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 therapists 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 :o-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.
Introducing Cognitive Restructuring: Probability Overestimation
In introducing the cognitive restructuring module of the program, the
following six points should be addressed.
:. Clients are guided to the understanding that, at times of high
anxiety, they are more likely to experience threatening images and
predictions and to treat these thoughts as if they were fact. Hence,
it is important to treat ones thoughts as hypotheses that may or
may not be accurate and as just one of many possible hypotheses
or interpretations. In order to sort out the probable hypotheses
from the improbable, it is important to evaluate the evidence for
and against each of the alternatives identied. This is especially
important in light of the fact that thoughts are more likely to be-
come biased toward perceived danger when anxiety is heightened.
Thus, clients are introduced to the techniques of identifying alter-
natives and evaluating the evidence.
:. Protective behaviors, such as always keeping a close watch on ones
children or always keeping ones house perfectly clean and tidy,
serve to prevent appropriate learning. Avoidance, such as not ask-
ing a friend for a favor or putting o asking for a raise at work,
serves a similar maladaptive function. In other words, clients may
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.
,. Cognitive processes operate at dierent levels of awareness, rang-
ing from conscious appraisals to relatively automatic processes that
we are not consciously aware of. Because worrisome thoughts and
assumptions may be automatic, clients are encouraged to question
themselves to identify their own anxious patterns of thinking
whenever they begin to feel their anxiety level increasing.
. Evidence of an events likelihood is evaluated by questioning its
objective probability, given consideration of all of the relevant
facts, without jumping to conclusions or overgeneralizing. Clients
are encouraged to use a c- to :cc-point scale to index the actual
likelihood.
,. Cognitive restructuring involves realistic thinking rather than
positive thinking. Sometimes negative events do happen, and
positive thinking would be inaccurate and maladaptive in these
situations. The cognitive restructuring exercises will aid in dis-
criminating between realistic and unrealistic worries, in addition
to challenging unrealistic worry.
o. The need to evaluate the evidence and consider alternatives is
critical, given that judgments and predictions based on emotional
reasoning are likely to be biased.
Negotiating Homework
For this session, the therapists 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.
97
Figure 9.1 Example of Worry RecordReal Odds completed by patient.
Date: Time began: (a.x./i.x.) Time ended: (a.x./i.x.)
Tuesday 22nd 3:30 8:00
Worry RecordReal Odds
Maximum level of anxiety (circle a number below):
c----- :c----- :c----- ,c----- c----- ,c----- oc----- ;c----- c----- ,c----- :cc
None Mild Moderate Strong Extreme
Indicate which of the following symptoms you are experiencing:
Restlessness, feeling keyed up or on edge
Easily fatigued
Diculty concentrating or mind going blank
Irritability
Muscle tension
Sleep disturbance
Triggering events: Given a job to finish by end of work day
Anxious thoughts: wont finish in time, fired from job
Alternative possibilities:
Real odds c:cc
I usually get things done & even if I dont get it finished, chances are low that I
would be fired just for this
5
Anxious behaviors: Irritable, called home and told husband I would be late
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.
Principles and Points to Consider
During training in cognitive restructuring, the therapist should act as a
coach who asks relevant questions, facilitating the clients development
of an understanding of principles, as opposed to providing direct reas-
98
Figure 9.2 Example of pie chart completed by patient.
Others may have no
opinions of
significance about
cars
Others wont be as
concerned about what
car I buy as I am
I will make
the wrong choice;
I will be viewed
as being dumb
Others may
like the choice
I made
There is no absolute
right or wrong
choice
Others are
unlikely to judge me
as being dumb just because
of the car I buy
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 red. 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 theyre 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 rst 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?
The state dependency of cognitions is emphasized. In other words, the
propensity to overestimate the likelihood of negative events is liable to
be particularly inated at times when anxiety is elevated. The perceived
increased risks of danger then serve to increase the strength of the emo-
tional state, thereby completing a positive feedback loop. State depend-
ency probably accounts for the majority of cases in which the client rec-
ognizes the irrationality of the worrisome thoughts when he or she is
feeling calm. State dependency also implies that there is no assumption
that the persons style of thinking is biased and inaccurate across all situa-
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.
It is also very important to complete a cognitive restructuring form to-
gether in session, when rst introducing the form, before sending the client
home to complete these forms on his or her own, when anxious. Fur-
ther, we typically have the client do the writing, with the therapist serv-
ing as a coach. This ensures that what is recorded is written in the clients
own words and maximizes the chances that the client will use the form
correctly on his or her own.
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 clients 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 ne in this re-
gard. The important point to keep in mind is rst 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 dicult 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 disconrming
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 dicult to observe anxiety reduction due to a low ini-
tial subjective units of distress rating.
100
Case Vignettes
Case Vignette 1
C: Its simple to ask myself these questions now, but I dont have a chance
of thinking rationally when Im feeling really nervous.
T: As with the other skills weve practiced, or any skill, for that matter,
modication of your self-statements takes practice to become eective
as a tool. Initially, it may be dicult 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 RecordReal Odds form and the Pie Chart form we lled out
today, contain some helpful reminders of the questions. Consequently,
at least in the beginning, I strongly encourage you to actually ll out
the forms when youre trying to apply the skills when you feel anxious.
Once youve mastered the skills and the questions start to become sec-
ond nature, youll 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 shes 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 c (not at all probable) to :cc (will
denitely occur). What is the actual likelihood that she will be in an
accident?
C: I dont knowmaybe :c%.
T: So, that means that, out of every :c times shes driven somewhere, shes
had one accident?
101
C: Well, no. Shes only had one accident in all the years shes been driving.
T: So then, what is the actual likelihood?
Case Vignette 3
C: I didnt have enough time to practice the relaxation exercises. How im-
portant is it really to practice them regularly?
T: Practice is important to benet from these exercises. Remember that
youre trying to supplant an old, habitual style of responding with a
new type of response. The only way the new response will become
natural is through regular practice. This is true for learning any other
kind of skill as well. For instance, deep sea divers are given instruction
in emergency procedures. However, its only after they have practiced
the emergency procedures thoroughly, so that they become auto-
matic, that the procedures are eectively used during times of real
emergency.
Case Vignette 4
C: If Im not aware of my automatic thoughts, how can I possibly iden-
tify them?
T: When a response becomes very well learned, because of repetition or
because it has been associated with very strong emotions, we often be-
come unaware of the cognitive processes associated with that response.
That doesnt mean that we cant get access to those cognitions. For ex-
ample, do you know how to drive a car with a manual transmission? If
so, do you remember when you rst learned how to drive a stick shift?
You were probably aware of telling yourself each step as you were
doing it. You might have said something like, First, I need to depress
the clutch with my left foot, then I need to put the car in gear, and
then I ease o the brake with my right foot. After enough experience,
it probably became automatic so that you werent aware of telling
yourself those things, and you could even have a conversation with
someone else and drive at the same time. Does that mean that your
102
mind wasnt 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 whats going through your mind when
you are feeling anxious. When you rst notice an increase in anxiety
or tension, the rst 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.
Atypical and Problematic Responses
Some clients have diculty understanding the notion of cognitive pro-
cesses that occur outside of conscious awareness. Other clients have di-
culty with the notion that their thoughts aect their mood. For these
clients, the concept of automatic thoughts and the basic premise of cog-
nitive therapythat such thoughts can inuence our moodlack credi-
bility. A wide array of examples of automatic thinking from everyday life
can be employed here. In case vignette , the therapist uses the example of
driving a car with a manual transmission to illustrate automatic thinking
and its typical development. Learning how to type is a similar example
that many people can relate to. Any skill that has become overlearned
can be used, if these two examples are not relevant for a particular client.
In addition, there are behavioral experiments, or demonstrations, that
one can do for the client so that he or she can experience automatic
thinking in the session. For example, the therapist can write a sentence
that has the word of in it several times, such as, For nding more
serenity and reducing the frequency and intensity of excessive anxiety,
regular practice of the Mastery of Your Anxiety and Worry program is of
the utmost importance. Next, the therapist would ask the client to read
this sentence out loud, while keeping a mental count of the number of
f s in the sentence. Most adults with adequate reading skills will say that
there are three, four, ve, or six f s, when in fact, there are seven. The rea-
son seems to be that the f in of gets automatically converted to a v by
103
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 rst.
Other behavioral experiments can powerfully demonstrate the inuence
of cognition on mood. Perhaps the simplest one is to manipulate the
clients focus of attention. The therapist would begin by obtaining a cur-
rent subjective units of distress rating, and then asking the client to begin
to describe one of his or her most worrisome current concerns. The
client is then given several minutes for describing this concern, with en-
couragment from the therapist to go into great detail and to form images.
If, for example, the client has been describing a worry about his or her
young child being abducted, the therapist would ask the client to form
a mental picture of the abduction, to see it in his or her minds eye,
and to focus on the sensations that he or she imagines experiencing when
the child does not show up on time or when he or she receives a call from
the abductor. Upon perceiving visible signs of emotional distress, the
therapist would obtain a second subjective unit of distress rating that is
almost always higher than the initial rating. At that point, the therapist
would encourage the client to focus on a positive image (such as imag-
ining the same small child in the abduction scene described earlier safely
snuggled into his or her daddys or mommys arms, paying attention to
how the child feels, smells, sounds, and so on, as well as the sensations
and emotions that the parent feels), or perhaps to describe an intricate
painting in the therapists oce to the therapist, as if the therapist were
blind and the client were helping the therapist to see this picture in his
or her minds eye. After several minutes of this distraction from the
worry (which we dont recommend as a long-term coping technique, but
rather only for the purpose of this behavioral experiment), and on per-
ceiving visible signs of dissipation of distress, the therapist would obtain
a third, and nal, subjective units of distress rating. The third rating is
almost always lower than the second rating. At that point, the therapist
would ask the client what he or she learned from this experience. If the
client does not immediately articulate the desired conclusion, the thera-
pist can help the client to realize the powerful impact that the contents
of consciousness just had on the clients mood.
Sometimes clients express reluctance to identify their automatic thoughts
because they worry that focusing on the thoughts will increase their anxi-
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 eectively. We have often
found a golf analogy to be helpful in illustrating this point. The identi-
cation of automatic thoughts is analogous to locating the ags in the
holes on a golf course. While successfully locating the ag does not guar-
antee that the golfer will get the ball in the hole, the golfer doesnt 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 doesnt have a chance at successful cog-
nitive restructuring without doing so.
Occasionally, clients report that they worry about everything. Some of
these clients express the belief that, by dealing with any one particular issue,
their problem is not being solved because they will just start worrying
about another issue. It is important to acknowledge that the process of
restructuring one worry does not mean that all other excessive worries
will automatically dissipate as well. However, it is also important to em-
phasize that the primary goal of a short-term program, such as the MAW
program, is skill mastery, rather than cure, by the time the formal ses-
sions end. Our realistic expectation is for the client to learn the skill,
which can then be applied to any worry in the future. It may take some
time, but just like any other set of skills, realistic thinking skills will even-
tually become natural and more automatic. As a matter of style, we pre-
fer to lead the client to these conclusions through Socratic questioning,
rather than simply providing this information to the client. In other
words, the client has just expressed to the therapist a worry that is alive
in the sessionthe worry that, even if he or she successfully resolves one
worry in session, another worry will just replace this one. When such
meta-worrying (worry about worrying) occurs in session, it should be
treated as an opportunity to work with a hot thought, and it can be sub-
jected to cognitive restructuring, as with any other worry (for a closely
related example, see case vignette : in chapter :c). There is an old saying
in cognitive therapy: Follow the aect. In this case, following the aect
translates into using the worry about the futility of restructuring a spe-
cic worry as grist for the cognitive therapy mill.
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 clients estimate of occurrence on a c- to :cc-point scale.
As reected 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 :c%, 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 dierent 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 clients goal then is to fa-
cilitate communication and debate between his or her rational self and
106
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 sillythey 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 clients
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 pasthe 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 red,
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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Summary of Information in Chapter 7 of the MAW Client Workbook
Review of the clients use of relaxation training.
Review of the clients identication of overestimation and application
of challenging corrections.
Instruction in the recall-relaxation procedure.
Outline of the second type of cognitive error, catastrophic thinking.
Catastrophic thinking refers to exaggerating the aversiveness of a nega-
tive event, if it were to occur. Examples of catastrophic thinking, based
on personal experiences, are obtained from the client.
Introduction of restructuring strategies: evaluating the severity of pos-
sible consequences, viewing events as manageable and time-limited,
and using a so what approach.
Identication of times at which clients believe that it is insuerable or
intolerable as an indicator of catastrophic thinking.
Application of decatastrophizing (so what) to events that are both
likely and unlikely to occur.
Session Outline
Brief check-in
Negotiating an agenda
109
Chapter 10 Controlling Thoughts That Cause Anxiety:
II. Thinking the Worst
(Corresponds to chapter ; of the client workbook)
Moving forward with progressive muscle relaxation training
Cognitive restructuring continued: catastrophic thinking
Negotiating homework
Session summary and feedback
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
RecordReal 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 therapists 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.
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. 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.
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Cognitive Restructuring Continued: Catastrophic Thinking
In introducing catastrophic thinking and strategies for decatastrophiz-
ing, the following four points should be addressed.
:. Just as with the tendency to overestimate the likelihood of nega-
tive events, clients are taught that tendencies to view events as
insuerable, unbearable, or intolerable are common when one is
highly anxious. Moreover, this tendency to catastrophize also serves
to increase anxiety further. Therefore, it is important for clients to
understand that, although some events may be uncomfortable or
unpleasant, they can be coped with. Recognition of the time-
limited nature of uneasiness and pain contributes to the develop-
ment of a perception of being able to cope.
:. Given that a primary source of distress is evaluating an event as
insuerable, it is important to evaluate the actual severity objec-
tively, and to apply the so what approach.
,. 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 red or lost a loved one, or if others actually
noticed that the client looked extremely anxious.
. On most occasions, both countering probability overestimation
and decatastrophizing are appropriate. Sometimes, however, one
or the other strategy may be more appropriate, since catastrophiz-
ing can occur in relation to both likely events and unlikely events.
For example, evidence-based analysis may not be very helpful for
concerns about visible signs of anxiety (e.g., Its likely that Ill
blush under certain conditions), while decatastrophizing would
be very appropriate (e.g., So what if I blush?).
Negotiating Homework
For this session, the therapists 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
RecordReal Odds & Coping form and the Pie Chart form to practice
cognitive restructuring as often as possible when anxious episodes occur.
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Figure 10.1 Example of worry record/real odds and coping completed by patient.
Worry RecordReal Odds & Coping Example
Date: Time began: (a.x./i.x.) Time ended: (a.x./i.x.)
Maximum level of anxiety (circle a number below):
c----- :c----- :c----- ,c----- c----- ,c----- oc----- ;c----- c----- ,c----- :cc
None Mild Moderate Strong Extreme
Indicate which of the following symptoms you are experiencing:
Restlessness, feeling keyed up or on edge
Easily fatigued
Diculty concentrating or mind going blank
Irritability
Muscle tension
Sleep disturbance
Triggering events:
Anxious thoughts:
Real odds c:cc
Alternative possibilities:
Ways of coping:
Anxious behaviors:
Friday 15th 10:00 11:30
Daughter went out with her friends and has not called
She was in a car accident and is injured and disoriented
3
She is having fun with her friends, she forgot to call, she will call later
if she is injured, I will help her recover
waited by the phone
Worry RecordReal Odds & Coping
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.
Principles and Points to Consider
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 dierent 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 persons 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
C: Is it best to say to myself that I should just stop worrying so much?
T: In a way, thats correct, but its much more eective to be as specic as
you can. Simply telling yourself to be less anxious or to stop worrying
is a great goal to keep in mind, but it doesnt help you to identify what
you need to do to become less anxious or worried. Telling yourself to
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be less worried doesnt really change any of the underlying mechanisms
that promote worry. Its important to identify specic predictions that
youre making and then to challenge those predictions. So, when you
rst notice yourself becoming anxious, ask yourself questions like:
What am I predicting or imagining will happen? What is the evidence
for and against that? Whats the worst thing that could happen if my
prediction did come true? Lets 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 Ill look really weird to other people. I can imagine being in a
crowd of people, with everyone staring at me and thinking Im crazy.
T: Who are these people?
C: Just anyone in one of my classes, or people on the street.
T: So, if these strangers were thinking theres a crazy guy, what would
happen?
C: Id feel really embarrassed.
T: And, if you did feel that way?
Case Vignette 2
C: On my drive over to see you today, I started to become very anxious. I
realized that I had experienced so many episodes of high anxiety and
so many dierent worries this week that Im not sure which is the best
one for us to start talking about.
T: What do you mean by the best worry? What do you think will hap-
pen if we dont talk about the best one?
C: Im afraid that I wont make any progress and Ill nish the program
feeling just as bad as when I started, or maybe worse.
T: OK. I suppose thats one possibility. Can you think of an alternative
to the view that your progress depends entirely upon nding the one
right or best worry to restructure in session with me?
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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
doesnt 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 Ill get red for making a
mistake is small. I tell myself that all the time. But what if I do get
red? Its that one-in-a-hundred chance that frightens me.
T: Well, thats a good question. What would happen if you get red?
C: I would feel awful, like I was a failure.
T: OK, and how long would that feeling lastforever?
C: No, a few days, maybe a week.
T: And then what would happen?
C: I guess I would start to feel a little better. But what if I never nd an-
other job?
T: And what is the probability that you will never nd another job?
Case Vignette 4
C: I worry that Ill blank out when I get anxious and forget what I was
saying. Since this happens to me a lot, I dont see how I can use the
self-statements to challenge this worry.
T: And what do you imagine happens as a result of your blanking out?
C: The other person will think Im some kind of moron.
T: Do you worry about that with everyone, regardless of how well they
know you, or just with people you dont know well?
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C: Just with people I dont know well. Im pretty sure that most of my
good friends wouldnt think that of me.
T: Then lets focus on the people you dont 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: Ive been trying to restructure one of my worries all week, and it just
doesnt seem to help.
T: Why dont we take a look at it together? Tell me about the worry
youve been working with.
C: Well, one of my friends has been asking me to have dinner at her
apartment for a long time now. Id really like to, but Im worried that I
might get mugged or something on my way there or back home.
T: OK. How have you tried to restructure that worry?
C: Ive 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 its
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, Im glad that youre feeling worried about going to have
dinner at her apartment. Can you imagine why I might say that?
C: Maybe because its a realistic anxiety.
T: And why would I want you to experience that realistic anxiety in this
situation?
C: Because it will help to alert me to danger so I can protect myself.
T: Exactly. Later on, in a few sessions, well talk about some techniques
for solving realistic problems that may be helpful to you in working
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out a way that you can get together with your friend in a way that isnt
so dangerous for you. In the meantime, youve 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 eective than cognitive restructuring because our predictions and
interpretations are accurate.
Case Vignette 6
(After having successfully reduced the clients probability overestimate relating
to her worry about experiencing an episode of major depression, the client re-
ported only somewhat of a reduction in her associated anxiety. Thus, the thera-
pist decided to see if decatastrophizing might help.)
T: So far, weve 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?
C: That would be awful.
(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?
C: I was totally dysfunctional back then.
T: Totally dysfunctional? Can you tell me more about what you mean
by that?
C: Well, for about : or , weeks, I just couldnt get out of bed. I couldnt
do anything. Im not even sure if I showered more than once during
that whole time. I didnt do my laundry or clean my apartment. I ate
some, but mostly junk food, because I couldnt even prepare a decent
meal for myself.
T: When you say you couldnt get out of bed or do anything else, like
shower or prepare a meal, how do you know that you couldnt do those
things?
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C: Im 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 couldnt do those things. Im wondering if you ever
tested that belief.
C: Tested it how?
T: For example, with the thought that you couldnt 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 rst told yourself to swing your legs over the side of the bed,
they would not have moved? And then, if youd 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 wouldnt have been able to move? And then, once you got to
the shower, if you had told yourself to turn on the water, you wouldnt
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 youre
having the thought that you cant get out of bed and do your usual ac-
tivities, what can you do dierently?
C: I could remind myself that my thoughts arewhat have you been
calling them? My thoughts are hypothesesusually, they are accurate,
but sometimes they are notso I need to test them. Im pretty sure
that, if I test the thoughts, like I cant get out of bed or shower, Ill
nd that I really can do those things.
Atypical and Problematic Responses
Occasionally, as reected in case vignette ,, problems arise because clients
try to apply the cognitive restructuring techniques to a realistic worry,
then become frustrated and lose condence in the techniques when they
are ineective at reducing the associated anxiety. To minimize the po-
tential negative impact of attempts to apply the techniques to realistic
worries, it is useful to point out that the cognitive techniques may be
used to help to distinguish realistic worries from excessive worries, when
rst introducing the techniques. The client knows that a worry is realis-
118
tic if the evidence suggests that the predicted event is indeed highly
likely and the events 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: Im glad youre feeling anxious about that. As-
suming that Im 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 :c 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 :c, 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 ag 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 eects on our mood, and
that we have identied some relevant cognitions. Thus, we are headed in
the right direction and are working on the things we need to work on.
Some clients have trouble identifying alternative, balanced thoughts,
even after the therapist has modeled such responses several times, over the
course of several sessions. In such cases, the therapist can try suggesting
that the client apply progressive muscle relaxation skills, and then im-
mediately try to identify an alternative thought again, when in a more
relaxed state. We have had some success with this approach, and attrib-
ute it to the state dependency principlethe negative bias that anxiety
exerts on our thinking not only makes catastrophic thoughts seem more
believable, but also can be so strong as to make it dicult to identify
more balanced alternatives.
Occasionally, clients have experienced the outcome about which they
are worried, such as losing a job, being rejected, or feeling embarrassed,
and have not coped well with it in the past. In case vignette o, the client
worried that she would become depressed, as she had in the past, when
119
she did in fact have great diculty coping and experienced a great deal
of functional impairment. In these cases, the therapist should help the
client explore what might be dierent if the feared outcome does recur
or how the client might cope with it dierently 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 nds most threatening about it. For ex-
ample, in case vignette o, 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 o 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 nding most threat-
ening, it is always better to ask or to check out ones 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-
ected 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 eectively
treated, as they tend to be hotthat 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 aect, try to identify the auto-
matic thought behind the perfectionism (such as I wont get any bene-
t from this exercise unless I do it perfectly), and then challenge it, as
illustrated in case vignette :.
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Summary of Information in Chapter 8 of the MAW Client Workbook
Review of identication of overestimation and catastrophic thinking,
and application of challenging corrections.
Review of the application of relaxation training.
Instruction in the method of cue-controlled relaxation.
Rationale for the purpose of systematic induction of the worry pro-
cess: the value of direct confrontation with worry to reduce anxious
responding. Worry exposure also allows for the provision of specic
practices for application of the anxiety management skills of relaxation
and cognitive restructuring.
Instruction in imagery training in preparation for imagery exposure.
Instruction in the method of repeated exposure to specic worrisome
images.
Specication of imagery exposure practices to perform during the
intersession interval.
Session Outline
Brief check-in
Negotiating an agenda
Moving forward with progressive muscle relaxation training
121
Chapter 11 Getting to the Heart of Worrying:
Facing Your Fears
(Corresponds to chapter 8 of the client workbook)
Introducing worry imagery exposure
Negotiating homework
Session summary and feedback
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
RecordReal 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 therapists 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.
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. 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
In introducing imagery exposure, the following ve points should be ad-
dressed.
:. An important worry control procedure is exposure to the salient
images that serve to increase anxiety. Typically, these images are
often chained together. At other times, these images are avoided
through distraction. Both chaining and distraction preclude re-
learning and habituation and therefore tend to maintain an anx-
ious response to these images. Hence, an essential component of
treatment is to confront the worrisome images repeatedly, until
they no longer elicit strong levels of anxiety.
:. Another important characteristic of worry is that it tends to be
associated with a suppression of imagery and a predominance of
verbal-linguistic processing, especially among people with GAD.
Suppression of imagery also precludes habituation and therefore
also contributes to the maintenance of anxiety in GAD. Thus,
an important component of the exposure is that it should be
very imagery-rich to facilitate activation of the full fear memory
structure.
,. It is important for clients to understand the dierence between
their own repeated experience of worrisome images in their every-
day life and the imagery exposure exercises conducted in the pro-
gram. Clients should understand that their own exposures to the
images have been associated with chaining or distraction, or a shift
to a verbal-linguistic mode of processingall of which serve to
maintain the fear structure. In contrast, the program exposure ex-
ercises will prevent chaining and distraction and encourage the
client to maintain an imagery-based mode of processing. Through
repeated exposures, clients will learn to experience the images
without becoming anxious.
. Because of the importance of prolonged concentration on the
worrisome images, imagery practice using scenes that dont involve
anxiety may be provided before imagery exposure is begun. It is im-
portant that clients try to put themselves in the situation, focusing
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 eerent commands to the autonomic
system. This suggestion implies that it is important to include
physiological response elements in imagery exposure.
,. It is important for clients to understand the dierence between the
anxiety management strategies and the exposure strategies. Until
this point, they have been instructed to apply relaxation and cog-
nitive restructuring techniques upon noticing worry or anxiety in
the course of their daily lives. Now, they are being asked to endure
worrisome images for specic periods, before applying manage-
ment strategies. Among other benets, by so doing, their success
in applying the management strategies when feeling very anxious
in their daily lives will become easier.
Negotiating Homework
For this session, the therapists 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
RecordReal 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 RecordReal 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).
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.
124
Principles and Points to Consider
The exposure procedure entails imagery exposure. Thus, in contrast to
the in vivo exposure and response prevention introduced in the next
chapter, this exposure does not involve actually confronting anxiety-pro-
voking situations. Rather, this exposure is purely imaginal. If clients hit a
stuck point in which their anxiety does not decrease, despite pro-
longed exposure, they should be instructed to apply relaxation and cog-
nitive strategies. Corrective feedback is then provided by the therapist,
when necessary, should the management strategies be applied incorrectly
or the exposure conducted ineectively. As the clients gain a sense of
mastery over a particular imaginal scene, they progress to exposing them-
selves to imagining more anxiety-provoking worries.
We strongly recommend that at least the initial imagery exposure be
conducted in session with the therapist. Some principles are important to
keep in mind when implementing imagery exposure. First, care should
be taken to minimize distraction and cognitive avoidance; we do so by
asking our clients to periodically describe their imagery out loud to us.
Thus, rather than actively generating the imagery for the client, we simply
obtain periodic subjective units of distress ratings and ask the client
what they see, feel, and hear next. It can also be useful to make an audio
recording of the in-session exposure exercise to send home with the client
for practice. To minimize experiential avoidance, we also encourage our
clients to describe the imagery in the present tense, as if it were happen-
ing right now. Second, to facilitate a sense of control, clients should be
allowed to decide which image to start with, as well as how quickly they
will advance to more anxiety-provoking worries. Third, clients almost
invariably report that they ordinarily do not let themselves contemplate
the most catastrophic scene associated with a given worry and never allow
themselves to imagine the subsequent scenes (typically, the most cata-
strophic scene is experienced as being so awful that clients believe that
they cant tolerate continuing to focus on the topic). Thus, it is impor-
tant to encourage the client to allow the imagery to advance to the most
catastrophic scene, and beyond. We have found that once the most cata-
strophic scene is encountered, asking the client to fast-forward the
imagerst by a day, then by a week, then by a month, then o months,
then a year or twocan help to initiate a spontaneous decatastrophiz-
ing process, as illustrated in case vignette .
125
Please also note that our suggestions for therapist-assisted imagery ex-
posure dier 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 dierently 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?
T: The point is not to concentrate on feeling awful, but to allow yourself
to fully experience the worry. That is, you should concentrate on the
worrisome thoughts and images. By giving yourself permission to
focus on these thoughts and images, you are replacing the avoidant
tendency with one of approach. In addition, the sense of being a vic-
tim is replaced with one of becoming an observer of your own reactions.
Remember that, with repeated exposures, the level of distress you ex-
perience will decline.
Case Vignette 2
C: One of my most troublesome worries is that the other mothers in the
play group I bring my :-month-old daughter to will think Im a bad
mother when my daughter starts to pinch one of the other infants or
126
pull his or her hair. But when I try to concentrate on that worry now
for exposure, it doesnt 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 outt 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. Lets see what
happens next.
Case Vignette 3
C: I imagined my worry for ,c minutes at a time during my practice at
home, and each time, my anxiety just kept increasing. I dont think
this is working.
T: Well, there may be a couple of possible reasons why your anxiety
wasnt decreasing. First, were you concentrating on the same worry, or
did other worries come into the picture?
C: No, Ive been focusing on the same worry.
T: Well, the rate of habituation diers from one person to the next, and
sometimes even within the same person, for dierent worries. Some
people require more prolonged exposure to begin to experience habitua-
tion, which is why we recommend that people start with about ,c
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minutes of exposure. However, some people require even more than that
for some of their worries. Why dont 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 ght with your mother. On
a scale from c to :cc, what is your anxiety level right now?
C: About c.
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 minds eye.
C: I hear the phone ringing. I pick it up, and I hear its my mothers voice.
She sounds very agitated. She tells me that theyre having another ght,
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 ght. She tells me
that Dad has pulled a large knife out of a drawer, and then she hangs
up. I tell Steve that theyre 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. Im driving as fast as I can, and I cant 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?
C: My heart is pounding, and I have a feeling in the pit of my stomach,
and the sense that this time hes is really going to do it.
T: Youre 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 c to :cc?
C: Its ,,.
T: Good. What happens next?
C: I pull up in their driveway and hop out of the car. Now Im running
up their driveway, and I can hear my mother. She sounds hysterical,
but its really weird cause I dont hear Dad at all. When I come in the
128
front door, I see him. He is lying on the oor, 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 Im waiting, I
start to cry, too, and Im 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?
C: Id say its c.
T: Youre 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. Im sitting there,
praying that hes going to make it and feeling just awful that I didnt
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 shes very sorry, but they couldnt
save my father, that hed lost too much blood. Then Steve nally gets
there, and Im 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: Oh, its :cc.
T: Now, lets fast-forward a day or two. Whats happening now? What do
you see, hear, and feel?
C: Well, Im 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 Dads con into the grave. I
take my turn shoveling some dirt on top of his con. 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 :cc.
T: Youre doing great. Lets stay with it a bit more. Lets fast-forward
about a week or so. Whats happening now?
C: Its my rst day back at work. Ive been crying o and on all week
long. Im still thinking about my father just about all the time. Im
having a hard time concentrating on my work, but I struggle through
and do get a little bit done.
T: OK, and how about a month later?
C: Well, Im 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 isnt all the time
now, and when Im 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.
T: And what is your anxiety level now?
C: A little better. I guess maybe ,c or c.
T: Ok. How about o months later? What happens then?
C: Well, when Im busyat work or doing something with Steve on the
weekendsIm ne. When I go to visit my mother and brother, or when
Im alone at home though, I start thinking about Dad, and I get pretty sad.
T: And a year later?
C: I see myself pretty much back to normal. When Im am at work or
with Steve or one of my friends, I dont really think of Dad much at
all. Now, its pretty much only on his birthday and the anniversary of
his death, and when I visit my mother and brother. And you know
what? At those times, I not only feel sad but I also get kind of a warm,
loving feeling. At those times, I think about the things that Dad and I
shared, and Im kind of appreciating himmaybe even more than I
did before he died.
T: And what is your anxiety level now?
C: A lot bettermaybe ,c, or even :c.
130
Case Vignette 5
C: When I do the cue-controlled relaxation, I think Ill become more
tense when I say the word relax to myself. People are always telling
me just to relax, so it just makes me feel worse.
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.
Atypical and Problematic Responses
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 diculty 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 ee from the image as the most catastrophic scene
approaches or is encountered. Here, there are two principles to keep in
mind. The rst is for therapists to give their clients praise throughout the
procedure and to express condence 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 o 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
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 :c. 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 clients
rate of progress.
Summary of Information in Chapter 9 of the MAW Client Workbook
Review of the application of relaxation training and self-statement
techniques. Review of practice of imagery exposure exercises. Relaxa-
tion should not be engaged in out of desperation.
Rationale for the purpose of response prevention of checking behav-
iors and in vivo exposure to situations that are avoided because of ex-
cessive anxiety. Response prevention and in vivo exposure provide the
opportunity to learn that catastrophes might not occur, even if one
doesnt engage in avoidance or checking behaviors. In addition, these
exercises provide specic practices for the application of anxiety man-
agement skills (relaxation and cognitive restructuring) in everyday
situations that are relevant to the clients anxiety problems.
Development of a hierarchy of in vivo exposure and response preven-
tion tasks, in order of increasing intensity, based on how much anxiety
they provoke.
133
Chapter 12 From Fears to Behaviors
(Corresponds to chapter , of the client workbook)
Instruction in the method of repeated exposure to the hierarchy items,
starting with the least anxiety-provoking exercise in the hierarchy.
Specication of the in vivo exposure practices to perform during the
intersession interval.
Session Outline
Brief check-in
Negotiating an agenda
Moving forward with progressive muscle relaxation training
Continuing with worry imagery exposure
Introducing in vivo exposure and response prevention
Negotiating homework
Session summary and feedback
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
RecordReal 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 therapists 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
By this point in the program, mostif not all clients should be in-
structed to practice the one-step relaxation procedure at home.
Continuing with Imagery Exposure
If the client is willing to do so, therapist-assisted exposure should be con-
ducted to a more anxiety-provoking worry than the exposure from the last
session. If the client is not ready to move up to a more anxiety-provoking
worry, then the imagery exposure from the last session should be repeated.
Introducing in Vivo Exposure and Response Prevention
In introducing in vivo exposure and response prevention, the following
three points should be addressed.
:. Clients should develop an understanding of reasons for which
reduction in anxiety does not occur, despite repeated practices.
These reasons include enduring patterns of subtle avoidance,
safety behaviors, and misinterpretation of the evidence.
:. If clients are escaping from practices or engaging in safety be-
haviors during practice, it is often helpful for them to focus on
understanding the times when they experience the urge to do so.
Awareness of the precipitant to these urges is highly signicant
and inevitably is based on a prediction that continued endurance
of the situation, without engaging in safety behavior, will result in
some threatening outcome. Clients should be encouraged to learn
from instances in which they escaped from practice or engaged
in safety behavior rather than castigate themselves. We sometimes
recommend that our clients post a wonderful cartoon from
p. :: of A Second Helping of Chicken Soup for the Soul (Caneld
& Hansen, :,,,) as a reminder of this point (the cartoon shows a
135
woman dividing her experiences into successes versus learning
experiences, with far more catergorized as learning experiences).
,. Anxiety management strategies, especially cognitive restructuring,
are reviewed before each in vivo exposure practice to allow the
client to develop a sense of ecacy in coping with the situation
and with feelings of anxiety that may be experienced.
Negotiating Homework
For this session, the therapists 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 RecordReal 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).
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.
Principles and Points to Consider
Graduated exposure is employed, so that clients proceed up their own
hierarchy of anxiety-provoking practices in order of increasing intensity.
The therapist does not typically accompany the client during in vivo ex-
posure, but assists the client in setting goals and designing practices. The
therapist also gives corrective feedback, particularly regarding reasons for
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 (:,,c) in Fear and Courage, there is an alternative denition 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 Im sure that Ill
feel very anxious. I havent said no when a friend has asked me for a
favor or made requests of other people for a long time, and now youre
asking me to do it.
T: Of course, you should expect to feel anxious the rst several times you
attempt to do the things youve been avoiding or putting o. But the
other side of the coin is that, through repeated practices, it will get eas-
ier. That long-term payo 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 dicult 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
C: I have so many exposures I need to practice that this program is going
to take me an eternity to complete. How long will it take?
T: We strongly recommend that you practice each exercise or situation
that you are currently avoiding or coping with by using safety behav-
iors. Anxiety is like a weed. If you skip over some situations in your
practices, its like not pulling out the root of the weed, and the chances
that the anxiety will grow to problematic proportions are increased. So,
it might take quite a bit of time. However, there is often a generaliza-
tion eect across situations. What I mean by that is that, with each
situation you master, youll probably nd that many of the other situa-
tions become somewhat easier as well. So, even though some exposure
practice seems overwhelming now, youll probably nd that it will start
to seem more manageable as you work your way up your hierarchy.
Case Vignette 3
C: If I dont call my wife to see if everything is OK, I know its going to
make me feel really anxious, and my worries about her will interfere
with my ability to concentrate. Then I know that I wont be able to
function at work. Do you really want me not to check in with her?
T: Again, you can use a graduated, or stepladder, approach and do this in
smaller steps. So, you could begin by not checking in with her on the
weekends, to allow yourself to become more comfortable with that,
and then stop checking in on workdays. In addition, if you are check-
ing in with her once every couple of hours, you could begin by checking
in once every hours. Then, when you become more comfortable with
138
checking in once every hours, you could go to just once a day, and so
on. Also, its important for you to examine realistically what youre say-
ing to yourself about the worry interfering with your work. You said
that you wouldnt be able to function. Do you mean to say that you
wouldnt 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 suer and how terrible that would be.
Case Vignette 4
C: I worry that, when I get anxious, Ill blank out and forget what I was
saying or what someone else was saying to me. How can I practice that?
T: Well, you could intentionally ask someone to repeat themselves be-
cause you were spacing out or were distracted.
C: You mean, even when I was paying attention?
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.
Atypical and Problematic Responses
Given that the majority of this section of the MAW program is self-
directed, compliance with practice assignments can become problem-
atic. The therapists 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 aected. Discussion of ways to inform
signicant others is useful, under such conditions.
Sometimes a client nds an exposure practice too overwhelming to ini-
tiate. When this occurs, the therapist should help the client apply the
stepladder principle to break the practice into smaller steps, as illustrated
in case vignette ,. Another example might be if the client was targeting
139
his or her tendency to arrive at appointments ,c 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 :,, :c, 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.
Occasionally, a reluctance to practice the in vivo exposure or response
prevention exercises comprising worry prevention is due to statements
such as, I never left dirty dishes in the sink, so why should I do it now?
Even if I wasnt anxious about what others will think, I wouldnt leave
dishes in the sink. Clients must realize that sometimes exposure hierar-
chies go beyond what is normally done to instill a strong sense of mas-
tery and control. Therefore, even though they would not typically do
certain activities, or leave certain things undone, clients must recognize
the value of such practices. Not practicing items at the top of the hier-
archy could leave the client susceptible to a return of excessive anxiety at
some later time. A gardening analogy may be helpful here, as in case
vignette :. If we leave the top hierarchy items unpracticed, it may be like
pulling out the top of a weed, without getting its root. It might also be
useful to discuss an example of overcoming one of the most common
fears of all, the fear of public speaking. Though one might initially be
very nervous lecturing to even :c people, after one has lectured several
times in front of :cc people, lecturing to :c seems like a piece of cake.
Some clients have a tendency to evaluate their success in terms of how
they felt during the exposure exercises. Encourage the clients to evaluate
their success in terms of whether they completed their assigned tasks,
rather than in terms of how they felt during the tasks. Therapists should
reserve their strongest expressions of praise and admiration for their clients
courage for occasions when clients report extreme discomfort during a
practice, but complete the practice anyway. At times like these, or when
an increase in background anxiety level results from exposure practices,
the therapist should also remind the client that behavioral change often
precedes fear reduction. Moreover, this feeling of worsening may be viewed
positively. Once again, the golf course and highway sign analogies may
be helpful here. The increase in anxiety functions like the ag in a hole
at a golf course or a sign on a highway we have not been on before to let
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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This chapter, dealing with being overcommitted and using ineective
problem-solving skills, obviously needs to be applied only if these prob-
lems are present. If the client already has eective time management and
problem-solving skills, the therapist could focus this session on relaxation
training and imagery exposure (and in vivo exposure, if relevant for the
client) only, or the client may simply skip to workbook chapter ::.
Summary of Information in Chapter 10 of the MAW Client Workbook
Review of the application of relaxation training and self-statement
techniques. Review of the practice of imagery exposure and in vivo ex-
posure exercises. Discussion of the clients repetition of practice, use of
any overt or covert safety aids, and cognitive distraction.
Description of two common sources of realistic stressors that com-
pound anxiety problems: (:) feeling overwhelmed as a result of being
overcommitted and (:) the crises and problems that everyone experi-
ences from time to time.
Instruction on techniques for coping with real problems, including
time management, goal-setting, and problem-solving through brain-
storming.
Evaluation of time management eciency.
Instruction in time management and goal-setting strategies for manag-
ing time more eciently. Time management principles include dele-
gating responsibility, saying no, and sticking to agendas. Goal-setting
143
Chapter 13 Dealing with Real Problems: Time Management,
Goal Setting, and Problem-Solving
(Corresponds to chapter 1v of the client workbook)
involves setting priorities among planned activities and scheduling
tasks in accordance with their priority.
Description of brainstorming, an eective problem-solving strategy.
Brainstorming involves several steps: dening the problem in specic
terms, identifying every possible solution before evaluating any one
solution, ranking the solutions, deciding on a specic plan of action
for each reasonable solution, and beginning to enact plans, starting
with the best solution.
Specication of brainstorming and time management practices for the
intersession interval.
Session Outline
Brief check-in
Negotiating an agenda
Moving forward with progressive muscle relaxation training
Continuing with imagery exposure
Continuing with in vivo exposure and response prevention
Introducing time management and brainstorming
Negotiating homework
Session summary and feedback
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
RecordReal 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 therapists 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.
Moving Forward with Progressive Muscle Relaxation Training
By this point in the program, mostif not all clients should be in-
structed to begin to practice applying the one-step relaxation procedure
when they are feeling tense throughout the day, if they have not already
begun to do so.
Continuing with Imagery Exposure
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 sucient time to conduct therapist-
assisted imagery exposure in session.
Continuing with in Vivo Exposure and Response Prevention
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
In introducing time management and brainstorming, the following four
points should be addressed.
:. It is important for clients to understand the dierence between the
anxiety management and control strategies and the time manage-
ment and problem-solving strategies. Until this point, they have
been instructed to apply anxiety management and control strate-
gies to excessive worries. Now, they are being asked to problem-
solve about real stressors that most people worry about to some
degree (although perhaps less intensely).
:. Clients should recognize any cognitive errors that may contribute
to inecient time management or becoming overcommitted. For
example, perfectionistic concerns and worry about how well others
will do things can contribute to diculty in delegating responsi-
bilities. Similarly, predictions of rejection can contribute to di-
culty saying no to unreasonable requests. Any such predictions
should be subjected to the cognitive restructuring strategies.
,. When brainstorming, the need to describe problems in very speci-
c and concrete terms is essential. The need to refrain from edit-
ing or censoring possible solutions before all solutions are identi-
ed is also emphasized. What sounds like a silly idea at rst may
contain the seed of a useful solution, on further consideration.
. Clients are encouraged to form backup or contingency plans so that
they are prepared for the possibility that their rst plan wont work.
Negotiating Homework
For this session, the therapists 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
RecordReal 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 RecordReal 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.
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.
Principles and Points to Consider
This session involves a combination of didactic presentations and coaching
by the therapist to provide corrective feedback for identifying and evalua-
ting alternative solutions during brainstorming. The strategies introduced
in this lesson contribute to the development of perceived controllability.
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.
T: What were you worried about when you felt so anxious?
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 Im a failure. I questioned the evidence, but then I dismissed the
facts and thought that it really could happen.
T: So you continued to overestimate the likelihood?
C: Yes.
T: How about if we do a pie chart relating to the thought that youre 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.
T: (Laughs) I suppose that is an alternative. How about a more balanced
alternative?
C: Maybe I have made progress, but Im 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: Good. Lets write that one down, too. Any others?
C: Mmm. Thats all Im coming up with for now.
T: Now, lets look at the evidence. What evidence do you have that youre
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?
C: No, thats it.
T: OK. Lets look at the other side. What evidence do you have that youve
made progress and either need to practice more or are just continuing
to experience some are-ups, but that, overall, you are doing better?
148
C: Im pretty sure that, if I looked at my monitoring forms, Id see that,
when I rst 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 Im busier than I need to be, but Im worried that if I start
saying no to my friends when they ask me to do favors for them,
they wont want to be my friends anymore.
T: It sounds like some of the other skills youve learned might help you in
dealing with that worry so you can manage your time more eciently.
How could you apply the skills youve already learned to this situation?
C: I can remind myself that just because Im thinking that they will reject
me doesnt 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
C: Ive got a problem that I havent been able to solve.
T: Lets try to brainstorm it together. First, what is the problem?
C: There is a gang of kids who have been vandalizing my car on a fre-
quent basis as they walk past on their way to school. Ive called the
police, and they said that they couldnt do anything unless I caught the
kids in the act.
149
T: Calling the police was a very good start. What other possible solutions
are there?
C: I dont know. I cant think of anything else that seems like it would re-
ally work or be feasible.
T: Thats OK. Lets get all of the possible ideas out on the table rst, and
then well evaluate them only after weve identied a number of them.
C: Well, I guess I could get a car alarmthere might be a chance that
one of my neighbors would be able to spot the kids if they heard an
alarm. Another possibility might be that I could park where I can see
the car from one of my windows and watch for the kids through the
window. Then I might be able to identify the kids for the police.
T: Good. I think we might be able to come up with some others as well.
Lets see. Is there a place where you could park the car where the kids
would be unlikely to nd it?
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. Im not
crazy about the idea, but I guess it is at least worth thinking about.
Atypical and Problematic Responses
Some clients are very hesitant about delegating responsibilities or saying
no to requests for their time. Almost invariably, these hesitancies are
related to probability overestimates or catastrophic thinking. In such cases,
identifying and restructuring these cognitions is very helpful. When dele-
gating responsibilities is a diculty, the therapist should be alert for
perfectionistic concerns and catastrophizing about how well the other
person will perform the task. Diculties in saying no are often related
to predictions of rejection or massive reprisals. If the client is predicting
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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Drugs for Anxiety and Their
Relation to This Program
(Corresponds to chapter 11 in the client workbook)
This session, dealing with discontinuation of medication, obviously needs
to be applied only if medications are being taken or if the client is con-
sidering beginning medications. Otherwise, the therapist could focus this
session on imagery exposure (and in vivo exposure, if relevant for the client)
and preparation for termination, or skip to workbook chapter ::.
Summary of Information in Chapter 11 of the MAW Client Workbook
Reasons for medication use.
Description of the most commonly used medications.
Instruction in methods by which drug use can be eliminated.
Session Outline
Brief check-in
Negotiating an agenda
Continuing with imagery exposure
Continuing with in vivo exposure and response prevention
Discussing medication issues
Preparing for termination
Negotiating homework
Session summary and feedback
153
Chapter 14
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 clients
self-monitoring and homework tasks negotiated during the previous
session.
Negotiate Agenda
For this session, the therapists 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.
Continuing with Imagery Exposure
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.
Continuing with in Vivo Exposure and Response Prevention
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
When discussing medication, the following three points should be ad-
dressed.
:. There is a great deal of variability in the extent to which individu-
als make use of medication versus behavioral treatment, or make
use of both. Medication is not described as a more or less eective
form of treatment, in general, but as more or less appropriate, de-
pending on certain beliefs and life circumstances. Under ordinary
circumstances, many medications are likely to begin to exert bene-
cial eects in a shorter period than psychotherapy programs,
such as the MAW program. This is especially true of the benzo-
diazepines, which can be eective within a day or two, but is also
true of the selective serotonin reuptake inhibitors (SSRIs) and
serotonin-norepinephrine reuptake inhibitors (SNRIs), which are
widely regarded as the rst choice in medications for GAD at this
time and take as long as , weeks to be eective. On the other
hand, many medications tend to be ineective in the long run,
unless they are taken indenitely.
Sometimes the medications lose some of their eectiveness when
taken continuously over an extended period. Thus, the MAW
program may be very benecial, even for individuals who have
achieved some relief from medication.
:. Drugs are described in such a way that clients may understand
their eectiveness, side eects, and withdrawal problems.
,. For those who are currently taking medication, a program to help
in gradually withdrawing from medication is described. Such
withdrawal should always be supervised by the clients prescribing
physician. In this program, an increase in anxiety as the client
comes o medication is recognized as being a suitable target for
the application of techniques employed in the MAW program.
If withdrawal from medications is particularly dicult (as would
be at least somewhat more likely with withdrawl from benzo-
diazepines), and includes panic attacks, then the program described
in the book Stopping Anxiety Medication (Otto, Pollack, & Barlow,
:,,,) may be more useful and appropriate.
155
Preparing for Termination
The therapist should remind the client that termination is approaching
and begin a discussion of how the client can continue to implement the
program on his or her own.
Negotiating Homework
For this session, the therapists suggestions for homework items should
include the same menu of choices as listed in the previous chapter.
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.
Principles and Points to Consider
This discussion of medication issues is primarily didactic in orientation.
In preparing the client for termination, it is crucial that the therapist re-
sist the temptation to tell the client which skills he or she can apply in
the future to make further progress, deal with diculties, maintain gains,
and overcome relapse. Rather, the therapist should adopt a Socratic stance
and ask the client questions regarding these issues, as in case vignette ,.
Adopting a Socratic stance will allow the therapist to better assess the
clients readiness for termination and will better promote internalization
of the skills.
156
Case Vignettes
Case Vignette 1
C: I always thought that the medication was correcting a chemical imbal-
ance or genetic abnormality.
T: To date, there is no clear evidence of a specic chemical imbalance or
genetic abnormality that is a primary cause of excessive worry and gen-
eralized anxiety. The question of how the medications work isnt well
understood, except that they do seem to reduce the intensity of the
symptoms experienced. Regardless of how the medications work, it is
still important to learn that you can cope with anxiety, even if you do
experience some intense symptoms.
Case Vignette 2
C: What if I experience a lot of anxiety when I withdraw from the
medication?
T: Tell me, why do you think youd experience a lot of anxiety during
withdrawal?
C: I think all those old feelings would return.
T: What feelings are you referring to? Can you be specic?
C: The muscle tension and restlessness, and the worries keeping me up at
night.
T: How would you respond to those feelings now if you experienced them?
C: I would try to apply the procedures weve gone through.
T: And what would that actually involve? What exactly would you do?
C: I would try to do my relaxation exercise to help with the muscle ten-
sion. And I would think through my worries, instead of trying to dis-
tract myself from them. I would think about how likely the things that
Im worrying about really are and how dangerous they really are. I
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 Im not ready to nish the program now. I still have
some worries that I havent worked on yet and some situations that Im
avoiding.
T: OK. Lets deal with the worries rst. How would you approach each of
these worries? What techniques would you use to confront them?
C: Well, I would examine the worries to see if I was overestimating any
probabilities or catastrophizing. Id examine the evidence and use the
so what technique to decatastrophize. I could also expose myself to
the worries before trying to challenge them.
T: What about the situations youre still avoiding? What techniques
would you use to handle them?
C: I would start by deciding which one Im going to do rst. 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 Im still a little nervous about the programs ending.
T: Well, its only natural for you to feel some anxiety about ending. But
you have successfully learned the principles of this program. Its up to
you now to continue to apply them for the amount of time necessary
to process the worries that are causing the diculty.
Atypical and Problematic Responses
Weaning oneself from the safety valve of benzodiazepines is often very
dicult in terms of both physical and psychological dependency. In addi-
tion to a process of gradual tapering from higher doses (always conducted
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 rst-choice medications for this condition.
159
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Summary of Information in Chapter 12 of the MAW Client Workbook
Instruction in how to evaluate objectively the changes made since
the beginning of the program, using the Worry Record, Daily Mood
Record, ratings of catastrophic images, and ratings of behavioral
changes.
Decision process for the next step: satisfactory progress or recognition
of the need for more change.
Instruction in how to maintain progress.
Consideration of high-risk times in the 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
Chapter 15 Your Accomplishments and Your Future
(Corresponds to chapter 1: in the client workbook)
Negotiating an Agenda
For this session, the therapists suggestions for agenda items should in-
clude discussion of termination.
Discussing Termination
When discussing termination, the following ve points should be ad-
dressed.
:. Instead of focusing on how one feels in general compared with
how one remembers feeling at the beginning of the program,
which is likely to be a biased reection of change, clients are in-
structed to evaluate their progress based on a comparison of their
current monitoring records against the monitoring records that
they completed at the outset of the program. To facilitate these
comparisons, we typically create a spreadsheet for each client in
which we have entered his or her ratings over time and we make
several graphs summarizing the information. We examine the ex-
tent to which there has been a change in the recorded frequency of
episodes of heightened anxiety, maximum anxiety ratings, proba-
bility and ability to cope estimates, ratings of anxiety in response to
the imagery exposure exercises, and ratings of anxiety in associa-
tion with the situations that were associated with avoidance and
safety behaviors. Change or improvement is seen as a continuing
process, as is the case when learning any new set of skills. There-
fore, some change in each of those areas is important, and clients
are encouraged not to base their judgments on reaching absolute
goals.
:. Clients are helped to understand possible reasons for lack of
progress or disappointing levels of progress. These could include
an initial error in diagnosis, the need for a longer period of prac-
tice time, lack of motivation for practice, lack of understanding of
the principles, and unrealistic goals. Future steps are based on
which of those ve reasons is primarily responsible for the disap-
pointing progress.
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 specic target, as opposed to covering up an under-
lying pathology.
. Should worry, tension, hesitation, or safety behaviors occur in the
future, it is important for clients to understand that these are not
signs of the underlying problem resurfacing as an entity, but rather,
they reect certain maladaptive reactions. Therefore, there are cer-
tain methods by which they can be controlled (reinstating MAW
principles).
,. Stressful events are described as leading to increased tension and
worry, which, in combination or alone, may tend to increase the
likelihood that the old processes will return for a brief period.
Principles and Points to Consider
Because this is the nal session of this program, the main focus is on
evaluating the clients progress and planning for the future. Termination
concerns frequently arise in this session, and its 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 oss. 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 benets of such booster sessions outweigh the po-
tential cost of fostering overdependency on the therapist.
Case Vignettes
Case Vignette 1
C: Even though Im 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 Ill never get over it now.
T: It sounds like youre separating keeping the house perfectly clean for
your in-laws from all of the other items in your hierarchy, just because
its the top item. Youve 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 its not perfect more manageable to
work on?
C: No.
T: Do you remember whether any of the other items seemed overwhelming
before you started to work on them, and how you overcame them?
C: Well, I guess some of the others did seem overwhelming at rst, and I
broke them down into smaller steps. But Im not sure how I can break
this situation down into smaller steps.
T: Are there some rooms that they dont spend much time in? Perhaps
you could start with them?
C: I suppose I could start with just leaving one roomthat I am con-
dent they wont go intomessy. They almost never go into the kids
bathroom. I could start with that and then go on to other rooms that I
feel more anxious about.
164
T: Excellent. But just to play devils 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 its really not that dierent from
the other situations, after all. I just need to give it some more thought
and be creative.
Case Vignette 2
C: On the self-evaluation checklist, I did make progress in several areas,
but what about the others?
T: The self-evaluation is a way to identify specic 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, its 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 Id be cured by the end of treatment, but here it isthe last
sessionand Im not. How much longer will it take before Im cured?
T: If by cured, you mean never feeling anxious, remember that anxiety
has adaptive values, so our goal should not be to eliminate it entirely.
Instead, treatment has concentrated on learning skills to control the
excessive expression of unwarranted levels of anxiety. Like any new set
of skills, these must be practiced regularly, and it takes time before
they are fully mastered and begin to become automatic. But the more
you practice, the more thoroughly integrated and automatic those skills
will become. How long it takes before these new responses feel natural
and are mastered varies from person to person, but it depends mostly
on the amount of time and eort you put into practicing regularly.
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, its helpful to review the clients 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 havent been worrying about my wife as much these days, I still
worry a lot about my kids, so Im not really any better o or Although
Im not having trouble sleeping every night anymore, Ive 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 benet is almost entirely dependent on the clients motivation to
continue working on problem areas.
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Richard E. Zinbarg, Ph. D., is Associate Professor in Psychology at North-
western University and a licensed clinical psychologist, specializing in
the treatment of anxiety and panic disorders. He is the Patricia M. Nielsen
Research Chair and Director of the Anxiety and Panic Treatment Pro-
gram at the Family Institute at Northwestern University. He received his
Ph.D. from Northwestern University in :,,. He also directed the Ore-
gon Program for Anxiety Study and Treatment at the University of Oregon.
He has published over c articles and chapters in the areas of anxiety dis-
orders and clinical research methodology, and has presented extensively
on these topics. He served as Project Director for the DSM-IV Mixed
Anxiety Depression eld trial, recently completed a term as Associate Edi-
tor for the British Journal of Clinical Psychology, and is incoming Associ-
ate Editor for the Journal of Abnormal Psychology. His research interests
focus on understanding the risk factors for the development of anxiety
and depressive disorders, clinical research methodology, and developing
more eective treatments for the anxiety disorders, with a particular
focus on generalized anxiety disorder.
Michelle G. Craske received her Ph.D. from the University of British
Columbia in :,,, and has published over :oc articles and chapters in
the area of anxiety disorders. She has written books on the topics of the
etiology and treatment of anxiety disorders, gender dierences in anxi-
ety, and translation from the basic science of fear learning to the clinical
application of understanding and treating phobias, in addition to several
self-help books. In addition, she has been the recipient of continuous
National Institute of Mental Health funding since :,,: for research proj-
ects pertaining to risk factors for anxiety disorders and depression among
children and adolescents, the cognitive and physiological aspects of anxi-
ety and panic attacks, and the development and dissemination of treat-
ments for anxiety and related disorders. She is Associate Editor for the
Journal of Abnormal Psychology and Behaviour Research and Therapy, and
is a Scientic Board Member for the Anxiety Disorders Association of
America. She was a member of the DSM-IV Anxiety Disorders Work
171
A b o u t t h e A u t h o r s
Group Subcommittee for revision of the diagnostic criteria for panic dis-
order and specic 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.
David H. Barlow received his Ph.D. from the University of Vermont in
:,o, and has published over ,cc articles and chapters, including nearly
,c books and clinical workbooks, mostly in the area of emotional dis-
orders and clinical research methodology. The book and workbooks
have been translated into more than :c languages, including Arabic,
Mandarin, and Russian.
He was formerly Professor of Psychiatry at the University of Mississippi
Medical Center and Professor of Psychiatry and Psychology at Brown Uni-
versity, and he founded clinical psychology internships in both settings.
He was also Distinguished Professor in the Department of Psychology at
the University at Albany, State University of New York. Currently, he is
Professor of Psychology, Research Professor of Psychiatry, and Director
of the Center for Anxiety and Related Disorders at Boston University.
Dr. Barlow is the recipient of the :ccc American Psychological Associ-
ation (APA) Distinguished Scientic Award for the Applications of Psy-
chology. He is also the recipient of the First Annual Science Dissemina-
tion Award from the Society for a Science of Clinical Psychology of the
APA and recipient of the :ccc Distinguished Scientic Contribution
Award from the Society of Clinical Psychology of the APA. He also re-
ceived an award in appreciation of outstanding achievements from the
General Hospital of the Chinese Peoples Liberation Army, Beijing, China,
with an appointment as Honorary Visiting Professor of Clinical Psy-
chology. During the :,,;:,, academic year, he was Fritz Redlich Fel-
low at the Center for Advanced Study in Behavioral Sciences, in Palo
Alto, California.
Other awards include Career Contribution Awards from the Massachu-
setts, California, and Connecticut Psychological Associations; The :cc
C. Charles Burlingame Award from the Institute of Living in Hartford,
172
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 certicate 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 eort. 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 Work
tm
series for Oxford Uni-
versity Press.
He was Chair of the APA Task Force of Psychological Intervention Guide-
lines, was a member of the DSM-IV Task Force of the American Psy-
chiatric Association, and was a Co-Chair of the Work Group for revising
the anxiety disorder categories. He is also a Diplomate in Clinical Psy-
chology of the American Board of Professional Psychology and main-
tains a private practice.
173