Expect Them to Feel Anxious: Embrace the Therapeutic Attitude Together
Anxiety is never a welcome visitor, but patients should never feel surprised, blindsided, or disappointed by their anxious whoosh. Deliberate exposure practice in which no anxiety occurs is not particularly useful, so symptoms are not only expected, they are desired. It is a conditioned response outside their control. Patients do best when they understand that sensitivity is not their fault, and they can expect reactions to anxiety-producing triggers. Embracing the therapeutic attitude of acceptance will be revisited throughout the experience as you talk through what is happening in the patient’s mind and body. There will be times when it is important to explore while not trying to relax, fix, fight, get rid of, deny, or resist. This is all part of learning to surrender the struggle and just let time pass.
Help Them Label the Experience as Anxiety in the Moment
This can be a difficult step for patients to embrace, and it directly addresses the decision process outlined in Figure 3.3. Patients need to be able to relabel their distressing and frightening thoughts, feelings, and memories as symptoms of their anxiety. Remind them about this often, since it is the nature of anxiety to bluff, trick, and mislead, and anxiety will continually be triggering doubt and uncertainty.
We have addressed some of these issues in Chapter 4. If patients can remember to ask themselves the question “Is this an anxiety reaction?” or “Is this an OCD thought?” while this is happening, we are helping the patient widen his psychological field of vision and thereby gain useful perspective on his experience. It does not eliminate the experience— and there is no need to—but rather helps to integrate that experience into a larger and more realistic contest. The automatic arousal and call to active avoidance triggered by the amygdala can now be viewed with less urgency. As our perspective expands, each individual element takes up less emotional space. The snarling tiger at our face is far more compelling than the one on the horizon. Remember that anxious thoughts are identified less by their content, and more by how they feel and by the accompanying urge to respond as if they are a real and present danger. Once patients have found alternative explanations for these feelings, they will become increasingly aware of an inner “wise mind” that really knows it is a panic attack or an obsessive thought and not a heart attack or an uncontrollable urge to do something crazy.
Patients are not clueless about this. It is more that the part of their mind that knows is not absolutely certain, but wants to feel that way. Grayson’s (2003) thought experiment, the “gun test,” helps patients to distinguish what they know intellectually and logically from what they are feeling. There are two parts: In the first part, ask the patient to imagine that someone has a gun to his head, knows the answer to this question, and forces him to make a choice between danger and anxiety. If he doesn’t make a choice, or if he makes the wrong choice, he will be shot. This experiment bypasses certainty, forces a person to go along with his best guess and helps him get in contact with his “wise mind.” In the second part of the gun test, patients are asked if they could proceed with exposure if someone put a gun to their head, and would be sure to pull the trigger if they refuse. This speaks to issues of motivation as well as certainty.
Anxiety is remarkably persistent. Repeatedly frame the truism that feeling anxious is not the same as being unsafe, and that anxiety will continually attempt to mislead by mistaking anxious feelings for danger. Patients will “get it” and then lose it, and then “get it” once again. They are coping with their uncertainty, which is inevitable while feeling anxious.
Stay as Close to the Present as Possible
Anxiety cannot exist without a future-oriented reference. (People can feel physiological arousal in the present, but the labeling of that arousal as anxiety requires a future reference.) Encourage patients to stay with “what is” as opposed to “what if?” Remind them when they get ahead of themselves, or otherwise stuck in the future. Help them to focus on the “here and now.” The most helpful thing for patients to do when they are coping with anxiety is also the most difficult thing: nothing. Help them to float with their feelings. Use metaphors. Stay with them as they learn to allow time to pass.
Label the Level of Distress From 0 to 10
Anxiety is not an all or nothing experience, nor does it remain static. Observing anxiety levels go up and down, and to experience—as it happens—the correlations between thoughts, feelings, and memories, on one hand, and anxiety levels, on the other.
Distress in the Present Will be Rewarded with Less Suffering in the Future
Congratulate them. Celebrate their courage. There is nothing easy about exposure. They have been facing fear and its terror—not just dirt or the subway or speaking to a clerk. Check for ways in which they tend to minimize or undermine their accomplishments (“I could not have done this without you or without my medication”; “So what if I went in a store, anyone can do that”). In fact, it is not uncommon for patients to become discouraged and say things like, “I work so hard and I put so much effort into this—and where do I end up? Right where other people start out!”
Exposure Can Be an Intrinsic Part of Diagnosis and Assessment
Sometimes exposure is the ideal way to get a clear idea of the nature of the patient’s anxious reaction. Standardized assessment tools cannot provide the moment-to-moment information that being with the patient during exposure can provide.
One of us has an office in Manhattan, and when patients indicate a fear of the subway, the suggestion might be made to approach a subway station next meeting. Making it extremely and explicitly clear that nothing too frightening will be attempted—perhaps not even getting past the subway entrance—the patient often arrives next session with intense anticipatory anxiety (see “Anticipatory anxiety” in Chapter 12). Patients must trust that they will never be tricked, or put in an anxiety-producing situation without their consent. Equally important is the attitude that this is not a test or contest, and whatever the patient is willing to do is enough. The goal only is to interact with the patient as she begins to experience the anxiety she would like to overcome.
Other times, there is no need to wait for an additional appointment. If an office is close to coffee shops, ask patients with SAD to accompany you and order a coffee for you, to observe their anxiety first hand. Some will refuse this request, saying it makes them too anxious. Right here is an opportunity to discuss the details of their frightening thoughts, feelings, and memories triggered by the request. Other social phobics might say there is no need—it wouldn’t trigger any anxiety. So you might ask them to go outside with you and ask a stranger for directions to some landmark. The point is to observe how they cope with such situations.
The process is similar for many people with OCD. Because of inexplicable and sometimes embarrassing symptoms, people with OCD often downplay its severity. If someone talks about being a cleaner, one suggestion is for you to put your hand on the office floor, and then rub your face with your hands. Ask the patient if they can do the same. Or, drop some loose change on the floor, pick it up, and ask the patient to repeat that. Patients will sometimes refuse, and sometimes comply, but the more important point is to ask them what is going on in their mind and body and memories as they respond to the request. If a patient has compulsions involving symmetry and order, shred a tissue and leave it on the floor—it will be informative to discuss the patient’s reactions. Here are some questions to ask: Does it matter if it is my office or your home? Would it make a difference if you knew I would pick it up before you leave? How much of your attention is on the tissue and how much on our conversation? How difficult is it for you to refrain from picking this up? Would you find it easier to leave it on the floor if I paid you $1,000?
It is also important for you to get a very clear idea of the triggers that set off your patient. So, for example, is your patient frightened of standing in line at the cashier? Or perhaps the patient is frightened of going into the rear of the st
ore, which might feel claustrophobic. Or, perhaps there are some items in the store that frighten your patient.
Exposure for Patients with Obsessive-compulsive Disorder: Exposure and Response Prevention
For people with OCD, exposure techniques require some modification. People with OCD get a distressing thought that hits them with a jolt. This is the obsession. There is a rapid spike of anxiety, and the person then searches for ways to reduce this anxiety and provide relief. This is the compulsion, which can be extremely varied. Compulsions can consist of overt behaviors, mental rituals, and combinations of both. Obsessions raise anxiety, while compulsions—whether they are mental or behavioral—always attempt to lower anxiety.
Exposing a patient with OCD involves putting him in contact with a trigger, encouraging the obsession (along with the whoosh of fear and distress) to remain, and then helping him to not engage in his habitual method of reducing the anxiety (the compulsion). Staying with the anxious feelings, refraining from running away from them, not fighting them off, accepting and allowing them—this is the attitude that you are trying to teach, so that anxiety can lower on its own, and new brain circuitry can be created.
Exposure work with OCD patients is called exposure and response prevention, or ERP for short. The therapist is deliberately evoking a distress-producing thought or image, while helping the patient to refrain from any kind of avoidance. The patient needs help allowing time to pass, not pushing away the obsessions (that is technically a compulsion), accepting and allowing the arousal, and staying focused on manageable and relevant tasks in the present. The distress triggered by compulsions can be extremely persistent, and you will almost certainly need to repeat these exposures a number of times. Patients will almost invariably look to you for reassurance, and you will need to provide as little as possible.
Sometimes this is more difficult than expected. For example, a patient who is afraid of radioactivity was standing with his therapist near the smoke detector section of a hardware store. He asked, “Are you sure I won’t get cancer from the radioactivity in the smoke detector?” From an exposure point of view, the very best answer is something like, “No, I’m not at all sure. As a matter of fact, you might possibly get cancer from the radioactivity you are subjecting yourself to right now.” This response helps focus the patient on the most relevant anxiety-arousing thoughts and images, even to the point of overstating the (practically) null chance of cancer from these smoke detectors. More supportive statements invariably reduce anxiety. If the response is, “Well, I’m not sure, but I’m willing to risk my life with you,” an element of reassurance is provided: the distress of exposure is reduced, but also its effectiveness. What the patient wants—and what our initial instincts tell us to say (and what well-meaning friends and family do say)— “Of course not,”—will be completely counter-productive.
The more general rule is not to distract during exposure, and—within manageable anxiety levels—to arouse anxiety. Work at a level that is a stretch, but not overwhelming. You can model exposure behaviors. If your patient is a cleaner, place the palm of your hand on the floor, touch your hand to your face, and ask your patient if she will do the same. It is possible to vary the exposure intensity. Placing a finger on the floor and touching your ear might be modeling a less difficult exposure than rubbing your hand on the bottom on your shoe and then rubbing your face.
OCD with Purely Mental Obsessions and Compulsions
We conceptualize OCD as a disorder with two distinct components that are defined by their relationship to each other. One component increases anxiety while the other lowers it, and, of course, it is this relationship that creates the self-maintaining cycle. With unwanted intrusive thoughts, the obsession is the unwanted thought, the patient engages in an attempt to reason, rationalize, or deny the content of the thought, and these mental gymnastics constitute compulsions. Unwanted intrusive thoughts that relate to harming, sexual orientation, unnoticed offensiveness, and unintended aggressiveness are all examples of OCD with purely mental obsessions and compulsions. A similar process occurs with ego-syntonic worry—a “what if?” thought that increases distress like an obsession, and an urgent attempt to answer that question, which is entirely mental and lowers distress temporarily like a compulsion. There is no functional distinction between these two phenomena.
The challenge is to maintain exposure to the thought that raises anxiety (the obsession) without setting off the thought that lowers it (the compulsion). Mental compulsions require some methodological changes. Since it is impossible for anyone to simply not think of calming thoughts, techniques aim to keep the patient focused on anxiety raising obsessions (Phillipson, 1991). The general rule is to let the frightening thoughts remain and to help the patient give himself permission to have the thoughts.
One approach is to take responsibility for the imagined consequences, once the thought is labeled as an OCD thought. So, for example, if a person has a thought that her mother will die if she doesn’t count backwards from 100 three times, then she might respond, “Perhaps she will, and I will do my best to accept that risk and the consequences if she does die.” The uncertainty is allowed. Deliberate evocation of the thoughts can be part of the treatment. Here is an illustration:
PATIENT: I keep having thoughts that my dog is going to die. I try to tell myself these are just thoughts and it doesn’t mean he is going to die.
THERAPIST: Well indeed they are thoughts. They don’t tell us anything about what will happen—either that he will or won’t die.
PATIENT: I guess you are right. But I keep thinking that my negative thoughts will somehow manifest themselves in reality. So I have to stop them or at least argue with them.
THERAPIST: Let’s try something. See that fish tank? Let’s see if we can kill the fish with our thoughts.
PATIENT: Are you serious? That is ridiculous.
THERAPIST: OK then, are you willing to imagine with me a scene in which your dog dies a miserable death?
PATIENT: I see what you mean. That scares me. But we can try.
Another technique specifies times to do nothing but mentally obsess and there are many variations of the approach (Foa and Wilson, 2009). Making a “worst-case” scenario script and reading it repeatedly. Recording an audiotape of the obsessions and listening to it for specified lengths of time. Or by making the obsessions even worse, for example, “what if I hit a person with my car on the way to work?” Instead of compulsively going over the memory of driving that morning making sure that couldn’t have happened, respond with “I may have hit many people, there might be a line of bodies lying in the street on my route to work. I’ll probably hear from the police any minute. I could be a murderer” (Grayson, 2003).
Sometimes the cognitive compulsion (the self-reassurance) happens so quickly and automatically that patients get frustrated trying to do deliberate exposure to obsessive thoughts. They will notice that they have supplied a habitual refutation or analysis or reassurance before they could stop themselves. Rather than berate themselves for such an automatic habit of the mind, the objective is to notice what has happened and then slowly, deliberately, and mindfully reintroduce the obsessive thought in its clearest form. This slowed-down and deliberate re-exposure will allow the patient to refrain from the automatic cognitive compulsion. Patients who understand the two-part nature of worry (see Chapter 9) will be able to see the alternating obsessive question and its accompanying attempt at neutralization. The rule of thumb is to always try to end such a sequence with the anxiety-raising thought.
Many of these methods are addressed in Chapter 6 and amplified in Chapter 9.
The Right Way to Practice Exposure
Intentional exposure is the active ingredient of the treatment and there are methods of practice that maximize its benefits. We illustrate this by describing two types of practice—incidental and planned. Only planned practice maximizes the therapeutic aspects of exposure.
Incidental Practice
Incident
al practice occurs when the primary task is to achieve a particular goal. It is a “grin and bear it” method. If someone afraid of driving must drive to pick up his kids, he will do whatever is needed to accomplish that. If someone is afraid of public speaking, but must make a presentation to keep a job, she will do what is needed to make the presentation. And if someone is terrified of germs, but feels intensely obligated to visit an ill family member in the hospital, he might do whatever is needed to make that visit. Completing the task is the primary goal—not learning how to better manage anxiety. So the anxiety practice is incidental to the primary task of goal completion.
Here is another example of incidental practice. A patient is afraid of taking elevators and must attend a meeting in an office that requires that he use one. So he screws up his courage, grins and bears it, and—anxiety be damned—puts himself on the elevator and presses the button for the correct floor. He does whatever is needed to make it through that elevator ride, and then scoot out the door as soon it opens. He has taken an elevator ride, but it probably won’t be any easier next time. Exposure to anxiety was incidental to the larger goal. The true goal was to get to the meeting. The patient probably engaged in lots of little avoidance tricks to get through the ordeal. He breathed a sigh of relief when the ride was over. But he has not gained many therapeutic benefits.
What Every Therapist Needs to Know About Anxiety Disorders Page 21
