Many misconceptions exist about the cognitive model of psychiatric disorders (Freeman et al. 1990) and anx- iety in general. In this section, we state each of these misconceptions and then provide an accurate descrip- tion of what the cognitive model implies.
• Faulty cognitions cause anxiety disorders. This miscon- ception is perhaps the most commonly cited, unjus- tified criticism of the cognitive model. The cognitive model does not assume that thoughts cause anxiety disorders. Rather, a variety of predisposing and pre- cipitating factors, including cognitive patterns, may coexist with and relate to the development of anxiety disorders. Cognitions and cognitive processing are not the only important elements, but they do repre- sent a useful focus for intervening.
• The cognitive model is simply a variant of Norman Vin- cent Peale’s Power of Positive Thinking. The cognitive model of anxiety assumes that individuals with anx- iety disorders perceive and appraise threat when no real danger exists. Actually, anxiety patients have un- realistic thinking and are unlikely to respond to pos- itive, reassuring thoughts in the long run. Numerous individuals, including family members, friends, and physicians, have encouraged positive thinking in these individuals to no avail. The model proposes that patients must learn to evaluate the triggers for anxiety in a realistic, valid manner.
• The cognitive model denies the importance of behavioral principles, such as exposure, in overcoming anxiety and associated avoidance. Although this model places pri- mary importance on the cognitive apparatus of the individual, it is simply untrue that the importance of behavioral principles is overlooked. The model may more aptly be described as the cognitive-behavioral- emotive model (Freeman and Simon 1989). Cogni- tive therapists freely use techniques that are designed to modify behavior (e.g., assertiveness training) and emotions (e.g., relaxation training). These techniques
are found to be effective in treating anxiety. In a re- cent meta-analysis, for example, cognitive therapy and exposure therapy alone, in combination, or com- bined with relaxation training resulted in positive treatment outcomes in patients with a variety of anx- iety disorders (Norton and Price 2007). Treatment effect sizes did not differ with various combinations of CBT components for any specific diagnosis. • Applying the cognitive model is simply a matter of talk-
ing patients out of their fears. The cognitive approach actively relies on the principles of collaborative em- piricism and guided discovery. The model assumes the Socratic approach by having the therapist lead patients through questioning to examine and alter faulty cognitions and underlying beliefs; the cogni- tive therapist actively teaches the patient a process he or she can take away and use. Cognitive therapists do not talk patients out of their problems by per- suading them or cajoling them to adopt a new per- spective. Rather, they talk to patients in ways that help them guide their patients to think, act, and feel more realistically and adaptively. These techniques are found to be effective in treating anxiety.
Conclusion
The cognitive-behavioral model of anxiety appears to be both a viable and a useful vehicle for furthering our un- derstanding of the complex phenomenon of anxiety and the onset, development, exacerbation, and treatment of anxiety disorders. Recent clinical applications of the cog- nitive model of anxiety include the use of self-help man- uals in primary care settings (van Boeijen et al. 2005) and brief, intensive CBT (Deacon and Abramowitz 2006). Although more research is needed, clinical research sup- ports the efficacy of the cognitive-behavioral model of psychotherapy for specific phobias (Beck 2005), panic disorder with and without agoraphobia (Friedman et al. 2006), social anxiety (Heimberg 2002; Rodebaugh et al. 2004), posttraumatic stress disorder (Ehlers et al. 2005), obsessive-compulsive disorder (Clark 2005), and gener- alized anxiety disorder (Lang 2004). Continued clinical research designed both to refine the hypotheses of the cognitive theory of anxiety and to develop the optimal delivery of cognitive-behavioral treatment by specific disorders and contexts are warranted.
Key Clinical Points
The treatment of anxiety disorders from a cognitive-behavioral perspective incorpo- rates some of the following clinical points that are directly derived from the model:
• Given the nature of the treatment, which ultimately incorporates confronting and addressing uncomfortable stimuli, the establishment of a sound therapeutic alliance is critical.
• The patient should be “psychoeducated” about a number of fundamentals, in- cluding the model, the therapy process, an explanation of symptoms, the iden- tification of patterns of escape/avoidance, and the development of a case for- mulation that integrates the patient’s thoughts, feelings, behaviors, beliefs, assumptions, and triggers. Psychoeducation may be viewed as a means of justi- fying the elements of the treatment package, and it provides a comprehensive framework allowing the patient to assimilate the treatment.
• The monitoring of symptoms, arousal level, situational triggers, thoughts, feel- ings, and behaviors is important in establishment of baseline levels, ongoing monitoring of progress, and ultimate outcome.
• Some form of relaxation training and breathing retraining may be employed as a means of reducing arousal.
• Cognitive interventions are often employed to reduce catastrophizing and the overestimation of negative outcomes.
• Exposing the patient to anxiety-related situations, thoughts, feelings, and be- havior is critical.
• Mutually developed homework exercises designed to bridge the gap between the session and the in vivo environment is essential. Homework provides signif- icant opportunities to test out unrealistic beliefs, practice new behaviors, expose oneself to feared stimuli and extinguish anxiety responses, develop more adap- tive behavior patterns, and enhance self-efficacy.
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Recommended Readings
Craske MG: Mastery of Your Anxiety and Panic: Therapist Guide. New York, Oxford University Press, 2006 Craske MG, Antony MM, Barlow DH: Mastering Your
Fears and Phobias: Therapist Guide. New York, Oxford University Press, 2006
Foa E: Mastery of Obsessive Compulsive Disorder: Therapist Guide. New York, Oxford University Press, 2004 Foa E: Prolonged Exposure Therapy for PTSD: Therapist
Guide. New York, Oxford University Press, 2007 Hope DA: Managing Social Anxiety: Therapist Guide. New
York, Oxford University Press, 2006
Zinbard RE: Mastering Your Anxiety and Worry: Therapist Guide. New York, Oxford University Press, 2006
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