Mastery of Your Anxiety and Worry (MAW): Therapist Guide 2nd Edition (Treatments That Work)

Mastery of Your Anxiety and Worry: Therapist Guide, Second Edition

Richard E. Zinbarg Michelle G. Craske David H. Barlow

OXFORD UNIVERSITY PRESS

M a s t e r y o f Yo u r A n x i e t y a n d W o r r y

-- David H. Barlow, Ph.D.    Anne Marie Albano, Ph.D. Jack M. Gorman, M.D. Peter E. Nathan, Ph.D. Bonnie Spring, Ph.D. Paul Salkovskis, Ph.D. G. Terence Wilson, Ph.D. John R. Weisz, Ph.D.

Mastery of Your Anxiety and Worry SECOND EDITION

T h e r a p i s t

G u i d e

Richard E. Zinbarg • Michelle G. Craske David H. Barlow

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1 Oxford University Press, Inc., publishes works that further Oxford University’s objective of excellence in research, scholarship, and education. Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam

Copyright ©  by Oxford University Press, Inc. Published by Oxford University Press, Inc.  Madison Avenue, New York, New York  www.oup.com Oxford is a registered trademark of Oxford University Press All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Oxford University Press. 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- ---- (pbk.) ISBN --- (pbk.) . Anxiety—Treatment. . Worry—Treatment. . Stress management. . Self-help techniques. I. Craske, Michelle Genevieve II. Barlow, David H. III. Title [DNLM: . Anxiety Disorders—therapy. . Stress, Psychological—therapy. . Psychotherapy—methods. WM  Zm ] RC.C  .⬘—dc 

         Printed in the United States of America on acid-free paper

A b o u t Tr e a t m e n t s T h a t W o r k ™

Stunning developments in health care have taken place over the last several years, but many of our widely accepted interventions and strategies in mental health and behavioral medicine have been brought into question by research evidence as not only lacking benefit, but also perhaps inducing harm. Other strategies have been proven effective using the best current standards of evidence, resulting in broad-based recommendations to make these practices more available to the public. Several recent developments are behind this revolution. First, we have arrived at a much deeper understanding of pathology, both psychological and physical, that has led to the development of new, more precisely targeted interventions. 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, governments around the world, as well as health care systems and policymakers, have decided that the quality of care should improve, that it should be evidence-based, and that it is in the public’s interest to ensure that these changes occur (Barlow, ; Institute of Medicine, ). Of course, the major stumbling block for clinicians everywhere is the accessibility 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, “Treatments 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 specific problems and diagnoses. But this series also goes beyond the books and manuals by providing ancillary materials that will approximate the supervisory process in assisting practitioners in implementing these procedures in their practice. In our emerging health care system, the growing consensus is that evidence-based practice offers the most responsible course of action for

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 occurs in approximately % of the population (about two-thirds of them female), but is underrecognized and undertreated. With its characteristic symptoms of uncontrollable, unstoppable worry about upcoming events, accompanied by chronic tension, fatigue, irritability, and difficulty sleeping, GAD can cause significant impairment. Most people seek treatment for this condition in primary care medical settings, where cognitivebehavioral treatments are seldom available. During the past  years, we have developed increasingly effective treatments for GAD, to the point where these interventions compare favorably with the best psychological treatments for other disorders (Borkovec & Ruscio, ). These treatments also have the advantage of proven durability after treatment ends, with the added benefit of allowing either substantial reduction or elimination of any anxiolytic medications prescribed before this treatment (Barlow, ). The approach in this manual was developed in our Center in the early s, and has now been substantially updated with the latest developments. We are gratified that countless numbers of individuals with GAD, in the hands of skilled therapists, have reported substantial benefit from this program. David H. Barlow, Editor-in-Chief, Treatments That Work™ Boston, MA

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Contents

Chapter 

Introductory Information for Therapists

Chapter 

The Nature of Anxiety and Generalized Anxiety Disorder 

Chapter 

Outline of the Treatment Procedures and the Basic Principles Underlying Treatment 

Chapter 

The Nature of Generalized Anxiety

Chapter 

Learning to Recognize Your Own Anxiety 

Chapter 

The Purpose and Function of Anxiety 

Chapter 

A Closer Look at Generalized Anxiety Disorder 

Chapter 

Learning to Relax 

Chapter 

Controlling Thoughts That Cause Anxiety: I. Overestimating the Risk 

Chapter 

Controlling Thoughts That Cause Anxiety: II. Thinking the Worst 

Chapter 

Getting to the Heart of Worrying: Facing Your Fears 

Chapter 

From Fears to Behaviors 

Chapter 

Dealing with Real Problems: Time Management, Goal Setting, and Problem Solving 

Chapter 

Drugs for Anxiety and Their Relation to This Program 

Chapter 

Your Accomplishments and Your Future  References  About the Authors 





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Chapter 1

Introductory Information for Therapists

The Mastery of Your Anxiety and Worry (MAW) program is designed to be presented in  or more separate sessions that may be conducted either individually or in small groups. If administered individually, each session should take approximately  minutes. Typically, we allocate  minutes for each session when conducting the program in small groups of six or eight. It is recommended that the therapist: () explain the principles 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 specified 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 described. Typical questions asked by patients and problems that may arise, based on our experience, are also included.

Who Will Benefit from This Program? This program is designed for people who suffer primarily from worry and tension. It is ideally suited for those who meet the criteria for the diagnosis of generalized anxiety disorder (GAD) in the Diagnostic and Statistical Manual of Mental Disorders, th edition, Text Revision (DSM-IV-TR), but will also be useful for those individuals who have occasional worries or tension, but do not meet the severity criteria for GAD. The DSM-IV-TR criteria for the diagnosis of GAD are given later. The key feature of GAD in the DSM-IV-TR is excessive and pervasive worry for at least  months. In this context, excessive worry means that the intensity, duration, or frequency of worry exceeds the actual likelihood or negative consequences of the event that is the object of worry. In addition, the worry has the

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quality of being uncontrollable; that is, the individual finds it difficult to keep worries from interfering with his or her concentration on tasks at hand and has difficulty ending the worry process. The pervasiveness of worry refers to a generalized focus on minor, everyday events or a focus on more than one major life circumstance (i.e., job, family, finances); these foci may shift repeatedly during the -month period. In addition, the worry is associated with physical symptoms of tension, such as restlessness, being easily fatigued, feeling keyed up or on edge, irritability, and sleep disturbances. This tension is seen as representing a state of motor readiness to respond to threat. Although the person may not always identify his or her worries as being excessive, he or she will report subjective distress due to unceasing worry, difficulty controlling the worry process, or associated impairment in functioning. In many cases, the therapist can make a judgment about whether the worry is excessive by thoroughly assessing the person’s life circumstances that are relevant to the worry. For example, if one of the person’s worries is finances, the therapist may need to ask about the person’s income, debts, savings, and other assets. We judged financial worries to be excessive in one of our clients, a radiologist, who earns several hundred thousand dollars a year and has large sums of money invested in stocks and bonds, but we would be hard pressed to do so in a client who had just lost his job and had meager savings that were not sufficient for paying his monthly bills. In other cases, the therapist may need to ask the person to compare his degree of worry relative to others belonging to the cultural groups the person identifies with. For example, one of our clients was a devout member of a congregation that believed that homosexuality 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.

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DSM–IV-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  months, about a number of events or activities (such as work or school performance). B. The person finds it difficult 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  months). Note: In children, only one symptom is required. . Restlessness or feeling keyed up or on edge . Being easily fatigued . Difficulty concentrating or mind going blank . Irritability . Muscle tension . Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep) D. The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety or worry is not about having a panic attack (as in panic disorder), being embarrassed in public (as in social phobia), being contaminated (as in obsessivecompulsive 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 significant distress or impairment in social, occupational, or other important areas of functioning. F. The worry is not due to the direct effects of a substance (e.g., drugs of abuse, medication) or a general medical condition (e.g.,

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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 suffering from worry and tension, it is not uncommon to also present with some depression or with a personality disorder characterized by histrionic, avoidant, dependent, or even schizotypal features. Treatment with the MAW program is not precluded by any of these problems 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 client’s functioning. On the other hand, the depression should be treated first 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 experiencing excessive worry and tension, despite undergoing a major life stress, such as marital difficulties or financial problems. Similarly, the MAW program would not be appropriate if the client experiences panic attacks and worries only about having more panic attacks or is depressed, without the complication of worry and tension. A different treatment protocol is used for people suffering from panic attacks and associated apprehension about panic and agoraphobic avoidance. This is the Mastery 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 Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV), which was devised for this purpose. The ADIS-IV generates diagnoses for all DSM-IV mood and anxiety disorders, and includes a brief screen for psychotic dis-

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orders and substance abuse. Extensive psychometric studies using earlier versions of the Anxiety Disorders Interview Schedule (ADIS) indicate that adequate reliability can be obtained with the ADIS for the diagnosis of mood and anxiety disorders (Barlow, ; Brown, DiNardo, Lehman, & Campbell, ). Information on obtaining this interview schedule can be found at www.oup.com/us/ttw.

Medication Many people suffering from worry and tension will be referred to mental health professionals while already taking psychotropic medication, most often prescribed by primary care physicians. In our experience, over half of these individuals are taking selective serotonin reuptake inhibitors (such as paroxetine [Paxil]) or serotonin norepinephrine reuptake inhibitors (such as venlafaxine [Effexor]), while some are taking variety of other drugs, most commonly, low doses of benzodiazepines, other minor tranquilizers, or tricyclic antidepressants. We do not recommend that clients decrease their medication during the course of the MAW program. 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 treatment 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 evaluation of the program’s effectiveness 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. Remember that any major change in medication must be closely monitored 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,

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without any outside urging to do so. Notwithstanding this general tendency, issues of medication withdrawal are discussed in workbook chapter  (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 prescribing physicians who choose to do so. If withdrawal from benzodiazepines is particularly difficult and includes panic, then the MAP program 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 sufficient 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 regarding these topics is presented in chapter . We also believe that it is important that the therapist have sufficient understanding of the conceptual 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 understanding. The references listed at the end of this guide provide more detailed and in-depth information on these topics. Finally, we also believe that it is useful for therapists to have some knowledge of the basic principles 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 formats, the program seems equally effective in either format. Thus, a decision on whether the program should be administered in a group versus 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

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to capitalize on the economies associated with this mode of administration. On the other hand, private practitioners may not wish to make clients wait until a group forms, and thus find it more suitable to administer the program on an individual basis. We customarily limit the number of clients to no more than six, when administering the program in a group format. We find that it is difficult to allocate sufficient individual attention to clients in the course of a -minute group session if the group is much larger than six. On the other hand, there is no formal research suggesting 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 difficult to resist the tendency to lecture. However, it is important that the therapist adopt a “Socratic” questioning style whenever possible. There is widespread consensus among leading cognitive therapists around the world regarding the importance of this point, and there is empirical evidence from the social psychology literature supporting 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 conclusions through questioning. The examples below illustrate an undesirable “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. Anxiety 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

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mild uneasiness to extreme terror and panic, and can vary in frequency from occasional distress to seemingly constant unease.

“Socratic” Style

T: So, what are your goals for this program? In concrete terms, how will your life be different  months or a year from now, if we are successful in helping you? C: I hope I’ll be able to handle my anxiety better, without becoming overwhelmed. These days, my anxiety is so strong that sometimes I just feel frozen and can’t make decisions. At my job, I don’t like what I’m doing now, but I’m 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 won’t be stuck where I am now in my job. T: I think those goals—reducing or eliminating the times when your anxiety is so high that it is overwhelming and helping you so you don’t feel stuck in your current job—are 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: I’m not sure if I’m following you. T: Let me try phrasing my question differently. 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 you’re saying. When I was a student and taking a subject I was pretty good at, I wouldn’t get too nervous before tests, but I did get a little bit nervous. Because I was a little nervous, I probably spent more time studying than I would have otherwise. T: That’s a great example. Therapists and researchers who study anxiety often relate it to the fight-or-flight response. Can you imagine what we might mean by that?

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Example 2 Overcautiousness and safety behaviors block the opportunity for learning that one’s 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 didn’t criticize you? Were you more likely to attribute their lack of criticism to the fact that you cleaned or to the possibility that they wouldn’t have rejected you, even if the house wasn’t spotless? 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 didn’t ? 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 assumptions, such as “I’m different from everybody else” or “I’ve only survived up until now because I am always ready and waiting.” Without eliciting the client’s objections and his or her evidence supporting the negative beliefs, these beliefs will persist unchallenged, and may undermine the effects of treatment. After eliciting objections, you can apply the cognitive restructuring techniques to them. The following are helpful questions for eliciting objections:

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Can you think of any reasons why this might not apply to you? Does that fit with your experience? Therapists should also clearly communicate to clients that cognitive therapy is not about the power of positive thinking; rather, it’s about realistic thinking, or “finding the truth.” Experienced cognitive therapists are also fond of saying that, in cognitive therapy, the therapist never loses. What is meant by this is that almost any experience that the client has, progress or distress, can fit into the cognitive model. Thus, even if someone has a very intense episode of heightened anxiety during treatment, you can always find some way of using it to demonstrate the importance of one of the factors in the model, (e.g., threatening misinterpretations, the role of cognitive avoidance or overcautiousness in maintaining anxiety, hypervigilance). As therapy progresses, the therapist should become less direct, to promote internalization of the coping skills. For example, in the first 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 first two or three sessions of cognitive restructuring, the therapist should try to assist the clients to challenge 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 someone else’s 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

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gets stuck when trying to restructure one of his or her own worries, we often find it helpful for the therapist to use the “put the shoe on the other foot” technique. That is, the therapist can ask the client to consider 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 find that one of the most common difficulties that arises when working with anxious clients is ambivalence or resistance about completing self-help assignments. The therapist must keep in mind that, when implementing 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 comply with such interventions, we find it useful to asssume that the person must have some motivation for change, or he or she would not keep coming to see us. Thus, our task becomes helping the client to articulate, and perhaps even strengthen, his or her motivation for change. One way to do this involves borrowing the approach advocated in Motivational Interviewing, developed by William R. Miller and his colleagues and side with the resistance (Miller & Rollnick, ; also see Newman, ). “Siding with the resistance” simply refers to reflecting back to the client what the therapist understands to be the client’s reasons for maintaining the status quo and resisting change, with an attitude that conveys that these reasons have validity and are understandable (e.g., “It sounds like you don’t want to heighten your awareness of the automatic thoughts that might be contributing to your anxiety because you believe that doing so will make you even more anxious than you already are; it makes sense to me that you would want to avoid focusing on your automatic thoughts, given your belief ”). Assuming that the invidual is ambivalent (i.e., has some motivation for change in addition to motivation 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 motivation for change? Might siding with the resistance backfire and lead to premature termination? Our view is that it may well be true that siding

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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 present time and terminating the therapy. However, we also believe that there is a lot of wisdom to the old joke: How many therapists does it take to change a light bulb? One, but the light bulb has to want to change. That is, if the client has no internal motivation to change, we don’t believe 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, Goldfried, Wiser, Raue, & Hayes, ; Castonguay, Schut, Aikins, & Constantino, ) suggests that the therapeutic alliance is important, even when conducting cognitive-behavioral therapy. More specifically, Castonguay’s work has shown that therapists’ rigid application of standard cognitive-behavioral techniques in response to problems in the therapeutic alliance correlates negatively with outcome. When a client expresses hostility toward the therapist or otherwise expresses negative opinions about the therapist’s behavior, it is probably not advisable to try to repair the strain on the alliance solely, or even initially, by identifying the negative reactions as evidence of the client’s 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 empathy for the client’s emotional reaction and taking at least some responsibility for contributing to the strain on the alliance. In our experience, 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 negative 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

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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 complete chapters  through , , and . Workbook chapter  (on safety behaviors and behavioral overcautiousness, including procrastination and other subtle patterns of avoidance) and workbook chapter  (on discontinuing medication) may be completed at the discretion of the therapist. If safety behaviors or behavioral overcautiousness is substantial, chapter  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 exercises to be practiced during the week. Later sessions may be held biweekly to give the client more practice in applying the skills more independently. Some therapists, however, may wish to accelerate treatment by scheduling two sessions per week or, alternatively, by trying to cover two lessons during weekly -minute or -minute sessions. Either way, the duration of the treatment program would be cut approximately in half. Initial evaluations of the program yielding successful results have been based on a pattern of administration of one lesson per week for the first eight weeks, with the last four sessions held on a biweekly basis. Nevertheless, there is no reason to believe that certain clients could not achieve equal benefits from the program delivered in a shorter period, if they are prepared to dedicate the extra time needed to the tasks.

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 sessions. If behavioral avoidance and safety behaviors are a problem, we suggest that the individual complete workbook chapter  as well. Similarly, if assertiveness or time management is a problem, we suggest that the person complete chapter . We have observed that people who ter-

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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 exercises. Until we become aware of evidence that some parts of the program might be superfluous, we will continue to advise that each client complete all aspects of the program.

Benefits of Using a Workbook The first “revolution” in the development of potent psychosocial treatments during the past decade has been the “manualization” of these treatments. Since these are structured programs for particular disorders, they can be written in sufficient detail to allow trained therapists to administer them in approximately the same fashion that they were proven effective. 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 structured 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 scientifically sound program that is written at the client’s level and can be a valuable adjunct to programs administered by professionals from a number of disciplines. There are many advantages to administering the program in this manner, including 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 finish the program in half the time by holding sessions twice a week or by trying to cover two workbook chapters in each week’s 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 between irregularly scheduled sessions is of substantial benefit.

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■ The client may consult the workbook when he or she is confused or overwhelmed. While many concepts may be readily apparent to trained therapists, we often lose sight of the fact that clients who seem to comprehend ideas during a session often get confused about the same ideas after leaving the session. One of the greatest benefits of the workbook is the opportunity for clients to reexamine pertinent conceptualizations, explanations, and instructions between sessions. This may be especially helpful during episodes of intense anxiety, when many clients understandably report the greatest difficulty remembering their newly learned coping skills. The MAW workbook often becomes the client’s bible during the course of treatment. Some clients go so far as to take the workbook, 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. Research at our center (Barlow, O’Brien, & Last, ; Cerny, Barlow, Craske, & Himadi, ) has shown that there is a significant benefit to having family members, especially spouses, be apprised of and involved in treatment for at least one type of anxiety problem, panic disorder with agoraphobia. For example, clients whose spouses were involved in treatment did much better at -year follow-up than those whose spouses were not involved. Recent research by Chambless and Steketee () has shown that greater levels of hostility expressed toward the client by relatives (% of whom were spouses) prior to the start of therapy predicted poorer response to cognitive-behavioral therapy for panic disorder with agoraphobia and obsessive-compulsive disorder. In contrast, nonhostile criticism—being critical of specific behaviors, without devaluing the client—actually predicted better response to the therapy (Chambless & Steketee, ). We have recently obtained identical results in a study of the efficacy of the major components of the MAW program in clients with GAD who were in committed relationships (Zinbarg, Lee, & Yoon, ). There are several possible ways in which family participation may benefit the client. First, any attempts to undermine the program,

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either intentionally or unwittingly, may be prevented if family members are familiar with the nature of the difficulty and the rationale underlying the different exercises that the client is performing. Similarly, it is possible that partners or family members who are very hostile toward the client might be less so if they had a greater understanding of the processes maintaining the worries. Second, family members can be very beneficial in encouraging the client to conquer some of the overcautiousness in behavior that often accompanies anxiety problems. Of course, there are some clients who would prefer that their spouse or family members be completely uninformed about their problem and the treatment program. In these cases, we invite the client to consider the potential benefits of sharing their problems with their spouses and try to restructure any excessive or unrealistic worries that they may have. Typically, these worries focus on apprehension that the family will think that they’re crazy or will be openly antagonistic to their efforts. In our experience, this very rarely happens. If the worries are particularly strong, we may bring the spouse into the sessions, either initially or for all of the sessions. In some of our group treatment programs, groups typically consist of four to six clients and their spouses, for a group size of eight to twelve. ■ Clients can consult the workbook at the end of the program. The MAW program advises clients to be prepared for the occasional recurrence of intense anxiety under especially stressful circumstances. 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 efforts 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.

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Benefits 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 find it useful to administer a standardized questionnaire battery to our clients on a repeated basis to assess how much they have benefited from therapy. For assessment of the severity of symptoms of GAD, we find two standardized questionnaires to be particularly useful. The first of these is the Penn State Worry Questionnaire (PSWQ), developed by Borkovec and colleagues (Meyer, Miller, Metzger, & Borkovec, ). The second is the Stress subscale from the Depression-AnxietyStress Scales (DASS; Lovibond & Lovibond, ). The DASS-Stress scale is a good measure of the tension characteristic of generalized anxiety, and research in our Center has shown that it effectively discriminates patients with GAD from those with other anxiety disorders (Brown, Chorpita, Korotitsch, & Barlow, ). These two measures are particularly useful for assessing changes associated with the MAW program because 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, ; Gillis, Haaga, & Ford, ). In our experience, most clients begin treatment scoring at least two standard deviations above the nonclinical mean on these and other related measures, but score no more than one standard deviation above the nonclinical mean on most measures (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 distributing the workbook chapters in several segments. In this way, they ensure that clients don’t skip too far ahead and are better able to focus on the material at hand. These therapists have used loose-leaf binders or similar mechanisms to put the various segments of the workbook together. On the basis of this feedback, we have carefully thought about supplying the MAW program in such formats, but have decided not to do so at

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this time. The disadvantage of this practice is that individual chapters are more prone to be lost, so that clients will not have complete MAW workbooks when the program ends. Obviously, having an incomplete workbook will make it difficult to consult in the months and years ahead. In addition, it does not particularly trouble us when clients do some jumping around. As a generalization, we find that the more time a client spends reviewing the MAW program, the deeper his or her comprehension 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 final analysis, there is no empirical evidence that we are aware of that addresses this issue. Thus, our preference notwithstanding, we certainly 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 incorporated into a program’s or therapist’s 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 fixed fee structures, have clients assume the responsibility and cost of ordering the workbook themselves. Thus, the treatment 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.

Efficacy of the MAW Treatment Program We recently completed a wait-list controlled study in adults ages  to  years of the efficacy of the major components of the MAW program, including cognitive restructuring, relaxation training, and worry imagery

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exposure (Zinbarg, Lee, & Yoon, ). Fifty percent of the individuals who completed the treatment had returned to within one standard deviation of the nonclinical mean on at least four of our five outcome measures at the end of the program, and can therefore be regarded as having achieved high-end state functioning. Another .% were markedly improved (returning to within one standard deviation of the nonclinical mean on three of the five outcome measures), and another % were somewhat improved (returning to within one standard deviation of the nonclinical mean on two of the five outcome measures). Thus, a total of .% were at least somewhat improved. Wetherell, Gatz, and Craske () adapted the MAW program for a late-life sample (mean age,  years) and compared it to a discussion group pertaining to worry-provoking topics and to a wait-list control. The MAW program was clearly more effective than the wait-list control and marginally more effective than the discussion group. Stanley, Beck, Novy, Averill, Swann, Diefenbach, and Hopko () also conducted a treatment study among older adults (mean age, . years) in which they compared a cognitive-behavioral therapy package that included many of the components of the MAW program with a minimal contact treatment that involved weekly phone calls to assess symptom severity and provide minimal support. The cognitive-behavioral therapy was clearly superior to the minimal contact treatment. However, consistent with other evidence for poorer treatment response in older age groups, the rates of high end-state functioning were quite low in the reports of both Wetherell et al. () and Stanley et al. ().

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Chapter 2

The Nature of Anxiety and Generalized Anxiety Disorder

For a full exposition of this theoretical model, see Barlow () and Zinbarg (). In brief, interactions among the following factors are recognized in the genesis of GAD: negative affectivity or neuroticism; attentional vigilance and narrowing to signals of potential threat; a tendency toward interpreting ambiguous situations as threatening; passive avoidance, overcautiousness, or procrastination; perceptions of uncontrollability and unpredictability; and cognitive avoidance, distraction, or other active efforts 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 development of excessive worry and anxiety (figure .). First, it is important to recognize that anxiety is universal and serves an adaptive function. Anxiety 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-flight mechanism when threat is imminent. Many of the physiological symptoms of a panic attack may be seen as the activation of the underlying physiology necessary to support the immediate and strenuous action involved in escape or fighting. Anxiety, on the other hand, is associated with simultaneous excitation and inhibition of the fight-orflight mechanism in response to signals of potential or approaching threat that is not yet imminent. In other words, anxiety involves a preparation, or priming, of the fight-or-flight mechanism, making it easier to activate this mechanism (figure .). This priming accounts for the ten-

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Diatheses

Synergistic Vulnerabilities Biological Vulnerabilities

Generalized Psychological Vulnerability

False Alarms (panic)

Stress

Generalized Anxiety

Depression Figure 2.1

Diatheses–stress model of the development of generalized anxiety and depression. Redrawn from Barlow (), with permission.

sion that is often associated with anxiety. When the threat of danger is real, anxiety is crucial to our survival. Seen in this light, it would be surprising 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 vulnerability). This component, labeled “negative affectivity,” “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 one’s parents. Rather, it is believed that this predispositional variable of physiological 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 excessive worry and tension, whereas others may experience panic attacks, hypertension, headaches, and so on.

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No threat potential

Preferred mode of safety and control

Threat potential

Worry: preparation and readiness

Approaching threat

Anticipatory anxiety: mobilization and vigilance

Imminent threat

Fear and panic: fight or flight

Figure 2.2

Relationship of worry, anxious apprehension, and fear (panic). Redrawn from Craske (), with permission.

Chronic and intense anxiety is particularly likely to develop when an inherited 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 complication of chronic anxiety, in some people (in figure ., this is represented 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  o’clock 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-

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stantly anxious person. Since the attack, Rick has had difficulty relaxing, and he feels constantly on edge and vulnerable to ever-present danger in his surroundings. This is accompanied by a high level of startle reactivity. 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 unpredictable 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 observed when he was asked to do relaxation exercises. He reported that, every time he tried to relax, he would become more anxious. He felt increasingly vulnerable to more bad things happening if he allowed himself 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 hypervigilance and cognitive biases favoring the processing of threat at early stages of processing (e.g., preattentive scanning for threat, favoring threatening interpretations of ambiguous stimuli), avoidance behaviors (that become more pronounced and observable, depending on the specificity of the situational cues that set the occasion for anxiety and the extent to which overt avoidance is possible); and cognitive avoidance at later stages of procesing, including both distraction and the shift away from imagistic processing of threat and toward verbal-linguistic processing that is characteristic of the process of worry (Borkovec, Shadick, & Hopkins,

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; figure .). Individuals characterized by preattentive scanning for threat and a bias toward threatening interpretations of ambiguous events would be more likely to identify mildly threatening stimuli and to encode ambiguous stimuli as threatening. As a result, such individuals would experience anxiety in response to cues that others do not find threatening. Moreover, it has been shown that the preattentive scanning for threat occurs at a relatively early and “automatic” level of information processing, 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, without even knowing what he or she is worried about! In any event, the automaticity of this preattentive bias is almost certain to lead to the experience 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 nevertheless do engage in subtle patterns of avoidance, including checking and preventive behaviors, procrastination, and attempts to control worry, such as cognitive avoidance and distraction (e.g., Brown, Moras, Zinbarg, & Barlow, ; Craske, Rapee, Jackel, & Barlow, ; Hoyer, Becker, & Roth, ; Schut, Castonguay, & Borkovec, ; 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 resources that are devoted to such planning, the fewer there are to evaluate the realistic likelihood and impact of the threat. Thus, worry and distraction 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 difficulty of sustaining distraction for very long (Wegner, Schneider, Carter, & White, ; Wegner & Erber, ; Wenzlaff, Wegner, & Roper, ). This evidence suggests that thought suppression produces an automatic priming of the unwanted thought (Wegner & Erber, ). Thus, thought sup-

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Evocation of Anxious Propositions (situation contexts, unexplained arousal, or other cues)

Negative Affect

Attentional Shift

A sense of uncontrollability and unpredictability (perceived inability to influence personally salient events and outcomes) Preparatory coping set accompanied by supportive physiology and activation of specific brain circuits (e.g., CRF system, Gray’s behavioral inhibition system)

Dysfunctional Performance and/or lack of concentration on task at hand

to self-evaluative focus (on physiological or other aspects of responding)

Intensification

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

Process of Worry

of situational context or other aspects of negative affect (e.g., arousal), if feasible

Heightened verbal and linguistic capabilities and restricted autonomic activity to support (often futile) attempts to plan and problem-solve Avoidance of core negative affect

Figure 2.3

The process of anxious apprehension. Redrawn from Barlow (), with permission.

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pression paradoxically increases the accessibility of the unwanted thought, increasing the likelihood that the individual’s processing resources will be automatically “recaptured” by the threat cues that initially triggered the worry episode. This inability to terminate bouts of worry and provide 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 encode efferent commands to the autonomic system. They further suggest that this tendency is strongest among people with GAD (see also Freeston, Dugas, & Ladouceur, ). A very recent study has found that verbal-linguistic processing of threat is associated with subjective reports of weaker negative affect 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 affect (Borkovec & Hu, ; Vrana, Cuthbert, & Lang, ). 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 anxiety—including its stimulus, meaning, and efferent components—which has been hypothesized to be necessary for anxiety reduction (Foa & Kozak, ; 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 stimuli, develops into GAD, when accompanied by an inability to effectively terminate bouts of worry. It is primarily the later stages of processing threatening information that appear to differentiate “nonclinical” worriers from those who go on to meet the criteria for a disorder (MacLeod & Hagan, ; Rutherford & MacLeod, ). “Nonclinical” worriers appear to be able to respond to the initiation of worry, either with a relatively accurate appraisal of an unrealistic danger (perhaps as a result of staying with the initial threatening image long enough for natural ha-

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bituation and decatastrophizing processes to operate) or by the formulation of a more or less effective plan for coping with a realistic danger. Either way, “nonclinical” worriers are able to effectively terminate a bout of worry. 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 effect of damping down arousal and negative affect, 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 figure ., 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 affect, but does not eliminate it entirely, the individual with GAD also tends toward volitional avoidance of elaborative processing of threat. In turn, efforts to distract paradoxically serve to increase the accessibility of the threatening images, and thoughts and thereby create difficulty terminating worry. In figure ., 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.

Tension

Trigger

Automatic threatening image

Anxiety

Dysfunctional performance

Verbal processing (suppress image)

Distract

Worry

Figure 2.4

Model of maintenance of generalized anxiety disorder. Redrawn from Barlow (), with permission

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Difficulty in terminating worry or the tendency for tension to heighten self-focus is likely to interfere with the individual’s ability to concentrate on other tasks, thereby impairing performance and providing additional sources of worry. Even when the worry trigger is a realistic danger, the individual with GAD may not be able to terminate worry long enough to engage in effective problem-solving. Thus, a third vicious cycle may begin, as the ineffective problem-solving is taken as further evidence that stressors are uncontrollable, and as a result, the individual begins to worry about worrying. In figure ., this aspect of the model is represented by the step labeled “dysfunctional performance,” which connects worry back to increases in the experience of negative affect, thereby completing 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 process. This is one of the functions of worry control treatment. The treatment targets the maladaptive cycle that maintains states of high anxiety and worry. (This will be covered in more detail later.)

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Chapter 3

Outline of the Treatment Procedures and the Basic Principles Underlying Treatment

There are four primary treatment modules in the MAW workbook. The first module consists of basic information, instruction, and cognitive restructuring. 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 recognition 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 effective in terms of treating generalized anxiety. Third, imagery exposure is used to evoke, in a methodical, controlled fashion, the worrisome images most salient to the individual. Repeated exposure, with increasing control over the worry process, focuses on replacing cognitive avoidance tendencies with one of cognitive modification through approach and challenge. The suggestion by Borkovec and colleagues that the process of worry itself suppresses the generation of imagery, particularly those aspects of imagery that encode efferent commands to the autonomic 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 off and response prevention of any “safety behaviors” are included. Since

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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 exercises and response prevention are conducted. The first two treatment modules are viewed principally as skills for managing 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 avoidance 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 difficulties, job loss). The workbook does not attempt to directly address additional problems that often occur with anxiety, such as depression or panic attacks. Consequently, we suggest that, for the duration of time devoted to implementing the MAW program, the focal point of treatment be limited to working with worry and generalized anxiety. If other emotional difficulties are primary, or if major life crises take place, we suggest that they be addressed before an attempt is made to reduce the client’s 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 differences, not all sections of the program will be entirely appropriate for every client. For example, in vivo exposure to external situations and response prevention of safety behaviors may not be relevant for everyone. In addition, research at our center and several other

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centers around the world (Zinbarg, Barlow, Licbowitz, Street, Broadhead, Katon, Roy-Byrne, Lepine, Teherani, Richards, Brantley, & Kraemer, ), suggested that there may be many individuals who experience chronic symptoms of anxiety that do not meet the full definitional thresholds for GAD. Some of these individuals primarily experience excessive worry whereas others primarily experience excessive arousal, even though their worry is judged to be in proportion to their life circumstances. Thus, for some sufferers of chronic anxiety, cognitive restructuring may be less relevant than relaxation, or vice versa. An initial individual response profile will be helpful for ascertaining which of the treatment components will be most useful. Such a profile can be determined by assessing the following areas: excessiveness of worry, degree of arousal and tension, and patterns of avoidance, including subtle patterns of passive avoidance of external situations, procrastination, overt or covert safety or checking behaviors designed to ward off danger, and cognitive avoidance or distraction strategies.

Principles Underlying the Treatment Procedures As discussed earlier, the primary features thought to be influenced 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 predictability, controllability, and safety. It is of the utmost importance to give these variables due regard, particularly when planning specific practices for clients to carry out. For example, a client who worries excessively about her children’s 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 client’s 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

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person moderates the level of anxiety and, therefore, the most functional exposure practice would involve gradually working up toward having the child spend time away from home without adult supervision. As another example, clients who worry about a spouse who is late may report much less anxiety when exposed to their spouse’s coming home  minutes late as a planned practice as opposed to the experience of the same delay that occurs with no advance notice. Here, the most functional exposure would involve the client and spouse agreeing to the number of days out of the week that the spouse will come home late, without the client knowing which particular days those will be, and gradually increasing how late the spouse will be. Perceptions of lack of safety, unpredictability, and uncontrollability are presumed to be influenced by all stages of the treatment process: Corrective information is of particular value to perceived safety and predictability; relaxation is relevant for perceived controllability 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 client’s 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 activation is associated with preparation for danger, the sensations are presented as the byproduct of a mechanism for coping and survival, 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 herself at greater risk for negative events. . The state of anxiety is differentiated from fear or panic, both theoretically and with respect to their three-response-mode pres-

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entation (cognitive, physiological, and behavioral). Anxiety is characterized by: () perception or awareness of distant threat, () chronic tension and hyperarousal, and () cautiousness, procrastination, and interference with performance and the ability to concentrate on the task at hand. In contrast, fear or panic is characterized by: () perception or awareness of immediate peril, () sudden autonomic discharge, and () strong escape or fight-orflight urges. Most often, the anxiety experienced by chronic worriers tends to be focused on various life circumstances, such as family, health, finances, and role performance. Due to the disruption of performance that sometimes results from high states of anxiety, one may worry about becoming anxious. Worry often occurs at a level of cognitive appraisal associated with awareness, for example, “I hope my boss doesn’t fire me for not meeting the deadline we were shooting for,” or “I hope I don’t become so nervous that I’ll blank out on my lines during the audition,” or at a preattentive level outside of conscious awareness. . 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 prevention) may begin with situations or tasks that are perceived as being relatively safe or manageable, and then progress systematically to practices that are perceived as being more threatening and challenging (see the following case for an example). . Throughout the program, a learning approach is adopted in which the development of skills is emphasized. The amount of improvement is thought to be related to the extent to which the individual actually practices the various skills and exercises. Practices are designed to challenge tendencies to avoid and replace them with approach tendencies.

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Case Example

Striving for Perfection: The Case of J When she presented for treatment at the center, J was a -year-old married woman with two children, aged  and  years. She reported that worry and high levels of general anxiety had been a problem for her for almost as long as she could remember—at least since she left college. Her two major spheres of excessive worry were concerns about her job and her family, and she reported having great difficulties controlling her worry. She described herself as a “perfectionist” and too much of a “people pleaser.” In the several months just prior to her initial assessment, she had experienced several stressors, including terminal illness in a close family member, that contributed to a marked increase in her usual high level of generalized anxiety. In addition to experiencing long-standing symptoms of motor tension, sleep disturbance, and difficulty concentrating, she reporting experiencing recent physical difficulties, such as irritable bowel syndrome, temporomandibular joint dysfunction, and possibly, a spastic bladder. J reported feelings of depression that seemed to come and go, but did not reach the definitional thresholds for either a major depressive episode or dysthymia. Her worries and generalized anxiety led to significant 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 conflict 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 failure and her attempts to be perfect—the perfect employee, the perfect mother, the perfect source of comfort and support for her sick relative. On top of everything else, J was becoming aware of worrying about her

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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 Anxiety Disorders. Given the initial focus on corrective information, relaxation training, and cognitive restructuring, J’s initial response was mixed. She learned the -muscle-group progressive relaxation procedure and applied 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 relaxation 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 exaggerating 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 incorporated 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 apparent that J employed the safety behavior of overpreparing with respect to many of her work-related projects. It was not until the imagery exposure and worry prevention phases were implemented that her reactivity to her worrisome thoughts and their intrusive quality truly diminished. J’s imagery exposure exercises primarily involved her worries about visiting her dying relative. Her greatest fear in this area was that she would cry uncontrollably, which would put additional strain and stress on her relative, 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 anxietyprovoking 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 imagery 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

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the imagery of the train trip. After becoming relatively comfortable with the imagery of the train trip, she progressed to exposing herself to the imagery of approaching his house, then entering the house, and finally, entering 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 outcomes 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 experienced a decrease in both the frequency of this worry and the anxiety it elicited as a result of repeatedly practicing the imagery exposures and cognitive restructuring. She eventually came to visit her relative on a regular 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 people—particularly people at work. Initially, these exposure practices (or, in her words, “reality testing”) 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 hierarchy 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 first  weeks of treatment, when imagery exposure was begun, after which the frequency of her episodes of heightened 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 beginning of treatment. She reported that she was socializing more regularly 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

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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 week’s session, in addition to reading the pertinent material in this guide. Some therapists prefer that clients read the workbook chapter before the session so that the therapist can elaborate on issues and tasks, as well as answer questions. Other therapists prefer that clients read each chapter after the session is over to review and consolidate points covered in the session. We usually follow the latter strategy and assign the relevant MAW workbook chapter after each session.

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Chapter 4

The Nature of Generalized Anxiety

(Corresponds to chapter  of the client workbook)

Summary of Information in Chapter 1 of the MAW Client Workbook ■ Definition 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, emphasizing 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 different type of treatment. ■ Complications arising from involvement in more than one psychotherapy at a time for the management of anxiety and worry. The limitation to one psychological program at any given time for the treatment 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 efficacy. ■ Discussion of the relationship between improvement and practice, since the approach is one of learning; this treatment is most appropriate for individuals who are highly motivated to make changes. ■ Chapter-by-chapter outline of the MAW program.

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Session Outline ■ Brief check-in ■ Negotiating an agenda ■ Discussion of the client’s goals for therapy ■ Discussion of the client’s 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 session, the brief check-in will consist of greetings, a chance for the client to state how he or she has been feeling recently, and a chance to briefly review whatever monitoring forms the therapist may have asked the client to complete prior to this session.

Negotiating an Agenda 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 therapist’s 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 discuss topics that the client considers high-priority issues. Whenever possible, the topics introduced by the client should be addressed in the context of the session topics. For this session, the therapist’s suggestions for agenda items should include a discussion of the client’s goals for therapy and the client’s expectations regarding how the therapy will help to achieve his or her goals. The

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therapist might also suggest that, if time permits, the therapist and the client can begin to formulate a shared understanding of the factors maintaining the client’s anxiety, worry, and tension—in other words, a shared understanding of the processes that they need to target for intervention.

Discussion of the Client’s Goals for Therapy In discussing the client’s goals, it is important to keep as concrete a focus as possible. The more concrete the client’s goals at the outset, the easier it will be to assess whether those goals have been achieved at the end of the program. We find it useful to begin with a simple question, such as “If the work we do together is successful, how would your life be different, say,  or  months from now?” In the course of the ensuing discussion, the following is a list of points that the therapist should consider addressing. ■ The specific clustering of features that distinguishes GAD is sufficiently prevalent to be recognized and labeled as a specific 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 associated existential anxiety. ■ Worry and anxiety are universally experienced and often serve adaptive functions. Other factors are important in the development of a disorder. Hence, the notion that all anxiety is abnormal and maladaptive is targeted. In addition, this treatment is not designed to remove any and all anxiety. Even if it were possible to eliminate anxiety entirely, it would not be in the client’s best interests to do so. ■ Whereas worry and anxiety often serve adaptive functions, they become problematic when experienced at intensities out of proportion to the level of objective threat in a situation or in situations in which there is no objective threat whatsoever. ■ The various ways of coping with worry and anxiety, including perfectionism, procrastination, and its opposite—putting pressure on oneself to complete things in unnecessarily short periods—are

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understandable. However, these approaches tend to diminish one’s feelings of enjoying life. Moreover, these attempts at coping may be effective at reducing anxiety in the short run, but often tend to perpetuate the anxiety and worry in the long run.

Discussion of the Client’s 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 client’s 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 feedback and focus more intensively on points that the client did not mention 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 won’t 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 repetitions are required before the skills begin to feel natural and become “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 childhood learning histories (such as when trying to reduce self-criticism that, for the moment, is focused on how “stupid” it is to experience a particular negative automatic thought or belief ), discussion of such factors is not necessary in most cases, and is not sufficient to produce the full benefit 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 particular case, it is impossible to go back and change those factors (although 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.

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Negotiating Homework At least some problems with compliance with homework can be prevented by making homework something that is truly negotiated and collaborative, rather than “assigned” by the therapist. We find it useful to offer 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 actually follow through more of the time now than when we assigned homework without offering the client any perceived control over the process. On occasion, a client does refuse to commit to one or more options; however, we are convinced that they would not have followed through on these if we had assigned them. For this session, the therapist’s suggestions for homework (or self-help, for those clients who have a negative reaction to the word “homework”) items should include reading over the appropriate MAW workbook chapter or chapters for the next session and giving more thought to goals for therapy to add to the goals identified in this session. If the client has already begun self-monitoring (we typically like to begin self-monitoring even before the first therapy session, if the logistics can be arranged), another suggestion should be to continue with self-monitoring. Alternatively, if the client has not already begun self-monitoring, but the therapist 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 important to assess proper understanding and facilitate consolidation of important 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,

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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 first 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 modification is begun through the provision of an alternative framework in which to understand anxiety.

Case Vignettes

Case Vignette 1 C: I’m 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 find that worrying helps me to be prepared for what might happen. I would feel even more anxious if I weren’t worrying. T: So, it sounds like you believe that worrying protects you, and you’re worried about feeling vulnerable by letting down your guard. May I ask you a couple of questions so that we can look at that belief a little more closely and evaluate its validity? C: OK. T: Have you ever experienced any stressful events that you weren’t able to foresee and so didn’t worry about in advance? C: Sure, many times. T: And would you say that you handled any of those situations adequately?

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C: Not usually, no. T: Not even once? C: Well, there was one time when my boss asked me to make a presentation 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 situation that you weren’t aware of and didn’t worry about in advance? C: Yes. Recently, my son took a trip with some of his college friends that I wasn’t aware of. Usually, I worry a lot before any of my family members takes a flight. This time, I didn’t worry because I didn’t even know he was flying until afterward. T: And how was his flight? C: No problems. He was fine. 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 remember 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 treatment process. In addition, the increase in your anxiety is temporary

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and usually recedes fairly quickly. Your worry about picking up more worries, or contagion, is probably related to your current level of anxiety and worry about becoming anxious. As you learn to regulate your anxious response, the worry of contagion will probably seem less and less relevant to you.

Case Vignette 3 C: How can such a brief program cure me after I’ve experienced this anxiety and tension for so long? I’ve been a worrier all my life—that’s just the way I am—so I feel there is no way it can resolve so rapidly. T: There are a few things to remember here. First, it has often been found that the duration of an anxiety problem doesn’t necessarily influence the response to treatment. Instead, it appears that the amount of practice and involvement you have with the program is most important in terms of achieving the maximum benefit. Second, this program is highly skills-oriented, and learning takes place fairly quickly. Third, and perhaps most important, we don’t expect you to be “cured” at the end of this short-term program. Rather, I have a different goal in mind for you, related to the notion that, during this program, you will acquire skills that you can apply on your own. Based on that, can you imagine what an alternative goal might be, other than that you will be cured by our last session? (The therapist appropriately shares some information with the client that the client is unlikely to have, but also begins to familiarize the client with the Socratic method and the process of identifying alternatives.) C: I’m not sure. Maybe that when I finish the program, I’ll know skills that will allow me to deal with the problems that remain? T: Exactly. In fact, many people continue to experience further improvements after the program is completed, if they continue to apply the skills they’ve 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 doesn’t help everyone.

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T: Well, the success rate is very high, but you’re right that not everyone improves. Do you agree, though, that the high success rate is, in itself, a reason for you to attempt to carry out the program, or at least to withhold a final judgment until you have had experience with some of the exercises and techniques?

Case Vignette 4 T: So, let’s talk some about your goals for our work together. If we’re successful, how will your life be different  or  months from now? Please try to be as concrete as possible. C: Well, I think the biggest way in which I hope my life will be different is that I won’t get so overwhelmed by my anxiety that I get frozen or stuck. Like now, when I think about what direction to go with my career or graduate programs, or when I think about where my relationship with Trevor is heading, or where I should live after my current lease is up, I just can’t make up my mind. Each direction I think about gets me worried, and I feel stuck. I even feel frozen when it comes to cleaning my apartment. The place is so messy that I know I can’t get it all straightened up in one shot, and that thought gets me so anxious that I don’t even do any cleaning! I just go and play a video game or watch TV. T: So, it sounds like an overarching goal is to feel less overwhelmed by your anxiety. More specific goals are that you would like to make decisions regarding your career path, your relationship with Trevor, and where to live. Another specific goal is that you would like to stop procrastinating and take some steps toward straightening up your apartment. 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 I’ll think of some more later. T: OK. We can always add to this list as we go. One thing I really like about what I hear from you is that you are saying that you want to re-

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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 anxiety. 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: That’s exactly what I’m talking about. In fact, a lot of therapists and researchers relate anxiety to the functioning of the fight-or-flight response. Any ideas what we might mean by that? C: I don’t think so. No. T: OK. Let me explain that to you . . .

Case Vignette 5 C: I can’t think of any times in my life when anxiety was helpful to me. T: How about when you were in school? C: I’m not sure what you mean. T: Well, how do you think you would have done on exams if you didn’t have any anxiety? C: I always got so anxious that I couldn’t concentrate when taking my exams. I’d 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 disrupted your performance. But I’m not asking you to think about how you would have done if you had been less anxious; I am asking you to

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consider how you would have done if you didn’t experience any anxiety 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 exams—studying? C: Well, I’m still not sure that I get your point. I was so tense while studying that I had difficulty concentrating then, too. So I think being more relaxed while studying would have helped. T: OK. Let’s try looking at this from a slightly different perspective. Try to imagine what it would be like for someone else, a student who doesn’t experience any anxiety at all. Would such a student, a student who had no concerns about his or her test score, spend a lot of time studying for tests? C: OK. He might not have studied much and gotten bad grades. He might have been playing and loafing off when he should have been studying. T: So, is it possible that low levels of anxiety can sometimes help motivate people to prepare for challenges? C: Now I think I can see your point. Even though I still can’t think of a time when my anxiety level wasn’t so high that it got in my way, I guess that not having any anxiety also would have created some problems for me. I guess the trick is finding an anxiety level that is somewhere in the middle, huh? T: Yes, that’s one way of putting it. The implication of this for our work together is that the overall goal of this program is not to eliminate any and all anxiety—even if we could do so, we wouldn’t want to. Rather, our goal is to eliminate excessive anxiety.

Case Vignette 6 C: I don’t think I meet the criteria for the diagnosis of generalized anxiety disorder. I experience a lot of muscle tension and the other physical

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symptoms you mentioned, but I don’t really worry all that much. Does that mean that this program is not right for me? T: Whether you are a worrier or not, portions of this program are designed to help with the tension and physiological aspects of anxiety that are troubling you. In addition, you might be experiencing worrisome thoughts that are so automatic that, ordinarily, you are not even aware of having them. The program includes techniques designed to help you identify whether you are experiencing such automatic thoughts. If you are experiencing automatic anxious thoughts, the techniques will help you learn a less anxious style of thinking.

Case Vignette 7 C: I definitely worry a lot, but I think my worries are realistic. Does that mean this program is not right for me? T: First of all, there are portions of this program that could help you, even if your worries are not excessive or unrealistic, including methods to control tension and physiological symptoms of anxiety and techniques for solving real problems. I’d also like to hear more about your worries. Can you give me an example of one of your biggest worries that you believe to be realistic? C: Well, I’ve been very worried about the fact that I’ve been out of work for the last  months. If that isn’t a realistic worry, I don’t know what is! 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 specific thoughts go through your mind when you’re worried about being out of work? (The therapist validates the realistic side of the client’s worry and gently probes further to find out if the worry might be excessive.) C: I’ve only been able to find temporary office work so far. I worry that I’ll never find another permanent job. T: It sounds like your job search has been frustrating so far. And I can certainly understand how thinking that you’ll never find another per-

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manent job would make you very anxious. But what evidence do you have that you’ll never find another permanent job? (The therapist simultaneously validates the patient’s feelings and gently points out the link between thoughts and feelings.) C: Well, the economy has been lousy lately. T: OK. Do you have any other evidence? C: No, it’s more just based on my feelings, I guess. T: OK. Do you know what the current rate of unemployment is in your field? C: I’m not sure, but I think it’s somewhere between  and %. T: And do you know anyone in your field who recently found a job? C: I heard that someone I used to work with, who was laid off a few months before me, found something recently. T: So, what do these bits of evidence tell us about your situation? Is it possible that you’ve been overestimating the likelihood that you won’t ever find another permanent job? C: I suppose that’s a possibility. But even if that is the case, I’m 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 five sessions, 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, medical, or chemical interpretation of anxiety seems more credible to some clients than an interpretation that takes psychological variables into ac-

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count. In addition, a genetic, medical, or chemical explanation is often seen as being less stigmatizing than a psychological explanation. Consequently, clients initially may be resistant to giving full regard to the information in the first few sessions, even in the absence of medical evidence of abnormality. Clients may express the attribution that “I inherited being high-strung” or attribute their anxiety to a “chemical imbalance” that cannot 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 specific bias in attributions for personal experiences. Consequently, an effort to challenge and explore that attribution is appropriate. Following are several steps that we recommend. ■ What evidence does the client have to assume an inherited, medical, or chemical abnormality? Typically, there is no medical evidence 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 observation of anxiety problems running in the family. However, the fact that one’s parents (or other relatives) had anxiety problems is just as consistent with a learning explanation as it is with a genetic explanation. In fact, in most individual cases, it is impossible to determine 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 entirely from a genetic perspective. That is, it seems that what is inherited 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 necessarily imply that the MAW program will not be efficacious. It is possible that some of the effects of the MAW program may be mediated by altering the underlying biochemical processes. The

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evidence regarding the treatment efficacy of the MAW program and similar approaches to the treatment of anxiety can be emphasized. Examples might also be given of medical problems—such as stroke and some forms of diabetes—that have known biochemical causes and yet are treated behaviorally. ■ Clients may not be able to connect all of their episodes of heightened anxiety with discrete and readily identifiable triggers. The resultant state that may be experienced as “free-floating” anxiety may seem more compatible with a genetic explanation. Recognition of the following factors is useful: () the general impact of stress on the body’s nervous system, () the presence of automatic thoughts that occur outside of conscious awareness and affect 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 currently aware of, but that may be discerned through systematic observation. A similar problem that may undermine motivation for treatment is that some clients don’t recognize their worries as being excessive (as reflected in case vignette ). In this situation, the client’s worries should be elicited in as much detail as possible. The realistic aspects of the client’s worry should be acknowledged, but the therapist should also initiate an examination of the relevant evidence to help the client begin to recognize the aspects of worry that may be excessive. Discussion of the ability to control worry versus the tendency for worry to take on a life of its own and interfere with other activities can also be helpful.

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Chapter 5

Learning to Recognize Your Own Anxiety

(Corresponds to chapter  in the client workbook)

Summary of Information in Chapter 2 of the MAW Client Workbook ■ The need for becoming an observer of one’s own behaviors and responses to enhance understanding of one’s anxiety and to adapt specific treatment procedures to one’s personal experience. ■ The degree to which retrospective recall is skewed by current mood and may contribute to the perpetuation of anxiety, regular and continuing monitoring and recording is therefore more advantageous and less detrimental than retrospective recall. ■ Justification for self-monitoring, which aids in the identification 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

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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 monitoring forms the therapist may have asked the client to complete prior to this session, and a brief review of how the client made out with any other homework tasks from the previous session.

Negotiating an Agenda For this session, the therapist’s suggestions for agenda items should include 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 significance of comprehending processes contributing to the development and maintenance of episodes of high anxiety, as opposed 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 first 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. Consequently, the client is led to appreciate that on-the-spot monitoring may be therapeutic in itself, and much more beneficial than retrospective recall. ■ An initial attempt to recognize triggers for heightened anxiety and early awareness that anxiety is starting to build should be emphasized. At this time, it is not necessary to suggest that all episodes of anxiety are cued. However, there is an effort to encourage clients to begin to discern precipitants that may be subtle and perhaps not immediately apparent. Monitoring of oscillations in states of

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anxiety assists in the development of an awareness of triggers. In addition, the earlier that clients can identify that their anxiety is beginning to spiral upward, the more successful they should be in their efforts to reduce it. A metaphor that might be useful here is that it is far easier to put out a small brush fire as soon as it starts rather than waiting until it turns into a raging forest fire. ■ Maintenance of complete records for the duration of the treatment program is a useful means for clients to evaluate their progress and maintain motivation to make changes.

Negotiating Homework For this session, the therapist’s suggestions for homework items should include reading over the appropriate MAW workbook chapter or chapters for the next session, 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 negative 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 first treatment session (going over the points from this chapter at the end of an initial diagnostic assessment and distributing the relevant forms at that time or discussing them over the phone prior to the first treatment session and then sending the relevant monitoring forms through the mail).

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Case Vignettes

Case Vignette 1 C: What should I self-monitor if I don’t experience any increases in my anxiety level because I’m avoiding almost all of the situations that increase 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 find that episodes of heightened anxiety will become more frequent. At that point, you can monitor their decline.

Case Vignette 2 C: Should I record each time I feel anxious? If so, then I’m going to be filling in the monitoring forms constantly. T: On the Worry Record, only record those times when you experience a pronounced increase in anxiety or a change in the major focus of your worry. Record the degree to which you’re constantly feeling anxious as part of your average anxiety rating on the Daily Mood Record. C: But I often start the day feeling really anxious and continue to feel that way all day long, so I’m still not sure what to do with the Worry Record. T: So, do you mean to say that there aren’t some times of the day when you are more or less anxious than at other times? C: Well, I guess when I get home from work at the end of the day, I feel a little more relaxed than at other times. And my anxiety goes up if I know that my boss is looking for me. T: So, your anxiety level drops a little when you get home. What about in the morning? Does your anxiety level rise at any point while you’re getting ready for work?

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C: Well, I guess when I first wake up, I’m almost too tired to be worried. It’s usually after I get out of the shower that the anxiety really starts to build. T: OK, so on mornings like that, you could begin to fill out a Worry Record when you get out of the shower. On days when your boss is looking for you, you could begin to fill out another Worry Record as soon as you can after your anxiety about that starts to increase. C: I’m worried that monitoring and recording will increase my anxiety level. T: Do you usually try to avoid thinking about how you feel because you’re worried that thinking about how you’re feeling will raise your anxiety level? C: Yes. 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 beneficial 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 position 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 inefficiency and interferes with performance. Can you think of any times when this has been true for you?

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C: Sure, that’s part of the reason I’m here. I worry so much about getting a project perfect that I usually take twice as long to complete my work as my co-workers. T: In that case, I’d like you to try to remember that the monitoring is essential for change. We can’t change your anxious patterns of responding if we don’t first 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 first 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 first one. Do you think this metaphor has any relevance for you? C: Well, sure. Taking the time to monitor is part of my program, so it’s 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 efficiently. T: Exactly. The short-term cost of putting in a few extra minutes a day should be associated with the long-term benefit of reducing your excessive anxiety. In the long run, the extra time you put in now should help you to be more efficient 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. Let’s take a look at the Daily Mood Record you completed this week.

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T: Wow! It looks like you’ve had a very anxious week! You rated most days a  on both overall anxiety and maximum anxiety. C: Yeah, that’s pretty much how things have been going lately. T: OK. Well, let me ask you a question about this week. I know it was a bad week for you, but I am wondering if some days or times might have been even worse than others? (The therapist asks about whether there were even worse times rather than asking about some less anxious moments, as he hypothesizes that the client may have filled out the Daily Mood Record the way he had to make sure that the therapist understood how bad off the client was. Therefore, the client might be reluctant to talk about more relaxed moments right away.) C: Yeah, Gina and I had a big fight on Monday night, and that night and most of Tuesday, I was even more anxious than usual, thinking that I wasn’t being a good husband and that Gina would leave me. T: I’m sorry to hear about that. Bad fights can be very distressing. Now what I would like you to do is think about our - to -point scale such that Monday night and Tuesday would be  points. OK? C: Yeah. T: Good. Now let’s go back and re-rate the last day or two, keeping in mind that Monday night and Tuesday, after the big fight with Gina, were rated as . So, if Monday night was , the maximum anxiety rating for Monday would be . Since it wasn’t quite that bad earlier on Monday, what would you now say was your overall anxiety level on Monday, averaged across the whole day? C: Well, if you look at it that way, I guess the rest of the day would have been an , so maybe  for the overall rating that day. T: Good. Now, how about yesterday? If your overall rating for Tuesday was , what would you now say was your overall anxiety level yesterday, averaged across the whole day? C: Well, it was about like Monday was before the fight, so I’d give it an .

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Daily Mood Record for James

Daily Mood Record

Rate each column at the end of the day, using a number from the - to -point scale below. -------------------- ------------------------- ----- None

Mild

Moderate

Strong

Extreme

Overall Anxiety

Maximum Anxiety

Physical Tension

Preoccupation with Worry

Headaches

Monday 7th

100

100

65

75

50

Tuesday 8th

100

100

45

45

10

Wednesday 9th

60

90

70

70

65

Thursday 10th

100

100

20

25

10

Friday 11th

100

100

50

55

30

Saturday 12th

100

100

10

30

15

Sunday 13th

100

100

30

40

20

Date

Figure 5.1

Example of Daily Mood Record completed by patient.

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 primarily to lack of motivation, then it would seem reasonable to assume that the client’s level of motivation for completing the treatment program is relatively low. If this is the case, then the therapist might try using techniques from Miller and Rollnick’s approach, as described in Motivational Interviewing (). Thus, the client can be asked to rank a set of values according to their order of importance. The therapist would then ask how the client’s anxiety, worry, and avoidance or safety behaviors relate to the values of greatest importance to the client. The therapist could

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Worry Record for James Worry Record Date: Wednesday 9th

Time began:

5:00

(../..) Time ended: 5:00

(../..)

Maximum level of anxiety (circle a number below): --------------- ----- ------------------------------ None

Mild

Moderate

Strong

Extreme

Indicate which of the following symptoms you are experiencing: Restlessness, feeling keyed up or on edge Easily fatigued Difficulty concentrating or mind going blank Irritability Muscle tension Sleep disturbance

Triggering events:

Sunday night—work tomorrow

Anxious thoughts:

Too much to do, won’t get everything finished, boss will be mad at me

Anxious behaviors:

Tried to watch TV to keep my mind occupied, but I continued to worry

Figure 5.2

Example of Worry Record completed by patient.

then ask the client to engage in a “decisional balance” exercise. In the decisional balance exercise the client first writes on the left side of a page all of the reasons for not wanting to participate in the program. Next, the client writes all of the reasons for wanting to participate in the program. When the therapist reflects these motivations back to the client, it is recommended to begin with the reasons for participating in the program and finishing with the reasons for not participating. The idea here is that, if the client has a “yes, but” style, the buts will tend to be directed at the points the therapist concluded with, and it is preferable for their

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“yes, buts” to be directed at the reasons for not participating. If these techniques do not have the desired effect of building internal motivation to change and participate in the program, then the therapist might suggest that now is not the best time to undergo this type of time- and effort-intensive program. In other cases, as reflected in case vignette , the client may avoid monitoring 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 decrease in anxiety over time is to be emphasized. If clients state that they know how they feel and, therefore, regular monitoring and recording is unnecessary, it is useful to ask whether there are any times when the anxiety seems to occur unexpectedly, or without awareness of the triggers. If so, the potential benefit of close monitoring to identify precipitants should be pointed out. Common examples of such triggers might be news reports or newspaper articles and comments made by friends, from which the client later overgeneralizes or makes personal references. In any case, monitoring records provide systematic and relatively 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 understanding. For example, on rare occasions, we have worked with some clients who recorded overall anxiety levels in the Daily Mood Record that exceeded their corresponding maximum anxiety level ratings. We have also worked with some clients who recorded scores of  for both overall anxiety and maximum anxiety every day the first week they used the Daily Mood Record. In such cases, it can be useful to ask the client whether there were some times or days that week when he or she felt even more anxious than at other times or days, as in case vignette . If the client is able to identify a “worst” time or day, then the therapist would ask the client to use that day or time as the anchor point for a rating of  points, and then to go back and reevaluate at least some of the other ratings, with that anchor point in mind.

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Chapter 6

The Purpose and Function of Anxiety

(Corresponds to chapter  of the client workbook)

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 affect 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 development 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 procrastination), 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 release of adrenaline and noradrenaline, as well as their effects on bodily functioning, are described. Particular emphasis is placed on cardiovascular, respiratory, and muscular effects. 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 escaping or fighting. While anxiety is associated with preparation for an alarm reaction, panic is identified with the actual firing of the alarm, or fight-or-flight, reaction.

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■ Description of the ways in which the three response components interact to escalate or reduce anxiety. The interaction of cognition, physiology, and behavior is offered as a cause of increased or decreased intensity of any emotion at any given time. ■ Illustrative types of interactions among the three response components. 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 components interact in a positive feedback cycle, escalating the overall emotional 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 intensification of the emotional state. ■ Categorization of reactions in the three response systems and their interactions as either anxiety or fear (panic) states. Fear involves perceptions 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 gradual increase in physiological arousal. ■ A review of the most common themes of worry: health, loved ones, work and school, finances, 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

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Brief Check-in The brief check-in will consist of greetings, a chance for the client to state how he or she has been feeling recently, a brief review of the Worry Record and Daily Record monitoring forms, and a brief review of how the client made out with any other homework tasks from the previous session.

Negotiating an Agenda For this session, the therapist’s suggestions for agenda items should include a discussion or review of the nature of anxiety and fear, a discussion 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 moment 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 conducive 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 client’s best interests. ■ The distinction between anxiety and fear (panic) is covered in this chapter. Fear is thought of as the fight-or-flight response that occurs when threat is perceived as being immediately present. Anxi-

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ety is viewed as a “priming” of the fight-or-flight response in preparation for future danger. It is assumed that clients can learn to distinguish between fear and generalized anxiety on the basis of accurate descriptions of the response components (physiological, cognitive, and behavioral) that are characteristic of the respective states. ■ 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 different 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 discussion. . 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, cognitive, and behavioral. The client should focus on a recent or particularly 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 different components “fuel” each other are emphasized. For example, worrisome thoughts can increase physical arousal, which interferes with behavior. The interference with behavior (such as difficulty concentrating at work) can in turn lead to further worry (such as worrying about job performance and evaluation). Therefore, a large part of the program involves learning to “disconnect” the response components. That is, learning that one’s 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.

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Sequence of Anxiety Components for a Recent Episode of Anxiety Anxiety Components for James Major physical symptoms:

Jittery, tense legs knot in stomach tension, especially head & neck

Major thoughts/images:

Errors at work, lose job Not getting things done Future of family

Major behaviors:

Irritable with colleagues & family Procrastinate about starting big jobs Review my work over and over

Figure 6.1

Example of Anxiety Components form completed by patient.

. In keeping with the notion that it will be helpful if clients can identify increasing anxiety at earlier and earlier points in the anxiety 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 introduced to systematize the client’s thinking about interactions among the three components and efforts to identify anxiety spirals at earlier and earlier points in the positive feedback loop. Complete 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 therapist’s suggestions for homework items should include reading over the appropriate MAW workbook chapters for the next session, continuing self-monitoring using the Worry Record and the Daily Mood Record, and completing an Anxiety Components form and a Sequence of Anxiety Components for a Recent Episode of Anxi-

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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 negative 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 predictability and perceived controllability. Perceptions of predictability are targeted by the discussion of the ways in which anxiety can escalate. Perceptions 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 () and Stanley Rachman (; also see Zinbarg, ). The tacit assumption underlying 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 network 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 benefit, in and of itself, although the mechanisms underlying these effects 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.

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Case Vignettes

Case Vignette 1 C: Sometimes I worry that I’ll get so anxious that I’ll go crazy. Does that ever happen to anyone? T: Many people believe that they are going crazy when they are experiencing high levels of anxiety. They are most likely referring to the severe class of mental disorders known as the psychoses. Let us look at psychosis to see how likely that is. Psychoses are characterized by such severe symptoms as disjointed thoughts and speech, sometimes extending to nonsensical speech; delusions, or strange beliefs; and hallucinations. An example of strange beliefs might be that one’s thoughts are being controlled by beings from outer space, and an example of hallucinations might be hearing voices when no one else is there. Psychosis runs strongly in families and has a genetic basis, so only a certain proportion of people can become psychotic, and in other people, no amount of stress will cause a psychotic disorder. Another important point is that people who have schizophrenia, the most common form of psychosis, usually show some mild symptoms for most of their lives (such as unusual thoughts or flowery speech). Thus, if you have not shown these symptoms and there is no history of psychosis in your family, then it is extremely unlikely that you will become schizophrenic. This is especially true if you are over  years of age since schizophrenia generally first appears in the late teens to early twenties. Finally, if you have been through interviews with a psychologist or psychiatrist, then you can be fairly certain that you would know by now if you are likely to become schizophrenic.

Case Vignette 2 C: I can understand how thinking that something bad might happen would produce an anxious feeling, but why do I feel anxious sometimes, even when I’m not thinking of anything?

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T: Automatic negative thoughts are a characteristic of the kind of problem that you’re experiencing and may explain why anxiety sometimes seems to occur, even when you are unaware of being worried. When I use the term “automatic” when referring to some negative thoughts, do you have some ideas about what I might mean? C: What comes to mind for me is that you’re talking about ways of thinking that have become a habit for me. T: That’s right. And what are the characteristics of a habit? C: Umm, like doing something, even when I don’t want to? T: That’s part of what I have in mind, yes. At the same time, “automatic,” to me, also means that you might have a thought, but not be consciously aware of it—perhaps because you have had the same thought so many times before. For example, when you came into my office, were you aware of having the thought “Oh, that’s a chair. A chair is for sitting on. I’ll sit down there.”? C: No, of course not. I just saw the chair and sat down on it. T: Exactly, but does that mean that your brain isn’t still analyzing the situation, recognizing the chair as something for sitting on, and sending the appropriate commands to your legs and muscles? Or might it be that, because you have seen and sat on so many chairs before, your brain still assigns meaning to the chair and issues commands to sit, but this happens automatically, without your awareness, so that you can devote your attention to thinking about other things, like what you want to put on the agenda for today’s session? C: It makes sense that my brain is still working like you said, without me being aware of it. So, you are saying that sometimes, even when I’m not aware of being worried about something, I might have had an automatic worry? T: Exactly. Over the next few sessions, we’ll discuss automatic thoughts in more detail. How about if, for now, we go back to concentrating on understanding the three response components that are usually present once anxiety has heightened?

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Case Vignette 3 C: If anxiety is an adaptive response, why do I have difficulty concentrating? What is the adaptive value of difficulty concentrating? T: It’s not necessarily the symptoms that are adaptive for survival, but the processes that underlie the symptoms. One might experience various sensations or reactions as a by-product of high levels of arousal. Difficulty concentrating is often the by-product of the mind’s tendency to scan the environment for possible signs of threat, when in an anxious state, making it difficult to concentrate on the task at hand. Similarly, a pounding or racing heart may be the by-product of increased activity in the cardiovascular system, which is pumping blood more efficiently to the muscles as part of preparation for a threat reaction. Under conditions of real danger, those particular sensations may not be the focus of attention. For example, imagine that you are deeply engrossed in a project at work or at home, when you suddenly hear an announcement on the radio warning of a possible tornado or flood in several hours. You are not likely to be distressed by the fact that the anxiety you experienced 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 difficulty concentrating on the task at hand. Moreover, by attending to any symptoms that you find distressing, such as difficulty concentrating, your anxiety may increase, possibly intensifying the symptoms.

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 specific threat cognitions. In these cases, it may be helpful 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 effects mean that the individual may become anxious, without even being aware of what they are

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worried about. The notion of automatic thoughts is explained in more detail in workbook chapter . In chapter  of this book (which corresponds to workbook chapter ), we also discuss some demonstrations, or “behavioral experiments,” that a therapist can do with a client to let the client experience automaticity and the impact of automatic thoughts on mood. For a client whose doubt about automatic thoughts is so strong that it threatens to undermine the credibility of the entire program, it might help to conduct these demonstrations, now rather than waiting for chapter  (workbook chapter ). Some clients may understand the main points discussed about the components of anxiety and the sequence of the components, but get confused at home and have difficulty completing the Anxiety Components form or the Sequence of Anxiety Components for a Recent Episode of Anxiety 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.

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Chapter 7

A Closer Look at Generalized Anxiety Disorder

(Corresponds to chapter  of the client workbook)

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 development of an anxiety problem at a specific 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 problems effectively; 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 effective plans for coping with realistic stressors that may exacerbate anxiety.

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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 previous session.

Negotiating an Agenda For this session, the therapist’s suggestions for agenda items should include 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.

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■ 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 appears 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 presence 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 following six factors should be considered. . Anxiety greater than some optimal level, interfering with performance and problem-solving . Attentional and interpretive biases favoring the processing and encoding of threat-related information . “Chaining” of worry—the 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 . Cognitive avoidance or distraction strategies

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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 components in the MAW program.

Discussion of the Rationale for the MAW Program In discussing the maintenance of excessive anxiety and worry, the therapist 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 therapist’s suggestions for homework items should include rereading chapter  several times, reading over other appropriate MAW workbook chapter or chapters for the next session, continuing self-monitoring using the Worry Record and the Daily Mood Record.

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 negative reaction to anything about the session.

Principles and Points to Consider Chapter  is primarily didactic in its orientation (though, once again, remember to try to maintain a Socratic approach) and addresses perceived safety. Information targeting misinterpretations of threat in situations that others do not find 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

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experiencing. Thus, this lesson consists of corrective information, but no specific exercises are introduced at this point.

Case Vignettes

Case Vignette 1 C: Does being physiologically sensitive mean that I’ll always have more anxiety than other people? T: Try to keep in mind that being physiologically sensitive or labile should not be equated with anxiety or fear. Anxiety and fear are emotional states that require more than simple arousal to be present. It appears 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 didn’t consider anxiety and worry to be a problem for you? If so, that’s obviously different 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 disorder 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

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disorders may be related to what is learned while growing up in a family. In any case, the majority of children with anxious families do not have anxiety disorders.

Case Vignette 3 C: You know, I can’t remember a time when tension and worry weren’t a problem for me. I’ve been a worrier all my life. So I can’t say that I can put my finger on any particular stresses that brought on my problem. Will I be able to learn to control my excessive anxiety if I can’t figure out what initially caused it? T: In fact, it is not necessary to “know” what initially caused your problems with anxiety to benefit from this program. It appears that the factors that initially trigger excessive anxiety and worry are different from the factors that maintain them. For example, some people first experience problems with anxiety and worry while having marital troubles, yet the excessive anxiety persists, even after the marital difficulties are resolved. Also, there are many other people who have benefited from this program and similar programs, even though they couldn’t identify the initial cause of their anxiety problems.

Case Vignette 4 C: I don’t understand why you say that distracting myself from negative images contributes to my anxiety problems. I’ve always felt that distracting myself is one of the few ways I’m able to give myself some relief. T: Undoubtedly, distraction provides some immediate relief from your anxiety. It’s when we look at the long-term effects that I say that distraction ultimately serves to maintain your anxiety. There are at least two reasons why I say this. First, it’s impossible to challenge a worrisome image, and evaluate it in an objective and thorough manner, if you aren’t holding it in your mind. Second, it seems that resisting an image or thought only serves to make it stronger. Maybe you’ve heard the old saying about what would happen if I put a gun to your head

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and said, “Don’t think about a white elephant, or else I’ll pull the trigger?” C: Sure. The harder you try not to think about the elephant, the more likely it is that you will. T: Right, and the same is true for worries. So, if you try to resist your worrisome images, it’s as if I’m holding a gun to your head and telling you not to worry or else I’ll pull the trigger. You might succeed at distracting yourself temporarily. However, you’ll be even more likely to experience that image in the future than if you didn’t distract yourself, and the image is likely to be just as anxiety-provoking in the future, since you didn’t evaluate it objectively in the past. Does that make sense? C: I guess so. I hadn’t 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 you’ll see that there are terrible events every day—and it’s 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 unwarranted anxiety, and then reducing the excessive anxiety. So, my question for you is: Have there ever been any times when you predicted that something bad would happen to you, and it didn’t? C: Well, yes, I guess so. My boss recently left a message saying that he wanted to see me. I thought he was going to chew me out and maybe even fire me. With all the reports of people being laid off in the newspapers 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 working on.

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T: So, would you agree that, in that instance, you were seeing more danger in the situation than was actually there? C: In that situation, yes, but there have been plenty of times when my worries proved to be warranted. T: Then our task is going to be to look very closely at your worries and evaluate them in an objective manner, to decide which are valid and which might be excessive and in need of modification. OK? C: OK.

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 fired or being criticized by in-laws or friends for the house being messy). However, they still feel very tense and anxious. In these cases, it is important to evaluate whether the clients engage in any behaviors to prevent these worries from coming true (see workbook chapter  and chapter  in this book). If so, questioning what they think might happen if they didn’t engage in these behaviors often helps to promote recognition of concerns 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.

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Chapter 8

Learning to Relax

(Corresponds to chapter  of the client workbook)

Summary of Information in Chapter 5 of the MAW Client Workbook ■ A reminder of the important role of tension in GAD. Generalized tension 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 cognition 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 become shorter as each phase is mastered. Initially, the procedure takes approximately  minutes, but gradually progresses to a one-step procedure. 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, -minute version of the procedure is very effective at the end of the day for reducing the tension that has built up throughout the course of the day. ■ Discussion of the physical and mental components of relaxation training. The physical component involves first tensing and then releasing specified 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 tension at an earlier point in the process.

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The mental component involves concentrating on the sensations that are experienced as a result of muscle tensing and releasing. Concentrating on the sensations aids the development of the ability to control bothersome thoughts. It also allows for a more detailed mental representation of the experience of deep relaxation that will be helpful when implementing the final phase of relaxation training—the recallrelaxation procedure. ■ Description of a Jacobsonian progressive muscle relaxation procedure, beginning with  muscle groups and progressing to eight muscle groups. The eight-muscle-group procedure is identical to the -musclegroup procedure, except that certain muscle groups are combined. ■ Specification 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.

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Negotiating an Agenda For this session, the therapist’s suggestions for agenda items should include 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 initial signs of increased tension and to reduce the intensity of physiological arousal and tension. Indirectly, it should also reduce the intensity and frequency of worry. This should especially be the case if the client takes advantage of his or her improved ability to detect 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 already found an effective technique that is easily portable, he or she may decide to continue to use that procedure rather than learn the Jacobsonian procedure presented in the MAW workbook. If he or she has tried the Jacobsonian technique in the past, without good results, this does not necessarily mean that the procedure will not work now. Together with the therapist, the client may be able to identify aspects of the way the client had been conducting the exercise that diminished its effectiveness. One example of such a factor would be implementing the technique with an added sense of pressure and urgency, such as “I have to relax or else . . .”

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■ Initially, the relaxation exercises are relatively lengthy, requiring about  or  minutes to introduce the -muscle-group procedure in session and about  to  minutes to implement it thereafter, and for this reason, they would be difficult to apply in many situations. However, the exercises will be modified gradually to increase their portability and, hence, their applicability across a broader range of everyday situations. In addition, in our recent trial of the major components of the MAW program, we began with the eight-muscle-group procedure (outlined on p. ‒ of the MAW workbook) rather than the -muscle-group procedure. Our goal in doing so was to shorten, by at least a week, the time it would take to reach the highly portable one-step relaxation procedure. Our plan was to revert to the -muscle-group procedure for any client who did not obtain an adequate relaxation response to the initial eight-muscle-group procedure. In fact, only one of  clients reported noticeable tension remaining after the eight-musclegroup procedure, and that client was instructed to begin practicing the -muscle-group procedure at home, rather than the eightmuscle-group procedure. ■ Initially, it will be helpful to practice the exercises under nondistracting 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 final stage of practice include not distraction, but pain to increase 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 having a partner, relative, or close friend apply firm pressure to pressure points on the body. Alternatively, the client can implement this by himself or herself by attaching a clothespin to the ear.

Negotiating Homework The therapist’s suggestions for homework items should include reading over the appropriate MAW workbook chapter or chapters for the next

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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 negative reaction to anything about the session.

Principles and Points to Consider This session contains a combination of didactic presentations and participant modeling. The demonstration of somatic control taps the construct of perceived controllability. The procedure of relaxation is designed to provide anxiety management skills as opposed to direct exposure to worrisome 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 relaxation—worries and other thoughts unrelated to the exercise are likely to occur. This is especially 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 exercise, 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 find the relaxation exercises anxiety-provoking. This may be the result of focusing attention on muscular tension or fear of losing control and equating the release of relaxation with loss of control.

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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, what’s most important is for you to simply learn how to do the relaxation exercise. After you gain confidence in your ability to relax in a relatively brief period of time, then you can begin to apply relaxation as a technique for managing anxiety-provoking situations.

Case Vignette 2 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, it’s best to remove the contacts before beginning the exercise since it entails squeezing your eyes tightly together. If you have lower back pain, it’s a good idea to use some kind of support behind your lumbar region. If you have temporomandibular joint dysfunction, or pain around the jaw, then it’s best not to tighten those particular muscles. In other words, it’s important to remember that we don’t want to induce pain.

Case Vignette 3 C: What should I do if worrisome thoughts keep going through my mind when I’m 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

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are experiencing. With practice, your ability to concentrate on the exercise will gradually increase.

Case Vignette 4 C: Why should I tense my muscles during the relaxation exercises? I already know what tension feels like. T: The tensing component is included for two reasons. First, imagine tension 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 discriminate 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 introduce. You can think of it as it being easier to put out a brushfire than a raging forest fire, and we are trying to catch your anxiety sequences while they’re still just brushfires.

Atypical and Problematic Responses As noted earlier, perhaps the most common difficulty experienced when practicing progressive muscle relaxation is an initial difficulty in maintaining attention on the sensations of tension and relaxation. It’s best to prepare clients for this eventuality in advance and, as reflected in case vignette , to advise clients not to fight 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 find that the relaxation exercises lack credibility, pointing out that, if simply telling themselves to relax were effective, then they would have no need for help from a therapist. Thus, for these clients, the exercise seems more like a gimmick than a somatic control technique. Because progressive muscle relaxation exercises have been used with good results in many cases, clients can be asked to withhold any such judg-

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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. Although it should be acknowledged that immediate benefit is not likely, it should be noted that the potential long-term benefits may justify the practice required. Some clients report that, if they schedule a practice just before bedtime, they fall asleep before completing the exercise. Though this is a good indicator that they are finding the exercise relaxing, these clients should be encouraged to schedule their last practice at another time of day, when they are not so tired, to get the benefit of working with each of the muscle groups included in the procedure. Finally, some clients actually experience increases in their level of anxiety during the relaxation exercises, the “relaxation-induced anxiety” phenomenon. 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. Second, 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  in this book regarding cognitive restructuring techniques).

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Chapter 9

Controlling Thoughts That Cause Anxiety: I. Overestimating the Risk

(Corresponds to chapter  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. Anxietyprovoking thoughts are said to be specific predictions of threat. These predictions often appear to vary across situations, and can become “automatic” on the basis of repetition. Therefore, the identification of specific predictions, hypotheses, interpretations, or images in any given situation is a vital first step in the process of effective cognitive restructuring. 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 during states of anxiety and that serve to increase anxiety further. The first of these cognitive styles, probability overestimation, is defined in more detail in this chapter. Probability overestimation is defined as overestimating the likelihood of the occurrence of a negative event. Examples 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 disconfirmation.

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■ 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 attempts 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 progressive muscle relaxation homework, and a brief review of how the client made out with any other homework tasks from the previous session.

Negotiating an Agenda For this session, the therapist’s suggestions for agenda items should include discussion of advancing in the progressive muscle relaxation training exercises; introduction of cognitive restructuring, with a focus on probability overestimation; and negotiation of homework.

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Moving Forward with Progressive Muscle Relaxation Training If the client has obtained good results from the progressive muscle relaxation training practice during the past week, the therapist should instruct the client to begin practicing the next phase of the relaxation module. If the client began with the -muscle-group procedure, he or she should begin practicing the eight-muscle-group procedure at home; if the client began with the eight-muscle-group procedure, he or she should begin practicing the four-muscle-group procedure at home. If the client was not achieving good results from the practice during the past week, he or she should continue to practice the same procedure for the coming 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 one’s 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 identified. This is especially important in light of the fact that thoughts are more likely to become biased toward perceived danger when anxiety is heightened. Thus, clients are introduced to the techniques of identifying alternatives and evaluating the evidence. . Protective behaviors, such as always keeping a close watch on one’s children or always keeping one’s house perfectly clean and tidy, serve to prevent appropriate learning. Avoidance, such as not asking a friend for a favor or putting off asking for a raise at work, serves a similar maladaptive function. In other words, clients may

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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 important 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 different levels of awareness, ranging 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 event’s 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 - to -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 discriminating between realistic and unrealistic worries, in addition to challenging unrealistic worry. . 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 therapist’s suggestions for homework items should include reading over the appropriate MAW workbook chapter or chapters for the next session, continuing self-monitoring using the Worry Record—

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Real Odds form and the Daily Mood Record, practicing the progressive muscle relaxation exercise (it would be ideal for the client to practice progressive muscle relaxation twice daily), and using the Worry Record— Real Odds form and the Pie Chart form to practice cognitive restructuring as often as possible when anxious episodes occur.

Worry Record—Real Odds Date: Tuesday 22nd

Time began:

3:30

(../..) Time ended: 8:00

(../..)

Maximum level of anxiety (circle a number below):  -------------------- ----- ------------------------- None

Mild

Moderate

Strong

Extreme

Indicate which of the following symptoms you are experiencing: Restlessness, feeling keyed up or on edge Easily fatigued Difficulty concentrating or mind going blank Irritability Muscle tension Sleep disturbance

Triggering events:

Given a job to finish by end of work day

Anxious thoughts:

won’t finish in time, fired from job

Alternative possibilities:

I usually get things done & even if I don’t get it finished, chances are low that I would be fired just for this Real odds –

5

Anxious behaviors:

Irritable, called home and told husband I would be late

Figure 9.1

Example of Worry Record—Real Odds completed by patient.

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Others may

There is no absolute

like the choice

right or wrong

I made

choice

I will make the wrong choice; I will be viewed as being dumb Others won’t be as concerned about what car I buy as I am

Others are unlikely to judge me as being dumb just because of the car I buy Others may have no opinions of significance about cars

Figure 9.2 Example of pie chart completed by patient.

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 negative 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 client’s development of an understanding of principles, as opposed to providing direct reas-

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suring information. For instance, therapists should ask clients what their most recent job evaluation revealed, instead of simply telling them that they will not be fired. Likewise, therapists should ask clients how many times other people have commented on how crazy they look or how often their family members have been involved in driving accidents, instead of telling them that no one thinks that they’re crazy or that their family members will not have accidents. Contrasting statements can also be useful to accentuate the principle of probability overestimation. For instance, therapists may respond to clients’ statements that their children 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, therapists begin to teach clients how to question evidence appropriately. When cognitive restructuring is first introduced, the therapist will probably need to be quite active, not only asking relevant questions, but also sometimes supplying alternative, balanced thoughts or sources of evidence when the client draws a blank or overlooks important sources of evidence. Over the course of the remaining sessions, however, the therapist should gradually reduce his or her contributions to the restructuring and explicitly encourage the client to internalize the skills. For example, 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 inflated at times when anxiety is elevated. The perceived increased risks of danger then serve to increase the strength of the emotional state, thereby completing a positive feedback loop. State dependency probably accounts for the majority of cases in which the client recognizes the irrationality of the worrisome thoughts when he or she is feeling calm. State dependency also implies that there is no assumption that the person’s style of thinking is biased and inaccurate across all situa-

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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 together in session, when first introducing the form, before sending the client home to complete these forms on his or her own, when anxious. Further, we typically have the client do the writing, with the therapist serving as a coach. This ensures that what is recorded is written in the client’s 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 restructure together in session, for an initial demonstration of the techniques that will heighten the client’s anxiety, if he or she focuses on it. Of course, if the client will become anxious again when focusing on the worries from a past anxious episode, then it will work just fine in this regard. The important point to keep in mind is first to ask the client if he or she is likely to become anxious again when focusing on a particular past anxious episode. There are at least three advantages to working with a “hot” topic rather than applying the technique to an anxiety episode that happened in the past and is no longer “hot.” First, given the state dependency principle discussed earlier, automatic thoughts can sometimes be difficult to access when they are “cold.” Second, the client gets some practice in taking a more balanced perspective, even when anxious, making it more likely that he or she will be able to break out of the negative bias associated with anxiety and be able to consider disconfirming evidence and alternative thoughts when applying the techniques outside of the session. Finally, if the therapist gets a subjective units of distress rating, both before and after applying the cognitive restructuring tools, then there will be an opportunity to see if the techniques were at all helpful to the client. This opportunity is obviously lost if the restructuring is applied to a worry that does not arouse anxiety during the session, as it will be difficult to observe anxiety reduction due to a low initial subjective units of distress rating.

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Case Vignettes

Case Vignette 1 C: It’s simple to ask myself these questions now, but I don’t have a chance of thinking rationally when I’m feeling really nervous. T: As with the other skills we’ve practiced, or any skill, for that matter, modification of your self-statements takes practice to become effective as a tool. Initially, it may be difficult for you to apply this strategy at the height of anxiety, but with practice and rehearsal, it will become more natural and easier to apply. Also, I think the forms, like the Worry Record—Real Odds form and the Pie Chart form we filled out today, contain some helpful reminders of the questions. Consequently, at least in the beginning, I strongly encourage you to actually fill out the forms when you’re trying to apply the skills when you feel anxious. Once you’ve mastered the skills and the questions start to become second nature, you’ll probably be able to do the cognitive restructuring in your head, without having to write it all down.

Case Vignette 2 C: You say that I should put my worries that my wife will have an accident on a scale of probability. What exactly do you mean by that? T: I mean that the next time she’s late coming home and you think she might have gotten into an accident, I want you to judge the actual likelihood that she had an accident, given all of the evidence you can gather, which is rated on a scale of  (not at all probable) to  (will definitely occur). What is the actual likelihood that she will be in an accident? C: I don’t know—maybe %. T: So, that means that, out of every  times she’s driven somewhere, she’s had one accident?

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C: Well, no. She’s only had one accident in all the years she’s been driving. T: So then, what is the actual likelihood?

Case Vignette 3 C: I didn’t have enough time to practice the relaxation exercises. How important is it really to practice them regularly? T: Practice is important to benefit from these exercises. Remember that you’re 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, it’s only after they have practiced the emergency procedures thoroughly, so that they become “automatic,” that the procedures are effectively used during times of real emergency.

Case Vignette 4 C: If I’m not aware of my automatic thoughts, how can I possibly identify them? T: When a response becomes very well learned, because of repetition or because it has been associated with very strong emotions, we often become unaware of the cognitive processes associated with that response. That doesn’t mean that we can’t get access to those cognitions. For example, do you know how to drive a car with a manual transmission? If so, do you remember when you first 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 off the brake with my right foot.” After enough experience, it probably became automatic so that you weren’t 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

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mind wasn’t still issuing those commands to your limbs? No, and if you wanted to teach someone else how to drive a stick shift, you could make the process very conscious again. So, what you need to do is to start paying more attention to what’s going through your mind when you are feeling anxious. When you first notice an increase in anxiety or tension, the first thing I want you to ask yourself is, “What am I thinking about?” Just like any other skill, identifying your automatic thoughts is something that will improve over time. In the meantime, when you get stuck and draw a blank, let your imagination run free. Try to imagine what negative event you might have been predicting, and try to examine and challenge whatever predictions enter your mind.

Atypical and Problematic Responses Some clients have difficulty understanding the notion of cognitive processes that occur outside of conscious awareness. Other clients have difficulty with the notion that their thoughts affect their mood. For these clients, the concept of automatic thoughts and the basic premise of cognitive therapy—that such thoughts can influence our mood—lack credibility. 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 finding 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, five, or six f s, when in fact, there are seven. The reason seems to be that the f in “of ” gets automatically converted to a v by

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experienced readers, such that the individual does not recognize each of the f s in the word “of.” If you have some doubts, we encourage you to try this demonstration on colleagues or friends first. Other behavioral experiments can powerfully demonstrate the influence of cognition on mood. Perhaps the simplest one is to manipulate the client’s focus of attention. The therapist would begin by obtaining a current 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 encouragment 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 “mind’s 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 imagining the same small child in the abduction scene described earlier safely snuggled into his or her daddy’s or mommy’s 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 therapist’s office to the therapist, as if the therapist were blind and the client were helping the therapist to see this picture in his or her “mind’s eye.” After several minutes of this distraction from the worry (which we don’t recommend as a long-term coping technique, but rather only for the purpose of this behavioral experiment), and on perceiving visible signs of dissipation of distress, the therapist would obtain a third, and final, 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 therapist can help the client to realize the powerful impact that the contents of consciousness just had on the client’s mood. Sometimes clients express reluctance to identify their automatic thoughts because they worry that focusing on the thoughts will increase their anxi-

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ety. In response to this situation, the therapist should acknowledge the possibility that identifying automatic thoughts may initially increase anxiety. However, the therapist should also emphasize that identifying the thought in detail is necessary to challenge it effectively. We have often found a golf analogy to be helpful in illustrating this point. The identification of automatic thoughts is analogous to locating the flags in the holes on a golf course. While successfully locating the flag does not guarantee that the golfer will get the ball in the hole, the golfer doesn’t have a prayer without it. He or she might not even know what direction to go! Similarly, while identifying an automatic thought does not guarantee anxiety reduction, the client doesn’t have a chance at successful cognitive 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 emphasize 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 sessions 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 eventually become natural and more automatic. As a matter of style, we prefer 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 session—the 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 subjected to cognitive restructuring, as with any other worry (for a closely related example, see case vignette  in chapter ). There is an old saying in cognitive therapy: Follow the affect. In this case, following the affect translates into using the worry about the futility of restructuring a specific worry as grist for the cognitive therapy mill.

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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 episode of worry. Third, occasionally, clients have experienced the outcome about which they are worried, such as losing a job, being rejected, or feeling embarrassed. First, if the therapist has not already done so, an attempt should be made to quantify the client’s estimate of occurrence on a - to -point scale. As reflected in case vignette , it is possible that the client is still making a probability overestimate, even though he or she states that the chances are “slim.” In case vignette , the client estimated that the likelihood of an accident was %, which might be regarded as slim, even though it is still an overestimate, based on the actual evidence. If the numerical probability 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 primarily the result of catastrophizing about the outcome. In these cases, the therapist may use decatastrophizing, as discussed in the next chapter. Alternatively, the therapist may suggest that the next chapter will cover another 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 cognitions is a very common feature of anxiety. That is, many people are able to recognize that their worries are irrational, when feeling relatively calm. However, the interaction among the different response systems is happening in a way that leads to anxious thinking styles when nervous. This is why the treatment concentrates on breaking the association between certain thoughts and thought processes and feeling anxious and tense. In addition, we have often found it useful to adopt a “Gestalt-like” approach with clients, and talk with the client about the multiple “selves,” or aspects, within each one of us. The client’s goal then is to facilitate communication and debate between his or her “rational self ” and

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“fearful self,” during episodes of heightened anxiety. In doing so, it is important that the “rational self ” does not simply tell the “fearful self ” to shut up and stop being silly. To emphasize this point, the therapist may ask the client to consider what would happen if he or she told his or her frightened children to shut up and stop being silly—they might stop talking about the fear, but begin to cower under their bed! In a similar 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 restructuring and adopting more balanced perspectives when anxious. This can be prevented or addressed, when it does arise, by following our earlier recommendation to identify a hot topic in session that raises the client’s anxiety, and then restructure to it to provide evidence and hope that the techniques can work when anxious. Finally, on occasion, a client will report that his or her worst worry has come true in the past—he or she has lost a job or felt rejected by a romantic interest. In these cases, the therapist may try to help lead the client to the realization that the chances of that event happening again are small (e.g., “Of all the times you have worried that you would be fired, how many times has it actually happened?”). Alternatively, if the client appears to be catastrophizing about the event, the therapist may want to use decatastrophizing strategies or suggest that they reprocess the worry during the next sessions when they will be discussing decatastrophizing in detail.

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Chapter 10 Controlling Thoughts That Cause Anxiety: II. Thinking the Worst

(Corresponds to chapter  of the client workbook)

Summary of Information in Chapter 7 of the MAW Client Workbook ■ Review of the client’s use of relaxation training. ■ Review of the client’s identification 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 negative 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 possible consequences, viewing events as manageable and time-limited, and using a “so what” approach. ■ Identification of times at which clients believe that “it is insufferable 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

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■ 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 Record—Real Odds, Pie Chart, and Daily Mood Record forms; a review of the progressive muscle relaxation homework; and a brief review of how the client made out with any other homework tasks from the previous session.

Negotiating an Agenda For this session, the therapist’s suggestions for agenda items should include discussion of advancing in the progressive muscle relaxation training exercises, continuing with cognitive restructuring, with a focus on catastrophic thinking; and negotiation of homework.

Moving Forward with Progressive Muscle Relaxation Training If the client has obtained good results from the progressive muscle relaxation training practice during the past week, the therapist should instruct the client to begin practicing the next phase of the relaxation module. 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 decatastrophizing, the following four points should be addressed. . Just as with the tendency to overestimate the likelihood of negative events, clients are taught that tendencies to view events as insufferable, 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 timelimited nature of uneasiness and pain contributes to the development of a perception of being able to cope. . Given that a primary source of distress is evaluating an event as insufferable, it is important to evaluate the actual severity objectively, 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 fired 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 catastrophizing 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., “It’s likely that I’ll blush under certain conditions”), while decatastrophizing would be very appropriate (e.g., “So what if I blush?”).

Negotiating Homework For this session, the therapist’s suggestions for homework items should include reading over the appropriate MAW workbook chapter or chapters for the next session; continuing self-monitoring using the Worry Record—

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Real Odds & Coping form and the Daily Mood Record; practicing the progressive muscle relaxation exercise (it would be ideal for the client to practice progressive muscle relaxation twice daily); and using the Worry Record—Real Odds & Coping form and the Pie Chart form to practice cognitive restructuring as often as possible when anxious episodes occur.

Worry Record—Real & Coping Worry Record—Real OddsOdds & Coping Example Date: Friday 15th

Time began:

10:00

(../..) Time ended: 11:30

(../..)

Maximum level of anxiety (circle a number below): -------------------------------------------------- None

Mild

Moderate

Strong

Extreme

Indicate which of the following symptoms you are experiencing: Restlessness, feeling keyed up or on edge Easily fatigued Difficulty concentrating or mind going blank Irritability Muscle tension Sleep disturbance

Triggering events:

Daughter went out with her friends and has not called

Anxious thoughts:

She was in a car accident and is injured and disoriented Real odds  –

3

Alternative possibilities:

She is having fun with her friends, she forgot to call, she will call later

Ways of coping:

if she is injured, I will help her recover

Anxious behaviors:

waited by the phone

Figure 10.1

Example of worry record/real odds and coping completed by patient.

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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 negative reaction to anything about the session.

Principles and Points to Consider As in the previous lesson, the therapist should serve as a coach for identifying catastrophic thinking and developing methods of challenging these thoughts. By modeling the method of asking relevant questions, therapists begin to teach clients how to look for alternative ways of interpreting 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 therapist may ask whether someone else could view an episode of embarrassment as a relatively minor event. In this way, the client begins to perceive the power of viewing a situation in different ways. Asking clients to imagine the worst possible thing that they believe could happen is a helpful way of identifying catastrophic predictions and beliefs. Just as with probability overestimation, we do not assume that the person’s style of thinking is catastrophic across all situations. Instead, catastrophizing is viewed as a learned cognitive style that is most likely to emerge during states of heightened anxiety.

Case Vignettes

Case Vignette 1 C: Is it best to say to myself that I should just stop worrying so much? T: In a way, that’s correct, but it’s much more effective to be as specific as you can. Simply telling yourself to be less anxious or to stop worrying is a great goal to keep in mind, but it doesn’t 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 doesn’t really change any of the underlying mechanisms that promote worry. It’s important to identify specific predictions that you’re making and then to challenge those predictions. So, when you first notice yourself becoming anxious, ask yourself questions like: What am I predicting or imagining will happen? What is the evidence for and against that? What’s the worst thing that could happen if my prediction did come true? Let’s practice using some of these tools with one of your worries. Tell me about about something that will make you anxious if we focus on it now. C: Maybe I’ll look really weird to other people. I can imagine being in a crowd of people, with everyone staring at me and thinking I’m crazy. T: Who are these people? C: Just anyone in one of my classes, or people on the street. T: So, if these strangers were thinking “there’s a crazy guy,” what would happen? C: I’d 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 different worries this week that I’m 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 happen if we don’t talk about the “best” one? C: I’m afraid that I won’t make any progress and I’ll finish the program feeling just as bad as when I started, or maybe worse. T: OK. I suppose that’s one possibility. Can you think of an alternative to the view that your progress depends entirely upon finding 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 doesn’t matter which worry I talk about. T: Good. So, maybe even restructuring your worry about which worry to talk about is helpful? Now, what evidence do you have or could you get to evaluate those alternatives?

Case Vignette 3 C: Sure. I can tell myself that the chance that I’ll get fired for making a mistake is small. I tell myself that all the time. But what if I do get fired? It’s that one-in-a-hundred chance that frightens me. T: Well, that’s a good question. What would happen if you get fired? C: I would feel awful, like I was a failure. T: OK, and how long would that feeling last—forever? 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 find another job? T: And what is the probability that you will never find another job?

Case Vignette 4 C: I worry that I’ll “blank out” when I get anxious and forget what I was saying. Since this happens to me a lot, I don’t see how I can use the self-statements to challenge this worry. T: And what do you imagine happens as a result of your “blanking out”? C: The other person will think I’m some kind of moron. T: Do you worry about that with everyone, regardless of how well they know you, or just with people you don’t know well?

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C: Just with people I don’t know well. I’m pretty sure that most of my good friends wouldn’t think that of me. T: Then let’s focus on the people you don’t know so well. What evidence do you have regarding whether an acquaintance or a stranger would think you were a moron because you blanked out during a conversation? What else might they think about you? How terrible would it be if a stranger or an acquaintance did think you were a moron? What impact would it have on your life?

Case Vignette 5 C: I’ve been trying to restructure one of my worries all week, and it just doesn’t seem to help. T: Why don’t we take a look at it together? Tell me about the worry you’ve been working with. C: Well, one of my friends has been asking me to have dinner at her apartment for a long time now. I’d really like to, but I’m 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: I’ve examined the evidence both for and against the possibility. The fact is that she lives in a very bad neighborhood. There have been several muggings and rapes reported right on her block. I know that it’s not guaranteed that I will be attacked, but since I would be going by myself at night, the actual chances seem fairly high. T: In that case, I’m glad that you’re feeling worried about going to have dinner at her apartment. Can you imagine why I might say that? C: Maybe because it’s 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, we’ll 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 isn’t so dangerous for you. In the meantime, you’ve learned that the techniques for restructuring probability overestimates can also help us to distinguish realistic from unrealistic worries. To the extent that the evidence suggests that a worry is realistic, problem-solving skills will be more effective than cognitive restructuring because our predictions and interpretations are accurate.

Case Vignette 6 (After having successfully reduced the client’s probability overestimate relating to her worry about experiencing an episode of major depression, the client reported only somewhat of a reduction in her associated anxiety. Thus, the therapist decided to see if decatastrophizing might help.) T: So far, we’ve only focused on the chances that you will become depressed 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 episode of depression? C: That would be awful. (Rather than assuming that he knows what would be so awful about the episode 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 couldn’t get out of bed. I couldn’t do anything. I’m not even sure if I showered more than once during that whole time. I didn’t do my laundry or clean my apartment. I ate some, but mostly junk food, because I couldn’t even prepare a decent meal for myself. T: When you say you couldn’t get out of bed or do anything else, like shower or prepare a meal, how do you know that you couldn’t do those things?

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C: I’m not sure that I follow you. What do you mean? T: Well, it seems clear to me that, when you were depressed, you had the belief that you couldn’t do those things. I’m wondering if you ever tested that belief. C: Tested it how? T: For example, with the thought that you couldn’t get out of bed and get in the shower, are you telling me that, if you had taken it one step at a time, and first told yourself to swing your legs over the side of the bed, they would not have moved? And then, if you’d told yourself to stand up, you would not have been able to? And then, if you had told yourself to put one foot in front of the other and walk toward the shower, your feet wouldn’t have been able to move? And then, once you got to the shower, if you had told yourself to turn on the water, you wouldn’t have been able to do that? Do you get the idea now? C: Well, when you put it that way, I guess I could have done those things. T: Good! So, if you do become depressed again to the point where you’re having the thought that you can’t get out of bed and do your usual activities, what can you do differently? C: I could remind myself that my thoughts are—what have you been calling them? My thoughts are hypotheses—usually, they are accurate, but sometimes they are not—so I need to test them. I’m pretty sure that, if I test the thoughts, like I can’t get out of bed or shower, I’ll find that I really can do those things.

Atypical and Problematic Responses Occasionally, as reflected in case vignette , problems arise because clients try to apply the cognitive restructuring techniques to a realistic worry, then become frustrated and lose confidence in the techniques when they are ineffective at reducing the associated anxiety. To minimize the potential 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 first introducing the techniques. The client knows that a worry is realis-

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tic if the evidence suggests that the predicted event is indeed highly likely and the event’s consequences are not being blown out of proportion. In such cases, we have found it useful to adopt an intervention that might be labeled as paradoxical. For instance, as in case vignette , we might say something like: I’m glad you’re feeling anxious about that. Assuming that I’m not sadistic, can you imagine why I might say that? Of course, the techniques for coping with realistic problems that are discussed in chapter  can be helpful, and the therapist may decide either to initiate them now or simply to tell the client that such techniques will be covered in chapter , and then refocus on an example of excessive worry. Some clients report that their anxiety levels actually increase when they begin focusing on their negative thoughts. Our preferred response to this problem illustrates the adage that “the cognitive therapist never loses.” We try to reframe this feeling of worsening so that it may be viewed positively, or at least so that the client can see a positive aspect to this feeling. A golf course analogy may be helpful here: The increase in anxiety functions like the flag in a hole on a golf course. Alternatively, a driving metaphor might be helpful: Anxiety functions like a road sign on a highway that we have never been on before. It lets us know that we are on the right track, that cognitions indeed have powerful effects on our mood, and that we have identified some relevant cognitions. Thus, we are headed in the right direction and are working on the things we need to work on. 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 immediately try to identify an alternative thought again, when in a more relaxed state. We have had some success with this approach, and attribute it to the state dependency principle—the 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 difficult 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 , the client worried that she would become depressed, as she had in the past, when

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she did in fact have great difficulty coping and experienced a great deal of functional impairment. In these cases, the therapist should help the client explore what might be different if the feared outcome does recur or how the client might cope with it differently the next time. One of the most common mistakes that we have seen our student therapists make, when attempting to implement cognitive restructuring, is to challenge an automatic thought prematurely, before being sure that they fully understand what the meaning of the feared outcome is to the client and what it is that the client finds most threatening about it. For example, in case vignette , when the client says that it would be awful to experience another depressive episode, some therapists might have assumed that the client was worried that the next episode would go on forever. Based on this assumption, they might have begun to ask questions about what evidence the client has that the episode would go on forever and what steps she could take to keep it from going on forever. If so, clearly, this line of questioning would have been off target and would likely be experienced by the client as not being very helpful. Thus, instead of assuming that one knows what the client is finding most threatening, it is always better to ask or to check out one’s assumption with the client (e.g., “So, when you worry about becoming depressed again, are you concerned that the depression would never end?”), before beginning the process of actively challenging the thought. Finally, we have found that some of our clients have worries about the treatment process. That is, clients occasionally worry about whether they have applied a particular exercise in perfect fashion, or whether, as reflected in case vignette , they are applying their exercises to the “right” worry. Given that excessive worry is at the core of GAD, this should not be too surprising. In our experience, the best strategy for dealing with these worries is to target them for intervention, as with any other worry that the client might have. In fact, these worries may be more effectively treated, as they tend to be “hot”—that is, the client is experiencing the anxiety in session, and the negative predictions are relatively easily accessible. So, if a client is troubled by perfectionistic concerns about the treatment, the therapist should follow the affect, try to identify the automatic thought behind the perfectionism (such as “I won’t get any benefit from this exercise unless I do it perfectly”), and then challenge it, as illustrated in case vignette .

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Chapter 11 Getting to the Heart of Worrying: Facing Your Fears

(Corresponds to chapter  of the client workbook)

Summary of Information in Chapter 8 of the MAW Client Workbook ■ Review of identification 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 process: the value of direct confrontation with worry to reduce anxious responding. Worry exposure also allows for the provision of specific 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 specific worrisome images. ■ Specification 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

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■ 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 Record—Real Odds & Coping, Pie Chart, and Daily Mood Record forms; a review of progressive muscle relaxation homework; and a brief review of how the client made out with any other homework tasks from the previous session.

Negotiating an Agenda For this session, the therapist’s suggestions for agenda items should include discussion of advancing in the progressive muscle relaxation training exercises, an introduction to worry imagery exposure, and negotiation of homework.

Moving Forward with Progressive Muscle Relaxation Training If the client has obtained good results from the progressive muscle relaxation training practice during the past week, the therapist should instruct the client to begin practicing the next phase of the relaxation module. 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 during the past week, he or she should continue to practice the same procedure for the coming week.

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Introducing Imagery Exposure In introducing imagery exposure, the following five points should be addressed. . 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 relearning and habituation and therefore tend to maintain an anxious 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 difference between their own repeated experience of worrisome images in their everyday life and the imagery exposure exercises conducted in the program. 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 processing—all of which serve to maintain the fear structure. In contrast, the program exposure exercises 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 don’t involve anxiety may be provided before imagery exposure is begun. It is important that clients try to put themselves in the situation, focusing

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on the physical and emotional sensations involved in each scenario. Remember the suggestion, cited in chapters  and  of this book, that the process of worry itself suppresses imagery, including those aspects that encode efferent commands to the autonomic system. This suggestion implies that it is important to include physiological response elements in imagery exposure. . It is important for clients to understand the difference between the anxiety management strategies and the exposure strategies. Until this point, they have been instructed to apply relaxation and cognitive restructuring techniques upon noticing worry or anxiety in the course of their daily lives. Now, they are being asked to endure worrisome images for specific periods, before applying management strategies. Among other benefits, 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 therapist’s suggestions for homework items should include reading over the appropriate MAW workbook chapter or chapters for the next session, continuing self-monitoring using the Worry Record—Real Odds & Coping form and the Daily Mood Record, practicing the progressive muscle relaxation exercise (it would be ideal for the client to practice progressive muscle relaxation twice daily), using the Worry Record—Real Odds & Coping form and the Pie Chart form to practice cognitive restructuring as often as possible when anxious episodes 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 negative reaction to anything about the session.

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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-provoking situations. Rather, this exposure is purely imaginal. If clients hit a “stuck point” in which their anxiety does not decrease, despite prolonged exposure, they should be instructed to apply relaxation and cognitive strategies. Corrective feedback is then provided by the therapist, when necessary, should the management strategies be applied incorrectly or the exposure conducted ineffectively. As the clients gain a sense of mastery over a particular imaginal scene, they progress to exposing themselves 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 happening 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 catastrophic scene is experienced as being so awful that clients believe that they can’t tolerate continuing to focus on the topic). Thus, it is important to encourage the client to allow the imagery to advance to the most catastrophic scene, and beyond. We have found that once the most catastrophic scene is encountered, asking the client to “fast-forward” the image—first by a day, then by a week, then by a month, then  months, then a year or two—can help to initiate a spontaneous decatastrophizing process, as illustrated in case vignette .

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Please also note that our suggestions for therapist-assisted imagery exposure differ somewhat from the instructions given in the MAW client workbook. We felt that the instructions for how we do the exposure in a session with a therapist would be too complicated for the client to keep in mind if doing the exposure on his or her own and also that there would be too much potential for the client to fail to continue beyond the point of the most catastrophic scene or to sustain the imagery on his or her own. Thus, the instructions in the MAW client workbook were written for clients who work through the program entirely on their own, without a therapist. Therapists should tell their clients this, and explain that they will be implementing the procedure a bit differently than how it is described in the client workbook.

Case Vignettes

Case Vignette 1 C: You said that it was important not to distract myself when I start to feel anxious while I concentrate on and imagine my worry. Should I concentrate on how awful I feel? 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 victim is replaced with one of becoming an observer of your own reactions. Remember that, with repeated exposures, the level of distress you experience 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 I’m a bad mother when my daughter starts to pinch one of the other infants or

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pull his or her hair. But when I try to concentrate on that worry now for exposure, it doesn’t do anything for me. What can I do to practice? T: Well, there are several possible reasons why this might be the case. First, we might have to make more use of your imagination so that you can picture yourself in that situation now. For example, you want to imagine that you are in the play group now. Imagine the outfit your daughter has on, how she feels in your arms as you are carrying her, and how she smells. What colors are the other children wearing? Hear the noises the children are making while they are playing. What colors are the other mothers wearing? Hear their voices as they are talking to you. Hear the sounds of the other child crying and screaming as your daughter pulls his or her hair. Feel the tension in your muscles increase and your breathing rate quicken as you experience the urge to run over to her. Were you trying to put yourself in the middle of the scene like that? C: No, I was just repeating the thought to myself. When I tried to imagine the scene as you were just talking, I did start to become more anxious. T: Good. Try to hold on to that scene now, and continue to keep yourself in the middle of it, as if it were happening now. Let’s see what happens next.

Case Vignette 3 C: I imagined my worry for  minutes at a time during my practice at home, and each time, my anxiety just kept increasing. I don’t think this is working. T: Well, there may be a couple of possible reasons why your anxiety wasn’t decreasing. First, were you concentrating on the same worry, or did other worries come into the picture? C: No, I’ve been focusing on the same worry. T: Well, the rate of habituation differs from one person to the next, and sometimes even within the same person, for different worries. Some people require more prolonged exposure to begin to experience habituation, which is why we recommend that people start with about 

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minutes of exposure. However, some people require even more than that for some of their worries. Why don’t we focus on that worry now and see if there is a change in your anxiety level over the next  minutes?

Case Vignette 4 T: So, we are going to expose you to your worry that your father will pull out a knife and cut himself during a fight with your mother. On a scale from  to , what is your anxiety level right now? C: About . T: OK. Start the movie wherever you would like. Remember, I want you to imagine it as if it were happening right now, describing to me what you see, feel, and hear. Close your eyes, if that will help you see it in your mind’s eye. C: I hear the phone ringing. I pick it up, and I hear it’s my mother’s voice. She sounds very agitated. She tells me that they’re having another fight, and I can hear my father screaming in the background. My mother asks me to come over as soon as I can to stop the fight. She tells me that Dad has pulled a large knife out of a drawer, and then she hangs up. I tell Steve that they’re at it again, and I have to go over there, or else Dad is going to hurt himself or Mom. I grab my car keys and jump in the car. I’m driving as fast as I can, and I can’t get the image of him, with a knife in his hand, out of my head. T: What are you feeling, and where are you feeling it? C: My heart is pounding, and I have a feeling in the pit of my stomach, and the sense that this time he’s is really going to do it. T: You’re doing great. Hold that scene for a bit. (The therapist is then silent for a minute or two.) Where is your anxiety level now, on a scale of  to ? C: It’s . T: Good. What happens next? C: I pull up in their driveway and hop out of the car. Now I’m running up their driveway, and I can hear my mother. She sounds hysterical, but it’s really weird ’cause I don’t hear Dad at all. When I come in the

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front door, I see him. He is lying on the floor, and I see that his wrist and his neck are cut. There is blood all around him. My mother is sobbing uncontrollably. I ask her if she has called an ambulance, and she shakes her head no, so I grab the phone and call an ambulance. A few minutes goes by before the ambulance gets there, and as I’m waiting, I start to cry, too, and I’m thinking that this is my fault. If I had driven even faster, I could have gotten here before he cut himself. (Client is now crying in session.) Now I hear the sirens of the ambulance, and the medics come inside. They immediately get him on a stretcher, and they ask if one of us is going to ride with him in the ambulance. My mother is still hysterical, so I go. T: Now hold that scene. (Silence for a minute or two.) And where is your anxiety level now? C: I’d say it’s . T: You’re really doing great. Stay with it now. What happens next? C: We get to the hospital and they immediately rush him to the ER. The nurse asks me to wait outside, in the waiting area. I’m sitting there, praying that he’s going to make it and feeling just awful that I didn’t get there sooner. I call Steve and ask him to come to the hospital, and then I start crying again and wishing that he were there already. Then the nurse comes out and tells me that she’s very sorry, but they couldn’t save my father, that he’d lost too much blood. Then Steve finally gets there, and I’m crying like a baby in his arms. T: Now hold that scene. (Silence for a minute or two.) And what is your anxiety level now? C: Oh, it’s . T: Now, let’s fast-forward a day or two. What’s happening now? What do you see, hear, and feel? C: Well, I’m at his funeral. I see all of our relatives and my parents’ friends. We are gathered around his gravesite, and my brother, Steve, my uncle, and one of my cousins lower Dad’s coffin into the grave. I take my turn shoveling some dirt on top of his coffin. I start to cry, and I keep seeing the image of him lying in that pool of blood. I feel really, really sad, and kind of empty inside.

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T: Now hold that scene. (Silence for a minute or two.) And what is your anxiety level now? C: Still . T: You’re doing great. Let’s stay with it a bit more. Let’s fast-forward about a week or so. What’s happening now? C: It’s my first day back at work. I’ve been crying off and on all week long. I’m still thinking about my father just about all the time. I’m having a hard time concentrating on my work, but I struggle through and do get a little bit done. T: OK, and how about a month later? C: Well, I’m am still thinking about Dad a lot, and I still see the picture in my head of him lying in that pool of blood. But it isn’t all the time now, and when I’m talking to a client, I can pay attention to what he is saying. When I think about Dad, my eyes do tear up, but I am not sobbing like I was. T: And what is your anxiety level now? C: A little better. I guess maybe  or . T: Ok. How about  months later? What happens then? C: Well, when I’m busy—at work or doing something with Steve on the weekends—I’m fine. When I go to visit my mother and brother, or when I’m alone at home though, I start thinking about Dad, and I get pretty sad. T: And a year later? C: I see myself pretty much back to normal. When I’m am at work or with Steve or one of my friends, I don’t really think of Dad much at all. Now, it’s 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 I’m kind of appreciating him—maybe even more than I did before he died. T: And what is your anxiety level now? C: A lot better—maybe , or even .

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Case Vignette 5 C: When I do the cue-controlled relaxation, I think I’ll 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 procedure, as with other forms of exposure, is getting the client started. This is likely to be particularly true for individuals who use cognitive avoidance (in other words, distraction) frequently as an attempt to control their worry. This difficulty is most often associated with worry about worrying. We have found it most useful to treat this worry like any other worry that a client may have. Thus, the therapist might suggest that such clients begin the exposure with the worry about conducting imagery exposure. 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 losing your job?”). Perhaps the next most common problem with the exposure procedure is the client wanting to flee from the image as the most catastrophic scene approaches or is encountered. Here, there are two principles to keep in mind. The first is for therapists to give their clients praise throughout the procedure and to express confidence in their clients’ ability to cope with the anxiety aroused by the most catastrophic scene. The second is for therapists to keep in mind that, if the client does break off the exposure

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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 discussed at the end of workbook chapter .

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Chapter 12 From Fears to Behaviors

(Corresponds to chapter  of the client workbook)

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 relaxation training and imagery exposure only, or the client may simply skip to workbook chapter . On the other hand, when these problems are present, the therapist may wish to spend several sessions dealing with them, depending on the pervasiveness of the problem and the client’s rate of progress.

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. Relaxation should not be engaged in out of desperation. ■ Rationale for the purpose of response prevention of checking behaviors and in vivo exposure to situations that are avoided because of excessive anxiety. Response prevention and in vivo exposure provide the opportunity to learn that catastrophes might not occur, even if one doesn’t engage in avoidance or checking behaviors. In addition, these exercises provide specific practices for the application of anxiety management skills (relaxation and cognitive restructuring) in everyday situations that are relevant to the client’s anxiety problems. ■ Development of a hierarchy of in vivo exposure and response prevention tasks, in order of increasing intensity, based on how much anxiety they provoke.

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■ Instruction in the method of repeated exposure to the hierarchy items, starting with the least anxiety-provoking exercise in the hierarchy. ■ Specification 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 Record—Real Odds & Coping, Pie Chart, and Daily Mood Record forms; a review of progressive muscle relaxation homework and imagery exposure homework; and a brief review of how the client made out with any other homework tasks from the previous session.

Negotiating an Agenda For this session, the therapist’s suggestions for agenda items should include discussion of advancing in the progressive muscle relaxation training exercises, continuing with imagery exposure, introducing in vivo exposure and response prevention, and negotiation of homework.

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Moving Forward with Progressive Muscle Relaxation Training By this point in the program, most—if not all—clients should be instructed 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 conducted 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 behaviors 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 significant 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 (Canfield & Hansen, ) as a reminder of this point (the cartoon shows a

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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 efficacy in coping with the situation and with feelings of anxiety that may be experienced.

Negotiating Homework For this session, the therapist’s suggestions for homework items should include reading over the appropriate MAW workbook chapter or chapters for the next session, continuing self-monitoring using the Worry Record— Real Odds & Coping form and the Daily Mood Record; practicing the one-step progressive muscle relaxation exercise (it would be ideal for the client to practice progressive muscle relaxation twice daily); using the Worry Record—Real Odds & Coping form and the Pie Chart form to practice cognitive restructuring as often as possible when anxious episodes 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 negative 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 exposure, but assists the client in setting goals and designing practices. The therapist also gives corrective feedback, particularly regarding reasons for

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escape or avoidance. At this point in the program, clients should be generating their own tasks or goals and developing a sense of their own method for achieving mastery. Many clients tend to view courage as the absence of fear, and so see themselves as cowardly and weak people. However, as noted by Stanley Rachman () in Fear and Courage, there is an alternative definition of courage. Within this view, courage is seen as action despite fear. Seen in this light, clients are displaying or creating courage whenever they engage in an exposure practice. If the client can be led to recognize this alternative 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 sessions out after this session. Until this point, sessions are typically scheduled  week apart. From this point forward, we usually schedule sessions on a biweekly basis to give the clients more practice in applying the skills on their own.

Case Vignettes

Case Vignette 1 C: I really would rather not do these exercises because I’m sure that I’ll feel very anxious. I haven’t said “no” when a friend has asked me for a favor or made requests of other people for a long time, and now you’re asking me to do it. T: Of course, you should expect to feel anxious the first several times you attempt to do the things you’ve been avoiding or putting off. But the other side of the coin is that, through repeated practices, it will get easier. That long-term payoff is important to remember. Also, you have developed a new set of coping skills and strengthened old ones, which you can use to help yourself when you begin to feel anxious about being assertive. Finally, remember our stepladder, or one-step-at-a-time, approach. You can break down some of the more difficult exposure tasks into a series of smaller steps. You can then perform each of these

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smaller steps a number of times to feel more comfortable, before proceeding to the next one. For example, you can start out with very small requests and gradually work your way to more involved ones. Alternatively, 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 behaviors. Anxiety is like a weed. If you skip over some situations in your practices, it’s 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 generalization effect across situations. What I mean by that is that, with each situation you master, you’ll probably find that many of the other situations become somewhat easier as well. So, even though some exposure practice seems overwhelming now, you’ll probably find that it will start to seem more manageable as you work your way up your hierarchy.

Case Vignette 3 C: If I don’t call my wife to see if everything is OK, I know it’s going to make me feel really anxious, and my worries about her will interfere with my ability to concentrate. Then I know that I won’t 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 checking in with her once every couple of hours, you could begin by checking in once every  hours. Then, when you become more comfortable with

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checking in once every  hours, you could go to just once a day, and so on. Also, it’s important for you to examine realistically what you’re saying to yourself about the worry interfering with your work. You said that you wouldn’t be able to function. Do you mean to say that you wouldn’t be able to get any work done? If so, what is the evidence for that? If not, then you need to ask yourself just how much your work performance actually will suffer and how terrible that would be.

Case Vignette 4 C: I worry that, when I get anxious, I’ll blank out and forget what I was saying or what someone else was saying to me. How can I practice that? T: Well, you could intentionally ask someone to repeat themselves because 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 comfortable doing this, then you could start with them. You could then progressively challenge yourself more over time.

Atypical and Problematic Responses Given that the majority of this section of the MAW program is selfdirected, compliance with practice assignments can become problematic. The therapist’s role, at this point, is to emphasize the value of practice and the extent to which further improvement depends on such practice. Occasionally, as clients make changes in their typical daily patterns, family members may be affected. Discussion of ways to inform significant others is useful, under such conditions. Sometimes a client finds an exposure practice too overwhelming to initiate. 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

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his or her tendency to arrive at appointments  minutes ahead of time. If the client found it too overwhelming to practice arriving a few minutes late, or right about on time, the therapist could suggest starting with a practice of leaving , , or  minutes later than usual. After this initial 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 wasn’t anxious about what others will think, I wouldn’t leave dishes in the sink.” Clients must realize that sometimes exposure hierarchies go beyond what is “normally done” to instill a strong sense of mastery 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 hierarchy 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  people, after one has lectured several times in front of  people, lecturing to  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 flag in a hole at a golf course or a sign on a highway we have not been on before to let

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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.

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Chapter 13 Dealing with Real Problems: Time Management, Goal Setting, and Problem-Solving

(Corresponds to chapter  of the client workbook)

This chapter, dealing with being overcommitted and using ineffective problem-solving skills, obviously needs to be applied only if these problems are present. If the client already has effective 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 exposure exercises. Discussion of the client’s repetition of practice, use of any overt or covert safety aids, and cognitive distraction. ■ Description of two common sources of realistic stressors that compound anxiety problems: () feeling overwhelmed as a result of being overcommitted and () the crises and problems that everyone experiences from time to time. ■ Instruction on techniques for coping with real problems, including time management, goal-setting, and problem-solving through brainstorming. ■ Evaluation of time management efficiency. ■ Instruction in time management and goal-setting strategies for managing time more efficiently. Time management principles include delegating responsibility, saying “no,” and sticking to agendas. Goal-setting

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involves setting priorities among planned activities and scheduling tasks in accordance with their priority. ■ Description of brainstorming, an effective problem-solving strategy. Brainstorming involves several steps: defining the problem in specific terms, identifying every possible solution before evaluating any one solution, ranking the solutions, deciding on a specific plan of action for each reasonable solution, and beginning to enact plans, starting with the best solution. ■ Specification 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 Record—Real Odds & Coping, Pie Chart, and Daily Mood Record forms: a review of progressive muscle relaxation, imagery exposure, and in vivo exposure homework; and a brief review of how the client made out with any other homework tasks from the previous session.

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Negotiating an Agenda For this session, the therapist’s suggestions for agenda items should include discussion of advancing in the progressive muscle relaxation training exercises, continuing with imagery exposure, introducing time management and brainstorming, and negotiation of homework.

Moving Forward with Progressive Muscle Relaxation Training By this point in the program, most—if not all—clients should be instructed 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 relevant for the client and will be covered this session, there will probably not be time for imagery exposure, so this should be practiced at home. If time managment and brainstorming are not relevant for the client and will be skipped, there should be sufficient time to conduct therapistassisted 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 practicing 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.

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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 difference between the anxiety management and control strategies and the time management and problem-solving strategies. Until this point, they have been instructed to apply anxiety management and control strategies to excessive worries. Now, they are being asked to problemsolve 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 inefficient time management or becoming overcommitted. For example, perfectionistic concerns and worry about how well others will do things can contribute to difficulty in delegating responsibilities. Similarly, predictions of rejection can contribute to difficulty 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 specific and concrete terms is essential. The need to refrain from editing or censoring possible solutions before all solutions are identified is also emphasized. What sounds like a silly idea at first 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 first plan won’t work.

Negotiating Homework For this session, the therapist’s suggestions for homework items should include reading over the appropriate MAW workbook chapter or chapters for the next session; continuing self-monitoring using the Worry Record—Real Odds & Coping form and the Daily Mood Record; applying the one-step progressive muscle relaxation procedure whenever an increase in tension is noticed; using the Worry Record—Real Odds & Coping form and the Pie Chart form to practice cognitive restructur-

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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 problem 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 negative 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 evaluating 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?

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C: Yes, I can understand it now much more readily than before. I felt embarrassed and immediately thought that the others must be thinking that I’m a failure. I questioned the evidence, but then I dismissed the facts and thought that it really could happen. T: So you continued to overestimate the likelihood? C: Yes. T: How about if we do a pie chart relating to the thought that you’re back at square one? Maybe you are back at square one, but maybe there are other ways to look at this. What is an alternative perspective? C: Well, maybe I never was beyond square one, and I was fooling myself when I thought I had made progress. T: (Laughs) I suppose that is an alternative. How about a more balanced alternative? C: Maybe I have made progress, but I’m always going to have some slips? T: Good. Write that one down on the pie chart, next to the original thought. Any others? C: How about that I need to practice more to be able to apply the skills more consistently? T: Good. Let’s write that one down, too. Any others? C: Mmm. That’s all I’m coming up with for now. T: Now, let’s look at the evidence. What evidence do you have that you’re back at square one? C: I did have those  days this past week when I was overestimating the likelihood of bad things happening. T: Anything else? C: No, that’s it. T: OK. Let’s look at the other side. What evidence do you have that you’ve made progress and either need to practice more or are just continuing to experience some flare-ups, but that, overall, you are doing better?

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C: I’m pretty sure that, if I looked at my monitoring forms, I’d see that, when I first started, I was having days like these almost every day, and now, they occur only on rare occasions.

Case Vignette 2 C: I know that I’m busier than I need to be, but I’m worried that if I start saying “no” to my friends when they ask me to do favors for them, they won’t want to be my friends anymore. T: It sounds like some of the other skills you’ve learned might help you in dealing with that worry so you can manage your time more efficiently. How could you apply the skills you’ve already learned to this situation? C: I can remind myself that just because I’m thinking that they will reject me doesn’t necessarily mean that they will actually reject me. Then I could examine the evidence to evaluate how likely it really is. T: Good. Is there anything else you can do to help yourself with this worry? C: Well, I could practice saying “no” to people, but I think I might be too nervous to start. T: Do you have some friends whom you believe would be more understanding 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: I’ve got a problem that I haven’t been able to solve. T: Let’s 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 frequent basis as they walk past on their way to school. I’ve called the police, and they said that they couldn’t do anything unless I caught the kids in the act.

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T: Calling the police was a very good start. What other possible solutions are there? C: I don’t know. I can’t think of anything else that seems like it would really work or be feasible. T: That’s OK. Let’s get all of the possible ideas out on the table first, and then we’ll evaluate them only after we’ve identified a number of them. C: Well, I guess I could get a car alarm—there 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. Let’s see. Is there a place where you could park the car where the kids would be unlikely to find 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. I’m 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 delegating responsibilities is a difficulty, the therapist should be alert for perfectionistic concerns and catastrophizing about how well the other person will perform the task. Difficulties in saying “no” are often related to predictions of rejection or massive reprisals. If the client is predicting

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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?”).

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Chapter 14 Drugs for Anxiety and Their Relation to This Program

(Corresponds to chapter  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 considering 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

Brief Check-in The brief check-in will consist of greetings, a chance for the client to state how he or she has been feeling recently, and a brief review of the client’s self-monitoring and homework tasks negotiated during the previous session.

Negotiate Agenda For this session, the therapist’s suggestions for agenda items should include continuing with imagery exposure, continuing with in vivo exposure and response prevention (if applicable), discussion of medication 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 conducted 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.

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Discussing Medication Issues When discussing medication, the following three points should be addressed. . There is a great deal of variability in the extent to which individuals make use of medication versus behavioral treatment, or make use of both. Medication is not described as a more or less effective form of treatment, in general, but as more or less appropriate, depending on certain beliefs and life circumstances. Under ordinary circumstances, many medications are likely to begin to exert beneficial effects in a shorter period than psychotherapy programs, such as the MAW program. This is especially true of the benzodiazepines, which can be effective 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 first choice in medications for GAD at this time and take as long as  weeks to be effective. On the other hand, many medications tend to be ineffective in the long run, unless they are taken indefinitely. Sometimes the medications lose some of their effectiveness when taken continuously over an extended period. Thus, the MAW program may be very beneficial, even for individuals who have achieved some relief from medication. . Drugs are described in such a way that clients may understand their effectiveness, side effects, 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 client’s prescribing physician. In this program, an increase in anxiety as the client comes off medication is recognized as being a suitable target for the application of techniques employed in the MAW program. If withdrawal from medications is particularly difficult (as would be at least somewhat more likely with withdrawl from benzodiazepines), and includes panic attacks, then the program described in the book Stopping Anxiety Medication (Otto, Pollack, & Barlow, ) may be more useful and appropriate.

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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 therapist’s 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 negative 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 resist the temptation to tell the client which skills he or she can apply in the future to make further progress, deal with difficulties, 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 client’s readiness for termination and will better promote internalization of the skills.

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Case Vignettes

Case Vignette 1 C: I always thought that the medication was correcting a chemical imbalance or genetic abnormality. T: To date, there is no clear evidence of a specific chemical imbalance or genetic abnormality that is a primary cause of excessive worry and generalized anxiety. The question of how the medications work isn’t 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 you’d 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 specific? 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 we’ve 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 tension. And I would think through my worries, instead of trying to distract myself from them. I would think about how likely the things that I’m worrying about really are and how dangerous they really are. I

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would think of the worst that could actually happen and whether I could cope with that or not.

Case Vignette 3 C: I really feel like I’m not ready to finish the program now. I still have some worries that I haven’t worked on yet and some situations that I’m avoiding. T: OK. Let’s deal with the worries first. How would you approach each of these worries? What techniques would you use to confront them? C: Well, I would examine the worries to see if I was overestimating any probabilities or catastrophizing. I’d 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 you’re still avoiding? What techniques would you use to handle them? C: I would start by deciding which one I’m going to do first. If I need to, I can break any that seem overwhelming into smaller tasks. Then I would practice doing each task enough times until I feel comfortable, before moving on to the next one. T: So, you know which techniques and principles to use and how to work toward the goals of learning to be less worried and avoidant? C: Yes, but I’m still a little nervous about the program’s ending. T: Well, it’s only natural for you to feel some anxiety about ending. But you have successfully learned the principles of this program. It’s up to you now to continue to apply them for the amount of time necessary to process the worries that are causing the difficulty.

Atypical and Problematic Responses Weaning oneself from the “safety valve” of benzodiazepines is often very difficult in terms of both physical and psychological dependency. In addition to a process of gradual tapering from higher doses (always conducted

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under the supervision of the prescribing physician), weaning from psychological dependence can be aided by progressively removing the medication bottle. By way of illustration, clients may practice by giving their medication to a friend accompanying them, then leaving the medication in the glove compartment of their car, then leaving it at home, and so on. Fortunately, the prescription of benzodiazepines for GAD appears to be on the decrease as the SSRIs and SNRIs have been gaining widespread acceptance as the first-choice medications for this condition.

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Chapter 15 Your Accomplishments and Your Future

(Corresponds to chapter  in the client workbook)

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 homework tasks the client committed to complete during the last session.

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Negotiating an Agenda For this session, the therapist’s suggestions for agenda items should include discussion of termination.

Discussing Termination When discussing termination, the following five points should be addressed. . 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 reflection of change, clients are instructed 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 extent to which there has been a change in the recorded frequency of episodes of heightened anxiety, maximum anxiety ratings, probability and ability to cope estimates, ratings of anxiety in response to the imagery exposure exercises, and ratings of anxiety in association 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. Therefore, 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 practice time, lack of motivation for practice, lack of understanding of the principles, and unrealistic goals. Future steps are based on which of those five reasons is primarily responsible for the disappointing progress.

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. 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 essential 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 associated with that specific target, as opposed to covering up an underlying 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 reflect certain maladaptive reactions. Therefore, there are certain 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 final session of this program, the main focus is on evaluating the client’s progress and planning for the future. Termination concerns frequently arise in this session, and it’s important to emphasize again that, while the treatment was designed to provide clients with the necessary skills with which to manage anxiety, these skills must be practiced regularly. To reinforce this point, we often use a dental health analogy. That is, we ask clients if they can imagine ever reaching a point when their dentist will tell them that their teeth and gums are so clean and healthy that they no longer need to brush and floss. We ask clients to consider whether a similar principle applies to emotional health: might it be that the maintenance of good emotional health and manageable levels of anxiety and tension similarly requires regular practice of good emotional hygiene?

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Some therapists choose to continue with “booster” sessions scheduled once a month. Each therapist will have to decide, on a case-by-case basis, whether the potential benefits of such booster sessions outweigh the potential cost of fostering overdependency on the therapist.

Case Vignettes

Case Vignette 1 C: Even though I’m doing most of the things I used to avoid and have stopped most of my safety behaviors, even the thought of not having the house perfectly clean when my in-laws come over still makes me anxious. Trying to be the perfect daughter-in-law was always one of my biggest problems, and it looks like I’ll never get over it now. T: It sounds like you’re separating keeping the house perfectly clean for your in-laws from all of the other items in your hierarchy, just because it’s the top item. You’ve already learned how to work through the other situations, so can you think of how you might make the idea of your in-laws seeing your house when it’s not perfect more manageable to work on? C: No. 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 first, and I broke them down into smaller steps. But I’m not sure how I can break this situation down into smaller steps. T: Are there some rooms that they don’t spend much time in? Perhaps you could start with them? C: I suppose I could start with just leaving one room—that I am confident they won’t go into—messy. 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.

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T: Excellent. But just to play devil’s advocate, let me ask you to imagine that you feel overwhelmed when you are ready to go on to another room, like the living room. What could you do then? C: I guess I could start by leaving just one ashtray unemptied, and then work up gradually from there. I guess it’s really not that different from the other situations, after all. I just need to give it some more thought and be creative.

Case Vignette 2 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 specific areas that are still problematic for you. Remember, the goal of these sessions was to teach you the skills necessary to overcome these problems, rather than to remove all of your symptoms by the last session. Since you now have a good understanding of these skills, it’s a matter of focusing on each area that still poses a concern and continuing to practice and apply the skills.

Case Vignette 3 C: I thought I’d be cured by the end of treatment, but here it is—the last session—and I’m not. How much longer will it take before I’m cured? 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 effort you put into practicing regularly.

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Atypical and Problematic Responses Clients sometimes feel troubled at this point because they still experience 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 experience. In these cases, it’s helpful to review the client’s experiences recorded at the beginning of treatment so that clients may more accurately evaluate their progress. Pointing out instances where the client minimizes progress in favor of obsessing on the negative may be helpful (e.g., “While I haven’t been worrying about my wife as much these days, I still worry a lot about my kids, so I’m not really any better off ” or “Although I’m not having trouble sleeping every night anymore, I’ve had a few bad nights recently”). The therapist can emphasize to clients that, even though there is still room for improvement, they have made great strides so far and have worked very hard to achieve their gains. It should be communicated 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 treatment can be encouraging. By reviewing these records together, therapists can help clients to recognize that they made progress before and realize that they can certainly do so again. Finally, some clients say that they are not yet ready to end treatment, or that they are unsure of their abilities to continue on their own. Clients must be helped to realize that they do not need the crutch of a therapist to continue making progress. Once they have an understanding of the treatment principles and have learned the requisite skills, all that is left is to continue practicing and applying these skills so that they become second nature, and nobody can do this work for the client. At this point, future benefit is almost entirely dependent on the client’s motivation to continue working on problem areas.

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References

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About the Authors

Richard E. Zinbarg, Ph. D., is Associate Professor in Psychology at Northwestern 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 Program at the Family Institute at Northwestern University. He received his Ph.D. from Northwestern University in . He also directed the Oregon Program for Anxiety Study and Treatment at the University of Oregon. He has published over  articles and chapters in the areas of anxiety disorders and clinical research methodology, and has presented extensively on these topics. He served as Project Director for the DSM-IV Mixed Anxiety Depression field trial, recently completed a term as Associate Editor for the British Journal of Clinical Psychology, and is incoming Associate 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 effective 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  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 differences in anxiety, 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 projects pertaining to risk factors for anxiety disorders and depression among children and adolescents, the cognitive and physiological aspects of anxiety and panic attacks, and the development and dissemination of treatments for anxiety and related disorders. She is Associate Editor for the Journal of Abnormal Psychology and Behaviour Research and Therapy, and is a Scientific Board Member for the Anxiety Disorders Association of America. She was a member of the DSM-IV Anxiety Disorders Work

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Group Subcommittee for revision of the diagnostic criteria for panic disorder and specific phobia. Dr. Craske has given invited keynote addresses at many international conferences and frequently is invited to present training workshops on the most recent advances in cognitive-behavioral treatment of anxiety disorders. She is currently Professor, Department of Psychology and Department of Psychiatry and Biobehavioral Sciences, 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  and has published over  articles and chapters, including nearly  books and clinical workbooks, mostly in the area of emotional disorders and clinical research methodology. The book and workbooks have been translated into more than  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 University, 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  American Psychological Association (APA) Distinguished Scientific Award for the Applications of Psychology. He is also the recipient of the First Annual Science Dissemination Award from the Society for a Science of Clinical Psychology of the APA and recipient of the  Distinguished Scientific Contribution Award from the Society of Clinical Psychology of the APA. He also received an award in appreciation of outstanding achievements from the General Hospital of the Chinese People’s Liberation Army, Beijing, China, with an appointment as Honorary Visiting Professor of Clinical Psychology. During the – academic year, he was Fritz Redlich Fellow at the Center for Advanced Study in Behavioral Sciences, in Palo Alto, California. Other awards include Career Contribution Awards from the Massachusetts, California, and Connecticut Psychological Associations; The  C. Charles Burlingame Award from the Institute of Living in Hartford,

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Connecticut; the First Graduate Alumni Scholar Award from the Graduate College, the University of Vermont; the Masters and Johnson Award from the Society for Sex Therapy and Research; G. Stanley Hall Lectureship, APA; a certificate of appreciation for contributions to women in clinical psychology from Section IV of Division  of the APA, the Clinical Psychology of Women; and a MERIT award from the National Institute of Mental Health for long-term contributions to the clinical research effort. He is past President of the Society of Clinical Psychology of the APA and the Association for the Advancement of Behavior Therapy, past Editor of the journals Behavior Therapy, Journal of Applied Behavior Analysis, and Clinical Psychology: Science and Practice, and currently Editor-in-Chief of the “Treatments that Worktm” series for Oxford University Press. He was Chair of the APA Task Force of Psychological Intervention Guidelines, was a member of the DSM-IV Task Force of the American Psychiatric Association, and was a Co-Chair of the Work Group for revising the anxiety disorder categories. He is also a Diplomate in Clinical Psychology of the American Board of Professional Psychology and maintains a private practice.

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