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Cognitive Therapy of Anxiety Disorders (Part 1) - Cognitive
Brief and Time-Limited
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10 Principles of Anxiety Disorder Therapy: Part 1 of 3
We will discuss the intervention techniques of the Cognitive Model, overcoming resistance
to learning, keeping therapy brief, assisting your client in distancing himself or herself
from the anxiety, guidelines for asking specific questions, techniques to explore
the questions of "What's the evidence?" "What's another way of
looking at it?" and "So, what if it does happen?" Also, we will
discuss how to help your client break the vicious cycle of anxiety, cognitive
mapping restructuring, and ways to raise self-confidence, as well as visualizations
to use with children.
To make sure we are all on the same page, so to
speak, let's start with Beck's 10 Principles in a cognitive approach to anxiety
disorders. This provides you with a checklist of strategies and concepts. You
will get the most out of this listing of 10 Principles if you have one or two
anxiety disordered clients in mind. As each Principle is explained, rethink your
last session with that client. Is there one of these basic principles you have
either forgotten or are overlooking?
Sometimes we become so familiar
with a principle we don't see the forest for the... well, you know. So here we
go... fine tune your recall skills of your last session with an anxiety disordered
client. If convenient, write down a few clients' names upon which to focus regarding
a particular principle.
♦ Principle 1: The Cognitive Model of Emotional Disorders
I feel use of this
model is helpful because people want to make sense of their emotions and find
it helpful to perceive their emotional problems as falling into four general categories:
anxiety, anger, depression, and pleasure. A patient's numerous complaints can
usually be placed in one of these categories. For example, a complaint about jealousy,
loneliness, shame, guilt, shyness, procrastination, lying, rumination, or indecisiveness
may well be a problem of anxiety management.
At the first interview, a client
I'll call "Joe" said he was having trouble with his fellow workers,
trouble in sleeping, trouble in making decisions, with women, and in telling the
truth. After listening to the details, I realized that Joe's problem was how to
manage anxiety, primarily, and anger, secondarily. This redefinition of his problems
was helpful in and of itself.
Once Joe saw that his problem was related
to anxiety management, he was ready to accept a cognitive explanation of anxiety.
Once Joe had grasped the idea that his misconstruing of his experiences had led
to his anxiety, I encouraged him to develop a systematic way of catching and correcting his thinking and his anxiety. I will go into more detail later about this.
Just a reminder... of course check that medical reasons for the client's symptoms
have been ruled out. One client had symptoms that appeared to be anxiety attacks.
Her physical examination, however, revealed that she had a gall bladder disease.
Once this was treated, the symptoms disappeared. Along the same lines, an anxious
client may have symptoms that are caused by a physical illness but are misinterpreted
as anxiety. A client with occasional periods of anxiety actually had a viral infection.
Instead of thinking, "I'm getting anxious," which in turn created real
anxiety, she discovered she really had the flu; Her anxiety diminished also.
To explain anxiety, I'll explain how the way a person
appraises the situation, determines feelings, and how this appraisal is related
to earlier learning experiences. For example, a person who has never before seen
a particular poisonous plant will not be afraid of it; Only after he has learned
to associate it with danger will he become afraid.
The First Level of Fear
I find it effective
to point out that what the client really fears are his feelings and sensations.
I then describe the two levels of fear. The first level is fear of some form of
a primary danger, for example a fear of a dreaded disease, such as cancer or a
heart attack, or for example, fear of accidents, fear of public humiliation,
fear of suffocation, fear of drowning, and so on.
The Second Level of Fear
However, the second level of fear is actually fear of the symptoms of anxiety rather than fear of
a danger. Inability to overcome the first as danger exaggerates the second level
and leads to a panic cycle.
While a client cannot always immediately overcome the first level of fear, he or she can stop frightening themselves over the anxiety
itself. In the first session, I like to give the client some concrete ways of
handling the second level of their fear, which is fear of their symptoms. We'll
talk about these in more detail later.
♦ Principle 2: Cognitive Therapy is Brief and Time-Limited
is sometimes undesirable. Brief therapy discourages the client's dependency on
the therapist, which is prevalent in anxiety disorders, and encourages the patient's
self-sufficiency. Frequent reassurance from the therapist prevents the patient
from thinking for himself. When the patient sees that the therapy is short-term,
I find the client often begins to realize that anxiety is a problem that I believe
can be overcome quickly. Specifying a certain number of sessions puts the client
in a task-oriented frame of reference for "getting down to business."
As you know, the reality of third-party pay or coverage for brief treatment often
sets the limit here.
Strategies for Keeping Treatment Brief
I find since time is a limited resource, each intervention
needs to have a purpose and a rationale. I like to think of this as "hurrying
slowly;" I cover important material, but move quickly. The following are
some general strategies I use for keeping treatment brief:
it simple. The abundance of theories about emotional disorders enhances
the human tendency to complicate problems. I find it easy to complicate a
client's problems but difficult to simplify them. A good rule to keep in mind
here is: "No matter how complicated a client's problem may be, a therapist
has it in his or her power to make it even more complicated." Complicating
the problem definition and treatment process prolongs treatment and often makes
it less effective.
2. Make treatment specific and concrete. The
more abstract the conceptualization and intervention, the longer the treatment.
Keeping the language relatively free of abstraction moves therapy along. For example,
instead of referring to the four basic emotions as "anxiety, depression,
anger, and euphoria," I use terms like "scared, sad, mad, and glad"
and aim for the lowest level of abstraction.
3. Stress homework. As you know, homework gives your client the best chance of getting better fast,
and it is the therapist who conveys to him or her its importance. Specific homework assignments
will be discussed later.
4. Make ongoing assessments. Most of the
information that I need to make proper intervention decisions is obtained throughout
the treatment. Usually elaborate assessment is unnecessary.
task-relevant. I can easily go off on a tangent with an anxious patient who
usually wants to avoid discussing his or her fears. If the client insists on such
discussions, I point out how it distracts the session from his or her main goal
of the session.
6. Look for ways to use therapy time effectively. Depending
upon the client, of course, some of the methods I have used are setting and sticking
to an agenda for a session, providing written handouts on standard material, or
using posters to illustrate strategies and techniques.
7. Develop a brief-intervention mindset. I find that by assuming that a client can learn
to manage his or her anxiety quickly, this mindset can create a self-fulfilling
prophecy. Thus, the client feels he or she can manage their anxiety quickly.
8. Stay focused on manageable problems. Because cognitive therapy is time-limited,
many client problems will remain unsolved at the end of treatment. By the time
treatment ends, ideally the client will have enough psychological tools to approach
and solve problems on his own, knowing that the therapist is available for added
sessions if necessary.
Peer-Reviewed Journal Article References:
Muir, H. J., Constantino, M. J., Coyne, A. E., Westra, H. A., & Antony, M. M. (2019). Integrating responsive motivational interviewing with cognitive–behavioral therapy (CBT) for generalized anxiety disorder: Direct and indirect effects on interpersonal outcomes. Journal of Psychotherapy Integration. Advance online publication.
Newman, M. G., & Fisher, A. J. (2013). Mediated moderation in combined cognitive behavioral therapy versus component treatments for generalized anxiety disorder. Journal of Consulting and Clinical Psychology, 81(3), 405–414.
Robichaud, M. (2010). Review of Cognitive therapy of anxiety disorders: Science and practice [Review of the book Cognitive therapy of anxiety disorders: Science and practice, by D. A. Clark & A. T. Beck, Eds.]. Canadian Psychology/Psychologie canadienne, 51(4), 282–283.
Utilizing an abundance of theories about emotional disorders, enhances the human tendency to do what?
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