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Treating a Client's Anxiety about Sin, Murder,
and a Worst-Case Scenario
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In the last section, we discussed the Tridimensional personality theory developed by Dr. Cloninger which includes three different dimensions and how they relate to obsessive compulsive client’s development. These dimensions are: harm avoidance; novelty seeking; and reward dependence.
In this section, we will discuss effective cognitive behavioral therapy strategy number five: Reducing Anxiety. To help an OCD client reduce anxiety during exposure, I use three different techniques. These three techniques include "Worry Time"; "Helpful Phrases"; and "Paradoxical Thinking."
3 CBT Techniques for Reducing Anxiety
♦ Technique #1 - Worry Time
The first CBT technique is "Worry Time." "Worry Time" refers to a specified time of the day during which an anxious client allows him or herself to worry about certain events for only a specified amount of time.
Eugene, age 46 and a ritualistic checker, was confused by the concept of this technique.
She stated, "But doesn’t worrying just hurt you? Shouldn’t I be concentrating on not worrying about disasters? I feel like I should fight these thoughts, not allow them to take control of me."
I explained to Eugene, "Worrying for you serves a specific purpose. Your checking ritual is a direct result of your belief that without preparing yourself or constantly confirming the safety of a situation, you are responsible if something should go wrong. If you allow yourself only twenty minutes a day, once a day, to worry, you fulfill your need without letting it affect the rest of your day."
Five Guidelines for Worry Time
To help Eugene organize her worry time, I gave her the following guidelines:
- Limit your worrying to fifteen to thirty minutes each day, once a day.
- Try to pick a time of day when you can be alone by yourself to worry, and stick with that time.
- Really let yourself get into your worrying. Try to cover any issues or problems you purposefully stopped yourself from worrying about during the previous twenty-four hours.
- At any other time during the day when you start to worry, say to yourself, "Stop! Save it for worry time."
- Make every effort to stick with this strategy. When you tell yourself to stop, then stop. When you let yourself worry, then worry.
A few weeks later, Eugene stated, "I’m starting to get the hang of this "Worry Time" thing. I still unintentionally worry and feel myself want to resort to checking, but I can at least answer it now. Not all the time, but some of the time." With "Worry Time" Eugene had begun to master her anxiety.
Think of your Eugene. Would "Worry Time" benefit him or her?
♦ Technique #2 - Helpful Phrases
The second CBT technique is "Helpful Phrases." Have you found, as have I, that many OCD clients easily talk themselves out of an exposure situation? I believe that the tendency for OCD clients to jump to negative talk relates to the way in which their mind often jumps from catastrophic thought to catastrophic thought. Rarely do they give themselves time to calm down and rationalize their thoughts.
I often use "Helpful Phrases" to demonstrate to OCD clients good and bad self-talk so that they may recognize this unhelpful behavior and stop it before it takes control.
Randy, age 34, was an obsessive hoarder. Randy stated, "Ever since I was a kid. I couldn’t throw anything away. I kept old egg shells and rubber bands. My apartment is a mess. There’s no room to walk anywhere. Just last week, a stack of boxes fell in front of the door and I had to ask my neighbor upstairs to let me crawl out her window and through the fire escape."
Whenever we began Randy’s exposure therapy and he would forget or relapse for a little while, he became paranoid. Randy stated, "Whenever I screw up, I think things like, ‘I’m such a loser, I’ll never get it right.’ Or ‘Why bother?’"
To counteract these negative expressions, I gave Randy a list of "Helpful Phrases" that he could use to respond to his inner critic.
These phrases included:
"Just wait a while longer. Nothing has really changed."
"It’s not going to happen right away. I need to take my time."
"This will eventually get easier."
For the next few weeks, Randy utilized these phrases whenever he heard the negative critic inside him start to speak out, he used these phrases instead. He stated, "Now that I have something to answer my inner voice with, it’s become a lot easier to let failures go."
By replacing his old negative self-talk with new positive self-talk, Randy can begin to understand failure not as an end to success, but as a process.
Think of your Randy. Would he or she benefit from "Helpful Phrases"?
♦ Technique #3 - Paradoxical Thinking
In addition to "Worry Time" and "Helpful Phrases", the third CBT technique to help reduce anxiety during exposure is "Paradoxical Thinking." I believe that this particular technique is extremely useful because it incorporates humor as a coping mechanism.
In "Paradoxical Thinking," I ask the client to imagine his or her worst-case scenario in relation to his or her own ritual. I ask them to intentionally exaggerate the scenarios to such a degree, that the fears become humorous rather than fearful.
Lawrence, age 42, had a checking obsession. Before he got out of his car, he checked the parking brake, the gear shift, and the lock upwards of seven times before he could felt confident enough that everything was taken care of. I asked Lawrence to try "Paradoxical Thinking" and write down the scenario in his ritual journal.
The next session, Lawrence related his story to me, "First, I got out of the car without checking the lock, parking brake, or gear shift. When I got into the house, that’s when I started getting anxious and the scenario started. I saw the car rolling down the hill. I imagined it rolling over people and them being flattened like pancakes. You know, like in the cartoons. A thief then stopped the car, stole it, and removed all evidence of the ‘murder weapon.’ In my mind, I went to confess my crime to the police, but they didn’t believe me, and I didn’t get my punishment. When I went to confess to my priest, he told me I couldn’t confess a sin I hadn’t committed. Thus, I died "in sin" and St. Peter told me I wasn’t allowed in heaven because I didn’t put on the parking brake."
Lawrence then laughed to himself and stated, "That sounds absolutely ridiculous out loud, doesn’t it?" Now that Lawrence takes his fears less seriously than before, he can begin to negate them altogether.
Think of your Lawrence. Would playing this section aloud be beneficial to him or her?
In this section, we discussed effective behavioral strategy number five: Reducing Anxiety. To help an OCD client reduce anxiety during exposure, I use three different techniques. These three techniques included: "Worry Time"; "Helpful Phrases"; and "Paradoxical Thinking."
In the next section, we will examine effective behavioral strategy number six: "Imagined Exposure" through four key concepts that I ask my clients to keep in mind. These four concepts included: sensory experiences; emotional responses; internal physiological reactions; and thoughts and ideas.
What are three CBT techniques that can help an OCD client reduce anxiety during exposure? To select and enter your answer go to .