Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (prevent): A randomised controlled trial

New Study (1)Abstract:

Individuals with a history of recurrent depression have a high risk of repeated depressive relapse or recurrence. Maintenance antidepressants for at least 2 years is the current recommended treatment, but many individuals are interested in alternatives to medication. Mindfulness-based cognitive therapy (MBCT) has been shown to reduce risk of relapse or recurrence compared with usual care, but has not yet been compared with maintenance antidepressant treatment in a definitive trial. We aimed to see whether MBCT with support to taper or discontinue antidepressant treatment (MBCT-TS) was superior to maintenance antidepressants for prevention of depressive relapse or recurrence over 24 months.

In this single-blind, parallel, group randomised controlled trial (PREVENT), we recruited adult patients with three or more previous major depressive episodes and on a therapeutic dose of maintenance antidepressants, from primary care general practices in urban and rural settings in the UK. Participants were randomly assigned to either MBCT-TS or maintenance antidepressants (in a 1:1 ratio) with a computer-generated random number sequence with stratification by centre and symptomatic status. Participants were aware of treatment allocation and research assessors were masked to treatment allocation. The primary outcome was time to relapse or recurrence of depression, with patients followed up at five separate intervals during the 24-month study period. The primary analysis was based on the principle of intention to treat. The trial is registered with Current Controlled Trials, ISRCTN26666654.

Between March 23, 2010, and Oct 21, 2011, we assessed 2188 participants for eligibility and recruited 424 patients from 95 general practices. 212 patients were randomly assigned to MBCT-TS and 212 to maintenance antidepressants. The time to relapse or recurrence of depression did not differ between MBCT-TS and maintenance antidepressants over 24 months (hazard ratio 0·89, 95% CI 0·67–1·18; p=0·43), nor did the number of serious adverse events. Five adverse events were reported, including two deaths, in each of the MBCT-TS and maintenance antidepressants groups. No adverse events were attributable to the interventions or the trial.

We found no evidence that MBCT-TS is superior to maintenance antidepressant treatment for the prevention of depressive relapse in individuals at risk for depressive relapse or recurrence. Both treatments were associated with enduring positive outcomes in terms of relapse or recurrence, residual depressive symptoms, and quality of life.

Kuyken, Willem et al. (2015) Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): A randomised controlled trial. The Lancet (386) 9988, p. 63 – 73.

Bringing Technology to Training: Web-Based Therapist Training to Promote the Development of Competent Cognitive-Behavioral Therapists

New Study (1)Abstract:

In general, as well as part of dissemination and implementation science, there is the need to focus on training of mental health professionals in cognitive-behavioral therapy (CBT). Unfortunately, the usual training methods (e.g., workshops, seminars) and the availability of treatment manuals have not produced full uptake or quality practice. Web-based therapist training programs can improve and expand access to CBT training. Advantages of a web-based training approach allows for increased flexibility, accessibility, cost-efficiency, scalability, potential for both didactive and interactive learning, consistency in quality, and importantly, the potential for remote supervision/consultation. We provide a rationale for the use of technology in clinician training in CBT, highlight several promising programs, and describe the technology and research considerations in web-based training using the example of computer-based training in CBT for childhood anxiety disorders. We also discuss directions for future research, as well as the challenges that remain.

Khanna, S. M. & Kendall, C. P. (2015) Bringing Technology to Training: Web-Based Therapist Training to Promote the Development of Competent Cognitive-Behavioral Therapists. Cognitive and Behavioral Practice 22(3) p. 291-301. doi:10.1016/j.cbpra.2015.02.002


From our Archives: Reflections on My Public Dialog with the Dalai Lama

Aaron T. Beck, M.D.

Göteborg  June 13, 2005


Judy Beck and I met with the Dalai Lama initially in his private drawing room in the hotel for an informal discussion a couple of hours prior to the actual public dialog.  Also attending were Paul Salkovskis, Astrid Beskow, and a number of his own representatives, including his long-time interpreter.  Initially, I presented His Holiness with a copy of Life magazine from 1959, which had a cover picture of him receiving bouquets from his American supporters after his escape from Tibet to the United States.  He seemed pleased to see this much younger picture of himself.  I also presented him with a hard copy of Prisoners of Hate.  He seemed taken by the title, which epitomized his own view that hatred imprisons the people who experience it.  He then remarked that there must be six billion prisoners in the world!


On a personal level, I found him charismatic, warm, engaging, and very attentive to what I had to say.  At the same time, he seemed to maintain an objective detachment not only with me but also with the members of the entourage.  He also impressed me with his wit and wisdom and his ability to capture the nuances of very complex issues.


The dialog was held at the Göteborg Convention Center with about 1400 attendees at the International Congress of Cognitive Psychotherapy (view full video here).  In keeping with his expressed wish, I started the dialog.  I began to recite the dozen or so main points of similarity between Tibetan Buddhism and cognitive therapy (listed below).  After I recited four or five similarities, he interrupted with the statement that they were as many items as he could absorb at one time.


My main challenge in the dialog was to inform him about the cognitive approach to human problems without in any way taking away from the broad philosophy and psychology of Buddhism.  My strategy was to find appropriate points in his discourse where I could introduce cognitive concepts that were relevant in some way to his train of thought.  I tried to represent the cognitive approach as a valid system or discipline in its own right that overlapped but also was complimentary to Buddhism.  I also had to be conscious of my choice of words.  Although His Holiness is quite fluent in speaking English, he is not familiar with more technical words, especially those for which there are no Tibetan equivalents.  For example, he used the term “negative thoughts,” which I repeated in preference to the more technical (and precise) cognitive terms, such as self-defeating thoughts or dysfunctional cognitions.


Among the points that I brought up, which he then expanded on from his own vantage point, were that both systems use the mind to understand and cure the mind.  Acceptance and compassion were key similarities.  Also, in both systems, we try to help people with their overattachment to material things and symbols (of success, etc., something we call “addiction”).  I gave a case example of a depressed scientist who was so attached to success (in this case, specifically winning a Nobel Prize) that he excluded everything else in his life, including his family.  I had used a typical cognitive strategy to give the patient perspective.  In the course of a single session, he changed his beliefs and got over his depression (at least temporarily).  The Dalai Lama’s response to this anecdote was, “You should get the Nobel Prize for Peace.”


Another point that I brought up was our distinction between pain and suffering.  I suggested that much of people’s suffering is based on the fact that they identify themselves with the pain.  People who are able to separate (“distance”) themselves from the pain and view it more objectively had significantly less distress (as pointed out by Tom Sensky’s group in London).  His Holiness seemed taken with this concept and then said in an amusing way that maybe he could use this notion to help himself with his chronic itch.  (This half-serious comment, of course, evoked a large amount of laughter from the audience.)  He later referred to cognitive therapy as similar to “analytical meditation.”


I asked His Holiness how he thought that his message could really take root in the world.  He then expanded on his ideas that education had to be the answer.  He also expressed his own philosophy, which he described as secular ethics.  Although people of different faiths could embrace the values that he expressed, such as total acceptance of all living things, he did not feel that religion was a necessary instrument for this.  He appeared to echo what is also the essence of the cognitive approach, namely self-responsibility rather than depending on some external force to inspire ethical standards.  Since I believe that CT also regards unethical and morally destructive behavior as a cognitive problem and thus would advocate a “cognitive morality,”  I later was able to get this point across but in different words.  When he asked me for my view of human nature, I responded that I agreed that people were intrinsically good but that the core of goodness was so overlaid with layer after layer of “negative thoughts” that one had to remove the layers for the goodness to emerge.  He expressed the belief that positive thinking (focusing on positive and good things) was the way to neutralize the negative in human nature.  My position was that the best way to reach this goal was to pinpoint the thinking errors and correct them.  After we concluded the dialog, Paul Salkovskis gave an outstanding summation of the topics that we had covered.


Since Astrid Beskow (the prodigious organizer of the event) discovered that by coincidence this was his birthday, there was a short birthday celebration during which he was then given a large bouquet.  He then gave Astrid, Paul, and myself a Buddhist prayer shawl.  I later learned from an intermediary that he enjoyed the dialog and that he would think about several points that I raised.


All in all, it was a thrilling experience for me and, from what I heard from several of the attendees, also for the audience.


From my readings and discussions with His Holiness and other Buddhists, I am struck with the notion that Buddhism is the philosophy and psychology closest to cognitive therapy and vice versa.  Below is a list of similarities that I suggested to the Dalai Lama in our private meeting.  Of course, there are many strategies we use such as testing beliefs in experiments and formulating the case that are not part of the Buddhist approach.



  1. Goals: Serenity, Peace of Mind, Relief of Suffering
  2. Values:
    1. Importance of Acceptance, Compassion, Knowledge, Understanding
    2. Altruism vs. Egoism
    3. Universalism vs. Groupism: “We are one with all humankind.”
    4. Science vs. Superstition
    5. Self-responsibility
  3.  Causes of Distress:
    1. Egocentric biases leading to excessive or inappropriate anger, envy, cravings, etc. (the “toxins”) and false beliefs (“delusions”).
    2. Underlying self-defeating beliefs that reinforce biases.
    3. Attaching negative meanings to events.
  4. Methods:
    1. Focus on the Immediate (here and now)
    2. Targeting the biased thinking through:
      1. Introspection
      2. Reflectiveness
      3. Perspective-taking
      4. Identification of “toxic” beliefs
      5. Distancing
      6. Constructive experiences
      7. Nurturing “positive beliefs”
    3. Use of Imagery
      1. Separating distress from pain
      2. Mindfulness training

The Link between Cognitive Behavior Therapy and Positive Psychology



Dennis Greenberger, Ph.D.

University of California, Irvine



Originally published June 2014, Advances in Cognitive Therapy – a Joint Newsletter of the International Association of Cognitive Therapy and the Academy of Cognitive Therapy, IACP Vol. 14, Issue 2/ACT Vol. 15, Issue 2

I have always appreciated the durable and expandable nature of the cognitive model.  The simple yet powerful idea that there is a reciprocal interaction between thoughts, moods, behaviors and biology is a remarkable way of understanding experiences – pathological and healthy. The model further accounts for early experiences that create or contribute to ways that we look at ourselves and others. The cognitive model allows for a clear understanding of a person’s experience and it creates a map of potential cognitive and behavioral interventions.


Positive psychology has been one of the more exciting developments in psychology in the last 15 years. It is not surprising that Martin Seligman, one of the luminaries of CBT has been at the forefront of positive psychology. The field of positive psychology has been embraced and advanced by other “CBTers” including many in the Academy of Cognitive Therapy, a non-profit organization that actively works towards the identification and certification of clinicians skilled in cognitive therapy.


The CBT model seems wholly consistent with newer developments in positive psychology. Positive psychology has researched positive emotion, gratitude, a positive vision of one’s self and future, meaning, engagement, optimism, positive ethics, resilience, self-determination, mindfulness, compassion, empathy, altruism and forgiveness. The traditional CBT model may be a template to understand positive as well as negative experiences as well as other dimensions that are the focus of positive psychology.


Sonja Lyubomirsky in The How of Happiness describes multiple happiness activities including cultivating optimism (cognition) and practicing acts of kindness (behavior). Cognitive therapists are very familiar with the negative, pessimistic explanatory style of depressed patients. We address this regularly in treatment. The opposite side of this coin is the cultivation of optimism – a positive psychology exercise. Research has demonstrated that optimism is correlated with happiness or a sense of well-being. A change in our thinking (optimism) affecting a change in our mood (happiness) is the nature of the reciprocally interacting CBT model.

Lyubomirsky goes on to describe research demonstrating that practicing acts of kindness (behavior) also contributes to happiness. Similarly, this is entirely consistent with the CBT model which suggests that any change in behavior or cognition will be followed by a change in mood. The CBT model is one way of explaining the results of these positive psychology exercises. Research findings in the field of positive psychology may expand the CBT model to positive emotions and a sense of well-being.


Gratitude is a foundational theme in many religious traditions and has been extensively researched in the positive psychology literature. Gratitude is the ability and willingness to think about people, events and experiences in one’s life that you are appreciative of.  Gratitude may be thought of as a belief or a cognitive processing style while the expression of gratitude is a behavior. Gratitude is a combination of the head and the heart. Research suggests that the activation of a grateful attitude and the behavioral expression of gratitude are likely to lead to a greater sense of happiness. In this situation the CBT reciprocal interaction model continues to work but in a positive direction instead of the negative direction that we traditionally talk about.


The link between CBT and positive psychology is also evident in treatment interventions originating out of positive psychology. Martin Seligman and Tayyab Rashid co-authored Positive Psychotherapy: A Treatment Manual. This is a fourteen session group psychotherapy model for depression based on positive psychology principles. In part, the treatment interventions include what may be considered positive cognitive and behavioral exercises including recognizing blessings (cognitive), identifying positive experiences that happened during the day (cognitive), writing (behavioral) a forgiveness (cognitive) letter, writing (behavioral) a gratitude (cognitive) letter, cultivating optimism (cognitive), engaging in pleasurable activities (behavioral), savoring (cognitive and behavioral), and developing meaning (cognitive) in life. Although this is in the very early stages of research, a positive psychotherapy group intervention with depressed patients based on this treatment manual produced significant and encouraging results.


The danger in using the CBT model to understand positive psychology is that it becomes a Procrustean Bed which unfairly neglects important and distinctive components of positive psychology. That being said the CBT model that we are all quite familiar with may provide a way for us to understand how positive psychology interventions work in clinical as well as non-clinical populations. There is an integrative power to the cognitive model and many of the exciting findings in positive psychology may be the opposite side of the coin that we are so familiar with. Integrating positive psychology principles and findings into the CBT model may not only help our patients get better but it may help them develop happiness, meaning, a sense of purpose and well-being.

CBT for Perinatal Distress

Amy Wenzel ProfileAmy Wenzel, Ph.D., ABPP

Beck Institute Faculty

Perinatal distress is defined as depression or anxiety experienced by women who are pregnant or who are in the first postpartum year (Wenzel, 2015). Those of you who have attended the Core 2 CBT for Anxiety Workshop at Beck Institute know that I do not include this issue as a part of the curriculum; nevertheless, questions pertaining to work with perinatal women are frequently asked once workshop participants know my background, and lively discussion usually ensues. Thus, we thought it would be of interest to address this topic in this e-newsletter.


On many occasions, I have encountered negative attitudes toward CBT in the community of mental health professionals (the vast majority of whom identify with other theoretical orientations) who treat perinatal women. Examples of these attitudes include:

  • Attention to the therapeutic relationship is paramount, and cognitive behavioral therapists place little, if any, significance on it.
  • Session structure is too rigid and cold for a perinatal woman in substantial distress, who needs to be provided with a “holding environment” (a Donald Winnicott construct) that provides nurturance, reassurance, and a sense of safety.
  • There is no way that a new mom who is frazzled and sleep-deprived can do homework in between sessions.


When I encounter these myths in conversations with colleagues, I treat them as assumptions that should be tested prospectively, rather than factual information that must be followed without critical evaluation in one’s clinical work. When I open up dialogue with these colleagues, they are pleased to learn about the central importance that cognitive behavioral therapists place on the therapeutic relationship and the high-quality research that has been published on the topic in the past decade. They are also surprised to learn that CBT with perinatal women (or with any clients, for that matter) should not be practiced in a mechanistic way, according to a checklist, but instead should proceed in a flexible, collaborative manner that is driven by the individualized case conceptualization and the client’s preferences. In contrast to the experience of some of my non-CBT colleagues, many perinatal women have expressed gratitude for CBT’s session structure and tangible exercises, remarking that it is precisely because they are frazzled and sleep-deprived that they respond well to CBT’s organized approach. Moreover, newer technology such as Mobile phone apps allow perinatal women much flexibility in completing homework; for example, many of my clients have completed the equivalent of a thought record or an activity log while nursing their infants to sleep.


Interestingly, unlike the literature on CBT for a host of adult mental health problems, there is mixed evidence for CBT’s efficacy with perinatal women (with postpartum depression being the perinatal mental health problem that has received the vast majority of the attention). Authors of meta-analyses on this subject generally conclude that there is strong evidence for the efficacy of interpersonal psychotherapy (IPT) and weak to moderate evidence for the efficacy of CBT for this population. However, in my recent comprehensive review of psychotherapy for perinatal mental health problems (Wenzel, 2016), I concluded that a true “Beckian” approach to CBT—one in which the case conceptualization lies at the heart of the treatment and informs intervention in a flexible, individualized, and collaborative manner—has not yet been evaluated with perinatal women. The majority of the “CBT” treatment packages evaluated to date are heavily focused on psychoeducation and specific techniques (e.g., relaxation) delivered at prescribed times throughout the course of treatment. Although these packages are thoughtfully designed and often theoretically driven, in many instances they did not fare better than usual care in outcome analyses. Thus, I recently published a manual that describes a case conceptualization-driven approach to CBT with perinatal women (Wenzel, 2015), and I look forward to empirical research that evaluates this approach to treating perinatal distress. I will also call your attention to an excellent article written by Arch, Dimidjian, and Chessick (2012) that refutes myths about the dangers of exposure therapy with pregnant women and provides guidelines for conducting exposures with this population in a safe but effective manner.


Arch, J. J., Dimidjian, S., & Chessick, C. (2012). Are exposure-based cognitive behavioral therapies safe during pregnancy? Archives of Women’s Mental Health, 15, 445–457.

Wenzel, A. (2015; with K. Kleiman). Cognitive behavioral therapy for perinatal distress. New York, NY: Routledge.

Wenzel, A. (2016). Psychotherapy for psychopathology during pregnancy and the postpartum period. In A. Wenzel (Ed.), Oxford handbook of perinatal psychology (pp. 341-365). New York, NY: Oxford University Press.

The Three-Month Effect of Mobile Internet-Based Cognitive Therapy on the Course of Depressive Symptoms in Remitted Recurrently Depressed Patients: Results of a Randomized Controlled Trial

New Study (1)Abstract

 Background: There are first indications that an Internet-based cognitive therapy (CT) combined with monitoring by text messages (Mobile CT), and minimal therapist support (e-mail and telephone), is an effective approach of prevention of relapse in depression. However, examining the acceptability and adherence to Mobile CT is necessary to understand and increase the efficiency and effectiveness of this approach.

Method:In this study we used a subset of a randomized controlled trial on the effectiveness of Mobile CT. A total of 129 remitted patients with at least two previous episodes of depression were available for analyses. All available information on demographic characteristics, the number of finished modules, therapist support uptake (telephone and e-mail), and acceptability perceived by the participants was gathered from automatically derived log data, therapists and participants.

Results: Of all 129 participants, 109 (84.5%) participants finished at least one of all eight modules of Mobile CT. Adherence, i.e. the proportion who completed the final module out of those who entered the first module, was 58.7% (64/109). None of the demographic variables studied were related to higher adherence. The total therapist support time per participant that finished at least one module of Mobile CT was 21 min (SD = 17.5). Overall participants rated Mobile CT as an acceptable treatment in terms of difficulty, time spent per module and usefulness. However, one therapist mentioned that some participants experienced difficulties with using multiple CT based challenging techniques.

Conclusion: Overall uptake of the intervention and adherence was high with a low time investment of therapists. This might be partially explained by the fact that the intervention was offered with therapist support by telephone (blended) reducing non-adherence and that this high-risk group for depressive relapse started the intervention during remission. Nevertheless, our results indicate Mobile CT as an acceptable and feasible approach to both participants and therapists.


Kok G., Bockting C., Burger H., Smit F. & Riper H. (2014). The Three-Month Effect of Mobile Internet-Based Cognitive Therapy on the Course of Depressive Symptoms in Remitted Recurrently Depressed Patients: Results of a Randomized Controlled Trial. Internet Interventions p. 65-73. doi:10.1016/j.invent.2014.05.002

Cathryn Prendergast – Workshop Participant Spotlight

Traveling all the way from Perth, Australia, Cathryn is a psychologist at the Hollywood Clinic, a private hospital, where she provides individual and group treatment to inpatients and outpatients for a variety of diagnoses including addiction, borderline-personality disorder, and eating disorders. Cathryn initially learned the foundation of CBT from her masters program at Curtin University and always wanted to travel to Beck Institute as, “the base of CBT globally.” DSC_0002

The most valuable part of the workshop for Cathryn was not a specific skill, but the entire experience. “At times, the workshop felt more like specialized supervision for my practice. I’m taking a lot home with me.” Cathryn also mentioned that, while the instructors are wildly experienced, they are still human and provide examples that apply to a variety of professions.

Unlike most workshop participants, Cathryn decided to stay in downtown Philadelphia to get the full experience, and used the convenient SEPTA bus to travel to the Crowne Plaza each day for the workshop. This allowed her to explore the Reading Terminal Market, and plan to visit Independence Hall and the Liberty Bell on Thursday.

“This workshop exceeded my expectations very much. I hope I can come back!”

Telephone-Delivered Cognitive Behavioral Therapy and Telephone-Delivered Nondirective Supportive Therapy for Rural Older Adults With Generalized Anxiety Disorder: A Randomized Clinical Trial

New Study (1)Abstract

Importance:  Generalized anxiety disorder (GAD) is common in older adults; however, access to treatment may be limited, particularly in rural areas.
Objective:To examine the effects of telephone-delivered cognitive behavioral therapy (CBT) compared with telephone-delivered nondirective supportive therapy (NST) in rural older adults with GAD.

Design, Setting, and Participants:Randomized clinical trial in the participants’ homes of 141 adults aged 60 years and older with a principal or coprincipal diagnosis of GAD who were recruited between January 27, 2011, and October 22, 2013.

Interventions: Telephone-delivered CBT consisted of as many as 11 sessions (9 were required) focused on recognition of anxiety symptoms, relaxation, cognitive restructuring, the use of coping statements, problem solving, worry control, behavioral activation, exposure therapy, and relapse prevention, with optional chapters on sleep and pain. Telephone-delivered NST consisted of 10 sessions focused on providing a supportive atmosphere in which participants could share and discuss their feelings and did not provide any direct suggestions for coping.

Main Outcomes and Measures: Primary outcomes included interviewer-rated anxiety severity (Hamilton Anxiety Rating Scale) and self-reported worry severity (Penn State Worry Questionnaire-Abbreviated) measured at baseline, 2 months’ follow-up, and 4 months’ follow-up. Mood-specific secondary outcomes included self-reported GAD symptoms (GAD Scale 7 Item) measured at baseline and 4 months’ follow-up and depressive symptoms (Beck Depression Inventory) measured at baseline, 2 months’ follow-up, and 4 months’ follow-up. Among the 141 participants, 70 were randomized to receive CBT and 71 to receive NST.

Results: At 4 months’ follow-up, there was a significantly greater decline in worry severity among participants in the telephone-delivered CBT group (difference in improvement, -4.07; 95% CI, -6.26 to -1.87; P?=?.004) but no significant differences in general anxiety symptoms (difference in improvement, -1.52; 95% CI, -4.07 to 1.03; P?=?.24). At 4 months’ follow-up, there was a significantly greater decline in GAD symptoms (difference in improvement, -2.36; 95% CI, -4.00 to -0.72; P?=?.005) and depressive symptoms (difference in improvement, -3.23; 95% CI, -5.97 to -0.50; P?=?.02) among participants in the telephone-delivered CBT group.

Conclusions and Relevance: In this trial, telephone-delivered CBT was superior to telephone-delivered NST in reducing worry, GAD symptoms, and depressive symptoms in older adults with GAD.

Brenes G. A., Danhauer S.C., Lyles M.F., Hogan P.E. & Miller M.E. (2015) Telephone-Delivered Cognitive Behavioral Therapy and Telephone-Delivered Nondirective Supportive Therapy for Rural Older Adults With Generalized Anxiety Disorder: A Randomized Clinical Trial. JAMA Psychiatry. 2015 Aug 5. doi: 10.1001/jamapsychiatry.2015.1154.

Worry and Worriers

Judith S. Beck, PhD

Judith S. Beck, Ph.D.

Worry, as defined by Clark and Beck (2012) is “a persistent, repetitive, and uncontrollable chain of thinking that mainly focuses on the uncertainty of some future negative or threatening outcome in which the person rehearses various problem-solving solutions but fails to reduce the heightened sense of uncertainty about the possible threat.”

This certainly describes the thinking of Stacy, a client I recently treated who suffered from Generalized Anxiety Disorder. She is a 44 year old woman, the mother of three children. And she worries constantly. “What if my boss doesn’t like my work?” “What if my kids get rejected at school?” “What if my husband falls in love with someone else?” “What if this cough I have is really throat cancer?” “What if the bus I’m on crashes?”

Some amount of worry is normal and can be productive when individuals think through a potential problem and come up with a way to prevent it, cope with it if it does arise, or lessen its impact.  But Stacy’s worry is pervasive and unproductive. Why does she keep worrying when it’s clearly dysfunctional? Why does she have so little control over it? A number of factors account for why she worries so incessantly (while another client of mine, an adolescent, fails to worry in situations in which at least a little anxiety is warranted and would be productive).

Stacy’s safety behaviors include the following:

  • She tries as hard as she can to predict problems. “If my boss could possibly be displeased with me, I should anticipate that and know how to respond.”
  • She is constantly trying to gain certainty that a given difficulty won’t occur. “If I think through every option thoroughly, I’ll be able to avoid the problem.”
  • She tries to figure out the optimal solution. “If I just keep thinking about it, maybe I can figure out the perfect thing to do.”
  • She avoids situations she deems risky. “The weather is bad; I better cancel my doctor’s appointment because I might get into a car accident.”
  • She tries to reassure herself and frequently asks for reassurance from others. “I can only feel better if I’m 100% sure that nothing bad will happen.”

Other contributing factors include the following:

  • She catastrophizes, automatically considering only the worst outcomes of a situation. “If my child is late, maybe it means she’s been in an accident.”
  • She misreads her physiological arousal. “I’m so on edge. There must be something bad going on.”
  • She lacks confidence about her ability to handle problems. “I won’t be able to handle it if the problem does arise.”
  • She holds positive beliefs about the worry process. “It’s good to worry because worrying can keep me safe.”
  • She has negative beliefs about worry. “I can’t control my worry. There’s nothing I can do about it.” “I’m going to worry so much that I’ll go crazy!”
  • She tries to stop worrying. But her attempt to suppress worry-related thoughts often rebounds and leads to more unwanted thoughts, which then triggers her positive worry beliefs and the worry process begins again.
  • She doesn’t realize that, most of the time, she can’t solve a given problem and therefore feel relief—because the problem hasn’t happened yet.
  • At the bottom of all this are her underlying negative beliefs about threat and uncertainty, and a sense of helplessness.

Rather than evaluating Stacy’s automatic thoughts (because successfully evaluating one worry-related automatic thought will often be replaced by another worry-related automatic thought), we focused on modifying her dysfunctional beliefs about worry itself (it helps me stay safe), reducing her safety behaviors (seeking reassurance) and attempts to control her worry (thought suppression), using functional problem solving when indicated, identifying when she was thinking catastrophically and mindfully refocusing her attention, facing her worst fear, and accepting and building her tolerance for uncertainty. Although she described having been “a worrier” her whole life, she was able to overcome her excessive worry. She gained a sense of competence and much improved peace of mind.



Clark, D., & Beck, A. (2012). The Anxiety and Worry Workbook: The Cognitive Behavioral Solution. New York: Guilford Press.