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Anxiety Diagnosis & Treatment of Phobias with Cognitive Restructuring Interventions
Diagnosis & Treatment of Phobias with Cognitive Restructuring Interventions

Section 5
Cognitive Therapy for Phobia

CEU Question 5 | CEU Test | Table of Contents | Phobias
Counselor CEUs, Psychologist CEs, Social Worker CEUs, MFT CEUs, Nurse CEUs

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On the last track we discussed differences and correlations between fear and anxiety and phobias and panic.

On this track we will discuss Hoch’s Paradox.  You might find that an understanding of Hoch’s Paradox can become a solid foundation on which to base a cognitive therapy intervention with your phobic client.  In addition, we’ll examine a case study in which the cognitive therapy technique of counting automatic thoughts is used.  As you listen to this track, you might consider your phobic client. 

Hoch’s Paradox
While a large proportion of writers concur with Freud’s concept, some, like P. Hoch, have challenged the logic of his formulation.  Hoch posed the question, "If anxiety is a signal that repressed instinctual forces have begun to erupt, why should the alarm burn down the house?"

Hoch’s paradox applies especially to cases in which the fear syndrome interferes with a person’s ability to cope effectively with a dangerous situation, and thus greatly increases the danger.  There are times, for instance, when a client freezes in the face of physical threat. 

For example, a young man is driving a car on a crowded metropolitan street.  He signals to make a left turn.  As he enters the intersection, he hears the blaring of a car horn.  He feels acute anxiety and automatically slams on the brakes.  The car is hit from the right.  In this example, the automatic defensive response interfered with his ability to execute an effective coping response.  If he had accelerated rather than stopped the automobile, he would not have been hit.  The freeze reaction, associated with anxiety, was clearly not adaptive in this situation.

The preceding example not only illustrates that fear can interfere with the execution of an effective coping response, but also demonstrates that subjective anxiety is not a necessary condition for the execution of the coping response.  In fact, the driver of the car could have executed the appropriate response in this situation if his skillful behavior had not been disrupted by his primitive inhibitory response and the distraction of the anxiety. 

Similarly, an athlete can readily mobilize his resources in a split­ second movement to make a net shot or catch a runner off base—without experiencing anxiety.  The competitive situation is sufficient to activate the central nervous system rapidly.  It therefore seems that anxiety is neither a sufficient nor a necessary condition for the activation of an instrumental coping response.  It can even hinder the execution of an adaptive response to a threatening situation. 

The question, therefore, becomes one of what interventions the therapist can implement to help phobic clients overcome anxiety as a coping response.  How might you apply the theory of Hoch’s paradox to the treatment goals in place with your client?  One way to begin might be a with a popular cognitive therapy technique. 

Technique:  Counting Automatic Thoughts
Do you currently use counting automatic thoughts?  If so, evaluate my use of this technique with Paul and consider how it is different from your own use.  How is it similar?  And, most importantly, how might I have improved my use of counting automatic thoughts? 

Paul, age 32, lived with a somewhat generalized phobic condition.  Paul stated, "I wouldn’t call it a phobia, but I’m definitely a worrier!  For me, the worst time is in the morning.  I’ll be asleep and wake up with my heart beating out of my chest!  I’ve got a million things running through my mind and I get so concerned that I don’t even want to get out of bed!"  Do you have a client like Paul?  Paul faced his fears by counting automatic thoughts. 

I stated, "Keep a stack of 3x5 cards on your bedside table.  Or you can use a golf stroke counter if you like.  When you wake up and those thoughts which make you want to stay in bed and avoid the world start, pick up the counter.  Each time you can identify a specific thought, count it and think, ‘Well, there’s another fearful thought.  I’ll just count it and let it go.’" 

At his next session I asked Paul how counting automatic thoughts worked for him.  Paul stated, "I counted 32 thoughts on the first couple days that just worried the hell out of me.  But by this morning there were only 27.  I don’t know if that means this counting thing is working or not, but at least it gives me something to do.  And it helps me get out of bed." 

Think of your Paul.  How might counting automatic thoughts benefit your client?

On this track we discussed Hoch’s Paradox.  Did you find that an understanding of Hoch’s Paradox can become a solid foundation on which to base a cognitive therapy intervention with your phobic client?  In addition, we also examined a case study in which the cognitive therapy technique of counting automatic thoughts is used.

On the next track we will discuss developing self awareness.  Three techniques for developing self awareness which we will discuss are eliciting automatic thoughts, self observation, and in vivo exercises. 

- Jensen, Vicki L.; Hougaard, Esben; Fishman, Daniel B. Sara, A Social Phobia Client with Sudden Change After Exposure Exercises in Intensive Cognitive-Behavior Group Therapy: A Case-Based Analysis of Mechanisms of Change. PCSP: Pragmatic Case Studies in Psychotherapy. 2013, Vol. 9 Issue 3.

-Moldovan, Ramona; David, Daniel. One Session Treatment of Cognitive and Behavioral Therapy and Virtual Reality for Social and Specific Phobias, Preliminary Results from a Randomized Clinical Trial. Journal of Evidence-Based Psychotherapies. Mar 2014, Vol. 14 Issue 1, p67-83.

Peer-Reviewed Journal Article References:
Bonsaksen, T., Lerdal, A., Borge, F.-M., Sexton, H., & Hoffart, A. (2011). Group climate development in cognitive and interpersonal group therapy for social phobia. Group Dynamics: Theory, Research, and Practice, 15(1), 32–48.

Craske, M. G., Niles, A. N., Burklund, L. J., Wolitzky-Taylor, K. B., Vilardaga, J. C. P., Arch, J. J., Saxbe, D. E., & Lieberman, M. D. (2014). Randomized controlled trial of cognitive behavioral therapy and acceptance and commitment therapy for social phobia: Outcomes and moderators. Journal of Consulting and Clinical Psychology, 82(6), 1034–1048.

Ehring, T., Ehlers, A., & Glucksman, E. (2008). Do cognitive models help in predicting the severity of posttraumatic stress disorder, phobia, and depression after motor vehicle accidents? A prospective longitudinal study. Journal of Consulting and Clinical Psychology, 76(2), 219–230.

Online Continuing Education QUESTION 5
Which cognitive therapy technique can be a productive way to begin approaching treatment goals with phobic clients? To select and enter your answer go to CEU Test.

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