Reducing Anxiety and Breaking Patterns of Avoidance
In Chapter 7 of Learning Cognitive-Behavior Therapy, Wright et al. (2006) argue that avoidance is one of the major hindrances to effective management of psychological disorders. The authors observe that a large percentage of the thoughts that people have daily are part of “a stream of cognitive processing,” which takes place “below the surface of the fully conscious mind” (Wright et al., 2006, p. 162). This view supposes that avoidance often involves suppression (consciously or unconsciously) of negative thoughts, with the hope that the problem will just go disappear.
The above observation reflects the findings from the research on cognitive-behavior therapy, which have shown that the inclination to evade unwelcome thoughts results from wishful thinking that an issue which is out of mind is as good as solved (Wright et al 2006). However, the authors further note, the habit of trying to suppress negative emotions does not address the symptoms of the problem, but only gives a person temporary relieve. Psychiatric studies on the outcomes of this coping mechanism, for example, getting drunk to forget a problem, support the authors’ view that the habit is an obstacle to treatment therapies for psychological disorders.
Cognitive behavior therapy (CBT) promises to overcome patterns of avoidance by encouraging patients to confront negative conscious and subconscious thoughts. For example, thinking about how a traumatic event affects one- as opposed to ignoring the event-, allows one to better understand the problem and how to address it. The tendency by victims of psychiatric disorders to seek avoidance is caused by the fact that thoughts about a traumatizing event can potentially generate “painful emotional reactions” (Wright et al., 2006, p. 163). In addition to ignoring the root cause of the problem, avoidance is a maladaptive reaction, which can lead to serious dysfunctional behaviors. CBT counters the problem of avoidance by encouraging psychiatric patients to consciously and purposely think about the cause of their condition and the best way to address it. In contrast, avoidance encourages negative thinking, which in turn promotes maladaptive behaviors.
In treating psychiatric problems, CBT employs a variety of strategies, which target the three aspects of pathological functioning: emotions, cognitions, and behaviors. For example, CBT trains patients on how to recognize and change their anxiety or depression-ridden thoughts. In addition, CBT encourages the use of relaxation as a means to reducing anxious emotions, and the adoption of a step-by-step hierarchy to break avoidance patterns. More importantly, CBT promotes cognitive processing geared towards conscious awareness, which enables the patient to make decisions on rational basis. For example, patients can address negative thoughts by assessing one’s interactions with the environment and linking past memories with current experiences. In addition, monitoring and evaluating future actions allows one to develop adaptive behaviors.
Nevertheless, the authors seem to downplay the significance of avoidance as a coping mechanism. This is especially the case when the nature of anxiety is connected to traumatic experiences from the past or distressing future events. In such cases, avoidance allows the individual to suppress emotionally and psychologically destabilizing emotions, albeit temporarily. The authors acknowledge the possibility of victims of traumatic events to overcome negative emotions through the cycles of avoidance. This fact partly explains why victims of traumatic events can suppress the negative thoughts associated with the event for years. Regardless, avoidance is not an effective solution to psychiatric problems, hence the relevance of CBT.
Panic Disorders and Their Treatment with Interoceptive Exposure
Panic disorder and agoraphobia are conventionally managed using the cognitive-behavioral approaches that are well defined; though, pharmacotherapeutic interventions are also needed to address the symptoms. According to Barlow (2014), panic episodes are linked to strong action tendencies, in most cases, the fight and flight. Additionally, people with panic disorders are vulnerable to nocturnal panics. Besides, nonclinical panic cases exist in about 3-5% of the population with panic disorder (Bolos et al., 2018). The chapter illustrates what it involves having a panic disorder and helps in the understanding of the role of behavioral and cognitive therapeutic models (Bolos et al., 2018). The relationship between panic disorder and agoraphobia is complex; though, they are chronic conditions with various relapse episodes.
The chapter outlines the history of the psychological treatment for the disorder. Previously, most of the psychological treatments were nonspecific, which made it difficult to establish their efficacy. The non-specificity in the therapeutic approaches leaves a huge gap in addressing the needs of the patients and this means that it may take a long period before the patients improve. The chapter reinforces the importance of understanding the patients’ medical history before initiating the treatment measure. Conceptualization of the etiology of the disorder and the maintaining factors helps in ensuring that all the perpetuating factors are addressed and minimize the chances of the patient having a relapse (Barlow, 2014). For example, some people have a genetic history while others are anxiety sensitive, or have a history of medical illnesses and drug abuse. As a result, it is necessary to have a clear understanding of a patient’s preexisting conditions to determine the appropriate treatment therapy.
The management of psychological disorders has evolved over time to assume evidence-based measures rather than relying on nonspecific approaches. Various treatment variables were highlighted in the chapter. The first variable is setting which refers to the environment where the therapeutic procedure is conducted. There are cases that require a clinic office while others can be conducted in outpatient settings. The therapist’s direct-exposure is essential for patients who lack social networks, especially those suffering from with agoraphobia. From the counseling perspective, it is important that a therapist builds rapport with their clients to facilitate the exchange of information required for an effective therapeutic session. According to the chapter, self-directed treatments occur in the natural environment and may be suitable for highly motivated and educated patients (Barlow, 2014). The other variable is the format and this refers to either the individual or group counseling sessions (Schwartze et al., 2017). Both formats have advantages and limitations; though, the need and history of the patients must be understood before deciding on the best method (Swift et al, 2017). Thirdly, interpersonal context and therapist variables among others also determine the level of success in the management of panic disorders.
Understanding the patient’s environment helps the therapist to design an appropriate environment and apply correct models. There are cases where therapists apply general knowledge to every client and so miss out on helping the patients (Liebscher et al., 2016). The behavioral and cognitive treatments must be customized and this is what the chapter elaborates. On the other hand, little has been given on the pharmacological interventions because there are cases where patients’ conditions are extreme and may require drugs to calm them down. Though, the overuse of such drugs could also be detrimental. Furthermore, initiating pharmacotherapy interventions can help limit the chance of a patient harming themselves or people around them. The readings provide clear guidelines on the protocol to follow when handling patients with panic disorder and agoraphobia. The guidelines are important for any psychotherapist since they are relevant to nearly all people with mental disorders.
Social Phobia and Its Treatment with Exteroceptive Exposure
Obsessive-compulsive disorder is characterized by a recurrent obsession that leads to interference with the normal functioning of a person (Barlow, 2014). Obsessions are created through images, thoughts, impulses that cause distress or anxiety, which are then defined by the actions in both mental and behavioral as a human attempt to reduce the distress brought about by the anxiety. The development of obsessive-compulsive disorder is gradual, but, in some instances, it can happen instantly.
It is mainly associated with impairment of the general functioning such as interpersonal relationship difficulties (Barlow, 2014). Peoples who suffer from OCD stay for a longer time before seeking treatment. However, OCD rarely occurs when an individual is isolated. Depressive ruminations and obsession is giving the clinician a difficult time to diagnose unless the patient report resistance to such thoughts. OCD was classified as an anxiety disorder, but it displays similar characteristics with other disorders. Obsession is usually experienced by a person as ego-dystonic.
Treatment for OCD includes exposure and ritual prevention, where the person suffering from OCD is prolong exposed to obsessional cues and procedures with the aim of blocking any access to ritual which takes place in real life (Barlow, 2014). Implementation of ritual behavior promotes ritual abstinence leading to successful treatment of a person suffering from OCD. Long exposure is more effective than a short one. To maximize treatment, ritualistic behavior and all avoidance should be prevented at all costs. There are complications that are encountered when offering behavioral treatment, which include non-compliance with treatment response prevention, non-anxious reaction to exposure, negative family reaction, functioning without symptoms, emotional overload, emergent fears, and rituals, and continue passive avoidance.
Social anxiety disorder, also termed as social phobia, is the fear of social setting or performance of social situations. It can range from fear of speaking in public places to performing activities in front of people. They fear negative evaluation from the people in a social setting to the point where these individuals shake, blush, and sweat. This disorder is the most common form of psychiatric disorder in our community. The behavior of these individuals displays a form of avoidance of social setting to a certain level, like while in a soccer match, they talk only to a familiar person only or subtle avoidance. Social anxiety can begin at an early age compared to other psychiatric disorders. Women suffer most from social phobia than me.
Effective treatment for social anxiety disorder can be done using psychotherapy and pharmacotherapy. Under psychotherapy, various cognitive-behavioral therapies, which include exposure to social situations of fear, are applied. In psycho-education, the therapist typically brings out different experiences that relate to the person’s anxiety and telling them to compare and contrast to whatever they have been experiencing. Before the application of exposure, the therapist usually works with patients to create the hierarchy of the feared situation with them ranked in order from least to most priority. The list will serve as a road map for treatment. Often, exposure to a feared situation happens during the treatment situation, which will facilitate the generalization of the social setting. Cognitive restructuring happens when the identification of automatic thoughts and challenging automatic thoughts with potentials alternatives. This activity will prompt a person to see a social setting as less biased.
GAD and Its Treatment with Applied Relaxation, Imaginal Exposure, and Cognitive Therapy
Generalized anxiety disorder (GAD), is a disorder whereby a general disorder is determined by the constituents of the anxiety that relates to other disorders. GAD is associated with characteristics such as chronic conditions and fluctuations. Excessive worry is the other characteristics of GAD whereby an individual who is thought to have been infected with GAD would tend to worry on certain days. In addition, an individual who shows a trait of GAD is normally unable to take control over matters they have early passed through. There are several symptoms that associate with GAD and some of them are problems with sleeping, tiredness, and concentration difficulties. Reduction in the rate of heartbeat is the other symptom of GAD in that the rate at which a heartbeat performs its work will slow down. People have different perceptions towards GAD, for instance, some individuals view it as a disorder developed in the growth development of a person because a period where GAD affects an individual cannot be easily determined.
The research has conducted a thorough investigation concerning the people who have a challenge of GAD (Barlow, 2014). The results show that the percentages of those who usually seek treatment in hospitals are people with GAD. Moreover, the researchers have found that most of the healthcare organization spend much money in offering treatment to people with GAD. The researcher’s findings also show that GAD has a closer link with cognitive behavior because worries, which arise from GAD, are difficult to control. People who are living with GAD are best in utilizing resources provided to them for medical services.
GAD has much impact on an individual affected. One of these effects is that the worries that occur as a result of exposure to a stimulus that relates to GAD lead to the relaxation of the muscle. It also makes an individual think about some of the worst occasions that had initially occurred and those that relate to future worries. GAD can be treated by the use of various means with the main aim of ensuring patient safety. Some of these ways include seeking medication in recognized hospital centers and using cognitive therapy. Cognitive therapy helps reduce the excessive worries and over-thinking of what will happen. It is also useful because it shapes the behaviors of individuals. GAD individuals should undergo the process of diagnosis, and most importantly, they are advised to seek help from people who have experienced the same problem.
Treatment can also be offered in terms of training whereby GAD measures should be applied to an individual gradually. The gradual introduction of relaxed measures will make people suffering from GAD to adapt to it. Teaching GAD individuals to adapt to some set training is also essential since it will help them to reduce their rate of fear and anxieties, thus living a normal way of life (McKay et al., 2010). Training can be done through thorough monitoring of the patients with GAD. Meta-cognitive beliefs would help to reduce the rate of worry among people with GAD by maintaining the worry of the individuals in case it occurs. People who are living with GAD are advised to have a positive view of the disease, and this would make them abstain from any kind of worries that they might come across. GAD individuals should also train to adapt to worries by exposing them to the occasion that is associated with anxiety and worries.
OCD and Its Treatment with Exposure/Response Prevention
The American Psychiatric Association describes OCD as the existence of both obsessions and compulsions. OCDs are distracting and unwelcome thoughts that contribute to anxiety or depression. In order to minimize the anticipatory anxiety with obsessions, compulsions are impulses to undertake repetitive actions or mental acts frequently. An extra specifier with low insight is included in the current diagnostic criteria. Notably, the emergence of either obsession or compulsion suggests Obsessive Compulsion Disorder, although both forms are evident in most situations. The paper aims at expounding on Obsessive Compulsion Disorder.
Research into the severity of Obsessive Compulsion Disorder ranges with figures that range from 1.1 percent. Comorbid Axis I disorders, especially other anxiety disorders and mood disorders, also cause the disease. Obsessive compulsion Disorder is often heterogeneous in terms of the forms of obsessions and compulsions that can arise, besides comorbidity. As stated by Barlow (2014), most experts accept that there are aspects of subtypes of the condition that concentrate on the theme of indications with specific therapeutic methods available based on symptom presentation accuracy. Sexually abusive, religious influences and muscle-focused obsessions, coupled with testing or reinforcing compulsions, are the most frequently reported symptom subcategories.
A definitive explanation of the etiology of Obsessive Compulsion Disorder is not yet accessible. Notably, Genetic and personal development activities patterns of initiation and development of the condition are confirmed by evidence. Biological theories indicate that there is an inevitable physiological deficit that contributes to compulsions and obsessions. The prevalence of dysfunction is demonstrated in other dominant physical models, but the deficiencies in particular regions of the brain are not emphasized. Cognitive-behavioral etiology models indicate that compulsions evolved to relieve obsessions as a negatively strengthened behavior.
More precisely, the most therapeutic approaches are the Exposure and Response Prevention form of CBT which has the best proof to support being used in the treatment of Obsessive Compulsion Disorder, and a class of drugs called monoamine oxidase inhibitors. The most common treatment for Obsessive Compulsion Disorder is exposure avoidance with reaction. Exposure to stimuli that potentially lead to obsessive anxiety and rituals and psychologist-assisted resistance to the resulting patterns are the essential ingredients of Exposure and Response Prevention (Barlow 2014). Notably, efficient therapies enable clients between appointments to continue to practice Exposure and Response Prevention. Various factors can contribute to an inadequate response to treatment. The parameters include the appearance of symptoms, comorbid Axis 1 and Axis 11 conditions and personality dimensions, grossly undervalued ideation and weak insight, perfectionist tendencies, and stimulus relationships between the environment and stimulation consequence.
For potential studies to enhance treatment results in Obsessive Compulsion Disorder there are at least two significant approaches. The first would be responsible for incurring off in the long run, where short-term gains can be given as the second. The first step is developing improved psychodynamic frameworks of Obsessive Compulsion Disorder with a deeper understanding of the condition. Besides, it should be possible to create strategies that improve critical pathways with interventions dedicated to a particular OCD subgroups or a specific OCD person. A better clinical research program with the hope that there will be a blend of interventions that might outshine the strongest possible mono-therapies so far is the second approach to improving the outcome of treatment is to stick with the quantitatively validated further.
PTSD and Its Treatment with E/RP and Cognitive Processing
Post-traumatic stress disorder (PTSD) has been on the rise in the United States, with prevalence rates averaging at 9.5% of the total population (Taylor, 2010). Increased crime incidents, violence, assault, and homicides have been highlighted as major influences on the condition. Additionally, military personnel especially those deployed in the Middle East have shown significantly higher risk than the general public (McKay et al, 2010). To explain the symptoms attributed to PTSD, two theoretical models have been approved: the two-factor mechanism and Ehler and Clark’s model. Mowrer in the two-factor theory proposes that fear triggers pyscho-emotional stimulation causing symptoms such as behavior change. On the other hand, Ehler and Clark used threat and recall ability to explain the long-term progression of PTSD since the initial exposure.
PTSD diagnosis is reliant on the patient’s interaction with danger, death, or having witnessed horrifying events that may later come back as flashbacks. These symptoms may be instant or delayed. It is the responsibility of the doctor to analyze the physical and psychological symptoms and determine the severity of a case. DSM-5 procedure helps analyze these symptoms and give proper feedback during the assessment stage. The utilization of psycho-physiological tools has been deemed weak due to insufficient infrastructure and inconsistencies with its clinical results. It is recommended that a final assessment be conducted using the standard DSM-5 process.
Exposure to traumatic events is the main cause of PTSD. The experiences may vary depending on the psychological attention given to the event by a patient. However, to be diagnosed with the disorder, one must prove that the event occurred with at least one recurring symptom, three numbing experiences, and two hypersensitivity symptoms, all of them within one month. Though the diagnosis relies on short-term symptoms, the historical background is worth looking at to understand the underlying risk factors. Personal history and family-based traumatic events can describe the PTSD etiological path and possibly hint at treatment options. Other risk factors include severe trauma, threat interaction after the main event, and life stressors. Sometimes genetics play also determines the vulnerability of a person to PTSD.
When disseminating these subjects, the doctor should always ensure that all information given by a patient is accurate and free of exaggerations or false information. Information gathered is assessed using a diathesis-stress mechanism and results categorized as either early or late-onset PTSD. Thereafter, a proper treatment plan is recommended and implemented. For early-onset, PTSD, critical incident stress debriefing is applied within 48 hours of exposure (Monson et al., 2014). The immediate attention seeks to create awareness of PTSD symptoms, enhance emotional encouragement, and teach ways of isolating from future stressors or stimuli. This method has shown high scores in terms of reoccurrence mitigation, emotional stability, and general recovery from the traumatic influences.
Secondly, cognitive-behavioral therapy (CBT) is also used to coach early survivors on various recovery skills using virile stimuli distributed in several sessions. Patients in the delayed stage also use CBT combined with pharmacological elements like sertraline. Lately, EMDR has been incorporated to train memory and neural functions through eye technology. Sometimes results are inconsistent due to a lack of statistical guidelines and technical biases derived from practitioners’ assumptions. However, medical inputs such as D-cycloserine increase exposure reaction enabling patients to effectively train their neural, cognitive, and behavioral functions.
Unified Protocol for Anxiety Disorder Treatment
Humans have come a long way in terms of psychological therapies used to treat various conditions. About 60 years ago, it was thought that psychotherapy has no benefit, and only medicines should be given. Many professionals have determined the effectiveness of Evidence-Based Therapy, which involves researching to enhance psychologists’ skills which collaborate with patients to identify the treatment strategies. Studies have shown that some conditions are better treated with psychological methods instead of medicines. For example, women who develop urine leakage can be managed by counseling the patients regarding their habits, which is more effective than medications. WHO recommends that a person who has experienced a recent trauma and is unable to sleep should be counseled regarding the changes in behavior to cope with stress, and no medicines should be prescribed to him. But despite all these arguments, some doctors prefer to prescribe medicines instead of using psychotherapies. Especially in depression and anxiety, medicines are being increasingly used.
Department of Veteran Affairs can be taken as an example to improve the practices regarding psychological treatments. This department favors psychotherapy to treat war veterans’ mental conditions, such as depression, stress, and anxiety. The results have been quite motivating, and the policies can be implemented by the health department overall. Trans-diagnostic approaches are becoming quite popular where the underlying psychological mechanisms regarding any condition are identified, and the psychotherapies are provided. Alcoholics have immensely benefited from this technique. The use of modern technology can overcome the problem of treating many people using psychotherapy alone.
Web-based therapies and telemedicine are the emerging fields that can provide psychological treatments to a large number of people. Facebook has become a platform where people tend to receive various therapies. This method is cheap, does not coincide with the work schedule, and raises patients’ confidence. Patients with addictive behaviors to multiple substances are reluctant to visit the doctors, and they can benefit from this form of therapy. Similarly, telemedicine can be used to provide psychotherapies to a large number of people. But there are specific confinements for both web-based and telemedicine approaches. People living in remote areas do not have access to these technologies and cannot be provided with such therapies. People have to remain patient and steadfast in order to revolutionize the field of psychotherapies.
Barlow (2014) states that post-traumatic stress disorder, which develops in those who have seen extreme forms of stressful conditions such as war, can be treated effectively by using only psychotherapies, and not the pharmaceutical drugs. He presents evidence supporting the argument that psychotherapy is superior to all other forms of therapy if the world of psychological disorders is considered. Cognitive behavior therapy is a form of psychological intervention where a therapist helps a person modify his behaviors for his own good and teaches him the techniques to regulate his emotions. This has been the most successful technique in treating symptoms that occur in PTSD (Barlow, 2014). Thus, instead of putting a burden on patients regarding pharmaceutical drugs and their associated costs, psychotherapy is a good alternative with favorable consequences.
Well’s Metacognitive Therapy for Anxiety Disorders
Generalized Anxiety Disorders (GAD) have been on the rise lately, which has led to increased interest in articulating basic mechanisms behind GAD and its pathological effects on an individual. The initial models of assessing GAD were developed by researchers who argued that worrying was more emotionally and imagery used as a suppression tool. They also argued that suppression leads to decreased arousal, which negatively reinforces the worry process. Wells (2005) proposed a model that easily demonstrates the differences between GAD’s two types of worry. The meta-cognitive model produced two different categories of worries: Type 1 and Type 2 worry (Wells, 2005). Type 2, also known as meta-worry, is essential since it develops from negative metacognitive beliefs around worrying, and as a variable, it contains a negative appraisal. The occurrence and contents of Type 2 worrying are believed to be the original and initial negative beliefs that a person has about the consequences and the nature of worrying.
The meta-cognitive model advanced the development and progression of psychometric characteristics in which it was possible to assess meta-worry on a scale. The scale is used to predict and assign central status in GAD’s development and persistence (Wells, 2005). The model shows that a person’s metacognitive beliefs about worrying result from repetitive and overwhelming worry (Wells, 2005). People with GAD generally use worrying as the primary mode and method of appraisal and handling personal threats. It encourages them to take worrying as the coping strategy for what they are going through. In type 1 worry, lack of distracters can cause an individual to worry more until they get their subjective aim of worrying.
The positive meta-belief about worrying substantiates the adoption of worry as their main coping strategy among individuals with GAD. In contrast, negative meta-beliefs are a result of the negative judgment of worrying. The beliefs appear to be based on uncontrollable worries and the negative consequences of worrying (Wells, 2005). The goal of worrying is generally to achieve desired internal feelings, and once the goal has been gained, worrying is suspended. Therefore, the individual’s positive belief is related to using worrying as the key coping technique against personal issues. The other two important processes that help in GAD maintenance are the behavioral strategy and the thought control strategy. The behavioral strategy involves the development of social and behavioral changes to control and avoid worrying. On the other hand, thought control strategy involves an individual trying to avoid thoughts that might trigger worrying.
GAD’s meta-cognitive model suggests that negative beliefs and meta-worry are the main facilitators in the growth, advancement, and maintenance of the condition. In a study done to develop this model, assessment of psychometric characteristics using the Meta-Worry Questionnaire (MWQ) was used to assess the hypotheses, which originated from the DSM-IV GAD model (Wells, 2005). This Meta-Worry Questionnaire had internal reliability, which made its scale relate expressively with existing techniques for determining worry and metacognition. People categorized as somatic anxiety showed lower meta-worry showed lower frequency than those meeting GAD’s criteria.
The meta-worry belief differentiated the GAD group from the non-anxious but not the somatic anxiety group who scored a lower frequency of GAD’s meta-cognitive model (Wells, 2005). The path analysis and assessment identified the connection between the individuals’ meta-worry frequency, the beliefs, and the GAD status (Wells, 2005). Therefore, this model proves that to reduce and disengage individuals from worrying, both positive and negative need to be modified to trigger thoughts.
References
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Liebscher, C., Wittmann, A., Gechter, J., Schlagenhauf, F., Lueken, U., Plag, J.,… & Kircher, T. (2016). Facing the fear–clinical and neural effects of cognitive behavioural and pharmacotherapy in panic disorder with agoraphobia. European Neuropsychopharmacology, 26(3), 431-444. Web.
McKay, D., Abramowitz, J.S. & Taylor, S. (2010). Cognitive-behavioral therapy for refractory cases: Turning failure into success. American Psychological Association.
Schwartze, D., Barkowski, S., Strauss, B., Burlingame, G. M., Barth, J., & Rosendahl, J. (2017). Efficacy of group psychotherapy for panic disorder: Meta-analysis of randomized, controlled trials. Group Dynamics: Theory, Research, and Practice, 21(2), 77. Web.
Swift, J. K., Greenberg, R. P., Tompkins, K. A., & Parkin, S. R. (2017). Treatment refusal and premature termination in psychotherapy, pharmacotherapy, and their combination: a meta-analysis of head-to-head comparisons. Psychotherapy, 54(1), 47. Web.
Wright, J. H., Basco, M. R., & Thase, M. E. (2006). Behavior methods II: Reducing anxiety and breaking patterns of avoidance. In J. H Wright, M. R. Basco, & M. E. Thase. (Eds.). Learning cognitive-behavior therapy: An illustrated guide (pp. 159-186). American Psychiatric Association Publishing, Inc.