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 prin- ciples and practices relevant to each of the lessons described in the
MAW workbook, and () ask the clients to read the relevant material from the MAW workbook and
complete the 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 de- scribed. 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 diagno- sis of generalized anxiety disorder (GAD) in
the Diagnostic and Statisti- cal Manual of Mental Disorders, th edition, Text Revision (DSM-IV-
TR), but will also be useful for those individuals who have occasional worries or tension, but do not
meet the severity criteria for GAD. The DSM-IV-TR criteria for the diagnosis of GAD are given
later. The key feature of GAD in the DSM-IV-TR is excessive and pervasive worry for at least
months. In this context, excessive worry means that the intensity, duration, or fre- quency of worry
exceeds the actual likelihood or negative consequences of the event that is the object of worry. In
addition, the worry has the
1

Chapter 1 Introductory Information for Therapists

quality of being uncontrollable; that is, the individual finds it difficult to keep worries from
interfering with his or her concentration on tasks at hand and has difficulty ending the worry
process. The pervasiveness of worry refers to a generalized focus on minor, everyday events or a
focus on more than one major life circumstance (i.e., job, family, finances); these foci may shift
repeatedly during the -month period. In addition, the worry is associated with physical symptoms of
tension, such as restless- ness, being easily fatigued, feeling keyed up or on edge, irritability, and
sleep disturbances. This tension is seen as representing a state of motor readiness to respond to
threat.
Although the person may not always identify his or her worries as being excessive, he or she will
report subjective distress due to unceasing worry, difficulty controlling the worry process, or
associated impairment in func- tioning. In many cases, the therapist can make a judgment about
whether the worry is excessive by thoroughly assessing the person’s life circum- stances that are
relevant to the worry. For example, if one of the person’s worries is finances, the therapist may need
to ask about the person’s in- come, debts, savings, and other assets. We judged financial worries to
be excessive in one of our clients, a radiologist, who earns several hundred thousand dollars a year
and has large sums of money invested in stocks and bonds, but we would be hard pressed to do so
in a client who had just lost his job and had meager savings that were not sufficient for pay- ing his
monthly bills. In other cases, the therapist may need to ask the person to compare his degree of
worry relative to others belonging to the cultural groups the person identifies with. For example,
one of our clients was a devout member of a congregation that believed that homosexual- ity was
immoral, and she worried a great deal about whether her sons would grow up to be gay. When we
asked her to compare her worry about this issue with that experienced by other mothers of young
boys in her congregation, it became clear that other mothers did not worry about this possibility
nearly as much as our client, even though they shared her conviction that homosexuality was
immoral.
2
DSM–IV-TR Criteria for Generalized Anxiety Disorder (includes Overanxious Disorder of Childhood)

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 hav- ing a panic attack (as in panic
disorder), being embarrassed in public (as in social phobia), being contaminated (as in obsessive-
compulsive disorder), being away from home or close relatives (as in separation anxiety disorder),
gaining weight (as in anorexia nervosa), or having a serious illness (as in hypochondriasis), and is
not part of posttraumatic stress disorder.
E. The anxiety, worry, or physical symptoms cause clinically signifi-
cant distress or impairment in social, occupational, or other im- portant 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.,
3
hyperthyroidism), and does not occur exclusively during a Mood Disorder, Psychotic Disorder, or
Pervasive Developmental Disorder.
(From American Psychiatric Association, .)
What if Other Problems (Diagnoses) Are Present?
Among people suffering from worry and tension, it is not uncommon to also present with some
depression or with a personality disorder charac- terized by histrionic, avoidant, dependent, or even
schizotypal features. Treatment with the MAW program is not precluded by any of these prob- lems
as long as they are not the major focus of treatment. Thus, if a client experiences GAD and is also
depressed, it is appropriate to proceed with the MAW program if GAD is the problem associated
with the greatest impairment in the client’s functioning. On the other hand, the depres- sion 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 ex- periencing excessive worry
and tension, despite undergoing a major life stress, such as marital difficulties or financial
problems. Similarly, the MAW program would not be appropriate if the client experiences panic
attacks and worries only about having more panic attacks or is depressed, without the complication
of worry and tension. A different treatment protocol is used for people suffering from panic attacks
and associated apprehension about panic and agoraphobic avoidance. This is the Mas- tery of Your
Anxiety and Panic (MAP) program, which was developed at the Albany Center for Stress and
Anxiety Disorders and substantially revised and updated at our Centers at Boston University
(directed by Dr. Barlow) and the University of California at Los Angeles (directed by Dr. Craske).
Information on obtaining the MAP protocol can be found at www.oup.com/us/ttw.
Mental health professionals may wish to screen patients using the Anxi- ety Disorders Interview
Schedule for DSM-IV (ADIS-IV), which was de- vised for this purpose. The ADIS-IV generates
diagnoses for all DSM-IV mood and anxiety disorders, and includes a brief screen for psychotic dis-
4
orders and substance abuse. Extensive psychometric studies using earlier versions of the Anxiety
Disorders Interview Schedule (ADIS) indicate that adequate reliability can be obtained with the
ADIS for the diagnosis of mood and anxiety disorders (Barlow, ; Brown, DiNardo, Lehman, &
Campbell, ). Information on obtaining this interview schedule can be found at
www.oup.com/us/ttw.
Medication
Many people suffering from worry and tension will be referred to mental health professionals while
already taking psychotropic medication, most often prescribed by primary care physicians. In our
experience, over half of these individuals are taking selective serotonin reuptake inhibitors (such as
paroxetine [Paxil]) or serotonin norepinephrine reuptake inhibi- tors (such as venlafaxine
[Effexor]), while some are taking variety of other drugs, most commonly, low doses of
benzodiazepines, other minor tranquilizers, or tricyclic antidepressants. We do not recommend that
clients decrease their medication during the course of the MAW pro- gram. Instead, we suggest that
clients continue with whatever dosage of medication they are currently taking, until they complete
the program. In this way, they will have skills for tension and worry management as the
medications are withdrawn.
We actively discourage clients from increasing dosages of medications, particularly
benzodiazepines, during the course of treatment with the MAW program. This policy is based on
evidence suggesting that high dosages of benzodiazepines initiated concurrently with a cognitive-
behavioral treat- ment program for anxiety may interfere with the cognitive-behavioral program
(Lavallee, Lamontagne, Pinard, Annable, & Tetrault, ). In addition, an increase in the dosage of
medication confounds the evalua- tion of the 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. Re- member that any major change in
medication must be closely moni- tored by the prescribing physician.
In our experience, a large proportion of patients successfully completing the MAW program decide
to discontinue medication use on their own,
5
without any outside urging to do so. Notwithstanding this general ten- dency, issues of medication
withdrawal are discussed in workbook chap- ter (see chapter ) for those clients who do need some
encouragement to initiate withdrawal. We have found that the MAW program is very helpful as an
aid to discontinuation of medication for clients and pre- scribing physicians who choose to do so. If
withdrawal from benzodi- azepines is particularly difficult and includes panic, then the MAP pro-
gram may be useful and has often been used with success under similar circumstances.
Who Should Run the MAW Program?
The question of who should run the MAW program has not been fully examined. However, we have
attempted to present the program in suffi- cient detail such that any mental health professional
should be able to supervise its application. The major prerequisite is being conversant with the
nature of anxiety and worry; some of the basic information regard- ing these topics is presented in
chapter . We also believe that it is im- portant that the therapist have sufficient understanding of the
concep- tual foundations underlying treatment to be able to tailor the various sessions to best suit
the needs of each individual client undergoing the MAW program. The goal of this therapist guide
is to impart this under- standing. The references listed at the end of this guide provide more de-
tailed and in-depth information on these topics. Finally, we also believe that it is useful for
therapists to have some knowledge of the basic prin- ciples of cognitive and behavioral
intervention.
Group versus Individual Sessions
In our center, the MAW program has been delivered in both individual and group formats. While
we have not yet formally compared these for- mats, the program seems equally effective in either
format. Thus, a de- cision on whether the program should be administered in a group ver- sus an
individual format should probably be resolved on a site-by-site basis, according to the preferences
of the therapist. Health maintenance organizations tend to administer this program in groups of six
to eight
6
to capitalize on the economies associated with this mode of administra- tion. On the other hand,
private practitioners may not wish to make clients wait until a group forms, and thus find it more
suitable to administer the program on an individual basis. We customarily limit the number of
clients to no more than six, when administering the program in a group format. We find that it is
difficult to allocate sufficient individual atten- tion to clients in the course of a -minute group
session if the group is much larger than six. On the other hand, there is no formal research sug-
gesting the optimal number of clients in this treatment program.
Session Style
Given the large amount of information that is disseminated to clients in this program, it may be
difficult to resist the tendency to lecture. How- ever, it is important that the therapist adopt a
“Socratic” questioning style whenever possible. There is widespread consensus among leading
cogni- tive therapists around the world regarding the importance of this point, and there is empirical
evidence from the social psychology literature sup- porting this position. This research shows that
people hold onto beliefs more strongly when the beliefs are self-generated rather than when they are
spoon-fed. Thus, it is important to try to lead clients to various con- clusions through questioning.
The examples below illustrate an undesir- able “spoon-feeding” style and a more desirable
“Socratic” style.
Example 1
Anxiety is universal and sometimes adaptive.
“Spoon-Feeding” Style
T: Anxiety is a natural emotion that is experienced by every single person. In fact, it is probably the
most basic of all emotions, being experienced in all species of animals, right down to the level of
the sea slug. Anxi- ety is not bad, in and of itself, and in many cases, it is a productive, driving
force. However, anxiety can vary tremendously in severity, from
7
mild uneasiness to extreme terror and panic, and can vary in frequency from occasional distress to
seemingly constant unease.
“Socratic” Style
T: So, what are your goals for this program? In concrete terms, how will
your life be 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 over- whelmed. 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 sub- ject I was pretty good at, I
wouldn’t get too nervous before tests, but I did get a little bit nervous. Because I was a little
nervous, I probably spent more time studying than I would have otherwise.
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?
8
Example 2
Overcautiousness and safety behaviors block the opportunity for learn- ing 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 as- sumptions, such as “I’m different from everybody else” or “I’ve only sur- vived 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
under- mine the effects of treatment. After eliciting objections, you can apply the cognitive
restructuring techniques to them. The following are help- ful questions for eliciting objections:
9
Can you think of any reasons why this might not apply to you? Does that fit with your experience?
Therapists should also clearly communicate to clients that cognitive therapy is not about the power
of positive think- ing; rather, it’s about realistic thinking, or “finding the truth.” Experi- enced
cognitive therapists are also fond of saying that, in cognitive ther- apy, the therapist never loses.
What is meant by this is that almost any experience that the client has, progress or distress, can fit
into the cogni- tive model. Thus, even if someone has a very intense episode of height- ened anxiety
during treatment, you can always find some way of using it to demonstrate the importance of one of
the factors in the model, (e.g., threatening misinterpretations, the role of cognitive avoidance or
overcautiousness in maintaining anxiety, hypervigilance).
As therapy progresses, the therapist should become less direct, to pro- mote 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 cog- nitive restructuring, the
therapist should try to assist the clients to chal- lenge their own thoughts by asking questions such
as the following.
What question or questions could you ask yourself to help you challenge that automatic thought the
next time you have it? If the program is being implemented in a group format, the therapist might
elicit attempts by the other group members to be cognitive restructuring coaches in the later
sessions through questions such as the following.
Can anyone think of a question that might be helpful to in challenging her automatic thought? In
our experience, when clients have more emotional distance from a worry, such as when discussing
some- one 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
10
gets stuck when trying to restructure one of his or her own worries, we often find it helpful for the
therapist to use the “put the shoe on the other foot” technique. That is, the therapist can ask the
client to con- sider what he or she might say to a good friend or relative, or even the therapist, if one
of these other people were experiencing the worry under discussion.

We find that one of the most common difficulties that arises when work- ing with anxious clients is
ambivalence or resistance about completing self-help assignments. The therapist must keep in mind
that, when im- plementing cognitive restructuring and exposure therapy, we are asking the client to
do exactly what he or she is anxious about and has been avoiding, to some degree. At times when
the client does not readily com- ply with such interventions, we find it useful to asssume that the
person must have some motivation for change, or he or she would not keep coming to see us. Thus,
our task becomes helping the client to articu- late, and perhaps even strengthen, his or her
motivation for change. One way to do this involves borrowing the approach advocated in Motiva-
tional Interviewing, developed by William R. Miller and his colleagues and side with the resistance
(Miller & Rollnick, ; also see Newman, ). “Siding with the resistance” simply refers to reflecting
back to the client what the therapist understands to be the client’s reasons for main- taining the
status quo and resisting change, with an attitude that con- veys that these reasons have validity and
are understandable (e.g., “It sounds like you don’t want to heighten your awareness of the automatic
thoughts that might be contributing to your anxiety because you believe that doing so will make you
even more anxious than you already are; it makes sense to me that you would want to avoid
focusing on your au- tomatic thoughts, given your belief”). Assuming that the invidual is
ambivalent (i.e., has some motivation for change in addition to motiva- tion to avoid), siding with
the resistance will encourage the client to side with the motivation for change and growth. What if
our assumption of ambivalence is wrong, and the client does not have any internal motiva- tion for
change? Might siding with the resistance backfire and lead to premature termination? Our view is
that it may well be true that siding
11
with resistance, when there is no internal motivation to change, will lead to the client deciding that
therapy is not right for him or her at the pres- ent time and terminating the therapy. However, we
also believe that there is a lot of wisdom to the old joke: How many therapists does it take to change
a light bulb? One, but the light bulb has to want to change. That is, if the client has no internal
motivation to change, we don’t be- lieve that the therapy would have progressed very far anyway,
and if we do side with the resistance, at least the client will feel understood and may be more
willing to return to therapy in the future, if and when some internal motivation develops.
Strains on the Therapeutic Alliance
Important research by Castonguay and his colleagues (Castonguay, Gold- fried, Wiser, Raue, &
Hayes, ; Castonguay, Schut, Aikins, & Con- stantino, ) suggests that the therapeutic alliance is
important, even when conducting cognitive-behavioral therapy. More specifically, Cas- tonguay’s
work has shown that therapists’ rigid application of standard cognitive-behavioral techniques in
response to problems in the therapeu- tic alliance correlates negatively with outcome. When a client
expresses hostility toward the therapist or otherwise expresses negative opinions about the
therapist’s behavior, it is probably not advisable to try to repair the strain on the alliance solely, or
even initially, by identifying the neg- ative reactions as evidence of the 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 em-
pathy for the client’s emotional reaction and taking at least some re- sponsibility for contributing to
the strain on the alliance. In our experi- ence, it is useful to end every session not only by asking the
client to summarize important points but also by asking if the client had any nega- tive reactions to
the session (e,g,, “Did anything rub you the wrong way?”). We believe that doing so may not only
help to catch some strains that the therapist did not pick up on during the course of the session but
also, and even more importantly, communicates an attitude of openness to discusssing such
reactions. Such an attitude can go a long way toward
12
creating an alliance that can more readily withstand such strains, and may even prevent some strains
from occurring.
Frequency of Meetings
The MAW workbook is divided into chapters. All clients should com- plete chapters through , ,
and . Workbook chapter (on safety be- haviors and behavioral overcautiousness, including
procrastination and other subtle patterns of avoidance) and workbook chapter (on dis- continuing
medication) may be completed at the discretion of the thera- pist. If safety behaviors or behavioral
overcautiousness is substantial, chap- ter may take several sessions to complete.
Ordinarily, the therapist will meet with the client or group once per week and assign readings from
the MAW workbook as well as various ex- ercises to be practiced during the week. Later sessions
may be held bi- weekly to give the client more practice in applying the skills more inde- pendently.
Some therapists, however, may wish to accelerate treatment by scheduling two sessions per week
or, alternatively, by trying to cover two lessons during weekly -minute or -minute sessions. Either
way, the duration of the treatment program would be cut approximately in half. Initial evaluations
of the program yielding successful results have been based on a pattern of administration of one
lesson per week for the first eight weeks, with the last four sessions held on a biweekly basis.
Nevertheless, there is no reason to believe that certain clients could not achieve equal benefits from
the program delivered in a shorter period, if they are prepared to dedicate the extra time needed to
the tasks.
Does Every Person Require the Entire Program?
We strongly suggest that each person complete workbook chapters through and , even clients who
feel greatly improved after several ses- sions. If behavioral avoidance and safety behaviors are a
problem, we suggest that the individual complete workbook chapter as well. Simi- larly, if
assertiveness or time management is a problem, we suggest that the person complete chapter . We
have observed that people who ter-
13
minate early because they are feeling better may be prone to higher rates of relapse than those who
carry out the entire program. It should also be evident that there is a progression in the program,
with each chapter building on the last and adding new information, interventions, and ex- ercises.
Until we become aware of evidence that some parts of the pro- gram might be superfluous, we will
continue to advise that each client complete all aspects of the program.
Working with Ambivalence and Resistance
The first “revolution” in the development of potent psychosocial treat- ments during the past decade
has been the “manualization” of these treat- ments. Since these are structured programs for
particular disorders, they can be written in sufficient detail to allow trained therapists to adminis- ter
them in approximately the same fashion that they were proven effec- tive. This does not imply that
therapeutic skills are no longer required. In fact, psychotherapeutic skills are valuable as the client
proceeds with the program.
The second stage of this “revolution” is creating a rendition of the struc- tured program that is
appropriate for direct distribution to clients who are working under therapeutic supervision. The
MAW program is one of a few exemplars of the adaptation of a scientifically sound program that is
written at the client’s level and can be a valuable adjunct to pro- grams administered by
professionals from a number of disciplines. There are many advantages to administering the
program in this manner, in- cluding the following:
■ Because the program is self-paced, the client can proceed at his or her own rate. It was noted
earlier that some therapists or clients may want to finish the program in half the time by holding
ses- sions 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 be- tween irregularly scheduled
sessions is of substantial benefit.
14
■ The client may consult the workbook when he or she is confused or overwhelmed. While many
concepts may be readily apparent to trained therapists, we often lose sight of the fact that clients
who seem
to comprehend ideas during a session often get confused about the same ideas after leaving the
session. One of the greatest benefits of the workbook is the opportunity for clients to reexamine
pertinent conceptualizations, explanations, and instructions be- tween sessions. This may be
especially helpful during episodes of intense anxiety, when many clients understandably report the
greatest difficulty remembering their newly learned coping skills. The MAW workbook often
becomes the client’s bible during the course of treatment. Some clients go so far as to take the
work- book, or portions of it, with them everywhere they go, to have it ready as a handy guidebook.
For many of these clients, this has proved very helpful.■ Family members and close friends can
read the workbook. Re- search at our center (Barlow, O’Brien, & Last, ; Cerny, Bar- low, Craske, &
Himadi, ) has shown that there is a significant benefit to having family members, especially
spouses, be apprised of and involved in treatment for at least one type of anxiety problem, panic
disorder with agoraphobia. For example, clients whose spouses were involved in treatment did
much better at -year follow-up than those whose spouses were not involved. Recent research by
Chambless and Steketee () has shown that greater levels of hostility expressed toward the client by
relatives (% of whom were spouses) prior to the start of therapy pre- dicted poorer response to
cognitive-behavioral therapy for panic disorder with agoraphobia and obsessive-compulsive
disorder. In contrast, nonhostile criticism—being critical of specific behaviors, without devaluing
the client—actually predicted better response to the therapy (Chambless & Steketee, ). We have
recently obtained identical results in a study of the efficacy of the major components of the MAW
program in clients with GAD who were in committed relationships (Zinbarg, Lee, & Yoon, ).
There are several possible ways in which family participation may benefit the client. First, any
attempts to undermine the program,
15
either intentionally or unwittingly, may be prevented if family members are familiar with the nature
of the difficulty and the ra- tionale underlying the different exercises that the client is perform- ing.
Similarly, it is possible that partners or family members who are very hostile toward the client
might be less so if they had a greater understanding of the processes maintaining the worries.
Second, family members can be very beneficial in encouraging the client to conquer some of the
overcautiousness in behavior that often accompanies anxiety problems. Of course, there are some
clients who would prefer that their spouse or family members be completely uninformed about their
problem and the treatment program. In these cases, we invite the client to consider the poten- tial
benefits of sharing their problems with their spouses and try to restructure any excessive or
unrealistic worries that they may have. Typically, these worries focus on apprehension that the
family will think that they’re crazy or will be openly antagonistic to their efforts. In our experience,
this very rarely happens. If the worries are particularly strong, we may bring the spouse into the
sessions, either initially or for all of the sessions. In some of our group treatment programs, groups
typically consist of four to six clients and their spouses, for a group size of eight to twelve.
■ Clients can consult the workbook at the end of the program. The MAW program advises clients to
be prepared for the occasional recurrence of intense anxiety under especially stressful circum-
stances. The workbook can be a reservoir of comfort during these periods, and even may prevent
the development of a full-blown relapse. In fact, for some clients, simply having the workbook
nearby during these times seems to serve an anxiolytic function.
■ 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.
16
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 question- naire 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 use- ful. The first of these is the Penn State Worry
Questionnaire (PSWQ ), de- veloped by Borkovec and colleagues (Meyer, Miller, Metzger, &
Borkovec, ). The second is the Stress subscale from the Depression-Anxiety- Stress Scales (DASS;
Lovibond & Lovibond, ). The DASS-Stress scale is a good measure of the tension characteristic of
generalized anxi- ety, and research in our Center has shown that it effectively discriminates patients
with GAD from those with other anxiety disorders (Brown, Chorpita, Korotitsch, & Barlow, ).
These two measures are particu- larly useful for assessing changes associated with the MAW
program be- cause each measures one of the two central diagnostic features of GAD and there are
norms are available for each of them (e.g., Crawford & Henry, ; Gillis, Haaga, & Ford, ). In our
experience, most clients begin treatment scoring at least two standard deviations above the non-
clinical mean on these and other related measures, but score no more than one standard deviation
above the nonclinical mean on most mea- sures (i.e., or less on the PSWQ and or less on the
DASS-Stress scale) after sessions of treatment with the MAW program.
Full Workbook versus Installments
Some very capable therapists who have been working with the MAW program since its initial
development report a preference for distribut- ing the workbook chapters in several segments. In
this way, they ensure that clients don’t skip too far ahead and are better able to focus on the material
at hand. These therapists have used loose-leaf binders or simi- lar mechanisms to put the various
segments of the workbook together.
On the basis of this feedback, we have carefully thought about supply- ing the MAW program in
such formats, but have decided not to do so at
17
this time. The disadvantage of this practice is that individual chapters are more prone to be lost, so
that clients will not have complete MAW workbooks when the program ends. Obviously, having an
incomplete workbook will make it difficult to consult in the months and years ahead. In addition, it
does not particularly trouble us when clients do some jumping around. As a generalization, we find
that the more time a client spends reviewing the MAW program, the deeper his or her com-
prehension and the greater his or her improvement. If the client wants to discuss something or read
from a future lesson during a session, we simply redirect him or her and keep focused on the current
assignment.
In the final analysis, there is no empirical evidence that we are aware of that addresses this issue.
Thus, our preference notwithstanding, we cer- tainly do not dissuade therapists from distributing the
MAW workbook in segments if they prefer to do so.
Fees for the MAW Treatment Program
Typically, the expense of the MAW treatment program materials is in- corporated into a 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 respon- sibility and cost of ordering the workbook
themselves. Thus, the treat- ment package, consisting of the Client Workbook, the Monitoring
Forms packet, and the Worry Record pad, may be bought in bulk and resold as each client begins
the program, or ordering information may be given to clients, with directions to buy the components
before they begin their program.
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, in- cluding cognitive restructuring, relaxation training,
and worry imagery
18
exposure (Zinbarg, Lee, & Yoon, ). Fifty percent of the individuals who completed the treatment
had returned to within one standard de- viation of the nonclinical mean on at least four of our five
outcome mea- sures at the end of the program, and can therefore be regarded as having achieved
high-end state functioning. Another .% were markedly im- proved (returning to within one standard
deviation of the nonclinical mean on three of the five outcome measures), and another % were
somewhat improved (returning to within one standard deviation of the nonclinical mean on two of
the five outcome measures). Thus, a total of .% were at least somewhat improved.
Wetherell, Gatz, and Craske () adapted the MAW program for a late-life sample (mean age, years)
and compared it to a discussion group pertaining to worry-provoking topics and to a wait-list
control. The MAW program was clearly more effective than the wait-list control and marginally
more effective than the discussion group. Stanley, Beck, Novy, Averill, Swann, Diefenbach, and
Hopko () also conducted a treatment study among older adults (mean age, . years) in which they
compared a cognitive-behavioral therapy package that included many of the components of the
MAW program with a minimal contact treat- ment that involved weekly phone calls to assess
symptom severity and provide minimal support. The cognitive-behavioral therapy was clearly
superior to the minimal contact treatment. However, consistent with other evidence for poorer
treatment response in older age groups, the rates of high end-state functioning were quite low in the
reports of both Wetherell et al. () and Stanley et al. ().
19
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Chapter 2
The Nature of Anxiety and Generalized Anxiety Disorder
For a full exposition of this theoretical model, see Barlow () and Zinbarg (). In brief, interactions
among the following factors are recognized in the genesis of GAD: negative affectivity or
neuroticism; attentional vigilance and narrowing to signals of potential threat; a ten- dency toward
interpreting ambiguous situations as threatening; passive avoidance, overcautiousness, or
procrastination; perceptions of uncon- trollability and unpredictability; and cognitive avoidance,
distraction, or other active efforts to resist or neutralize worrying.
Conceptualization of the Development of Excessive Worry and Anxiety
A diathesis-stress model is postulated to account for the initial develop- ment of excessive worry
and anxiety (figure .). First, it is important to recognize that anxiety is universal and serves an
adaptive function. Anxi- ety arises from activity in a neuropsychological system whose functions
are to detect signals of danger and to prepare to cope with threat. The closely related emotion of
panic, or fear, implies a discharging of the fight-or-flight mechanism when threat is imminent.
Many of the physio- logical symptoms of a panic attack may be seen as the activation of the
underlying physiology necessary to support the immediate and strenu- ous action involved in escape
or fighting. Anxiety, on the other hand, is associated with simultaneous excitation and inhibition of
the fight-or- flight mechanism in response to signals of potential or approaching threat that is not
yet imminent. In other words, anxiety involves a prepa- ration, or priming, of the fight-or-flight
mechanism, making it easier to activate this mechanism (figure .). This priming accounts for the
ten-
21
Synergistic Vulnerabilities
Biological Vulnerabilities
Generalized Psychological Vulnerability
Stress
Generalized Anxiety
Depression
sesehtaiD
False Alarms (panic)
Figure 2.1 Diatheses–stress model of the development of generalized anxiety and depres- sion. Redrawn from Barlow (),
with permission.

sion that is often associated with anxiety. When the threat of danger is real, anxiety is crucial to our
survival. Seen in this light, it would be sur- prising if someone were born without the capacity to
experience anxiety.
There is considerable evidence showing that the reactivity, or sensitivity, of the anxiety system has
an inherited component (biological vulnera- bility). This component, labeled “negative 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 par- ents. Rather, it is believed that this predispositional variable of physio- logical
arousability interacts with stressful life events to produce intense anxiety. That is, the tendency to
experience anxiety runs in families, and for reasons not fully understood, some people respond to
stress with ex- cessive worry and tension, whereas others may experience panic attacks,
hypertension, headaches, and so on.
22
No threat potential
Threat potential
Preferred mode of safety and control
Worry: preparation and readiness
Approaching threat Anticipatory anxiety:
mobilization and vigilance
Imminent threat Fear and panic: 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 in- herited strong level of
physiological arousability combines with a learning history that fosters the perception that aversive
events are unpredictable and uncontrollable (psychological vulnerability). For such a person, the
tendencies to perceive threat to be ever-present, or lurking around every corner, and to be constantly
on guard and aroused in preparation for dealing with danger become understandable. There is also
evidence to suggest that depression can emerge out of chronic anxiety, or as a com- plication of
chronic anxiety, in some people (in figure ., this is repre- sented by the arrow from generalized
anxiety to depression).
The case of Rick is a good clinical representation of these constructs. Rick was a computer
programmer who was robbed years ago in the parking garage of his condominium complex. The
robbery took place at 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-
23
stantly anxious person. Since the attack, Rick has had difficulty relaxing, and he feels constantly on
edge and vulnerable to ever-present danger in his surroundings. This is accompanied by a high level
of startle reactiv- ity. Rick feels a need to be on guard, since he attributes the mugging to a lack of
readiness. In other words, he believes that, had he been ready at the time, he would not have gotten
out of his car or he would have done something to avoid being mugged. Therefore, it remains
crucial to him to be always ready and on guard now, to be prepared for further un- predictable
dangers. What he had once perceived as being a safe world was upset by this unexpected event, and
now his whole sense of safety and danger has been altered. Clinically, his guardedness was readily
ob- served when he was asked to do relaxation exercises. He reported that, every time he tried to
relax, he would become more anxious. He felt in- creasingly vulnerable to more bad things
happening if he allowed him- self to relax.
Conceptualization of Worry within Generalized Anxiety Disorder
All of us experience occasional worry and anxiety, especially when under stress. Moreover, it
appears that most of us tend to worry about the same themes, regardless of whether we have GAD
or not. When these worries occur infrequently and are controllable, they are considered realistic and
normal worries. Research from our Center and elsewhere has suggested that, phenomenologically,
the uncontrollability of worry may be the prime pathological feature of worry associated with GAD
(Borkovec, Shadick, & Hopkins, ; Craske, Rapee, Jackel, & Barlow, ).
The processes that serve to maintain high levels of anxiety are hyper- vigilance and cognitive biases
favoring the processing of threat at early stages of processing (e.g., preattentive scanning for threat,
favoring threat- ening interpretations of ambiguous stimuli), avoidance behaviors (that become
more pronounced and observable, depending on the specificity of the situational cues that set the
occasion for anxiety and the extent to which overt avoidance is possible); and cognitive avoidance
at later stages of procesing, including both distraction and the shift away from imag- istic
processing of threat and toward verbal-linguistic processing that is characteristic of the process of
worry (Borkovec, Shadick, & Hopkins,
24
; figure .). Individuals characterized by preattentive scanning for threat and a bias toward
threatening interpretations of ambiguous events would be more likely to identify mildly threatening
stimuli and to en- code ambiguous stimuli as threatening. As a result, such individuals would
experience anxiety in response to cues that others do not find threaten- ing. Moreover, it has been
shown that the preattentive scanning for threat occurs at a relatively early and “automatic” level of
information process- ing, outside of conscious awareness. Hence, the individual may not even be
immediately aware of the triggers of his or her anxiety, experiencing worry, characterized by a
vague sense of dread and apprehension, with- out even knowing what he or she is worried about! In
any event, the au- tomaticity of this preattentive bias is almost certain to lead to the expe- rience of
worry and anxiety as being intrusive.
Though avoidance behavior is not as obvious in patients with GAD as it is in patients with other
anxiety disorders, patients with GAD neverthe- less do engage in subtle patterns of avoidance,
including checking and pre- ventive behaviors, procrastination, and attempts to control worry, such
as cognitive avoidance and distraction (e.g., Brown, Moras, Zinbarg, & Bar- low, ; Craske, Rapee,
Jackel, & Barlow, ; Hoyer, Becker, & Roth, ; 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 re- sources that are devoted to such planning, the fewer
there are to evalu- ate the realistic likelihood and impact of the threat. Thus, worry and dis- traction
increase the likelihood that the cues triggering unnecessary or disproportionate anxiety retain their
anxiety-provoking properties. Such cognitive avoidance strategies undoubtedly must be reinforced
by the immediate relief that they might produce. However, this relief is likely to be short-lived, as
there is evidence documenting the difficulty of sus- taining distraction for very long (Wegner,
Schneider, Carter, & White, ; Wegner & Erber, ; Wenzlaff, Wegner, & Roper, ). This evi- dence
suggests that thought suppression produces an automatic priming of the unwanted thought (Wegner
& Erber, ). Thus, thought sup-
25
26
Evocation of Anxious Propositions (situation contexts, unexplained arousal, or other cues)
Negative Affect
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)
Attentional Shift to self-evaluative focus (on physiological or other aspects of responding)
Dysfunctional
Intensification Performance
and/or lack of concentration on task at hand
Hypervigilance and
Additional Increases Cognitive Biases
in Arousal
Attentional biases: enhanced recognition of threat Attention narrowing on sources of threat
Interpretative biases Memory biases
Attempts to Cope Characterized by:
(Possible) Avoidance
of situational context or other aspects of negative affect (e.g., arousal), if feasible
Process of Worry Heightened verbal and linguistic capabilities and restricted autonomic activity to support
(often futile) attempts to plan and problem-solve
Avoidance of core negative affect
Figure 2.3 The process of anxious apprehension. Redrawn from Barlow (), with permission.
pression paradoxically increases the accessibility of the unwanted thought, increasing the likelihood
that the individual’s processing resources will be automatically “recaptured” by the threat cues that
initially triggered the worry episode. This inability to terminate bouts of worry and pro- vide more
than momentary relief, together with the intrusive quality of the initiation of worry, contribute to the
sense of uncontrollability of worry that appears to distinguish normal worry from worry associated
with GAD.
As alluded to earlier, Borkovec and his colleagues (Borkovec, Shadick, & Hopkins, ) have
suggested that the process of worry itself reduces the generation of imagery, particularly those
aspects of imagery that en- code efferent commands to the autonomic system. They further suggest
that this tendency is strongest among people with GAD (see also Free- ston, 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 (Borko- vec & 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 ef- ferent 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 stim- uli, 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” worri- ers 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 rela- tively accurate
appraisal of an unrealistic danger (perhaps as a result of staying with the initial threatening image
long enough for natural ha-
27
bituation and decatastrophizing processes to operate) or by the formu- lation of a more or less
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 nega- tive 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 vo- litional avoidance of elaborative processing of
threat. In turn, efforts to distract paradoxically serve to increase the accessibility of the threaten- ing
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.
28
Tension
Automatic Trigger threatening Anxiety Dysfunctional
image performance
Verbal processing (suppress image)
Distract Worry
Figure 2.4 Model of maintenance of generalized anxiety disorder. Redrawn from Barlow (), with permission
Difficulty in terminating worry or the tendency for tension to heighten self-focus is likely to
interfere with the individual’s ability to concentrate on other tasks, thereby impairing performance
and providing additional sources of worry. Even when the worry trigger is a realistic danger, the
individual with GAD may not be able to terminate worry long enough to engage in effective
problem-solving. Thus, a third vicious cycle may begin, as the ineffective problem-solving is taken
as further evidence that stressors are uncontrollable, and as a result, the individual begins to worry
about worrying. In figure ., this aspect of the model is repre- sented by the step labeled
“dysfunctional performance,” which connects worry back to increases in the experience of negative
affect, thereby com- pleting the last of the three positive feedback loops.
Worry about the recurrence of worry or anxiety decreases as a function of decreasing sensitivity to
worry themes and control over the worry pro- cess. This is one of the functions of worry control
treatment. The treat- ment targets the maladaptive cycle that maintains states of high anxiety and
worry. (This will be covered in more detail later.)
29
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Chapter 3
Outline of the Treatment Procedures and the Basic Principles
Underlying Treatment
There are four primary treatment modules in the MAW workbook. The first module consists of
basic information, instruction, and cognitive re- structuring. This module is designed to correct
faulty information and misconceptions of the nature, processes, and consequences of anxiety and
worry. Furthermore, cognitive restructuring is designed to foster the recog- nition and replacement
of anxious, negatively skewed styles of thought.
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 effec-
tive in terms of treating generalized anxiety.
Third, imagery exposure is used to evoke, in a methodical, controlled fash- ion, the worrisome
images most salient to the individual. Repeated expo- sure, with increasing control over the worry
process, focuses on replacing cognitive avoidance tendencies with one of cognitive modification
through approach and challenge. The suggestion by Borkovec and colleagues that the process of
worry itself suppresses the generation of imagery, particu- larly those aspects of imagery that
encode efferent commands to the au- tonomic system, implies that it is important to include
physiological response elements in imagery exposure (Borkovec, Shadick, & Hopkins, ). Imagery
exposure begins with simulation activities, (e.g., recording images on audiotapes or on paper and
then replaying or rereading them) and progresses to everyday, naturalistic activities (e.g., rereading
stories in newspapers or magazines that trigger worries).
Fourth, in vivo exposure to situations that are being avoided or put off and response prevention of
any “safety behaviors” are included. Since
31
overcautiousness and checking and safety behavior are understood to be motivated principally by
the anticipation of a negative outcome or of levels of anxiety that might impair performance,
cognitive restructuring and relaxation are introduced and practiced before in vivo exposure ex-
ercises and response prevention are conducted.
The first two treatment modules are viewed principally as skills for man- aging anxiety once it has
been elicited. On the other hand, the imagery exposure, in vivo exposure, and response prevention
modules are seen as the principal vehicles by which control over the initiation of the anxiety and
worry processes is acquired.
Treatment Targets
The workbook targets cognitive biases, physiological arousal, and avoid- ance behaviors. It also
introduces time management and problem-solving skills to speak to other issues that may be, in
some cases, pertinent to the experience of anxiety, such as life stressors (e.g., relationship
difficulties, job loss). The workbook does not attempt to directly address additional problems that
often occur with anxiety, such as depression or panic at- tacks. Consequently, we suggest that, for
the duration of time devoted to implementing the MAW program, the focal point of treatment be
lim- ited to working with worry and generalized anxiety. If other emotional 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 en- tirely appropriate for every client. For example, in vivo exposure to ex-
ternal situations and response prevention of safety behaviors may not be relevant for everyone. In
addition, research at our center and several other
32
centers around the world (Zinbarg, Barlow, Licbowitz, Street, Broadhead, Katon, Roy-Byrne,
Lepine, Teherani, Richards, Brantley, & Kraemer, ), suggested that there may be many individuals
who experience chronic symptoms of anxiety that do not meet the full definitional thresh- olds for
GAD. Some of these individuals primarily experience excessive worry whereas others primarily
experience excessive arousal, even though their worry is judged to be in proportion to their life
circumstances. Thus, for some sufferers of chronic anxiety, cognitive restructuring may be less
relevant than relaxation, or vice versa. An initial individual re- sponse profile will be helpful for
ascertaining which of the treatment components will be most useful. Such a profile can be
determined by as- sessing the following areas: excessiveness of worry, degree of arousal and
tension, and patterns of avoidance, including subtle patterns of passive avoidance of external
situations, procrastination, overt or covert safety or checking behaviors designed to ward off danger,
and cognitive avoid- ance or distraction strategies.
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 pre- dictability, controllability, and
safety. It is of the utmost impor- tance to give these variables due regard, particularly when plan-
ning 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
33
person moderates the level of anxiety and, therefore, the most functional exposure practice would
involve gradually working up toward having the child spend time away from home without adult
supervision. As another example, clients who worry about a spouse who is late may report much
less anxiety when exposed to their spouse’s coming home minutes late as a planned practice as
opposed to the experience of the same delay that occurs with no advance notice. Here, the most
functional exposure would involve the client and spouse agreeing to the number of days out of the
week that the spouse will come home late, without the client knowing which particular days those
will be, and gradually in- creasing how late the spouse will be.
Perceptions of lack of safety, unpredictability, and uncontrollability are presumed to be influenced
by all stages of the treatment pro- cess: Corrective information is of particular value to perceived
safety and predictability; relaxation is relevant for perceived con- trollability over tension, worry or
in vivo exposure is pertinent to all three constructs, and problem-solving and time management are
of value to perceived controllability over stressful life events.
. The survival value of anxiety is stressed throughout the course of
the program, and taps the perceived safety-danger dimension of the 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 activa- tion is associated with preparation for danger, the sensations
are presented as the byproduct of a mechanism for coping and sur- vival, and as natural and
harmless.
. The majority of cognitive restructuring focuses on perceiving the
world to be a safer place than is currently estimated by the chronic worrier. Therefore, it is safe to
let go of excessive worry because, by doing so, the individual is not in reality placing himself or
her- self at greater risk for negative events.
. The state of anxiety is differentiated from fear or panic, both
theoretically and with respect to their three-response-mode pres-
34
entation (cognitive, physiological, and behavioral). Anxiety is characterized by: () perception or
awareness of distant threat, () chronic tension and hyperarousal, and () cautiousness, pro-
crastination, and interference with performance and the ability to concentrate on the task at hand. In
contrast, fear or panic is characterized by: () perception or awareness of immediate peril, () sudden
autonomic discharge, and () strong escape or fight-or- flight urges. Most often, the anxiety
experienced by chronic worriers tends to be focused on various life circumstances, such as family,
health, finances, and role performance. Due to the disruption of performance that sometimes results
from high states of anxiety, one may worry about becoming anxious. Worry often occurs at a level
of cognitive appraisal associated with awareness, for example, “I hope my boss doesn’t fire me for
not meeting the deadline we were shooting for,” or “I hope I don’t become so nervous that I’ll blank
out on my lines during the audition,” or at a preattentive level outside of conscious awareness.
. One of the main approaches taken during treatment is graduated
exposure. Thus, the triggers for anxiety may be ordered in terms of a hierarchy, or “stepladder,” of
intensity. Consequently, imagery exposure practices may begin with exposure to negative images
that generate relatively manageable levels of worry and anxiety, and then progress gradually to
images that are more troubling. Similarly, worry prevention (in vivo exposure and response pre-
vention) may begin with situations or tasks that are perceived as being relatively safe or
manageable, and then progress systemati- cally to practices that are perceived as being more
threatening and challenging (see the following case for an example).
. Throughout the program, a learning approach is adopted in which
the development of skills is emphasized. The amount of improve- ment is thought to be related to
the extent to which the individual actually practices the various skills and exercises. Practices are
de- signed to challenge tendencies to avoid and replace them with ap- proach tendencies.
35
Case Example
Striving for Perfection: The Case of J
When she presented for treatment at the center, J was a -year-old mar- ried woman with two
children, aged and years. She reported that worry and high levels of general anxiety had been a
problem for her for almost as long as she could remember—at least since she left college. Her two
major spheres of excessive worry were concerns about her job and her family, and she reported
having great difficulties controlling her worry. She described herself as a “perfectionist” and too
much of a “people pleaser.” In the several months just prior to her initial assessment, she had
experienced several stressors, including terminal illness in a close family member, that contributed
to a marked increase in her usual high level of generalized anxiety. In addition to experiencing
long-standing symp- toms of motor tension, sleep disturbance, and difficulty concentrating, she
reporting experiencing recent physical difficulties, such as irritable bowel syndrome,
temporomandibular joint dysfunction, and possibly, a spastic bladder. J reported feelings of
depression that seemed to come and go, but did not reach the definitional thresholds for either a
major depressive episode or dysthymia.
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 fail- ure and her attempts to be
perfect—the perfect employee, the perfect mother, the perfect source of comfort and support for her
sick relative. On top of everything else, J was becoming aware of worrying about her
36
high levels of worry! She was worried that she had so much to do that her worrying would take up
too much of her time and prevent her from accomplishing all that needed to be done.
J underwent our treatment program at the Center for Stress and Anxi- ety Disorders. Given the
initial focus on corrective information, relaxation training, and cognitive restructuring, J’s initial
response was mixed. She learned the -muscle-group progressive relaxation procedure and ap- plied
it successfully at times to reduce tension at the end of the day and help her sleep at night. However,
she did not always practice the relax- ation exercises on a regular basis. Thus, she did not progress
beyond the eight-muscle-group procedure to be able to make the relaxation skills portable enough to
use whenever she noticed tension, regardless of where she was or what she was doing. She did
realize that she was vastly exag- gerating the consequences of not being perfect in many areas of
her life. However, as sometimes occurs, J used this information in a reassuring way, without fully
processing or understanding the role of cognitions. That is, the information reassured her, but was
not adequately incorpo- rated into her “fear structure.” In fact, she initially found the cognitive
restructuring to be extremely anxiety-provoking as it became apparent that J had often been
accustomed to using distraction from her worries to cognitively avoid or, in her words, “shut
down.” It also became ap- parent that J employed the safety behavior of overpreparing with respect
to many of her work-related projects. It was not until the imagery expo- sure and worry prevention
phases were implemented that her reactivity to her worrisome thoughts and their intrusive quality
truly diminished.
J’s imagery exposure exercises primarily involved her worries about visit- ing her dying relative.
Her greatest fear in this area was that she would cry uncontrollably, which would put additional
strain and stress on her rela- tive, worsening his condition and hastening his death. Before
beginning the imagery exposure, even the thought of getting on the train to travel to his house was
almost overwhelming, so we wanted to begin there. In fact, the thought of doing imagery exposure
to the train trip was so anxiety- provoking that J refused to do the exposure. We took one step
further back and asked her to do imagery exposure to the image of doing im- agery exposure! Once
she got comfortable with the imagery of herself doing imagery exposure to the train trip and
becoming highly distraught and tearful in front of her therapist, she was willing to expose herself to
37
the imagery of the train trip. After becoming relatively comfortable with the imagery of the train
trip, she progressed to exposing herself to the im- agery of approaching his house, then entering the
house, and finally, en- tering his room and crying. Her increased tolerance for this worry and for
“holding on to it” rather than distracting herself, or “shutting down,” allowed her to make great
strides in her cognitive restructuring work with it. As she began to examine her worry content more
closely, she was able to elaborate that, for her, crying uncontrollably meant that she would cry the
entire time she was with him and not be able to talk at all. Through examination of the evidence,
she was able to see that these out- comes were very unlikely. Identifying the possibility that her
relative might interpret her crying as a sign of how deeply she cared for him helped to
decatastrophize the consequences of crying in his presence. She experi- enced a decrease in both the
frequency of this worry and the anxiety it elicited as a result of repeatedly practicing the imagery
exposures and cog- nitive restructuring. She eventually came to visit her relative on a regu- lar basis
and felt much better about herself for having done so.
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 test- ing”) increased her general anxiety level and the number of episodes of
heightened anxiety that she reported. However, with repeated practice, her anxiety decreased and
she proceeded through the rest of the hierar- chy relatively smoothly. In fact, at times, she appeared
almost gleeful when thinking about turning down a request to take on a new project at school.
J experienced frequent episodes of heightened anxiety and high levels of average anxiety through
the first weeks of treatment, when imagery ex- posure was begun, after which the frequency of her
episodes of height- ened anxiety and her average anxiety ratings declined steadily. By the end of
treatment, J was sleeping much better and only rarely experienced the gastrointestinal symptoms
that had bothered her frequently at the be- ginning of treatment. She reported that she was
socializing more regu- larly and getting more enjoyment from her leisure and family activities. She
also reported, with some excitement, that she was contemplating the idea of returning to school for
an advanced degree, even though this change was not directly targeted in treatment. Six months
after the end
38
of the program, J was reevaluated and found to experience little or no evidence of the signs and
symptoms of GAD.
Outline of the Therapist Guide
A chapter-by-chapter description of the MAW treatment program is provided in the remainder of
this guide. One chapter is devoted to each chapter in the MAW program workbook. Each chapter is
arranged as follows:
■ A suggested agenda for the session, including a point-by-point summary of information to be
discussed
■ A description of the main concepts imparted to the client in the chapter
■ A description of the principles underlying the particular treatment procedures included in the
chapter
■ Case vignettes that illustrate commonly asked questions arising in each chapter and examples of
therapist responses
■ A description of atypical or problematic client responses
We strongly recommend that therapists read each chapter in the MAW workbook before that
week’s session, in addition to reading the pertinent material in this guide. Some therapists prefer
that clients read the work- book chapter before the session so that the therapist can elaborate on is-
sues and tasks, as well as answer questions. Other therapists prefer that clients read each chapter
after the session is over to review and consoli- date points covered in the session. We usually follow
the latter strategy and assign the relevant MAW workbook chapter after each session.
39
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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, emphasiz- ing the excessiveness and
uncontrollability of the worry process.
■ Prominence of other types of emotional disorders, within which worry and anxiety may occur
(e.g., depression or panic), as a signal to opt for a different type of treatment.
■ Complications arising from involvement in more than one psycho- therapy at a time for the
management of anxiety and worry. The limi- tation to one psychological program at any given time
for the treat- ment of generalized anxiety is recommended.
■ Combination of medication with the MAW program. Weaning from medication can be
incorporated into the MAW program.
■ Information regarding treatment efficacy.
■ Discussion of the relationship between improvement and practice, since the approach is one of
learning; this treatment is most appropri- ate for individuals who are highly motivated to make
changes.
■ Chapter-by-chapter outline of the MAW program.
41
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 ses- sion, the brief check-in
will consist of greetings, a chance for the client to state how he or she has been feeling recently, and
a chance to briefly review whatever monitoring forms the therapist may have asked the client to
complete prior to this session.
Negotiating an Agenda
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 dis- cuss topics that the client considers high-priority issues. Whenever pos- sible, the
topics introduced by the client should be addressed in the con- text of the session topics.
For this session, the therapist’s suggestions for agenda items should in- clude a discussion of the
client’s goals for therapy and the client’s expecta- tions regarding how the therapy will help to
achieve his or her goals. The
42
therapist might also suggest that, if time permits, the therapist and the client can begin to formulate
a shared understanding of the factors main- taining the client’s anxiety, worry, and tension—in
other words, a shared understanding of the processes that they need to target for intervention.
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 differ- ent, say, or months from now?”
In the course of the ensuing dis- cussion, the following is a list of points that the therapist should
con- sider addressing.
■ The specific clustering of features that distinguishes GAD is suffi- ciently 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 associ- ated existential anxiety.
■ Worry and anxiety are universally experienced and often serve adaptive functions. Other factors
are important in the develop- ment of a disorder. Hence, the notion that all anxiety is abnormal and
maladaptive is targeted. In addition, this treatment is not de- signed to remove any and all anxiety.
Even if it were possible to eliminate anxiety entirely, it would not be in the client’s best interests to
do so.
■ Whereas worry and anxiety often serve adaptive functions, they become problematic when
experienced at intensities out of pro- portion to the level of objective threat in a situation or in situa-
tions in which there is no objective threat whatsoever.
■ The various ways of coping with worry and anxiety, including per- fectionism, procrastination,
and its opposite—putting pressure on oneself to complete things in unnecessarily short periods—are
43
understandable. However, these approaches tend to diminish one’s feelings of enjoying life.
Moreover, these attempts at coping may be effective at reducing anxiety in the short run, but often
tend to perpetuate the anxiety and worry in the long run.
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 feed-
back and focus more intensively on points that the client did not men- tion and even more so on
those expectations that are inconsistent with how we work with clients. It is crucial that the
following two points are included in this discussion.
. Practice is essential. Clients 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 repeti- tions are required before
the skills begin to feel natural and be- come “second nature.”
. The primary focus will be on maintaining factors in the “here and
now.” Though, in some cases, it might be useful to discuss child- hood learning histories (such as
when trying to reduce self-criticism that, for the moment, is focused on how “stupid” it is to experi-
ence a particular negative automatic thought or belief ), discussion of such factors is not necessary
in most cases, and is not 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 particu-
lar case, it is impossible to go back and change those factors (al- though genetic engineering might
someday allow us to change at least one of those factors, this is not possible today). In contrast, we
can often learn how to gain control over the maintaining factors.
44
Negotiating Homework
At least some problems with compliance with homework can be pre- vented by making homework
something that is truly negotiated and col- laborative, rather than “assigned” by the therapist. We
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 ac- tually follow
through more of the time now than when we assigned home- work without offering the client any
perceived control over the process. On occasion, a client does refuse to commit to one or more
options; how- ever, we are convinced that they would not have followed through on these if we had
assigned them.
For this session, the therapist’s suggestions for homework (or self-help, for those clients who have a
negative reaction to the word “homework”) items should include reading over the appropriate
MAW workbook chap- ter or chapters for the next session and giving more thought to goals for
therapy to add to the goals identified in this session. If the client has al- ready begun self-monitoring
(we typically like to begin self-monitoring even before the first therapy session, if the logistics can
be arranged), an- other suggestion should be to continue with self-monitoring. Alterna- tively, if the
client has not already begun self-monitoring, but the thera- pist covers both chapters and from the
MAW client workbook in this session, the suggestion would be to begin self-monitoring.
Session Summary and Feedback
It is important to end every session by asking the client to summarize any take-home messages or
points that might be helpful. This is impor- tant to assess proper understanding and facilitate
consolidation of im- portant points. We also encourage therapists to ask the client if he or she had a
negative reaction to anything about the session. The vast majority of the time, our clients tell us that
nothing troubled them about the session. Despite this fact, we believe that ending sessions in this
way is helpful,
45
as it contributes to the establishment of a collaborative partnership, shows openness to discussing
problems in the relationship, and demonstrates a willingness to work through any such problems. In
addition, there have been occasions when our clients have responded to this question with negative
feedback, and we were able to resolve the issue on the spot, if time permitted, or at the beginning of
the following session.
Principles and Points to Consider
The 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?
46
C: Not usually, no.
T: Not even once?
C: Well, there was one time when my boss asked me to make a presenta- tion at the last minute.
Afterward, everyone told me that I did a good job, and I guess I felt OK about it.
T: Good. And can you think of any times when any member of your
family confronted a stressful situation or a potentially dangerous situa- tion that you weren’t aware
of and didn’t worry about in advance?
C: Yes. Recently, my son took a trip with some of his college friends that I
wasn’t aware of. Usually, I worry a lot before any of my family mem- bers takes a flight. This time,
I didn’t worry because I didn’t even know he was flying until afterward.
T: 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 remem-
ber that the goal of this program is not to eliminate any and all anxiety and worry. Rather, we are
going to focus on reducing the anxiety and worry you experience that is excessive or unnecessary.
Case Vignette 2
C: I was hesitant about starting this kind of therapy program because I
feared hearing about things that would make me feel more anxious. It sort of feels as if these kinds
of worries are contagious.
T: Undoubtedly, as you start to confront the things you are anxious
about, you may very well experience an increase in your anxiety level. However, confronting your
anxieties is an essential part of the treat- ment process. In addition, the increase in your anxiety is
temporary
47
and usually recedes fairly quickly. Your worry about picking up more worries, or contagion, is
probably related to your current level of anxi- ety and worry about becoming anxious. As you learn
to regulate your anxious response, the worry of contagion will probably seem less and less relevant
to you.
Case Vignette 3
C: How can such a brief program cure me after I’ve experienced this anxi-
ety and tension for so long? I’ve been a worrier all my life—that’s just the way I am—so I feel there
is no way it can resolve so rapidly.
T: There are a few things to remember here. First, it has often been found
that the duration of an anxiety problem doesn’t necessarily influence the response to treatment.
Instead, it appears that the amount of practice and involvement you have with the program is most
important in terms of achieving the maximum benefit. Second, this program is highly skills-
oriented, and learning takes place fairly quickly. Third, and perhaps most important, we don’t
expect you to be “cured” at the end of this short-term program. Rather, I have a different goal in
mind for you, related to the notion that, during this program, you will ac- quire skills that you can
apply on your own. Based on that, can you imagine what an alternative goal might be, other than
that you will be cured by our last session?
(The therapist appropriately shares some information with the client that the client is unlikely to
have, but also begins to familiarize the client with the Socratic method and the process of
identifying alternatives.)
C: I’m not sure. Maybe that when I finish the program, I’ll know skills
that will allow me to deal with the problems that remain?
T: Exactly. In fact, many people continue to experience further improve-
ments 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.
48
T: Well, the success rate is very high, but you’re right that not everyone
improves. Do you agree, though, that the high success rate is, in itself, a reason for you to attempt to
carry out the program, or at least to withhold a final judgment until you have had experience with
some of the exercises and techniques?
Case Vignette 4
T: So, let’s talk some about your goals for our work together. If we’re suc-
cessful, how will your life be different or months from now? Please try to be as concrete as
possible.
C: Well, I think the biggest way in which I hope my life will be different
is that I won’t get so overwhelmed by my anxiety that I get frozen or stuck. Like now, when I think
about what direction to go with my ca- reer or graduate programs, or when I think about where my
relation- ship with Trevor is heading, or where I should live after my current lease is up, I just can’t
make up my mind. Each direction I think about gets me worried, and I feel stuck. I even feel frozen
when it comes to cleaning my apartment. The place is so messy that I know I can’t get it all
straightened up in one shot, and that thought gets me so anxious that I don’t even do any cleaning! I
just go and play a video game or watch TV.
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 deci- sions regarding your career
path, your relationship with Trevor, and where to live. Another specific goal is that you would like
to stop pro- crastinating and take some steps toward straightening up your apart- ment. Does it
sound like I got it right?
C: Yeah.
T: OK. Are there any other goals, or does that pretty well cover it?
C: Those are the ones that come to mind right now, but maybe I’ll think
of some more later.
T: OK. We can always add to this list as we go. One thing I really like
about what I hear from you is that you are saying that you want to re-
49
duce your anxiety to manageable levels rather than eliminate it entirely. Some of the people I work
with say that they want to get rid of all of their anxiety, and I have to tell them that, even if that
were possible, we would be doing them a disservice by eliminating all of their anxi- ety. Can you
imagine why I might say that?
(The therapist uses the Socratic method to initiate discussion of the adaptive functions of anxiety
rather than lecturing to the client about something he or she might already have a good
understanding of.)
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 re- sponse. 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 dis-
rupted your performance. But I’m not asking you to think about how you would have done if you
had been less anxious; I am asking you to
50
consider how you would have done if you didn’t experience any anxi- ety whatsoever.
C: I still think I would have done better since I would have been relaxed
while taking the exams.
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 prob- lems for me. I guess the trick is finding an anxiety level that is some- where in the
middle, huh?
T: Yes, that’s one way of putting it. The implication of this for our work
together is that the overall goal of this program is not to eliminate any and all anxiety—even if we
could do so, we wouldn’t want to. Rather, our goal is to eliminate excessive anxiety.
Case Vignette 6
C: I don’t think I meet the criteria for the diagnosis of generalized anxiety disorder. I experience a
lot of muscle tension and the other physical
51
symptoms you mentioned, but I don’t really worry all that much. Does that mean that this program
is not right for me?
T: Whether you are a worrier or not, portions of this program are de-
signed to help with the tension and physiological aspects of anxiety that are troubling you. In
addition, you might be experiencing worri- some thoughts that are so automatic that, ordinarily, you
are not even aware of having them. The program includes techniques designed to help you identify
whether you are experiencing such automatic thoughts. If you are experiencing automatic anxious
thoughts, the techniques will help you learn a less anxious style of thinking.
Case Vignette 7
C: I definitely worry a lot, but I think my worries are realistic. Does that
mean this program is not right for me?
T: First of all, there are portions of this program that could help you,
even if your worries are not excessive or unrealistic, including methods to control tension and
physiological symptoms of anxiety and tech- niques for solving real problems. I’d also like to hear
more about your worries. Can you give me an example of one of your biggest worries that you
believe to be realistic?
C: Well, I’ve been very worried about the fact that I’ve been out of work for the last months. If that
isn’t a realistic worry, I don’t know what is!
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-
52
manent job would make you very anxious. But what evidence do you have that you’ll never find
another permanent job?
(The therapist simultaneously validates the patient’s feelings and gently points out the link between
thoughts and feelings.)
C: 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 ses- sions, I will be introducing
you to exercises that will help you change anxious patterns of thinking. These exercises will help
you evaluate objectively whether your worries are realistic.
(The therapist considers it a success to have helped the client acknowledge that this worry might be
excessive, and does not take it further at this time.)
Atypical and Problematic Responses
Given the physiological sensations accompanying anxiety, a genetic, medi- cal, or chemical
interpretation of anxiety seems more credible to some clients than an interpretation that takes
psychological variables into ac-
53
count. In addition, a genetic, medical, or chemical explanation is often seen as being less
stigmatizing than a psychological explanation. Conse- quently, clients initially may be resistant to
giving full regard to the in- formation in the first few sessions, even in the absence of medical
evidence of abnormality. Clients may express the attribution that “I inherited being high-strung” or
attribute their anxiety to a “chemical imbalance” that can- not be tested.
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 chal-
lenge and explore that attribution is appropriate. Following are several steps that we recommend.
■ What evidence does the client have to assume an inherited, medi- cal, or chemical abnormality?
Typically, there is no medical evi- dence or the anxiety persists, despite control of a medical
problem (e.g., thyroid medication for hyperthyroidism, diet changes for hypoglycemia). Genetic
evidence typically consists of the observa- tion of anxiety problems running in the family. However,
the fact that one’s parents (or other relatives) had anxiety problems is just as consistent with a
learning explanation as it is with a genetic ex- planation. In fact, in most individual cases, it is
impossible to de- termine the extent to which genetic factors or experiential factors are involved in
the onset of the problem.
The evidence from the research literature does support a genetic contribution to the experience of
anxiety. However, the main question of why excessive anxiety occurs cannot be answered en- tirely
from a genetic perspective. That is, it seems that what is in- herited is a predisposition or
vulnerability to an anxiety problem, but other factors come into play in determining whether this
vulnerability results in a disorder.
■ Even if inherited abnormalities are present and could be shown to account for the presence of
excessive anxiety, this does not neces- sarily imply that the MAW program will not be efficacious.
It is possible that some of the effects of the MAW program may be mediated by altering the
underlying biochemical processes. The
54
evidence regarding the treatment efficacy of the MAW program and similar approaches to the
treatment of anxiety can be empha- sized. Examples might also be given of medical problems—
such as stroke and some forms of diabetes—that have known bio- chemical causes and yet are
treated behaviorally.
■ Clients may not be able to connect all of their episodes of height- ened anxiety with discrete and
readily identifiable triggers. The re- sultant state that may be experienced as “free-floating” anxiety
may seem more compatible with a genetic explanation. Recogni- tion 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 cur- rently aware of, but that may be
discerned through systematic observation.
A similar problem that may undermine motivation for treatment is that some clients 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 exami- nation of the relevant evidence to
help the client begin to recognize the aspects of worry that may be excessive. Discussion of the
ability to con- trol worry versus the tendency for worry to take on a life of its own and interfere with
other activities can also be helpful.
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Summary of Information in Chapter 2 of the MAW Client Workbook
■ The need for becoming an observer of one’s own behaviors and re- sponses to enhance
understanding of one’s anxiety and to adapt speci- fic treatment procedures to one’s personal
experience.
■ The degree to which retrospective recall is skewed by current mood and may contribute to the
perpetuation of anxiety, regular and contin- uing monitoring and recording is therefore more
advantageous and less detrimental than retrospective recall.
■ 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
57

Chapter 5 Learning to Recognize Your Own Anxiety

(Corresponds to chapter in the client workbook)
Brief Check-in
The brief check-in will consist of greetings, a chance for the client to state how he or she has been
feeling recently, a brief review of whatever moni- toring forms the therapist may have asked the
client to complete prior to this session, and a brief review of how the client made out with any other
homework tasks from the previous session.
Negotiating an Agenda
For this session, the therapist’s suggestions for agenda items should in- clude a discussion of self-
monitoring and negotiation of homework.
Discussion of Self-Monitoring
In discussing self-monitoring, the following is a list of points that the therapist should consider
addressing.
■ The significance of comprehending processes contributing to the development and maintenance
of episodes of high anxiety, as op- posed to focusing on symptoms and distress levels. The latter
only serves to maintain anxiety. On the other hand, objective awareness and understanding of
processes is the 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.
Conse- quently, the client is led to appreciate that on-the-spot monitoring may be therapeutic in
itself, and much more beneficial than retro- spective recall.
■ An initial attempt to recognize triggers for heightened anxiety and early awareness that anxiety is
starting to build should be empha- sized. At this time, it is not necessary to suggest that all episodes
of anxiety are cued. However, there is an effort to encourage clients to begin to discern precipitants
that may be subtle and perhaps not immediately apparent. Monitoring of oscillations in states of
58
anxiety assists in the development of an awareness of triggers. In addition, the earlier that clients
can identify that their anxiety is beginning to spiral upward, the more successful they should be in
their 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 treat- ment program is a useful means for
clients to evaluate their progress and maintain motivation to make changes.
Negotiating Homework
For this session, the therapist’s suggestions for homework items should include reading over the
appropriate MAW workbook chapter or chap- ters for the next session, and starting self-monitoring
(or continuing doing so if they have already begun self-monitoring).
Session Summary and Feedback
Ask the client to summarize any take-home messages or points from this session that might be
helpful. Also, ask the client if he or she had a nega- tive reaction to anything about the session.
Principles and Points to Consider
Again, the procedures in this lesson are basically didactic. The notion of predictability is introduced
by suggesting the importance of looking for precipitants to episodes of anxiety. As chapter in the
client workbook is brief, we typically either combine this chapter with chapter or begin self-
monitoring even before the first treatment session (going over the points from this chapter at the end
of an initial diagnostic assessment and distributing the relevant forms at that time or discussing
them over the phone prior to the first treatment session and then sending the relevant monitoring
forms through the mail).
59
Case Vignettes
Case Vignette 1
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 in- crease my anxiety?
T: For the time being, you may record your level of overall, or average, anxiety. When you begin to
practice confronting situations that you currently avoid and refraining from the safety-checking
behavior in which you currently engage, you will probably find that episodes of heightened anxiety
will become more frequent. At that point, you can monitor their decline.
Case Vignette 2
C: Should I record each time I feel anxious? If so, then I’m going to be
filling in the monitoring forms constantly.
T: On the Worry Record, only record those times when you experience a pronounced increase in
anxiety or a change in the major focus of your worry. Record the degree to which you’re constantly
feeling anxious as part of your average anxiety rating on the Daily Mood Record.
C: But I often start the day feeling really anxious and continue to feel
that way all day long, so I’m still not sure what to do with the Worry Record.
T: So, do you mean to say that there aren’t some times of the day when
you are more or less anxious than at other times?
C: Well, I guess when I get home from work at the end of the day, I feel a little more relaxed than at
other times. And my anxiety goes up if I know that my boss is looking for me.
T: So, your anxiety level drops a little when you get home. What about in the morning? Does your
anxiety level rise at any point while you’re get- ting ready for work?
60
C: Well, I guess when I first wake up, I’m almost too tired to be worried. It’s usually after I get out
of the shower that the anxiety really starts to build.
T: OK, so on mornings like that, you could begin to fill out a Worry
Record when you get out of the shower. On days when your boss is looking for you, you could
begin to fill out another Worry Record as soon as you can after your anxiety about that starts to
increase.
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
posi- tion to change the processes involved.
Case Vignette 3
C: I am already so busy that the monitoring is just going to add another
burden to my already hectic schedule and make me feel more tense.
T: Certainly, the monitoring will take some time. However, there are a
few things that are important to keep in mind. First, the monitoring, at this point in the program,
should only take a few minutes each day. Second, excessive anxiety usually creates some
inefficiency and inter- feres with performance. Can you think of any times when this has been true
for you?
61
C: Sure, that’s part of the reason I’m here. I worry so much about getting a project perfect that I
usually take twice as long to complete my work as my co-workers.
T: In that case, I’d like you to try to remember that the monitoring is es- sential for change. We
can’t change your anxious patterns of respond- ing if we don’t first understand them and their
precipitants. Does that make sense?
C: Sure.
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 rele- vance 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 ex- cessive 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.
62
T: Wow! It looks like you’ve had a very anxious week! You rated most
days a on both overall anxiety and maximum anxiety.
C: Yeah, that’s pretty much how things have been going lately.
T: OK. Well, let me ask you a question about this week. I know it was a
bad week for you, but I am wondering if some days or times might have been even worse than
others?
(The therapist asks about whether there were even worse times rather than asking about some less
anxious moments, as he hypothesizes that the client may have filled out the Daily Mood Record the
way he had to make sure that the therapist understood how bad off the client was. Therefore, the
client might be reluctant to talk about more relaxed moments right away.)
C: Yeah, Gina and I had a big fight on Monday night, and that night and
most of Tuesday, I was even more anxious than usual, thinking that I wasn’t being a good husband
and that Gina would leave me.
T: I’m sorry to hear about that. Bad fights can be very distressing. Now what I would like you to do
is think about our - to -point scale such that Monday night and Tuesday would be points. OK?
C: Yeah.
T: Good. Now let’s go back and re-rate the last day or two, keeping in
mind that Monday night and Tuesday, after the big fight with Gina, were rated as . So, if Monday
night was , the maximum anxiety rating for Monday would be . Since it wasn’t quite that bad earlier
on Monday, what would you now say was your overall anxiety level on Monday, averaged across
the whole day?
C: Well, if you look at it that way, I guess the rest of the day would have
been an , so maybe for the overall rating that day.
T: Good. Now, how about yesterday? If your overall rating for Tuesday
was , what would you now say was your overall anxiety level yester- day, averaged across the
whole day?
C: Well, it was about like Monday was before the fight, so I’d give it an .
63
Daily Daily Mood Mood Record Record
for James
Rate each column at the end of the day, using a number from the - to -point scale below.
--------------------------------------------------
None Mild Moderate Strong Extreme
Overall Maximum Physical Preoccupation Date Anxiety Anxiety Tension with Worry Headaches
Monday 100 100 65 75 50
7th
Tuesday 100 100 45 45 10
8th
Wednesday 60 90 70 70 65
9th
Thursday 100 100 20 25 10
10th
Friday 100 100 50 55 30
11th
Saturday 100 100 10 30 15
12th
Sunday 100 100 30 40 20
13th
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 prima- rily to lack of motivation, then it would seem
reasonable to assume that the client’s level of motivation for completing the treatment program is
relatively low. If this is the case, then the therapist might try using tech- niques from Miller and
Rollnick’s approach, as described in Motivational Interviewing (). Thus, the client can be asked to
rank a set of values according to their order of importance. The therapist would then ask how the
client’s anxiety, worry, and avoidance or safety behaviors relate to the values of greatest importance
to the client. The therapist could
64
Worry Worry Record Record
for James
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 de- cisional balance exercise
the client first writes on the left side of a page all of the reasons for not wanting to participate in the
program. Next, the client writes all of the reasons for wanting to participate in the pro- gram. When
the therapist reflects these motivations back to the client, it is recommended to begin with the
reasons for participating in the pro- gram and finishing with the reasons for not participating. The
idea here is that, if the client has a “yes, but” style, the buts will tend to be directed at the points the
therapist concluded with, and it is preferable for their
65
“yes, buts” to be directed at the reasons for not participating. If these techniques do not have the
desired effect of building internal motivation to change and participate in the program, then the
therapist might sug- gest that now is not the best time to undergo this type of time- and effort-
intensive program.
In other cases, as reflected in case vignette , the client may avoid moni- toring because he or she
fears that the process of monitoring will increase anxiety levels. In response to this worry, the
possibility, at least initially, of becoming more anxious should be acknowledged, but the usual de-
crease in anxiety over time is to be emphasized.
If clients state that they know how they feel and, therefore, regular moni- toring and recording is
unnecessary, it is useful to ask whether there are any times when the anxiety seems to occur
unexpectedly, or without aware- ness of the triggers. If so, the potential benefit of close monitoring
to identify precipitants should be pointed out. Common examples of such triggers might be news
reports or newspaper articles and comments made by friends, from which the client later
overgeneralizes or makes personal references. In any case, monitoring records provide systematic
and rela- tively objective evidence for later assessment of change. In addition, the evidence
regarding the extent to which retrospective recall is skewed, particularly in ways that may enhance
the anticipation of future anxiety, can be repeated.
Finally, some clients may need ongoing corrective feedback and repeated instruction regarding the
method of monitoring, due to lack of under- standing. For example, on rare occasions, we have
worked with some clients who recorded overall anxiety levels in the Daily Mood Record that
exceeded their corresponding maximum anxiety level ratings. We have also worked with some
clients who recorded scores of for both over- all anxiety and maximum anxiety every day the first
week they used the Daily Mood Record. In such cases, it can be useful to ask the client whether
there were some times or days that week when he or she felt even more anxious than at other times
or days, as in case vignette . If the client is able to identify a “worst” time or day, then the therapist
would ask the client to use that day or time as the anchor point for a rating of points, and then to go
back and reevaluate at least some of the other rat- ings, with that anchor point in mind.
66
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 de- velopment of an anxiety disorder. Rather, the focus is on a description of the
phenomenology of anxiety states. The physiological component is said to be based on central and
autonomic nervous system arousal. The cognitive component consists of thoughts, beliefs, self-
statements, or images associated with perceived danger and uncontrollability. The behavioral
component is manifested as avoidance (including procrasti- nation), checking and safety behavior,
or disruption of performance.
■ A model of the physiological basis of anxiety and fear. The functioning of the sympathetic and
parasympathetic nervous systems and the re- lease of adrenaline and noradrenaline, as well as their
effects on bodily functioning, are described. Particular emphasis is placed on cardiovas- cular,
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 escap- ing 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.
67

Chapter 6 The Purpose and Function of Anxiety

(Corresponds to chapter of the client workbook)
■ Description of the ways in which the three response components inter- act to escalate or reduce
anxiety. The interaction of cognition, physiol- ogy, and behavior is offered as a cause of increased
or decreased inten- sity of any emotion at any given time.
■ Illustrative types of interactions among the three response compo- nents. For example, worry
combined with physical tension, agitation, and restlessness may interfere with performance at work,
which can lead to further worry and tension. In this example, the three compo- nents interact in a
positive feedback cycle, escalating the overall emo- tional intensity. On the other hand, the presence
of symptoms of physical tension and arousal in the absence of worrisome thoughts is much less
likely to result in the same intensification of the emotional state.
■ Categorization of reactions in the three response systems and their in- teractions as either anxiety
or fear (panic) states. Fear involves percep- tions of immediate threat, behavioral escape or
avoidance tendencies, and acute physiological arousal. Anxiety involves perceptions of more distant
threat, behavioral interference or avoidance, and a more grad- ual increase in physiological arousal.
■ A review of the most common themes of worry: health, loved ones, work and school, 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
68
Brief Check-in
The brief check-in will consist of greetings, a chance for the client to state how he or she has been
feeling recently, a brief review of the Worry Record and Daily Record monitoring forms, and a
brief review of how the client made out with any other homework tasks from the previous session.
Negotiating an Agenda
For this session, the therapist’s suggestions for agenda items should in- clude a discussion or review
of the nature of anxiety and fear, a discus- sion of the components of anxiety, and negotiation of
homework.
Discussion and Review of the Nature of Anxiety and Fear
In discussing or reviewing the nature of anxiety and fear, the following is a list of points that the
therapist should consider addressing.
■ Anxiety is thought of in dimensional as opposed to typological terms, and can vary from mild to
severe. It is important for clients to realize that the level of anxiety experienced at any given mo-
ment is a function of particular processes that can be controlled. Consequently, treatment involves
identifying these processes and altering them.
■ It is of considerable import that clients realize that anxiety is not “all bad.” Some moderate level
of anxiety is very adaptive and con- ducive to performance and, in some situations, even necessary
for survival. Therefore, the goal of the treatment program is to reduce the expression of anxiety at
times when it is not warranted or is out of proportion to the actual threat, as opposed to removing
any and all anxiety. Even if it were possible to remove all anxiety, doing so would not be in the
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 oc- curs when threat is perceived as being immediately present.
Anxi-
69
ety is viewed as a “priming” of the fight-or-flight response in preparation for future danger. It is
assumed that clients can learn to distinguish between fear and generalized anxiety on the basis of
accurate descriptions of the response components (physiological, cognitive, and behavioral) that are
characteristic of the respective states.
■ 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 dis- cussion.
. Anxiety is a set of reactions, as opposed to an entity over which the individual has little or no
control (despite the perception of being out of control). We break anxiety reactions (and all other
emotional reactions) into three components: physiological, cogni- tive, and behavioral. The client
should focus on a recent or particu- larly memorable episode of anxiety and complete an Anxiety
Components form, with the therapist coaching the client.
. To reinforce the notion of anxiety as a set of reactions, the ways in
which the 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 fur- ther worry (such as
worrying about job performance and evalua- tion). Therefore, a large part of the program involves
learning to “disconnect” the response components. That is, learning that 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.
70
Anxiety Sequence Components of Anxiety for James Components for a Recent Episode of Anxiety
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 anxi- ety sequence, clients are
encouraged not only to break down their anxiety reactions into the three components, but also to
start thinking about the sequence of these reactions. The Sequence of Anxiety Components for a
Recent Episode of Anxiety form is in- troduced to systematize the 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. Com- plete a Sequence of Anxiety Components for a Recent
Episode of Anxiety form together in session, with the client doing the writing and the therapist
coaching the client.
Negotiating Homework
For this session, the 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-