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Brief Interventions for Anxiety Disorders with Children and Adults
Anxiety Disorders continuing education counselor CEUs

Section 10
Intervention Targets for Social Anxiety

Decentering & Treating a Client's Limited View of Reality

CEU Question 10 | CE Test | Table of Contents | Anxiety
Social Worker CEUs, Counselor CEUs, Psychologist CEs, MFT CEUs

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What's Another Way of Looking at It?
Next, let's look at the question, "What's another way of looking at it?"
The interventions we'll discuss are... Generating Alternative Interpretations, Dysfunctional Thought Records, Decentering, Enlarging Perspective, and Reattribution.

♦ 1. Generating Alternative Interpretations
As you know, your anxious child or adult client's closed and limited view of reality excludes more neutral and more realistic interpretations. A major therapeutic aim is to teach the client to consider possibilities other than his or her dire predictions. Although the therapist uses different methods to achieve this aim, the standard procedure is to have the client write down his anxiety-producing thoughts, then search for alternative interpretations (the "two-column" technique). I model this first during the session, using a clipboard.

♦ 2. Interpretations
Mike's anxiety is centered on his fear of being fired. When his supervisor was aloof, he would think, "He's avoiding me. He's going to fire me. That's why he won't smile at me."
Alternative explanations that he was able to generate include:
a. "The supervisor does not smile at any of the workers. It's not just me."
b. "There is a real status difference between our roles."
c. "He could dislike me regardless of what he thinks of my competence."
d. "Even if he does think I'm incompetent, the other supervisors there know I'm not."

The client was eventually able to lower his anxiety by repeatedly considering alternative interpretations. He came to see that the alternatives were nearly always more accurate, and certainly more functional, than his original appraisal of the situation.

While the ideal situation is for the client to generate believable viewpoints, he or she often has difficulty doing so because their focus is on the threat. If you excel at divergent thinking, you can be most helpful by constructing a large list of alternatives and the client is likely to find one or two useful ones. I make this technique effective by repeatedly asking, "Which alternative way of thinking is the most helpful to you?" and, "What is the resulting behavior of each?"

♦ 3. Dysfunctional Thought Records
A primary strategy of a dysfunctional thought record is to teach the client to recognize his automatic thoughts outside of the session and to strive for a more balanced alternative view.
Provide your client with a notebook. Have them write:
a. The situation leading to anxiety;
b. The emotion felt and degree of emotion; and
c. The automatic thought and degree of belief in the thought.

This process helps your client learn how to monitor changes in level of anxiety, to recognize automatic thoughts, and to understand their relationship to anxiety. When he or she has mastered these skills, the client is ready to begin providing the "rational response" and outcome ratings.

Simply giving a notebook to a client, I have found, makes it more likely that they will do the written homework. However, often the client may try writing their thinking and concentrate only on the threat side. The therapist needs to stress the importance of dividing the written homework into at least two parts: anxiety-producing thoughts and corrections of their exaggerations.

I, of course, have found, like you, that the client may not want to write down their thoughts because they fear doing so will make them more anxious or because they will look "silly" or "childish." The reasons the client has for avoiding the homework often are the same ones that maintain their anxiety. When the client fails to bring in written homework, I probe the thoughts behind his or her avoidance. Linda avoided doing her homework because she believed she "would screw it up!" Eliciting avoidance thinking helped identify Linda's underlying assumptions. ("I have to show everyone a flawless image of myself.") Bob believed that I was incompetent. We ended up exploring Bob's general distrust of others. His assumption was, "I can't trust anyone."

♦ 4. Decentering
Another technique regarding, "What's Another Way of Looking at It?" is called decentering. As you know, decentering is the process of having your client challenge the basic belief that he or she is the focal point of all events. Many clients with social anxiety report thinking that everyone is watching them or that others are actually aware of their tensions or shyness. Rose believed that others could read her mind.

Feeling the Focus of Attention
Let's review the variety of strategies you can use to help a client see that his or her social world does not revolve around them. You work out with your client to established concrete criteria to determine when he or she feels the focus of attention and what behavior or attributes are being attended to by others.

Since the client is required to adopt the perspective of another person, participation in this task requires a shift in focus on the part of the client. Jeff, age 25, was severely handicapped and self-conscious and so preoccupied with his own internal reactions that he noticed little about other's reactions to him; paradoxically, he attributed keen powers of observation and utter objectivity to those around him ("Because I watch myself so closely, they must be watching me in the same way"). As he became aware of how infrequently he attended closely to others and how limited his own observations were, he came to realize that the attention of most people is similarly restricted, and he became more relaxed in social situations.

♦ 5. Enlarging Perspectives with Positive Attributes
The anxious client usually takes the "worm's eye view" of his or her situation, and as you know, one of the functions of therapy is to provide your client with a broader perspective, that is, the "long term" or "bird's-eye" view of the situation. For example, Logan, a college student was homesick and afraid that her pain would last forever. The therapist helped her broaden her perspective by looking at some of the positive attributes of her homesickness.

9 Attributes of Logan's Homesickness
Together they created the following list:
1. Her homesickness was a form of growing pains.
2. Her homesickness was to teach her how to accept changes.
3. She was inoculating herself against future losses she would have to deal with.
4. She was demonstrating loyalty to her family.
5. By sticking out the pain instead of going home, she was putting into practice the principle of "getting better instead of feeling better."
6. The experience was helping her increase her tolerance of frustration.
7. Her homesickness was a socially acceptable way to express a lot of fearful and depressing feelings.
8. She was learning to appreciate her family more than she did at home.
9. Because pleasure follows pain, she would probably feel very good when the pain left.
Logan was able to recover from her homesickness rather quickly, and most of her positive predictions proved to be true.

♦ 6. Reattribution
Next, let's look at Reattribution as an intervention for "What's Another Way of Looking at It?"
In reviewing your anxiety-prone client's automatic thoughts, you often discover that clients attribute to themselves an excessive amount of control for a potential negative outcome. To reattribute, you can help the client recognize that some elements in a situation - possibly the determining ones - are inevitably beyond his or her control.

Reattribution Intervention
Here's a specific reattribution intervention I use.
a. First, the client rates the degree of responsibility they feel for the feared outcome. I find this is not uncommon for a client to give a rating of 100 percent.
b. I then attempt, through questioning, to reduce the estimate of control to a more realistic level.
c. Depending upon the client's level of commitment to the process, I have them list every conceivable factor that could affect the outcome of an anxiety-provoking situation. Thus, they assess the relative degree of influence of each factor.
d. Finally, they evaluate the degree of control they have over each factor.

For example, Leslie, a woman sales executive, experienced extreme anxiety when anticipating closing sessions with buyers. She thought, "If I don't pull off a major sale, it shows I'm inept and not aggressive enough." After a review, she recognized that she was hampered in her efforts by a major problem: The competitor's product was superior to her own company's! While her persuasive skills undoubtedly played a part in the outcome, they were unlikely to be the deciding factor. This reattribution enabled her to minimize her anxiety and address herself to the real problem.

Another client was anxious about going to a party where she knew only a few people. She felt that she was totally responsible for everything going well. Once she reflected on the fact that she was only one of twenty people who would be there and that she could not control how the others responded, she lowered her perceived sense of responsibility and had a corresponding drop in her anxiety.

Often, the client will dislike not having more control over events. The therapist can point out the difference between responsibility and accountability. The manager of a large division is not directly responsible for those who work under him. He is, however, accountable to his boss, and if he is a successful manager, holds himself accountable for what happens in his division. A therapist is not responsible for clients but is accountable. Similarly, a client, while not responsible for those he or she interacts with, can choose to hold themselves accountable for his or her relationship with them -- that is, have some control, both direct and indirect, over how the relationship develops.

Peer-Reviewed Journal Article References:
Maes, M., Nelemans, S. A., Danneel, S., Fernández-Castilla, B., Van den Noortgate, W., Goossens, L., & Vanhalst, J. (2019). Loneliness and social anxiety across childhood and adolescence: Multilevel meta-analyses of cross-sectional and longitudinal associations. Developmental Psychology, 55(7), 1548–1565.

Miers, A. C., Weeda, W. D., Blöte, A. W., Cramer, A. O. J., Borsboom, D., & Westenberg, P. M. (2020). A cross-sectional and longitudinal network analysis approach to understanding connections among social anxiety components in youth. Journal of Abnormal Psychology, 129(1), 82–91.

Rodebaugh, T. L., Tonge, N. A., Piccirillo, M. L., Fried, E., Horenstein, A., Morrison, A. S., Goldin, P., Gross, J. J., Lim, M. H., Fernandez, K. C., Blanco, C., Schneier, F. R., Bogdan, R., Thompson, R. J., & Heimberg, R. G. (2018). Does centrality in a cross-sectional network suggest intervention targets for social anxiety disorder? Journal of Consulting and Clinical Psychology, 86(10), 831–844.

Online Continuing Education QUESTION 10: What are interventions to assist your client in answering the question: What's Another Way Of Looking At It? To select and enter your answer go to CE Test.

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