Treatment

Part II

Component #2: COGNITIVE BEHAVIORAL THERAPY (CBT)

CBT is one of the most widely used methods in the treatment of anxiety disorders. This approach has two principal aims: 1) to foster intellectual (i.e., mental/cognitive) and 2) behavioral (i.e., feelings/actions) change. To accomplish these important objectives, CBT generally incorporates a number of specific therapeutic strategies. Three of the most commonly employed strategies are briefly reviewed below: :

• Symptom Induction & De-Escalation: This simple procedure encourages clients to purposely attempt to generate anxiety symptoms – by any method they choose – as best they can. In so doing, they gain the opportunity to experience the symptoms while in the therapeutic setting. As an example, a client might be encouraged to try to hyperventilate (taking rapid short breaths), in order to experience some of the usual symptoms of anxiety (e.g., accelerated heart rate, sweating, dizziness, etc.). The purpose of this technique is to demonstrate to the client that his/her anxiety is tolerable. With time, the anxiety normally experienced would become less frightening and debilitating. After a number of trials, clients ultimately achieve an increased sense of mastery and control over their anxiety symptoms.
  
  
• Paradoxical Intention: Despite the apparent contradiction implicit in the phrase paradoxical intention, this ingenious technique, introduced by psychiatrist Victor Frankl (The Will To Meaning, 1969) has substantial therapeutic value. The basic idea of paradoxical intention is quite simple. In therapy, clients are instructed (therapists refer to this as “prescribing the symptom”) to re-create or re-produce the troublesome symptoms that cause them suffering. For example, a middle aged man with generalized anxiety disorder might be given the instruction: “I would like you to now worry as intensely as you possibly can about your current financial situation.” Or, a young female, who presents with obsessive-compulsive disorder (OCD), may be instructed to “try to imagine that you left your front door unlocked and that your house is being robbed at this very moment.”

  More often than not, clients find that when asked to “try to worry at this moment” or given some other similar instruction, they are not able to comply. Despite their best efforts to re-create or generate the unwanted symptoms, they are not able to do so in the therapist’s office. What does the client learn from this? Not surprisingly, he/she learns that trying to do something (e.g., worrying), sometimes produces the opposite effect. So, for those who struggle with constant worrying, a therapist’s prescription might be “try your best, starting right now, to worry for as long as you possibly can.” Strange as it may seem, prescriptions such as this one are sometimes effective. Admittedly, this approach does appear illogical (hence the term, paradoxical intention). However, in some instances, clients actually do attain what they are unintentionally (but truly) seeking – greater mastery and control over their anxiety.

• SAEB Paradigm: SAEB is an acronym that stands for: symptoms-automatic thoughts-emotion/behavior. It is a formal CBT system designed specifically to help clients understand the relationship between their anxious feelings and behavior and the thoughts and bodily sensations (i.e., symptoms) that generally precede them. To illustrate the SAEB paradigm, let’s consider an example of panic attacks.

  Sandra is a young woman in her mid thirties and the mother of two children. From time to time, Sandra experiences severe panic attacks. Sometimes the attacks occur without warning. Hence, she is often nervous and expectant, never knowing for certain when they will strike.
  Importantly, during one therapy session, Sandra discloses that she has given a lot of thought to why she has panic attacks. In so doing, she has noticed a distinct pattern. She describes this pattern as follows: Each time she feels a sudden increase in her heart rate, occasioned by increased sweating and hot flashes, she immediately says to herself, “I think I’m having a heart attack.”

  As a consequence of this thinking, she invariably becomes extremely frightened. Her fear is accompanied by intense worry that something is physically wrong with her. At this point, she cannot control the worrying. She then becomes agitated, highly emotionally distressed and afraid of losing control. Scared, confused and virtually in the grip of panic, she tries to calm herself down as best she can.

  With this example in mind, do you have a sense of why the SAEB paradigm is an important therapeutic tool? The purpose of the SAEB protocol is to elucidate the critical link between the symptoms of panic and the specific negative thoughts and beliefs that generally precede them. Once clients grasp the crucial significance of this relationship, they usually begin to make progress in therapy. Thus, they realize, “I’m creating my symptoms by how I think.” It becomes clear to them that these panic attacks are mostly self-generated; their occurrence is principally the result of internal mental processes (i.e., workings of the mind) – not external situations (e.g., driving on the expressway). Accepting this point is critical to an accurate understanding of the etiology (i.e., causes, or origin) of most panic attacks. It also represents the cornerstone of the CBT approach.

  Finally, and no less important, panic attack sufferers often experience a sense of helplessness because of their inability to control the attacks. Therefore, knowing that panic attacks are almost always self-generated can be of enormous help to them. How so? Because along with this realization (i.e., that episodes of panic are almost invariably self-generated), comes the gradual attainment of that singular, all-important goal I’ve mentioned over and over. That’s right! MASTERY AND CONTROL!

Component #3: EXPOSURE & PRACTICE: (EP)

As its name implies, EP is a simple method that enables clients to encounter a feared stimulus (e.g., snakes) or situation (e.g., giving an oral presentation), and through repeated exposures and practice, gradually become less fearful or anxious. The following case study illustrates this procedure:

CASE STUDY #3: Public Speaking Anxiety

Several years ago, an attractive married female (whom we’ll call Melissa) in her late 20’s came in for counseling because she was having extreme difficulty giving oral presentations at work. Despite her best efforts at being composed, she experienced considerable anxiety – sometimes days before – and during these presentations. This situation was causing her a lot of stress and had reached the point of becoming intolerable to her. During the first session, Melissa admitted that she needed help. She was also highly motivated to overcome her problem. As is my custom, my first step was to do some “depth” (psychodynamic psychotherapy – which focuses on developmental, personality and other relevant issues), work with Melissa. As therapy progressed, I explained to her about EP and then implemented this procedure: First, I suggested that Melissa set aside several hours each week in order to give “at- home” oral presentations. During the initial practice sessions her goal was simple: I instructed her to just complete the presentation – from start to finish – without judging her performance.

Because she had made some progress, at the beginning of the fourth week I suggested that Melissa rate her level of anxiety immediately after giving both the at-home and at-work presentations. This would allow her to better monitor her progress. Next, I recommended that Melissa conduct her at-home practice sessions in front of others. (She did so, in the company of her husband and several of her friends).

By the end of the sixth week, Melissa reported that she had made substantial progress. Her anxiety – which she initially rated at level #9 – dropped to about level #5. After another six weeks or so, she was almost anxiety free. Because her anxiety level had dropped so dramatically, it appeared that she had become virtually desensitized to it. Importantly, Melissa also found that she no longer worried or thought about having to give oral presentations (over the weekend) as had been her tendency. She had ceased ruminating about them, and was rewarded by not experiencing virtually any anticipatory anxiety, as a result. I should mention here that, although Melissa still felt a bit anxious prior to giving the presentations, she characterized this feeling as “nervousness” rather than anxiety. Unlike the anxiety she experienced previously, being nervous, much to her delight, did not interfere with her performance.

It is important to note here that I generally use the EP procedure in conjunction with other forms of intervention (e.g., desensitization, “depth-work”). As is the case with most clients, I did spend some time exploring with Melissa the meaning of her anxiety symptoms. Hence, I believe that the combination of depth-work together with EP (which incorporated desensitization) were both instrumental in helping Melissa overcome her public speaking anxiety difficulties.