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Track #6 - CBT Interventions for Exposure, Rituals, & a 'Tower of Fear'
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On the last track we discussed uncertainty training in two steps. Step one was examining the costs and benefits of accepting uncertainty and step two was flooding with uncertainty. We also examined problems associated with "thought stopping" regarding anxiety.
On this track we will discuss overriding obsessive anxiety. In addition to discussing ways clients can prepare for this Cognitive Behavior Therapy technique, we will focus on the two steps to overriding obsessive anxiety. The two steps are exposure and response prevention.
As you know, the obsessive, unwanted thoughts that create anxiety may lead some clients to present with signs of OCD. Therefore, this track will discuss how to deal with your anxiety clients who appear to have a differential diagnosis of OCD. I find that this type of client is generally trying to relieve the anxiety caused by their thoughts by performing one of a number of compulsive acts. Unfortunately, it seems that the relief obtained from the compulsive acts only fuels the vicious cycle and keeps it going. Would you agree?
2 CBT Steps for Overriding Obsessive Anxiety
Step 1. Exposure
For OCD/anxiety clients, exposure, as discussed on previous tracks regarding the acceptance of reality and uncertainty training, is only the first step.
But let’s start with the first step - exposure. Because OCD has an obsessional component, in other words, feared thoughts, images, and impulses - exposure often starts with imaginary exposure such as when your client imagines the worst case scenario.
4 Criteria for Imagined Exposure
Imaginary exposure may be the only strategy for some clients if certain obsessions couldn’t or shouldn’t be acted out in real life, such as in the following examples:
1. Thoughts that violate personal religious beliefs.
2. Repetitive thoughts of harm coming to a family member or loved one.
3. Frequent worries about burning alive in a home fire.
4. Unwanted thoughts about getting cancer or some other disease.
3-Step Exposure CBT Technique
Greg’s anxiety was characterized by obsessive worry. Therefore, I asked Greg, 39, to implement three steps to exposure.
First, I stated, "List your distressing thoughts and images, and then rate each one for
the amount of distress it causes." One example of Greg’s distressing thoughts was that he constantly worried about germs and being dirty.
Next, I asked Greg to select the thought that caused the least upset and dwell on the thought over and over, until his distress decreased at least 50 percent. At a later session, after Greg had continued this technique for exposure at home, he stated, "Sometimes, listening over and over to a tape recorded description of my obsessions is useful."
Finally, I asked Greg to proceed to the next item on his list that caused him a little more discomfort and keep working his way up the list. Think of your Greg. Could this exposure CBT technique work for your client?
I find that this approach is quite the opposite of what people with OCD usually do
with their unwanted obsessions. Normally, they try to sweep the haunting thoughts out of their minds the moment that they appear, but that only succeeds ever so briefly, and it maintains the cycle.
Step 2. Response Prevention - ‘Tower of Fears.’
Greg also suffered from compulsive acts and sometimes avoidance due to his obsessive anxiety. Therefore, Greg’s next treatment goal was response prevention. Again, Greg made a hierarchy of feared events and situations that he typically avoided. Greg referred to this hierarchy of anxiety as his ‘tower of fears.’ Then Greg proceeded to put himself into each of those situations but without performing the compulsive act.
For example, Greg feared contamination from dirt and grime. Therefore, in one of our sessions, I brought in a plastic tub of potting soil. At the bottom of the tub was a rock. I asked Greg to reach into the soil and find the rock. Afterwards, I asked Greg if he could stand not washing his hands right away. Greg remained seated until his distress dropped by about 50 percent. If your client’s stress doesn’t drop that much, ask them to stay at least an hour and a half and try not to quit until a minimum of a third of your distress goes away. Also, you might suggest not proceeding to the next item until your client conquers the one that he or she is working on.
Preparing for Exposure and Response Prevention
In addition to exposure and response prevention, let’s discuss ways your client can prepare for the implementation of these techniques. Prior to actual exposure and response prevention, Greg found it useful to alter his compulsive rituals in ways that started to disrupt and alter their influence over him. Methods Greg used for initiating this assault on compulsions included delaying performing his ritual when he first felt the urge. For example, Greg had a strong compulsion to wipe the doorknobs and the phones with Lysol. Greg stated, "I put it off for 30 minutes. The next day, I tried to delay the urge for 45 minutes."
Greg also carried out his compulsion at a much slower pace than usual. For example, when Greg felt compelled to wipe the doorknobs and the phones with Lysol, he went ahead and did it, but with excruciating slowness.
Perhaps your client, like Greg can benefit from change his or her compulsion in some way. If it’s a ritual, could you suggest changing the number of times that your client does it? If it involves a sequence, such as checking all the door locks in the house, maybe he or she can do them in a completely different order than usual. Could playing this track in your next session also be a productive way of implementing exposure and response prevention?
On this track we discussed overriding obsessive anxiety. In addition to discussing ways clients can prepare for this technique, we focused on the two steps to overriding obsessive anxiety. The two steps are exposure and response prevention.
On the next track we will discuss the first key to past redemption.
What are the two steps to overriding obsessive anxiety?
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