An Introduction to Cognitive Behaviour Therapy, 2 edition
The first treatment manual for cognitive therapy for anxiety disorders was published by Beck and his colleagues in 1985, and was an exciting development in the world of CBT. It heralded the beginning of the revolution that has gradually applied CBT to an ever-wider range of problems.
The application of CBT to anxiety disorders was understandable given their prevalence (affecting 13.3% of the US population [NIMH, 2001]), and evidence of its efficacy in treating anxiety disorders has been compelling (see, for example, Clark & Beck, 1988; Heimberg, 2002).
The anxiety response
It is important to remember that the anxiety response is a normal, vital reaction to threat. When we perceive danger, our bodies rapidly produce adrenaline that primes us to respond to dangerous situations. The classic responses are ‘fight’ (challenging the fear directly) or ‘flight’ (escaping from or avoiding the fear), although ‘freeze’ (being physically or mentally immobile) is a third possible reaction. When faced with perceived threat, we feel fear and the mind and the body get ready to deal with it. The mind considers the worst-case scenario, and the body prepares to tackle it – breathing increases to provide more oxygen; the heart beats faster to get the oxygen-rich blood to key muscles; sweat glands become active to cool the body during activity; and blood is diverted away from the skin, which can result in uncomfortable sensations and paleness.
The response reflects the four systems referred to in Chapter 4: emotional, cognitive, physiological and behavioural. This quite complex response happens swiftly and efficiently every day, for example:
A mother is standing at the side of the road close to her small son. A bus is heading towards them. The mother has a fleeting image of her son stepping into the road in front of the bus. She feels fear. Her adrenaline rises, she becomes tense, focused and primed for action. Swiftly, she takes her son’s arm, despite his protestations, and holds him close to her as the bus passes them safely.
Thus, the anxiety response is a normal and largely unconscious process that regularly occurs in each of us. Anxiety only becomes a problem when the normal response is exaggerated or occurs in the absence of real threat. For example:
Sally frequently had intrusive images and thoughts about her children being hurt on the street. Several times a day, she would feel very nervous about this. She never let them go out alone and she tried to take them everywhere in her car.
Geoff had suffered a panic attack and now lived in fear of having another. In order to minimise the likelihood, he tried not to vary his breathing for fear of hyperventilating; he moved slowly in order not to get light-headed; and he avoided situations which, he predicted, would be stressful. As a result, his life was very restricted.
In these examples, fears are exaggerated or dangers overestimated so that the individuals feel compelled to take quite dramatic actions to alleviate their fears. They have each developed an anxiety disorder. It is important that your clients appreciate that their anxiety response is fundamentally normal but that it has become exaggerated so that it is no longer working well for them.
A person’s interpretation of events determines his responses, so throughout this chapter you will note the use of the term ‘perceived danger’ or ‘perceived threat’. This means that two individuals can be in precisely the same situation but anticipate different consequences and, therefore, react in different ways. Imagine two musicians both waiting for the concert to begin:
The first musician is filled with dread: she fears that she will make a mistake, or that the audience will be hostile. She feels tense, her heart races and she concludes that these are bad signs. This undermines her confidence further. The other musician is looking forward to the opportunity of performing, anticipating an enjoyable experience. He feels tense, his heart races and he concludes that this is what will give him the energy necessary to perform. Thus, in the identical situation, the first musician is worried and interprets her reaction as a bad thing; the second is excited and assumes that his physical responses are helpful.
Characteristics of anxiety and anxiety disorders
Typically, dealing with anxiety is a linear process that comes to a natural conclusion. For example:
Trigger → Perceived threat → Anxiety response → Successful coping reaction → Resolution of anxiety
- A driver sees a child run out in front of a car → production of adrenaline → this promotes quick and focused thinking which enables the driver to brake and swerve in time → resolution of anxiety.
- A student learns of an impending assessment → production of adrenaline → the resulting focused thinking and raised energy levels enable the student to study efficiently → resolution of anxiety.
However, anxiety disorders are represented by a circular process (Figure 13.1) in which cognitive and behavioural responses serve to maintain or worsen anxiety.
- An anxious driver sees a child who he thinks is about to run out in front of his car → he is highly anxious and becomes physically tense and cannot think straight → he swerves to avoid a child who is not actually in the road and is reprimanded by another motorist for driving dangerously → this confirms that driving is hazardous and he remains a highly anxious driver.
Figure 13.1 The cycle of problem anxiety
- An anxious student learns of an impending oral assessment → she finds this threatening and experiences high levels of anxiety → her thinking becomes overly focused on the exam and she becomes so tense that she cannot study effectively → she does not perform well in the assessment; this promotes her belief that she is incapable, and she remains a highly anxious student.
The ‘ultimate’ fear cycle is probably ‘fear of fear’, where the experience of anxiety itself becomes aversive and is therefore avoided long after the original trigger for the anxiety has receded.
Roger thought that he had had a heart attack, but at the hospital he was reassured that he had experienced a panic attack. Roger was not totally relieved by this as he had found the panic attack so unpleasant. Now he lived in dread of it happening again. This of course elevated his fear, which made him feel more panicky and more prone to having a panic attack.
Figure 13.2 Symptoms of anxiety
As we have seen, anxiety prepares the mind and body for dealing with danger: the mind is focused on the bad things that could happen, and the body is primed for action. Thus, anxiety comprises both psychological and physical symptoms, symptoms that become exaggerated and unhelpful in anxiety disorders. This is summarised in Figure 13.2.
As we have seen, anxiety disorders are characterised by distorted beliefs about the dangerousness of certain experiences. They can be triggered by particular situations (for example, being on a high building or speaking in front of a crowd of people) or internal stimuli (such as chest pains or an alarming thought).
There are many types of anxiety disorder, not always easily distinguished from each other. Box 13.1 lists the anxiety-related problems that you might encounter in your clinical practice. This list reflects the Diagnostic and Statistical Manual classification (DSM-IV-TR; APA, 2000) of anxiety disorders which is commonly (although not exclusively) used to distinguish the different presentations.
Box 13.1 DSM-IV diagnoses of anxiety disorders
Specific phobia: describes a persistent fear of an object or situation and, often, a fear of one’s reaction to it. The fear is often recognised as exaggerated, but sufferers still tend to avoid the phobic stimulus (overtly or covertly), and their ability to functioning optimally is disrupted.
Panic disorder: describes the repeated experience of panic attacks (panic attacks are described as sudden increases in anxiety accompanied by symptoms such as palpitations, breathlessness and dizziness). Such symptoms are often experienced as terrifying and are typically misinterpreted as signs of impending or current ill health, like a heart attack or a stroke. Panic disorder can occur with or without agoraphobia.
Hypochondriasis: describes an anxiety that is characterised by a preoccupation with, and fears of, having a serious illness, either now or in the future.
Social phobia: is characterised by a marked and persistent fear of social or performance situations in which a person feels scrutinised by others and fears embarrassment or humiliation. The fear is restricted to social situations and the sufferer is very focused on their physical symptoms and behavioural performance.
Generalised anxiety disorder (GAD): manifests as persistent and excessive worries, fears and negative thoughts about the future which then lead to distress and/or impairment of performance.
Obsessive-compulsive disorder (OCD): is characterised by recurrent obsessions (persistent and intrusive thoughts, images or impulses) and/or compulsions (compelling repetitive behaviour or rituals or mental acts intended to put right or neutralise the obsession). Sufferers realise that their fears are probably unfounded but remain compelled to act on them trying to ignore, suppress or ‘neutralise’ the obsession with some other thought or action.
Acute stress disorder (ASD): is diagnosed when a person, who has been exposed to a traumatic event, develops anxiety symptoms, a sense of re-experiencing of the event and marked avoidance of stimuli that trigger recollections of the trauma. The disturbance occurs within four weeks of the traumatic event.
Post-traumatic stress disorder (PTSD): occurs ollowing an event deemed seriously threatening to oneself (or others) which resulted in intense fear, helplessness or horror. Symptoms include intrusive memories of the traumatic events (e.g. nightmares, flashbacks), avoidance, numbing and hyperarousal.
Labels are all very well, but what is it like to experience an anxiety disorder?
- Specific phobia: People with phobia also tend to be on the look-out for signs of ‘danger’: so someone with a spider phobia would always check out the corners of a room or someone with a fear of heights would be vigilant in spotting road signs indicating bridges. Phobias can focus on a range of things: animals, the natural environment, specific situations and so on. Specific fears will trigger an elevation in blood pressure – with the exception of blood phobia, which causes it to drop. Thus, blood phobia, unlike other phobias, can lead to fainting.
Lucas was afraid of frogs. Ever since his older bothers had frightened him by dropping one down his shirt, he had found them unbearable – their slimy skin and, worst of all, their quick unpredictable movements. As his work took him into the countryside a lot, his fear presented a problem. It limited his ability to go into damp areas, he was so busy looking out for frogs that his concentration was impaired, his physical nervousness was unpleasant and it also distracted him from the job.
- Agoraphobia: is a particular form of fear whereby the sufferer fears being away from a place of safety or a place where escape is easy. In DSM-IV it is not regarded as a diagnosis in itself and is associated with panic disorder (see below) as agoraphobia is commonly linked with the fear of having a panic attack or panic-like symptoms whilst away from a safe base. However, agoraphobic-like behaviours can be associated with other fears such as social anxiety or PTSD (see below), where it can be a safety behaviour to avoid social embarrassment or to avoid the triggering of a flashback, for example.
- Panic disorder: Sufferers of panic disorder have an enduring tendency to misinterpret benign experiences as indicative of catastrophe and this leads to repeated panic attacks. Agoraphobia is common as it is a means of avoiding the situations which the sufferer believes will trigger a panic attack.
Monika described herself as a sensitive and highly strung woman but until recently she had been confident in her career and seemed to be coping well. Several months ago work stress and uncertainly took its toll and she went to the doctor with palpitations, dizziness and nausea. Monika believed that she was having a heart attack. Her GP assured her that this was a panic attack. At first she found it hard to accept that her experience was not heralding a heart attack, especially as the symptoms worsened over time and her chest pains became more intense. Each ‘attack’ seemed worse and her fears grew. Gradually she began to consider that she was experiencing panic – but this gave her little consolation as she was now terrified of the awful sensations of a panic attack. She became very sensitive to the slightest discomfort in her chest and awareness of chest pain would usually escalate into a panic attack. She tried not to attend to sensations in her chest and refused to talk about panic with her therapist in case this triggered an attack.
- Hypochondriasisor health anxiety: both these terms are used to describe fears associated with health. Sufferers tend to be hypervigilant for, and to misinterpret, benign bodily symptoms as indications of illness. However, the experience is different from panic disorder in that panic attacks are extremely acute, while those with health anxiety experience more chronic concerns and preoccupations. Sufferers of health anxieties also tend to seek reassurance very actively but, typically, the reassurance does not have an enduring effect and the health concerns return.
Maya worried about developing cancer. She regularly checked her body for outward signs of the disease and she noted any sensation that could indicate cancer. In particular she noted headaches which she feared indicated a brain tumour, abdominal discomforts (ovarian cancer), and changes in her bowel movements (bowel cancer). She veered between avoiding reading articles about health (in case she developed new concerns) to spending hours on the Internet reading about cancer symptoms. She visited her GP practice regularly to discuss her ‘symptoms’. Typically she felt initial relief when reassured that she was healthy, but this soon wore off and doubt and worry would set in again. She tried not to turn to friends for reassurance because she knew that this now irritated them.
- Social phobiaor social anxiety: The description of social phobia in DSM-IV is specific (see above) but extreme shyness can also be a problem in those who do not meet DSM diagnostic criteria. In these cases the term ‘social anxiety’ tends to be used (Butler & Hack-mann, 2004). Avoidance is a common coping strategy in both social phobia and social anxiety (including subtle avoidance such as using alcohol to cope in a social setting or avoiding eye-contact) and this helps to maintain the problem. It is sometimes also maintained because symptoms of anxiety impair social performance – not being able to think clearly or shaking, for example – and this enhances self-consciousness and social fears.
Lilia was perfectly confident and able in her work as long as she did not have to speak to a group of her peers or present herself to prospective customers. If she knew that she would have to address her colleagues she would begin to worry that they would realise that she was incompetent and she would become so tense that she was unable to concentrate or sleep properly. She would first try to delegate the task to someone else and if she was unable to do this she then tended to ‘stick her head in the sand’ and ignore the challenge. As a result, she was often ill prepared for presentations and they never went as well as she had hoped. This confirmed to her that she had been incompetent and that it was now public knowledge. If she needed to meet a new customer, she had similar fears.
- Generalised anxiety disorder (GAD): Typically, sufferers of GAD are beset with ‘What if …’ worries, pervading many aspects of their lives: ‘What if I miss my connection?’, ‘What if I can’t answer the questions?’, ‘What if my child is harmed?’ Worry is the main cognitive feature and it is not uncommon for sufferers to worry about worry, thinking that they are going mad. On the other hand, some clients attribute positive qualities to their worrying, such as: ‘Worrying means that I will be prepared’. However, worrying undermines problem-solving and so clients with GAD tend not to deal well with challenges. They also tend to be intolerant of uncertainty, and this underpins reassurance-seeking behaviours.
Colin experiences high levels of worry and anxiety sometimes amounting to panicky feelings, physical tension and shortness of breath. He wakes ‘with a feeling of dread’ and describes ‘worrying about everything: one worry just seems to merge into the next’. He worries about his daughter’s health and academic progress, about financial matters and whether he will be made redundant and fail to meet the mortgage repayments, about his own health. He finds it difficult to make decisions at work and frequently seeks reassurance from his boss. He fears that his worry will take lead to a ‘mental breakdown’. He avoids watching the news and reading newspapers, especially anything to do with health and finance, to prevent himself from ‘obsessing’ about it.
- Obsessive-compulsive disorder (OCD): OCD sufferers believe that they are responsible for the safety of themselves or others, and their fears centre, for example, on contamination (e.g. passing on germs by not washing hands sufficiently); disaster due to neglect to do something properly (e.g. switching off switches); behaving inappropriately as a consequence of having improper thoughts (e.g. thinking about swearing in church resulting in swearing). Some compulsions represent exaggerated helpful behaviours, such as washing excessively to avoid contamination, others represent more superstitious behaviours, such as ritualistic counting.
Joachin could not remember a time when he had not felt the urge to touch things in a ritualised way. He had an awful feeling of foreboding – that something bad would happen to him or a loved one – which was only relieved when he tapped a surface with his elbow or, if he was passing through a doorway, he rocked three times (in Joachin’s mind this was like tapping the floor with his feet). He felt embarrassed by his actions as he knew that they were irrational and he had been teased at school for them – however, the sense that something bad might happen if he didn’t was so strong and so very unpleasant that he always gave in to the urge in order to get mental and emotional relief.
- Acute stress disorder (ASD): lasts for a maximum of four weeks. After this time, this presentation is diagnosed as PTSD (see below).
Alison had been sexually assaulted. Two weeks later she still could not sleep in her bedsit where it had happened even though she had redecorated the next day in order to try to eliminate the memory of her rape. She had taken leave from her studies because she found that she could not concentrate, was tearful and snapped at everybody. Being at home, though, made it worse: she was agitated and she couldn’t eat or sleep properly. When she closed her eyes she saw his face and at night she was terrified by every noise and sometimes she felt as if he were there, as if she could smell him.
- Post-traumatic stress disorder (PTSD): In this disorder, concerns focus on an enduringsense of danger, although shame, disgust and anger are also reported. Typically, clients with PTSD can recall fragments of the traumatic event, or events, in detail, but the entire picture is jumbled or incomplete (Foa & Riggs, 1993). A common and frightening traumatic memory is the very vivid ‘flashback’ which can give the sense of re-experiencing the traumatic event, but PTSD sufferers can also experience nightmares and other less vivid recollections. A common coping strategy is avoiding the triggers for these memories.
Anton had witnessed a fatal shooting. Six months later he still had nightmares of the event and even in his waking hours he experienced brief ‘flashbacks’ to the killing. He felt as though he was in a constant state of physical tension and the slightest provocation made him jump. Anything that sounded like a shot would trigger a panic reaction and flashbacks. He could not walk past the shopping arcade where the shooting took place and more recently he had begun to avoid that part of the shopping district altogether – it brought back too many memories.
There are also anxiety disorders that fall outside a formal diagnostic category, and DSM-IV uses the category ‘Anxiety Disorder Not Otherwise Specified (Anxiety Disorder NOS)’ (DSM-IV-TR; APA, 2000). This reminds us not to assume that clients will slip neatly into a category, and we should certainly not try to ‘ease’ them into one.
Why do anxiety disorders persist? The key to this (and to managing problems) is identifying the maintaining cycles that explain their persistence.
Figure 13.3 The maintaining cycle of anxiety
There is a common pattern to the maintenance of anxiety problems (see Figure 13.3). In response to an internal or external trigger, the anxious client assumes threat or danger and either draws a catastrophic conclusion (something bad has happened and this has frightening implications for the future) or makes a catastrophic prediction (something bad will happen). Understandably, the client then tries to protect himself from the perceived threat. For example, the person with agoraphobia retreats to a ‘safe’ base or the client with health anxiety seeks reassurance. Such responses give immediate relief but do not challenge the validity of the belief. Thus, the person with agoraphobia fails to learn that it is possible to be in a public place without something terrible happening; the client with health anxiety does not learn to assure herself of her good health. In short, the original fears remain intact, ready to be triggered sometime later.
Essentially, anxiety disorders are perpetuated by how we feel, what we think and what we do. Clark (1999) has proposed that six processes maintain distorted beliefs about the (irrational) dangerousness of certain situations, even in the face of evidence that the world is a safe place. These are summarised below and might give you some hypotheses about the nature of your clients’ problem(s).
Safety-seeking behaviours (Salkovskis, 1988): these are behaviours or mental activities which are carried out in an attempt to minimise or prevent something bad from happening (see also Chapter 4). Of course, behaving in a safe way is not dysfunctional: looking both ways before we cross the road is a highly functional safety-seeking behaviour. However, standing at the kerbside repeatedly checking for cars, unable to take the risk of crossing, is an exaggerated and unhelpful safety-seeking behaviour – it is the latter that Salkovskis describes. In Figure 13.3, they fall into Box 2. These responses can prevent a person from learning that they overestimate danger, because each ‘safe’ experience is attributed to the success of a safety behaviour (SB). For example, a young woman with vomit phobia might get through the day without feeling nauseous and certainly without being sick. This should provide assurance that she is not at risk of vomiting. However, if she has been sucking mints as a safety strategy, she will attribute her well-being to the sweets. Alternatively, a man with panic disorder who fears having a heart attack may move around slowly in order to remain safe; he may attribute his good health to slow movement rather than realise that he has a healthy heart. Colin and Maya, in the previous examples, both engaged in the unhelpful safety-seeking behaviour of seeking reassurance, while Joachin’s ritualised touching was his safety behaviour.
The distinction between ‘helpful coping behaviour’ and ‘unhelpful safety behaviour’ reflects the intention behind the behaviour. For example, a man might relax his shoulders and slow his breathing in response to feeling tense and, subsequently, feel calmer. If he interpreted this as, ‘I’m only feeling better because I did my relaxation routine and if I had not done it something terrible would have happened’, it is unlikely that he would develop confidence that he could manage tension and need not be afraid of it: the ‘relaxation routine’ would be a safety behaviour. However, if he concluded, ‘If I’m tense, I relax’, then relaxing is simply a functional coping behaviour, and he is likely to grow confident that he can cope. Rachman et al. (2008) remind us not to reject all SBs as anti-therapeutic as their judicious use, particularly in the early stages of therapy, can facilitate change by giving clients the confidence to take the first steps of engaging in treatment. Over time they can be encouraged to systematically drop unhelpful behaviours as their adaptive coping repertoire grows.
Focus of attention: this falls into two categories, (1) attention directed towards threat cues and (2) attention directed away from them. Examples of the former would include Lucas who, because of his frog phobia, scans for signs of undergrowth or wet areas that could conceal a frog, or Lilia, with her social anxiety, who ruminates on her behaviour at work, concentrating on all the dissatisfying aspects of it. Increased focus of attention serves to emphasise the fear, as it is constantly in mind and because anyone who scans for threat is vulnerable to assuming the worst: thus a clump of moss ‘is’ a frog, bubbles on the water’s surface ‘is’ frogspawn. In these ways, this person experiences an inappropriately increased amount of fear.
Examples of attention being directed away from threat cues would include Lilia’s ‘head in the sand’ strategy or the socially anxious person who avoids eye contact, or the road-traffic-accident victim who averts his gaze when nearing the site of the accident. In doing this, the fundamental fears are not faced, not even named in some instances, and it becomes impossible to challenge the beliefs about the perceived threat.
Spontaneous imagery: several studies indicate that mental images can enhance the sense of threat (Ottavani & Beck, 1987; Clark & Wells, 1995). For example, the person with social phobia might hold a vivid mental picture of himself looking incompetent, or the client with panic disorder might have a catastrophic image of herself losing control. Such images appear to heighten anxiety. Imagery is particularly relevant in the maintenance of PTSD, where vivid traumatic intrusions are thought to maintain a sense of current threat to the individual and thus prevent anxieties from remitting.
Emotional reasoning: this refers to the process of believing that ‘If I feel it, then it must be so’ (see also Chapter 8). Arntz, Rauner and van den Hout (1995) showed that anxious patients rate situations as being more dangerous than control subjects do – even when given information that assured them of safety. Anxious clients conclude that there must be a threat because they feel anxious. Thus, based on her feelings, a highly nervous woman might not be able to identify danger but would assume it existed; or a man might feel anxious about his thoughts and thus assume that his thoughts are dangerous. Often, such assumptions serve to further heighten anxiety.
Memory processes: Clark (1999) suggests that there are distortions of memory that account for the perpetuation of problem anxiety: namely, selective recall of threat and anxiety-provoking situations. Selective recall means that anxious individuals tend to have the capacity for more negative and traumatic recall of their own past experiences than do non-anxious individuals (Mansell & Clark, 1999). This, of course, helps maintain a view of the world as personally threatening. Selective recall also prevents someone from being able to appraise the bigger, more balanced, picture. Without this, fears cannot be put into perspective. The most striking example of this process is PTSD, where sufferers have intense recollections or flashbacks which maintain a sense of current threat whilst having an imprecise recall of the entire event – which would otherwise help to put the intense recollection into context and combat the impression of danger being current.
Interpretation of reactions to a threat event: the conclusions that a person draws when experiencing anxiety symptoms can exacerbate the problem. For example, if someone with a perfectly normal initial response to threat jumps to the catastrophic conclusion ‘I’m going crazy!’ or, ‘I’m going to pass out!’ this can heighten fear, provoke anticipatory anxieties and result in the use of avoidant strategies which are likely to prolong the fears.
Another process that has been associated with protracted or exaggerated anxiety is worry (Borkovec, 1994). Although a brief period of worrying is helpful as it guides our attention to potential threats (Davey & Tallis, 1994), prolonged worrying becomes unproductive and can even be actively undermining. For example, whilst on holiday, I might worry about losing my passport. This focuses my thinking: I check that I have my passport and I consider where I might put it for safety. A more anxiety-prone person might worry about losing his passport but continue this cycle of worry even though he had checked that he was carrying it. He might keep thinking, ‘but what if …’ and increase his anxiety levels with each repetition of this (usually unanswered) question. This further exacerbates the problem because the sufferer, locked into repetitive worrying, often avoids addressing more central concern(s), hence preventing problem-solving.
For example, Tom came to therapy for help with his concern about contracting genital herpes back in his village in Africa. Exploration and challenging of his fear always ended in: ‘but what if I have caught it and it will show itself later?’ Over several sessions, he began to talk about the shame that he would experience if he had herpes and later spoke of his shame for having run from his village when he saw military-police vehicles. He had later discovered that several members of his family had been shot by the military police that day and his active concerns about herpes helped him to avoid the pain of this. However, it also prevented his grieving and the resolution of that pain.
Clearly, the groups of thinking biases described in Chapter 8 (selective attention, extreme thinking, relying on intuition, self-reproach) can also play a part in the maintenance of problem anxiety, so you need also to bear them in mind when understanding your clients’ problems.
In summary, then, understanding the maintaining cycles that drive problem anxiety is fundamental to managing it. What implications does this then have for therapy? The beauty of identifying maintaining cycles is that we can then plan interventions to break these unhelpful patterns, and in the next section we will look at this.
As we indicated earlier in this chapter, it is essential that you carry out a thorough assessment before attempting to classify your client’s problem. You can find detailed guidelines on assessment in Chapter 4, and McManus (2007) and Butler et al. (2008) provide brief, but useful, guides to the assessment of anxiety. In those cases where it becomes clear that the difficulty does indeed fall into a recognisable DSM category, you are urged to use the established cognitive model and treatment protocols for that disorder. These are elaborated in the next chapter.
Earlier we outlined the generic anxiety cycle: a trigger taps into a fear, the client responds in a self-protective way (usually a form of avoidance), the fear is unchallenged and remains intact, ready to be triggered in the future.
John is so scared of confined spaces that he can no longer travel by air or public transport, he cannot use lifts and he will not ride in another person’s car. His alarming prediction is that, in a confined space, he will not be able to get sufficient air and will suffocate. John protects himself as best he can: for example, if he has to travel, he will use his own car; he will choose a route that allows him to stop as he feels necessary; he will have the windows open to ensure that he gets enough air. The consequence of his use of safety behaviours is that he avoids the lack of air that he fears and thus his belief that something dreadful will happen remains intact.
Pamela fears contamination of herself and loved ones and has a catastrophic prediction that someone might die as a result of contamination. Like John, she does her best to deal with her fear and engages in quite elaborate cleaning rituals and uses plastic covers on her furniture to repel dirt. She also asks her family to remove their shoes outside the house, immediately go into the cloakroom by the door and to ‘scrub up’ before entering the main living areas. Each of these strategies ensures that Pamela avoids facing her fear and, as a result, she never gains confidence that she can relax her standards for cleanliness. Her problem is further enhanced by her family members colluding with the avoidance.
Essentially, if John and Pamela are to overcome their problems, they need to break the cycle by challenging their fears (Figure 13.4).
Figure 13.4 Breaking maintaining cycles
John, with the help of his therapist, agreed to let go of some of his safety behaviours (giving up all of them was too threatening to begin with), and he began driving with his window closed. He found that he had ample air and the only times that he felt short of breath were when his anxiety increased because of a driving challenge and not because of a shortage of air in his car. This began to undermine his fear-related beliefs and he dared to relinquish more of his unhelpful behaviours. He and his therapist worked out a programme of behavioural experiments (BEs), and he began to drive on motorways where he might have to stay on a stretch of road for miles before being free to take a break. He gradually took on increasingly challenging tasks and soon became comfortable driving on any stretch of motorway. By now his fearful predictions of catastrophe were significantly undermined and the maintenance cycle for his fear broken. As a result, he was able to begin to use public transport with relative ease. In John’s case, the results of behavioural changes facilitated cognitive change: his behavioural achievements challenged his earlier beliefs with very little input from the therapist.
Pamela’s excessive cleaning and her demands on her family members eventually became intolerable, and her husband and children persuaded her to seek therapy. At first, Pamela was both sceptical of therapy and very frightened of making changes. It seemed improbable that she would begin to change her behaviours without some compelling assurance that it would be worth the risk. Thus, her therapy began with a cognitive emphasis (see Chapter 8) and data-gathering, using a survey method of BE (see Chapter 9). She made a checklist for her friends, asking them what precautions they took to avoid contamination in their homes. She gave options such as: covering the furniture with plastic and asking family members to leave their shoes outside, and so on. She also asked how often they or their family members were sick. Using this approach, she first discovered that not only did her friends not engage in elaborate precautions, but that they and their loved ones were rarely ill and never fatally. This helped her feel less afraid of changing her own behaviours and she was then able to engage in a series of behavioural experiments that systematically helped her to drop her SBs.
When aiming to break unproductive cycles, you are always faced with the question of what interventions to use. As cognitive therapists, we have a collection of cognitive, behavioural and physical strategies at our disposal (see Chapters 8, 9 and 10). The key is in identifying relevant components of the maintaining cycle and ‘matching’ the techniques accordingly.
The physical strategies, such as relaxation, are particularly useful when the physical consequences of being anxious impair performance (shaking, for example) or when physical activity becomes aversive, because of physical discomfort, and is avoided. The behavioural techniques are invaluable in tackling avoidance head on and can also be used in self-monitoring and planning, as with activity scheduling. The cognitive approaches are relevant for helping clients ‘stand back’ from their problems and identify the components of a maintenance cycle, for helping them evaluate the usefulness of certain ways of processing information and in helping them re-evaluate unhelpful perspectives.
An additional adaptable technique is the ‘Theory A vs. Theory B’ strategy. This collaborative intervention, developed by Salkovskis and Bass (1997), promotes therapy as a behavioural experiment offering the opportunity for testing two opposing theories. Essentially, one theory is, ‘There is danger’, and the other is, ‘I am worrying too much about danger’. As a therapist, you need to adopt a curious, experimental approach to considering the two theories. Rather than proposing that the client is incorrect in holding a particular belief, instead, you suggest that perhaps the client is right but perhaps there is another possibility. These alternatives are then explored in therapy: Theory A reflects the client’s predicted belief (for example, ‘I am seriously ill’), while Theory B states an alternative explanation (for example, ‘These symptoms are due to anxiety’). You and your client can test the theories both retrospectively (by reviewing past beliefs, behaviours and outcomes) and prospectively (by setting up behavioural tests). This both brings the benign theory into the client’s awareness and potentially collects data to support it.
Table 13.1 Problems and techniques
Examples of problems
Examples of techniques
Muscular tension impairing sleep or public speaking
Avoidance of exertion because of a prediction of threat to health
Avoidance of perceived threat
Unawareness of relevant patterns or fluctuations in anxiety. Limited
engagement in soothing, relaxing activities
Focusing on the worst prediction. Avoiding behavioural challenges
Behavioural experiment (Theory A vs. Theory B) Cognitive
Poor insight into the processes maintaining anxiety. An inability to
see ‘thoughts’ as ‘thoughts’
Chronic and unproductive worry cycles
Skewed beliefs or images which perpetuate anxiety
Inability to define difficulties, to make decisions, to plan ahead
In summary, anxiety disorders reflect a normal reaction to stress or threat which has become exaggerated by heightened physical reactions, skewed thinking and/or problem behaviours. This sets up unhelpful cycles which can be broken by introducing techniques to counter problem sensations, cognitions and behaviours. Table 13.1 shows several examples of CBT techniques and type of problems for which they would be relevant.
Problems when working with anxious clients
Self-fulfilling prophesies: cognitive
It is not unusual for the mental effects of heightened anxiety to undermine thinking. We have all probably encountered the client who describes his mind ‘going blank’ or who complains that so many concerns race through his mind that he cannot think straight. A graded approach to facing difficult situations, backed up by strategies to reduce stress levels (such as constructive self-talk) can help your clients learn to manage their anxiety levels, allowing them to then systematically face their fears.
Self-fulfilling prophesies: physical or behavioural
Similarly, we often encounter clients who report that the physical effects of anxiety impair their performance: struggling to find words during public speaking, shaking while writing in public and so on. Again, helping them learn self-calming strategies that will minimise the physical effects of anxiety, followed by facilitating them through a series of graded and systematic behavioural experiments can help your clients build a body of positive data that will help to consolidate their confidence.
The power of avoidance
Avoidance is the most compelling safety behaviour. It often represents the path of least resistance, providing tremendous short-term reward. Avoidance can be passive, as with clients who simply do not engage with their fears (not leaving the house, not using public transport, not attending social events, for example), or it can be active, when a client puts much active effort into avoiding facing their fears (for example, the person with OCD who carries out elaborate or time-consuming rituals in order to avoid facing a fear of contamination or a fear of causing harm). Avoidance can also be subtle: for example, a person carrying out a frightening task but drinking a unit or two of alcohol first; or a socially anxious person helping with ‘hostess duties’ to avoid having to engage in proper conversations; or someone with agoraphobia appearing to get out and about but using a mobile phone as a constant link to his safe base. A thorough assessment is needed to clarify the complexities of avoidance – remember to ask questions such as: ‘And is there anything else that helps/that you use to get you through such times?’, ‘What do you do that you wouldn’t do if you did not have this problem?’, ‘What do you not do as a result of having this problem?’
In order to help clients reappraise the usefulness of avoidance, we can:
- encourage self-monitoring – including monitoring the longer-term consequences of avoidance;
- share a formulation – clearly illustrating the disadvantages of this choice of coping;
- negotiate a graded reduction in the use of avoidance for the particularly reluctant client (using a series of behavioural experiments); the positive feedback of success will then support further reductions.
‘I’m anxious all of the time’
This common statement rarely stands up to self-monitoring. Although a client’s retrospective appraisal might be, ‘I have the headache all of the time’ or ‘The images are with me all of the time’, both daily thought records (see Chapter 8) and activity grids (Chapter 9) can reveal a variation in levels of physical tension and visual intrusions. Once these variations are clear, patterns and correlates can be established and cycles understood and ultimately managed.
‘I do all the things that we agree, and my anxiety does not decrease’
If this is the case, look for subtle forms of avoidance and safety-seeking behaviours, including superstitious behaviours such as doing or saying things so as ‘not to tempt fate’. This can include the misuse of distraction, which results in the client concluding ‘I only got through this because I distracted myself’, rather than concluding ‘I took my mind off my worries and calmed myself’. In addition, you might find it helpful to consider the rate at which the client is facing the feared situation: although graded practice can be helpful, if it is too gentle and cautious, the client will gain little sense of achievement. Also check if others are helping to maintain the problem: a doctor reassuring his patient, a partner being critical and undermining, a ‘helpful’ neighbour shopping for your client.
Not being bold enough to face the fear
This can apply to both you or your client. When your client is reluctant to tackle a demanding challenge, you need to ask, ‘Is this an appropriate task for this person at present?’ Although it is important to encourage clients to engage in challenging tasks, they should not be over-stretched, as this can cause demoralisation and drop-out. However, it is possible that the task is appropriate yet the client cannot overcome reluctance to take it on. This might be because they have inhibiting beliefs about feeling anxious, such as ‘Feeling anxiety is bad or dangerous and I must avoid it’. Ensure that your client appreciates that feeling anxious is not synonymous with failing and that it is to be expected during a behavioural assignment geared to facing fears. Also, make sure that you have shared a rationale that makes clear the advantages of tolerating the discomfort of the task. Similarly, you may need to address unhelpful assumptions concerning behavioural assignments (such as: ‘This won’t work for me – my anxieties are different from others’, or ‘What’s the point – I know the theory and that should be enough’), perhaps including behavioural experiments to test such assumptions.
The client relies on medication to manage anxiety
This is a problem if your client really invests his confidence in medication so that the CBT intervention holds little credibility for him and his motivation to engage is low. In addition, there is some evidence that some anxiolytics interfere with CBT for anxiety (Westra & Stewart, 1998). If you feel that your client is over-reliant on medications, explore his assumptions about drugs and CBT to see if it is possible to engage him in behavioural experiments that might help him develop more confidence in a psychological approach. It is not unusual for even well-motivated clients to be taking anxiolytic medication when they begin therapy, but they often readily learn cognitive behavioural techniques and then systematically reduce their medication – however, this should always be done with medical supervision.
- Anxiety disorders reflect a normal reaction to stress or threat which has become exaggerated by heightened physical reactions, skewed thinking and/or problem behaviours.
- Problem anxiety is maintained by unhelpful cycles which are driven by cognitive biases and, usually, avoidant behaviours.
- There are many presentations of anxiety disorder and careful assessment will tell you which disorder best describes your client’s condition. Some anxiety presentations, however, do not fit neatly into a diagnostic group and some clients will present with one or more types of anxiety disorder: you need to be prepared for this.
- As a cognitive therapist you have a range of interventions that can be used to help your clients manage their anxiety-related problems. These include physical, behavioural and cognitive strategies. Deciding on the appropriate intervention depends on developing an appropriate formulation, which will be based on a sound assessment.
- The anxiety with which your clients struggle can sometimes hinder therapy, but this is often readily overcome by attending closely to unhelpful thoughts and behaviours.
Review and reflection:
- Do you recognise your own clients in the description of anxiety disorders? In what ways are your clients similar or different?
- Does the description of anxiety disorders being an unhelpful development of ‘normal’ anxiety fit with your experience? How could you use this understanding to better help your clients?
- Do you see the cognitive biases described in this chapter in your own clients? Can you bring to mind examples from your own work?
- Look through the summary of strategies for managing anxiety-related problems – are you familiar with them? Are there gaps in your knowledge?
Taking it forward:
- Review your anxious clients and reformulate their difficulties in the light of having read this chapter.
- Consider how you will share an understanding of the development of problem anxiety.
- Check that your maintaining cycles make sense for you and for your client. Ensure that you have considered the cognitive, the behavioural, the physical and the systemic factors that could be fuelling vicious cycles.
- Read more about the strategies for managing anxiety – go back to source materials to ensure that you properly understand them.
- Keep your formulation updated. Anticipate that there might be some difficulties when working with the very anxious and be ready to revise your formulation and to understand why these difficulties make sense rather than assuming that the therapy is not working or that your client is not complying.
Butler, G., Fennell, M., & Hackmann, A. (2008). Cognitive-behavioural therapy for anxiety disorders: mastering clinical challenges. New York: Guilford Press.
A wise and excellent formulation-based approach to treating anxiety disorders which remains evidence-based. It is extremely readable yet avoids oversimplifying the management of anxiety disorders.
Clarke, D.A., & Beck, A.T. (2009). Cognitive therapy of anxiety disorders. New York: Guilford Press.
A comprehensive, integrative text which combines theoretical and clinical wisdom. It provides an overview of models of anxiety and an easy-to-read summary of the empirical literature. It is an accessible, up-to-date and practical text.