On the last track we discussed treating phobic conditions. Our discussion was based on Claire Weekes’s Self-Care Approach, using Cognitive Behavioral Therapy. Weekes’s Self-Care Approach is comprised of four concepts for coping with phobic conditions. Weekes’s four concepts are face, accept, float, and let time pass.
On this track we will discuss successive approximations. Successive approximations consist of setting sub goals, identifying triggers, and implementing the technique through behavior. I find that there are no certain steps to follow in the technique of successive approximation after finding a starting point. Would you agree that successive approximations will differ for each client depending on the type of anxiety involved?
3 Parts of Successive Approximations
1. Setting Sub Goals
First, let’s discuss setting sub goals. In systematic desensitization, a nonfunctional behavior is gradually modified and converted into a desired behavior through a series of successive approximations. This approach uses successive approximations of a desired behavior to gradually shape that behavior. For example, Andy’s goal was to be able to climb a ladder to put up his storm windows.
Andy, however, got very nervous on ladders. Therefore, Andy, age 41, broke down his eventual goal into a series of sub goals.
The first rung of the ladder was Andy’s first sub goal, the second rung was Andy’s second sub goal, and so on. By the time Andy reached the fourth or fifth rung of the ladder, after many training trials spaced out over a few days, he experienced a setback and was unable to go higher than the third rung. This is a normal part of training. If it happens with your client, you might suggest continuing training at the third-rung level until the client is comfortable trying the fourth once again. It is not uncommon for clients to make rapid progress for a while after they have successfully coped with a setback.
2. Identifying Triggers
Next, let’s discuss identifying triggers. Another client, Luke, liked to go running on the beach every day. Luke, age 29, found that he suddenly had a phobic reaction when he walked onto a fishing pier that extended some distance from the beach. He felt dizzy and weak as soon as he was over the surf breaking on the beach below the pier. Luke set as his goal being able to walk all the way to the end of the pier without experiencing dizziness and anxiety.
4 Sensitive Aspects of the Situation
Luke and I analyzed his experience. Luke decided he was sensitive to at least four aspects of the situation:
--First, the distance from the shore;
--Second, being over water;
--Third, the other people on the pier; and
--Fourth the panoramic scene.
Luke and I agreed that the basic problem was the distance from the shore. Noticing that there was a series of 16 lampposts on the pier, Luke decided to use the lampposts as markers and to see whether he could gradually extend the distance he could walk without feeling uncomfortable.
Luke stated, "Cold feet, a feeling of warmth, and sweaty palms seem like mild anxiety. I get a sick feeling in the pit of my stomach and cold hands with moderate anxiety. Then I get chills with a high level of anxiety."
3-Step Successive Approximation Technique
Following the first rule of successive approximation, Luke knew that he should try not to exceed a mild level of anxiety at any point in his training. I found with Luke that accidentally exceeding mild anxiety did not necessarily cause training to fail, but it did not help, either.
Step #1: Finding the Starting Place
The first CBT step in the technique of successive approximation would be to find a starting place for Luke’s training. This he did the next time he went running on the beach. Walking slowly out onto the concrete pier, Luke observed no symptoms at all as he passed the first two "easy" lampposts. Just beyond the third lamppost, Luke began to experience mild anxiety. Therefore, the third lamppost became Luke’s starting place.
Luke stated, "I stood by the third lamppost and scoped out the scene. For a few moments, I watched the beach down below, where occasional waves washed over the sand. I watched the swirling patterns on the surface of the water. Then I just shrugged my shoulders and relaxed my back and neck muscles. When other people walked by, I just looked at their faces and briefly met their eyes. For a while I focused on distant objects, trying to pick out familiar buildings in nearby towns on the coast."
Step #2: Approaching the Lamppost
When Luke felt no anxiety symptoms, he decided to approach the fourth lamppost. Striding confidently along, he began to experience mild anxiety symptoms halfway to his goal. Following the second rule of successive approximation—to withdraw immediately from a situation when you experience mild anxiety—Luke stated, "I just turned around and walked back to the third lamppost."
After a few deep breaths, some muscular tensing and relaxing, and a few moments spent observing the scene, Luke began to walk, a bit more cautiously this time, toward the fourth lamppost. Luke stated, "I made it this time and spent a few moments relaxing there and feeling pretty good about it."
Luke decided that on every following day he would add at least one more lamppost to his "safe territory" on the pier. He began to do so, and the following days were much the same, except that he now had to get used to being over deep water. Stormy winter weather complicated the situation and slowed his progress, but he decided to treat the wind and big waves simply as one more element to get used to.
Step #3: After Finishing Luke's Training
By the time Luke finished his CBT training—and had overcome his phobic reaction—he liked to walk out on the pier toward sundown, enjoy the view and ask the fishermen how they were doing. Even in stormy weather he enjoyed walking all the way to the end of the pier. Luke stated, "I kind of like watching the ocean waves and feeling the rain and sea spray in my face. Anyone who sees me out there all alone on a stormy day may think I’m crazy, but I don’t care." Think of your Luke. How can you use successive approximation to help your client cope with anxiety related phobic reactions? Could playing this track for client education benefit your client?
On this track we discussed successive approximations. Successive approximations consist of setting sub goals, identifying triggers, and implementing the technique through behavior.
On the next track we will discuss accepting reality. Three techniques that we will discuss are gaining distance, describing the present, and disappearing to see reality.
- Nakamura, B. J. Pestle, S. L., & Chorpita, B. F. (2009). Differential Sequencing of Cognitive-Behavioral Techniques for Reducing Child and Adolescent Anxiety. Journal of Cognitive Psychotherapy, 23(2), 114-135.
Peer-Reviewed Journal Article Reference:
Boswell, J. F., Iles, B. R., Gallagher, M. W., & Farchione, T. J. (2017). Behavioral activation strategies in cognitive-behavioral therapy for anxiety disorders. Psychotherapy, 54(3), 231–236.
Hong, N., & del Busto, C. T. (2020). Collaboration, scaffolding, and successive approximations: A developmental science approach to training in clinical psychology. Training and Education in Professional Psychology, 14(3), 228–234.
Weaver, A., & Himle, J. A. (2017). Cognitive–behavioral therapy for depression and anxiety disorders in rural settings: A review of the literature. Journal of Rural Mental Health, 41(3), 189–221..
Online Continuing Education QUESTION 3
What are two steps in successive approximations?
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