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Section 1
Cognitive Therapy of Anxiety Disorders (Part 1) - Cognitive Brief and Time-Limited

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10 Principles of Anxiety Disorder Therapy: Part 1 of 3
We will discuss the intervention techniques of the Cognitive Model, overcoming resistance to learning, keeping therapy brief, assisting your client in distancing himself or herself from the anxiety, guidelines for asking specific questions, techniques to explore the questions of "What's the evidence?" "What's another way of looking at it?" and "So, what if it does happen?" Also, we will discuss how to help your client break the vicious cycle of anxiety, cognitive mapping restructuring, and ways to raise self-confidence, as well as visualizations to use with children.

To make sure we are all on the same page, so to speak, let's start with Beck's 10 Principles in a cognitive approach to anxiety disorders. This provides you with a checklist of strategies and concepts. You will get the most out of this listing of 10 Principles if you have one or two anxiety disordered clients in mind. As each Principle is explained, rethink your last session with that client. Is there one of these basic principles you have either forgotten or are overlooking?

Sometimes we become so familiar with a principle we don't see the forest for the... well, you know. So here we go... fine tune your recall skills of your last session with an anxiety disordered client. If convenient, write down a few clients' names upon which to focus regarding a particular principle.

♦ Principle 1: The Cognitive Model of Emotional Disorders
I feel use of this model is helpful because people want to make sense of their emotions and find it helpful to perceive their emotional problems as falling into four general categories: anxiety, anger, depression, and pleasure. A patient's numerous complaints can usually be placed in one of these categories. For example, a complaint about jealousy, loneliness, shame, guilt, shyness, procrastination, lying, rumination, or indecisiveness may well be a problem of anxiety management.

At the first interview, a client I'll call "Joe" said he was having trouble with his fellow workers, trouble in sleeping, trouble in making decisions, with women, and in telling the truth. After listening to the details, I realized that Joe's problem was how to manage anxiety, primarily, and anger, secondarily. This redefinition of his problems was helpful in and of itself.

Once Joe saw that his problem was related to anxiety management, he was ready to accept a cognitive explanation of anxiety. Once Joe had grasped the idea that his misconstruing of his experiences had led to his anxiety, I encouraged him to develop a systematic way of catching and correcting his thinking and his anxiety. I will go into more detail later about this.

Just a reminder... of course check that medical reasons for the client's symptoms have been ruled out. One client had symptoms that appeared to be anxiety attacks. Her physical examination, however, revealed that she had a gall bladder disease. Once this was treated, the symptoms disappeared. Along the same lines, an anxious client may have symptoms that are caused by a physical illness but are misinterpreted as anxiety. A client with occasional periods of anxiety actually had a viral infection. Instead of thinking, "I'm getting anxious," which in turn created real anxiety, she discovered she really had the flu; Her anxiety diminished also.

Introducing Cognitive Therapy
To explain anxiety, I'll explain how the way a person appraises the situation, determines feelings, and how this appraisal is related to earlier learning experiences. For example, a person who has never before seen a particular poisonous plant will not be afraid of it; Only after he has learned to associate it with danger will he become afraid.

The First Level of Fear
I find it effective to point out that what the client really fears are his feelings and sensations. I then describe the two levels of fear. The first level is fear of some form of a primary danger, for example a fear of a dreaded disease, such as cancer or a heart attack, or for example, fear of accidents, fear of public humiliation, fear of suffocation, fear of drowning, and so on.

The Second Level of Fear
However, the second level of fear is actually fear of the symptoms of anxiety rather than fear of a danger. Inability to overcome the first as danger exaggerates the second level and leads to a panic cycle.

While a client cannot always immediately overcome the first level of fear, he or she can stop frightening themselves over the anxiety itself. In the first session, I like to give the client some concrete ways of handling the second level of their fear, which is fear of their symptoms. We'll talk about these in more detail later.

♦ Principle 2: Cognitive Therapy is Brief and Time-Limited
Long-term therapy is sometimes undesirable. Brief therapy discourages the client's dependency on the therapist, which is prevalent in anxiety disorders, and encourages the patient's self-sufficiency. Frequent reassurance from the therapist prevents the patient from thinking for himself. When the patient sees that the therapy is short-term, I find the client often begins to realize that anxiety is a problem that I believe can be overcome quickly. Specifying a certain number of sessions puts the client in a task-oriented frame of reference for "getting down to business." As you know, the reality of third-party pay or coverage for brief treatment often sets the limit here.

Strategies for Keeping Treatment Brief
I find since time is a limited resource, each intervention needs to have a purpose and a rationale. I like to think of this as "hurrying slowly." I cover important material, but move quickly. The following are some general strategies I use for keeping treatment brief:
1. Keep it simple. The abundance of theories about emotional disorders enhances the human tendency to complicate problems. I find it easy to complicate a client's problems but difficult to simplify them. A good rule to keep in mind here is: "No matter how complicated a client's problem may be, a therapist has it in his or her power to make it even more complicated." Complicating the problem definition and treatment process prolongs treatment and often makes it less effective.
2. Make treatment specific and concrete. The more abstract the conceptualization and intervention, the longer the treatment. Keeping the language relatively free of abstraction moves therapy along. For example, instead of referring to the four basic emotions as "anxiety, depression, anger, and euphoria," I use terms like "scared, sad, mad, and glad" and aim for the lowest level of abstraction.
3. Stress homework. As you know, homework gives your client the best chance of getting better fast, and it is the therapist who conveys to him or her its importance. Specific homework assignments will be discussed later.
4. Make ongoing assessments. Most of the information that I need to make proper intervention decisions is obtained throughout the treatment. Usually elaborate assessment is unnecessary.
5. Stay task-relevant. I can easily go off on a tangent with an anxious patient who usually wants to avoid discussing his or her fears. If the client insists on such discussions, I point out how it distracts the session from his or her main goal of the session.
6. Look for ways to use therapy time effectively. Depending upon the client, of course, some of the methods I have used are setting and sticking to an agenda for a session, providing written handouts on standard material, or using posters to illustrate strategies and techniques.
7. Develop a brief-intervention mindset. I find that by assuming that a client can learn to manage his or her anxiety quickly, this mindset can create a self-fulfilling prophecy. Thus, the client feels he or she can manage their anxiety quickly.
8. Stay focused on manageable problems. Because cognitive therapy is time-limited, many client problems will remain unsolved at the end of treatment. By the time treatment ends, ideally the client will have enough psychological tools to approach and solve problems on his own, knowing that the therapist is available for added sessions if necessary.
Reviewed 2023