June - July 2008

The Worry Cure: Seven Steps to Stop Worry from Stopping You, Robert L. Leahy, Ph.D. (paperback, 322 pages), Harmony Books, 2006 Dr. Leahy is one of the world’s leading theorists in cognitive therapy, and we are fortunate that he set time aside to apply his principles to worry and the struggles of those diagnosed with generalized anxiety disorder.  Within his seven steps are numerous strategies to shine a light on every nook and cranny of the worry process.  For instance, with Step 2—accept reality and commit to change—he outlines a 2-stage process he calls “uncertainty training.”  If worriers did nothing but follow the instructions on those 2 pages, they could regain control of their mental life.  Stage 1: Examine the costs and benefits of accepting uncertainty.  Stage 2: Flood yourself with uncertainty.  I’m not saying it’s easy, but it’s an excellent strategy.  You can base an entire book on that one concept. Here’s one of many little gems for therapists (page 113). When clients feel swallowed up by a worry, ask them to fill in the blank: “This is not a problem because…” I ask them to brainstorm out loud 5 or 6 answers.  My clients hate this exercise… at first.  “What do you mean?! Of course this is a problem!” But be persuasive; clients can get some novel insights here. Good book.  Read it.  Use it.

Tic Disorders, Trichotillomania, and Other Repetitive Behavior Disorders: Behavioral Approaches to Analysis and Treatment,D. W. Woods,R. G. Miltenberger (Eds). (319 pages, hardback). Kluwer Academic Publishers, 2001   This is a detailed, edited book, covering tics, trichotillomania, and the oral-digital habits of finger sucking and nail biting.  There is a single chapter on the oral-motor behaviors of stuttering, bruxism and rumination. (Tourette syndrome, with its vocal tics, is not covered extensively.) Since this is behavioral treatment, it is built around the well-tested habit reversal procedure. But this is no once-over-lightly, repetitive theme.  You will learn a comprehensive protocol for each of the disorders, with session-by-session interventions to orient you.   Helpful tips can be culled throughout this volume.  I’ll give you an example in the Professional Update on tic disorders, below.

Self-Help & Professional Update:
Stand without Crutches, Part 2

(This is Part 2 of a 2-part article. Professionals: I’ve written this as though the reader is someone with anxiety.)

In the last issue, I introduced some of the principals involved with safety crutches, the things and actions you use to reduce or avoid discomfort. I’m going to pick up where I left off, so it will be best to read that article first: March-May ’08. I’ll write this as though I’m talking directly to someone with anxiety.

Here’s how safety crutches make you more fearful, not less. When you face an event that you perceive as threatening (1), you grab one or more of your crutches (2) and feel some immediate relief (3). But as you mentally register that relief, you simultaneously (even if you don’t notice this) conclude that you averted an experience that could have been dangerous (4) if you hadn’t used your crutch (5). This causes you, at least unconsciously, to again associate the event with danger (6). Now your fear about the event becomes stronger (7) in an ever-reinforcing cycle.

For instance, as you approach a lunch date with your friend and perceive it as a threat, you ask your spouse to come along, you monitor your heart rate and check for your medication. If you have OCD, and you are afraid someone will break into your home, you may develop a series of repeated checking behaviors to feel certain the doors and windows are locked. These crutches offer you relief and support, and you carry on through the event. When it’s over, you continue to feel reassured that those crutches “worked” because you averted disaster. The next time you approach a similar scene, your fear-of-threat returns and you begin reaching for your crutches again.

LEARNING TO COPE WITHOUT CRUTCHES

Is there another option?

Consider approaching that same threatening event (1). When you have the urge to use a safety crutch, hold back (2).  Instead, tolerate your anxiety sensations and be willing to directly face your doubt about what bad might happen.  Believe that you will figure out how to cope with whatever comes your way, as we worked on in the earlier chapters (3).  Then let yourself discover what actually happens in the scene (4).

With every crutch you use, you weaken your sense of competence. Imagine that you leave a party and then say, “Maybe if I stayed more than 30 minutes, I would have humiliated myself.” The only way to challenge that as a valid conclusion is to stay longer next time.  You have to do enough for long enough to disconfirm your unrealistic, threatening beliefs. For OCD, you typically have to do less for long enough.  In this example, you will need to check less frequently and risk something bad happening, in order to discover what actually happens.

Your goal is to challenge any unrealistic beliefs that you have about how such events will unfold. You don’t know if those unrealistic beliefs are true or false, and that thought will make you anxious.  Good.! That’s what we’re looking for: to go forward, into a threatening situation, while feeling uncomfortable and uncertain, and discover what happens in the scene. You must face the situation without those crutches in order to discover that you can cope. With time and practice, you will have fewer and fewer doubts about your ability to cope. 

As you practice, remember that you aren’t just focusing on your fear of how anxious you might get. The bigger threat is what you imagine will happen next.  You will grab on more tightly to any safety crutch that you think will prevent your feared catastrophes—running out of the grocery store, fainting, causing a scene, having a heart attack.  With OCD, it may be causing someone to become sick or die, or committing some immoral act. You must practice to test out those theories, not just practice to find out if your uncomfortable sensations fade away. 

How do you do that?  When you decide to practice, to the best of your ability, don’t do anything to save yourself from embarrassment or to reduce your anxiety or to feel more secure. Do nothing to hide your anxiety or to improve your performance.  If sweat is getting in your eyes as you give that speech, take a moment to wipe your brow, then keep going.  If you get lost or confused, pause to look back at your notes, then push on. Just be yourself in the moment, and focus on the task at hand, whether it is making the point to your audience or wiping the sweat from your face.  Then discover what happens and how you cope with it. Whatever you learn, apply that to your next encounter with threat.

Professional Update:
Working with Tics

In Chapter 6 of Tic Disorders, Trichotillomania, and Other Repetitive Behavior Disorders: Behavioral Approaches to Analysis and Treatment, Douglas Woods creates a treatment manual for tic disorders.  In one of his helpful suggestions, you learn how to train clients to identify the antecedents of the urge and label them as “warning signs.”  The therapist then has clients describe and demonstrate the tics.  Now the session continues, while the therapist occasionally slips in a just-learned tic.  As the clients notice, they signal.  When they master that recognition exercise, the therapist begins modeling any visible warning signals during the session and clients signal as they identify those moments.  In successive approximations to the goal, clients then signal whenever they notice their own warning signs and tics during the session.

You are always looking for a competing response that is physically incompatible with the tic. Pressing or tensing a body part is often used, since most tics involve movement.  So when the issue is related to making an obscene hand gesture, they can make fists and push the elbows into their side.  If they are blurting out a vocal tic, they can lower the chin slightly and tense the neck muscles.

Resources

Campbell-Sills, L. and D. H. Barlow (2007). Incorporating Emotion Regulation into Conceptualizations and Treatments of Anxiety and Mood Disorders. Handbook of emotion regulation. New York, NY, Guilford Press: 542-559.

Kim, E.-J. (2005). The effect of the decreased safety behaviors on anxiety and negative thoughts in social phobics. Journal of Anxiety Disorders, 19(1), 69-86.

Lohr, J. M., B. O. Olatunji, et al. (2007). "A functional analysis of danger and safety signals in anxiety disorders." Clinical Psychology Review 27(1): 114-126.

Powers, M. B., Smits, J. A., & Telch, M. J. (2004). Disentangling the Effects of Safety-Behavior Utilization and Safety-Behavior Availability During Exposure-Based Treatment: A Placebo-Controlled Trial. Journal of Consulting and Clinical Psychology, 72(3), 448-454.

Rachman, S. (1984). "Agoraphobia: A safety-signal perspective." Behaviour Research and Therapy 22(1): 59-70.
Rachman, S. (1984). "The experimental analysis of agoraphobia." Behaviour Research and Therapy 22(6): 631-640.

Salkovskis, P. M., Clark, D. M., & Gelder, M. G. (1996). Cognition-behaviour links in the persistence of panic. Behaviour Research and Therapy, 34(5-6), 453-458.

Sloan, T., & Telch, M. J. (2002). The effects of safety-seeking behavior and guided threat reappraisal on fear reduction during exposure: An experimental investigation. Behaviour Research and Therapy, 40(3), 235-251.