Read an Excerpt
The Anxiety and Worry Workbook
The Cognitive Behavioral Solution
By David A. Clark, Aaron T. Beck The Guilford Press
Copyright © 2012 The Guilford Press
All rights reserved.
ISBN: 978-1-60623-918-6
CHAPTER 1
Making a New Start
We all know what it feels like to be afraid when confronted by a threatening stranger on the street, or to be anxious before an important exam or job interview, or to worry about the outcome of a medical test. It's hard to imagine living in a state of perpetual calm and safety, free from uncertainty, risk, danger, or threats. Fear and anxiety are part of living—and often a useful part, at that. Fear warns us of an impending danger, like when we feel the car slide on a wet or icy road or when a suspicious stranger appears to be following us. Feeling anxious can motivate a person to be better prepared for an important business meeting or take extra precautions when traveling to an unfamiliar place. The fact is, we need some fear and anxiety in our lives.
But not all fear and anxiety experiences are good for us. As a psychologist (D. A. C.) and a psychiatrist (A. T. B.), we've heard thousands of stories about individuals' daily struggles to contain their fears and anxiety. For some people anxiety becomes overwhelming, characterized by excessive and persistent feelings of apprehension, worry, tension, and nervousness over everyday situations that most people face with little concern.
Worried to Death
Rebecca can't sleep. In the past 5 years since being promoted to store manager, this 38-year-old mother of two school-age daughters has been fraught with apprehension, nervousness, and worries over her work, her children's safety, her aging parents' health, personal finances, and her husband's job insecurities. Her mind seems to generate an endless list of possible catastrophes—she won't be an effective manager at work, she'll fail to meet monthly sales projections, her younger daughter will get injured at school or her older daughter will be teased by friends, her parents will be disappointed in her for not visiting them, she won't have enough money left over after paying bills to contribute to their retirement savings plan, her husband could lose his job any day ... the list goes on. Rebecca has always been a worrier, but it has become almost unbearable in the last few years. In addition to sleepless nights, Rebecca finds that she is almost constantly agitated, shaky, "rattled," unable to relax, and irritable, with occasional anger outbursts. She breaks down in tears for no apparent reason. The worries are relentless and impossible to control. Despite her best efforts at distraction and reassuring herself that everything will be fine, she has a sick feeling in her stomach that "everything is going to come unraveled."
Losing His Grip
Todd is losing control—at least that's how it seems to him. As a recent college graduate starting a new job in sales, Todd had just moved to a new city and for the first time had his own apartment. He was making friends; he had a steady girlfriend, and he was making great progress in his new occupation. His initial performance evaluations were extremely positive. Life was good; but all this suddenly changed for Todd on a cool November day while driving home from work. His job had been somewhat stressful, with Todd working extra hours to finish a large client project on time. He had gone to the gym afterward to do his cardio routine and work off some of the stress of the day. On his way home a strange and unexpected feeling overtook Todd. Suddenly his chest tightened and his heart started pounding rapidly. He felt lightheaded, almost dizzy, as if he was about to faint. He pulled off to the side of the road, turned off the car, and gripped the wheel. By now he was feeling tense and started to shake and tremble. He felt extremely hot and started gasping for breath, convinced he was suffocating. Instantly, Todd wondered whether he was having a heart attack, just like his uncle had had 3 years earlier. He waited a few minutes until the symptoms settled down and then drove to the emergency room. A thorough examination and medical tests revealed no physical problems. The attending physician called it a panic attack, gave Todd an Ativan, and told him to see his family doctor.
That first attack happened 9 months ago, and since then Todd's life has changed dramatically. He now has frequent panic attacks and is almost constantly worried about his health. He has cut back on social activities and now finds he is afraid to go places for fear of having another attack. He restricts himself to work, his girlfriend's apartment, and his own place, afraid to venture into new or unfamiliar territory. Todd's world has shrunk, dominated by fear and avoidance.
Dying of Embarrassment
Elizabeth is a painfully shy single woman in her mid-40s. Since childhood she has always felt anxious around other people and so avoids social interaction as much as possible. It seems like just about everything to do with other people makes her anxious—carrying on a conversation, answering the phone, speaking up in a meeting, asking a store clerk for assistance, even eating in a restaurant or walking up the aisle of a movie theater. All of these situations make her feel tense, anxious, and self-conscious as she worries about blushing and coming across as awkward. She's convinced that people are always looking at her and wondering what's wrong with her. On occasions she has had panic attacks and has felt incredibly embarrassed by her behavior in social settings. As a result, Elizabeth avoids social and public situations as much as possible. She has only one close friend and spends most weekends with her aging parents. Although very competent in her job as an office clerk, she has been overlooked for promotion because of her awkwardness around others. Elizabeth is caught in her own little world, feeling depressed, lonely, and unloved—trapped by her fears and anxiety over people.
Rebecca, Todd, and Elizabeth all experienced intense and persistent anxiety that caused significant distress and interference in their lives. Given that you've started reading this workbook, it is likely that fear and anxiety are causing a problem for you as well. Fortunately for the three individuals you just read about, each of them was able to make a new start by learning how to use proven psychological strategies to overcome debilitating anxiety. In this workbook we share with you numerous approaches that are used by effective therapists in their treatment of anxiety and its disorders. As will be evident, you too can begin afresh with greater understanding and more effective strategies that will enable you to overcome the burden of anxiety.
How Can This Workbook Help?
You can use this workbook on your own, but in our experience the methods you'll be using are even more effective when used in therapy with an experienced mental health professional. The methods in this book are based on cognitive therapy (CT), which was first developed in the 1960s by one of us (Aaron T. Beck) for the treatment of depression. In 1985 Beck and his colleagues published Anxiety Disorders and Phobias: A Cognitive Perspective, which outlined a new version of cognitive therapy for the treatment of anxiety. In 2010 we refined and updated the therapy in Cognitive Therapy of Anxiety Disorders: Science and Practice based on scientific findings on the nature and treatment of anxiety made in the last 25 years.
Today cognitive therapy (or cognitive behavior therapy [CBT]) is practiced by hundreds of mental health practitioners worldwide and has been shown in dozens of scientific clinical outcome studies to be an effective treatment for many forms of anxiety disorder: 60–80% of people with an anxiety problem who complete a course of cognitive therapy (i.e., 10–20 sessions) will experience a significant reduction in their anxiety, although only a minority (i.e., 25–40%) will be completely symptom free. This is equivalent to or better than the effectiveness of medication alone, but in a number of studies cognitive therapy produced longer-lasting improvement than medication alone. Cognitive behavior therapy is substantially more effective for anxiety than doing nothing or getting basic supportive counseling. Because of their known effectiveness, cognitive behavior therapies are now recommended as one of the first-choice treatments for anxiety by the American Psychiatric Association, the American Psychological Association, and the British National Health Service.
What Is Cognitive Therapy?
The term cognitive refers to the act of knowing or recognizing our experiences. So cognitive therapy is an organized, systematic psychological treatment that teaches people how to change the thoughts, beliefs, and attitudes that play an important role in negative emotional states like anxiety or depression. The basic idea in cognitive therapy is that the way we think influences the way we feel, and therefore changing how we think can change how we feel. The basic idea of the therapy can be expressed in the following way:
Life Situation, Event Thought
Feeling
(trigger) (perception, (tense, anxious)
interpretation)
Examples
Waiting for job
"I have no clue what to
Feel nervous,
interview (trigger) say; they'll think I'm an tense, butterflies in
idiot." stomach
Waiting for job
"I'm well prepared for
Feel calm, confident,
interview (trigger) this interview; I should safe
be able to make a good
impression."
What to Expect from a Cognitive Therapist
If you have severe anxiety and you've struggled with it for many years, you may find it necessary to seek out a qualified cognitive therapist to get maximum benefit from the cognitive therapy approach. You can use this workbook as a companion volume while your therapist uses our professional text Cognitive Therapy of Anxiety Disorders, which explains to therapists how to conduct cognitive therapy sessions for anxiety disorders. (As mentioned earlier, the workbook has been written so you can also use it on your own.) Even if you're not already working with a therapist, you might want to know more about what cognitive therapy is like.
A course of therapy for an anxiety disorder ranges from 6 to 20 individual sessions normally offered weekly at the beginning and then tapering to biweekly and then monthly sessions. There are three phases to treatment:
* Assessment. The first session or two focuses on assessing the nature of your anxiety problem. The therapist will ask lots of questions about the history of your anxiety, its symptoms, your everyday experiences with it, and how you've tried to cope. Most cognitive therapists also give clients questionnaires to complete at home. The goal of the assessment is to understand the nature of your anxiety and develop a treatment plan that will work for you.
* Intervention. This is the main part of cognitive therapy, which focuses on identifying the problematic thinking that is making you anxious, correcting these thoughts, helping you discover a new perspective on anxiety, and structuring action plans that will alter how you deal with episodes of anxiety.
* Termination. The final few sessions occur less frequently and focus on skills necessary for dealing with the occasional return of anxiety. Therapists refer to this as relapse prevention, and its goal is to ensure the person has the ability to cope with future experiences of anxiety without therapist assistance.
Cognitive therapy sessions follow a fairly typical structure, which is explained in Table 1.1. Although cognitive therapists differ on how strictly they adhere to this session format, most elements, if not all, will be present during most therapy sessions for anxiety.
In addition, cognitive behavior therapists adopt a particular therapeutic style that they believe provides the best context for learning how to overcome anxiety. These characteristics are summarized in Table 1.2. This therapeutic style, along with the characteristics of a good therapeutic relationship (trust, confidence in therapist's understanding, demonstrated concern and empathy, ease of self-disclosure, assurance of confidentiality), produces the best therapeutic environment for treatment of fear and anxiety.
Many mental health professionals have adopted elements of cognitive therapy into their practices, but only a few practitioners routinely offer a complete course of cognitive therapy or are formally trained as cognitive therapists. So how can you know whether your therapist is a cognitive therapist? The easiest way is to determine whether your therapist has formal certification in cognitive therapy through the Academy of Cognitive Therapy (ACT). Currently ACT has more than 600 members worldwide—psychologists, social workers, psychiatrists, and other mental health professionals who have passed strict competency standards in cognitive therapy. You can find a certified cognitive therapist in your region by going to the ACT website (www. academyofct.org). A therapist without ACT certification may offer many elements of cognitive therapy or cognitive behavior therapy. Knowing what cognitive therapy consists of will help you decide whether a therapist you're considering working with can offer enough of the elements of cognitive therapy to help you.
How to Benefit from This Workbook
We wrote this book for people who have varying levels of fear and anxiety and to help alleviate, specifically, panic attacks, social anxiety, and generalized anxiety and worry, the three types of anxiety exhibited by Rebecca, Todd, and Elizabeth. If you identified with symptoms of any one or all of these people, you'll find help in this book. If you're using it along with a therapist, the therapist could use the workbook as a companion to your treatment by assigning certain chapters, special sections, or particular exercises that would enhance the therapy experience and help you make quicker and more effective progress in reducing anxiety. Many of the exercise forms, diaries, and rating scales in this book are modified reproductions from the therapist manual Cognitive Therapy of Anxiety Disorders.
Again, you can work through the book on your own, although you'll get more out of it if you seek professional treatment, because working on difficult emotions like anxiety is a matter of not only knowing what to do but also learning how to apply this knowledge to your everyday experiences of anxiety. Either way, you'll gain the greatest benefit if you:
* Have a significant problem (anxiety is an important issue for you because it's causing substantial distress and interference in your life).
* Are highly motivated (ready to devote time and effort to getting better).
* Have positive expectations (expect you can make improvements in anxiety whether you're working with a therapist or using this workbook on your own).
* Can approach your anxiety as a learner (willing to discover new ways to understand and respond to your anxiety experiences).
* Are willing to work on the role you may play in making anxiety worse (it will be difficult to benefit from the cognitive therapy approach if you believe other people or your circumstances are to blame for your anxiety).
* Can be aware of and write about your thoughts and feelings (can "catch" your thoughts and feelings and talk about them to a therapist or write them down in this workbook).
* Can take a critical, investigative approach to your thoughts and behavior (are ready to use this workbook to look critically at the various elements of your anxiety experiences).
* Are willing to invest time and effort in completing action-based exercises (i.e., homework).
You may be wondering whether the cognitive therapy approach can work for you because you don't fully meet all these criteria. We're not suggesting that you should avoid treatment or set aside this book if you don't feel like you measure up to these criteria. Rather these criteria are "readiness for change" indicators. People with many of these characteristics will probably get a lot more out of this workbook than people with only a few characteristics. A therapist can help you maximize your desire and ability to loosen anxiety's grip on your life, and this book will help you stay motivated and on track with various reminders, summaries, and troubleshooting tips (such as the shaded boxes you've already seen in this chapter). You may also find as you get into the workbook and do the exercises that your "readiness for change" gets stronger and your openness to the cognitive approach improves.
The best way to work through this book is mostly in order, reading the first eight chapters and then turning to the specialized cognitive therapy chapters that provide specific interventions for panic attacks, social anxiety, and worry (Chapters 9–11) if you need more help. The first two chapters contain a brief introduction to cognitive therapy and an invitation to take another look at your own anxiety. In Chapter 3 you'll read about the anxious mind—the cognitive view of anxiety. Then, in Chapter 4, you will learn about how cognitive therapy works and what types of exercises you'll be doing to address your anxiety using this book. In Chapter 5 you'll create your own anxiety profile, which will be packed with information that you'll use throughout the book's exercises so that you really target your unique problems and identify your strengths. You should complete the exercises and worksheets as you read through Chapters 1–5 of the workbook.
In Chapters 6 and 7 you'll learn the techniques that will help you lessen anxiety and its hold on you. We suggest you read those two chapters without doing the exercises and then follow the instructions in Chapter 8 for putting together the cognitive and behavioral techniques into an Anxiety Work Plan that you can use to systematically carry out your cognitive therapy program. Then start implementing the work plan by doing the exercises and worksheets you've selected from Chapters 6 and 7.
(Continues...)
Excerpted from The Anxiety and Worry Workbook by David A. Clark, Aaron T. Beck. Copyright © 2012 The Guilford Press. Excerpted by permission of The Guilford Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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