(See Appendix at the end of this Manual for reproducible
Client Worksheet #3)
Ideally with your anxiety-disordered client, he or
she learns to pose your questions to themselves. This section contains 15 Questions and is followed by a checklist containing these questions. Duplicate and provide
your client with a checklist to assist in keeping a weekly record of the questions
that proved to be of the most assistance in decreasing their anxiety.
1. "What's the evidence for or against this idea?"
This is one of the most frequently asked questions in therapy and one
clients readily learn to use. Together, therapist and client develop an agreement
regarding what constitutes acceptable evidence.
As you know, anxious clients jump to conclusions
without considering their logic. One client with a health phobia thought her doctor
was withholding information that something was wrong with her. Once she looked
for the logic in the situation, she saw that it was unlikely that her doctor would
lie to her. The question posed as a follow-up was, "What would the doctor
have to benefit from lying?" The resulting course of events was explored.
3. "Are you oversimplifying the result of your actions?"
A student assumed that if he failed a test he would be expelled from college.
We then discussed other students that were making less than perfect grades, and
that mistakes did not automatically lead to leaving college.
4. "Are you confusing a habit with a fact?"
23, had social anxiety and thought strangers would have the impression, "She
looks funny, and there's something wrong with her." Mary was unable to provide
the therapist with any evidence that strangers reacted to her this way, but she
still believed it. The therapist pointed out that she had these thoughts in many
different situations and that perhaps the thought seemed to only be true simply
because she had a strong habit of thinking along these lines. Mary learned to
ask herself, "Is this thought coming from reality or is it coming from my
habit of thinking a certain way?"
your interpretations too far removed from reality to be accurate?"
therapist may say: When you become too remote from what you can perceive with
your five senses, it's easy to enter the world of fantasy and nonreality. In short,
ask yourself, "What did you see or hear?" When you stick with what you
can perceive, you're usually on much safer ground.
"Are you confusing your version of the facts with the actual facts?"
Clients are told to keep in mind the facts in their entirety can
never be known, and to discriminate between the known facts and the added information
they put on these facts. Facts remain the same, but opinion varies. For example,
"You really do not know what another person is thinking."
"Are you thinking in all-or-none terms?"
As you know,
your anxious client often sees his experiences as black or white and overlooks
the fact that almost nothing is "either/or." One client believed she
was going to be either completely loved by others or totally rejected. In one
session, the therapist gave her the following explanation: In general, everything
we know, we know by contrast; the English language is set up in such a way. We
need to know "down" to understand "up." When you're anxious,
you often make absolute and sharp contrasts. A useful strategy for anxiety is
to cut off the extremes by considering the worst possible expectation ("Everyone
there will ridicule me") and the best possible expectation ("Everyone
there will be overjoyed to see me"). Usually you end up dropping both extremes
and expecting the middle course ("I'll go and see what happens"). Clients
usually accept the middle possibility much more easily after the therapist has
presented both extremes.
8. "Are you using words
or phrases that are extreme or exaggerated?"
Words such as
"always, forever, never, need, should, must, can't, and every time"
rarely correspond with reality. The same applies to the verb to be: "I am
anxious" versus "I have some anxiety." This point is explored further
in the Audio Tape.
9. "Are you taking selected
examples out of context?"
Clients are often so consumed with
a feared event that they do not perceive the larger context in which it takes
place. One of the effects of anxiety is that a person loses touch with the general
context of the situation. Ask your client, "If you can imagine one year from
now, how do you think you will view this situation?"
"Are you using cognitive defense mechanisms?"
may be rationalization, denial, or projection: "I'm not afraid, I just don't
want to go out"; "The other people expect me to be perfect"; or,
"I don't want to make the call because I don't have the time." A further
practical application of cognitive defense mechanisms is provided in Section Six
of this Manual, "The Five R's ."
your source of information reliable?"
Is Uncle George's opinion
of the situation likely to be colored by vested interest, lack of experience,
prejudice, or other factors? Clients will often give credence to unreliable sources.
One client who feared bankruptcy believed all the dire financial predictions he
read or heard about without considering their source. Do you need to ask your
client to "consider the source" in your next session?
"Are you thinking in terms of certainties instead of probabilities?"
Clients often demand a degree of certainty that is unattainable.
Many anxious people want to have 100-percent assurance that what they fear will
not happen. It is helpful to point out to clients that there is often a 10-percent
uncertainty factor that everyone has to live with. Thus, clients confronted with
an ambiguous situation can see it as part of this uncertain 10 percent.
13. "Are you confusing a low probability with a high probability?"
The therapist can help clients see that a possibility differs from
a probability. The fact that one could go insane does not necessarily imply a
high probability that one will. In your next session, do you need to discuss the
difference between "probability" and "possibility?"
14. "Are your judgments based on feelings rather than on
Many anxious clients use their feelings to validate
their thoughts, and thus start a vicious cycle: "I'll be anxious when I ask
for the date so there must be something to fear." Your client connects his
or her feelings as a validation of the fact. Would it be appropriate to point
this out to them in your next session?
you over focusing on irrelevant factors?"
One person thought,
"Because three people I know died of heart attacks, I know I'll have one."
When presenting these questions, I find an attitude that displays curiosity, which
minimizes the feeling of a threat, is most effective. As mentioned earlier, give
clients a listing of these questions and ask them to keep a record for a week.
The questions they find most useful can then be listed on a smaller card and kept
in their wallet as a reminder while standing in a checkout line. (The preceding
is based on an article by Beck).
Anxiety Disorders of Childhood and Adolescence
- Rhoads, J. C. and Donnelly, C. L. Anxiety Disorders of Childhood and Adolescence. Pediatric Psychiatry Network. The article above contains foundational information. Articles below contain optional updates.
Reflection Exercise #3
Would it be of assistance for you to pose
any of the following questions to your anxiety-disordered client in your next
session? Review this list prior to your session to perhaps assist in providing
a fresh focus and added insights.
1. What is the evidence for
or against this idea? 2. What is the logic? 3. Are you oversimplifying
the result of your actions? 4. Are you confusing a habit with a fact? 5. Are your interpretations of the situation too far removed from reality
to be accurate? 6. Are you confusing your version of the facts with
the facts they are? 7. Are you thinking in all-or-none terms? 8. Are you using words or phrases that are extreme or exaggerated? 9. Are you taking selected examples out of context? 10. Are you using
cognitive defense mechanisms 11. Is your source of information reliable? 12. Are you thinking in terms of certainties instead of probabilities? 13. Are you confusing a low probability with a high probability? 14. Are your judgments based on feelings rather than on facts? 15. Are
you over focusing on irrelevant factors?
three case study examples regarding how you might use the content of this section
of the Manual in your practice.
Online Continuing Education QUESTION
11: Ideally your anxiety-disordered client learns to pose what kind of questions?
To select and enter your answer go to CEU Answer