Section 2
CD Track #2: Elevator Phobia and Procrastination

Table of Contents | NCCAP/NCTRC CE Booklet

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10 Principles of Anxiety Disorder Therapy: Part 2 of 3

Principle 3: A Sound Therapeutic Relationship
Of course, the client must talk openly about fears and anxiety for the therapeutic process to occur. As you know, clients often avoid talking about their fears. One client explained, "If I talk about my anxiety, that will make me feel anxious. I don't want to chance it." As you know, a major part of treatment consists of encouraging the client to face frightening situations so as to be able to view them realistically; talking about them is one way of reaching the client's goal.

To build this sound relationship, I find especially with an anxiety disorder client, I have to be acutely aware of possible misinterpretations and misunderstandings of my intention. I recall in one session, I used humor and the "So what if?" technique; that is, to hypothesize the worst possibility - an approach that appeared helpful to the client. At the end of the session, I asked a standard feedback question, "Was there anything about the session that bothered you?" The patient responded, "You seemed to be making fun of me and taking my concerns lightly." This feedback enabled me to correct these misperceptions immediately.

Principle 4: Therapy is a Collaborative Effort between Therapist and Patient
I find with an anxiety disordered client the emphasis is on working on problems rather than on correcting defects or changing personality. The therapist fosters the attitude, "Two heads are better than one" in approaching difficulties. When the client is so entangled in symptoms that he or she is unable to join in problem solving, I find I may have to assume a leading role. As therapy progresses, I encourage the client to take a more active stance.

Principle 5: Cognitive Therapy Uses Questions
The therapist is modeling coping strategies by asking questions that expand a client's constricted thinking. Often a client reports that when confronted by a new anxiety-producing situation, he or she will start by asking himself the same questions he heard from the therapist: "Where is the evidence?", "Where is the logic?", "What do I have to lose?", "What do I have to gain?", "What would be the worst thing that could happen?", "What can I learn from this experience?"

Principle 6: Cognitive Therapy is Structured and Directive
Anxious patients tend to go off on tangents; as you know, the therapist can model task-oriented behavior by keeping the discussion on the problem at hand. The therapist has to set the appropriate tempo for the session. If the pace is too fast, the client may miss much of what is being discussed; and if too slow, he may lose confidence in reaching the end result.

The Key
I find a key with the structure of the session is to look for a common ground or to an earlier casual link. With one client, Phil, he was afraid of strangers, his boss, and his parents; the common denominator was fear of rejection. Such reductions make the problems more manageable. Sue had a fear of elevators that prevented her from looking for a job, and her joblessness caused even more difficulties for her. Dealing with the first problem, elevator phobia, solved her other problems. Bill had many fears of starting a new job ("People won't like me--I won't be able to do the job--I don't think I'll like the people"), all of which could be traced back to the basic fear that his bosses would discover he had exaggerated on his job application.

Principle 7: Cognitive Therapy is Problem Oriented
The key here is Conceptualization of Problem Definition. As you know in conceptualizing the client's problem, the therapist has to elicit from the patient what the problem means to him. The passive-aggressive person may be procrastinating because he believes this is the way to avoid being controlled by others. The anxious client, the depressed client, the angry client, and the manic client will all have different reasons. Procrastination may indicate a shift of priorities that the client has not fully accepted; or it may be due to a secondary gain, such as a way to get attention or rationalization ("I could be a great painter, but I don't have the self-discipline").

The point is that there are many reasons a client may be procrastinating. Therapist and client need to conceptualize the problem jointly before an adequate strategy can be chosen. Conceptualization, strategy selection, and technique implementation influence and feed each other. Usually this process is an evolving one of conceptualization and reconceptualization with corresponding strategy shifts.

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