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Cognitive Therapy of Anxiety Disorders (Part 2) - Problem Oriented
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10 Principles of Anxiety Disorder Therapy: Part 2 of 3
♦ Principle 3: A Sound Therapeutic Relationship
Of course, the client must
talk openly about fears and anxiety for the therapeutic process to occur. As you
know, clients often avoid talking about their fears. One client explained, "If
I talk about my anxiety, that will make me feel anxious. I don't want to chance
it." As you know, a major part of treatment consists of encouraging the client
to face frightening situations so as to be able to view them realistically; talking
about them is one way of reaching the client's goal.
To build this sound
relationship, I find especially with an anxiety disorder client, I have to be
acutely aware of possible misinterpretations and misunderstandings of my intention.
I recall in one session, I used humor and the "So what if?" technique;
that is, to hypothesize the worst possibility - an approach that appeared helpful
to the client. At the end of the session, I asked a standard feedback question,
"Was there anything about the session that bothered you?" The patient
responded, "You seemed to be making fun of me and taking my concerns lightly."
This feedback enabled me to correct these misperceptions immediately.
♦ Principle 4: Therapy is a Collaborative Effort between Therapist and Patient
I find with an anxiety disordered client the emphasis is on working on problems
rather than on correcting defects or changing personality. The therapist fosters
the attitude, "Two heads are better than one" in approaching difficulties.
When the client is so entangled in symptoms that he or she is unable to join in
problem solving, I find I may have to assume a leading role. As therapy progresses,
I encourage the client to take a more active stance.
♦ Principle 5: Cognitive Therapy Uses Questions
The therapist is modeling coping
strategies by asking questions that expand a client's constricted thinking. Often
a client reports that when confronted by a new anxiety-producing situation, he
or she will start by asking himself the same questions he heard from the therapist:
"Where is the evidence?", "Where is the logic?", "What
do I have to lose?", "What do I have to gain?", "What would
be the worst thing that could happen?", "What can I learn from this
♦ Principle 6: Cognitive Therapy is Structured and Directive
tend to go off on tangents; as you know, the therapist can model task-oriented
behavior by keeping the discussion on the problem at hand. The therapist has to
set the appropriate tempo for the session. If the pace is too fast, the client
may miss much of what is being discussed; and if too slow, he may lose confidence
in reaching the end result.
I find a key with the structure of the session is to look for a common ground or to an earlier casual link. With one client,
Phil, he was afraid of strangers, his boss, and his parents; the common denominator
was fear of rejection. Such reductions make the problems more manageable. Sue
had a fear of elevators that prevented her from looking for a job, and her joblessness
caused even more difficulties for her. Dealing with the first problem, elevator
phobia, solved her other problems. Bill had many fears of starting a new job ("People
won't like me--I won't be able to do the job--I don't think I'll like the people"),
all of which could be traced back to the basic fear that his bosses would discover
he had exaggerated on his job application.
♦ Principle 7: Cognitive Therapy is Problem Oriented
The key here is Conceptualization
of Problem Definition. As you know in conceptualizing the client's problem,
the therapist has to elicit from the patient what the problem means to him.
The passive-aggressive person may be procrastinating because he believes this
is the way to avoid being controlled by others. The anxious client, the depressed
client, the angry client, and the manic client will all have different reasons.
Procrastination may indicate a shift of priorities that the client has not fully
accepted; or it may be due to a secondary gain, such as a way to get attention
or rationalization ("I could be a great painter, but I don't have the self-discipline").
The point is that there are many reasons a client may be procrastinating. Therapist
and client need to conceptualize the problem jointly before an adequate strategy
can be chosen. Conceptualization, strategy selection, and technique implementation
influence and feed each other. Usually this process is an evolving one of conceptualization
and reconceptualization with corresponding strategy shifts.
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.
To effectively deal with conceptualizing, the therapist has to elicit what from the client?
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