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

Section 6
Mindfulness and Cognitive Restructuring Strategies for Phobia

CEU Question 6 | CEU Test | Table of Contents | Phobias
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On the last 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 this track we will discuss developing self awareness.  As you know, an initial goal in therapy is to help a client restructure his thinking by first becoming more aware of his thought processes.  I stress that learning to catch one’s thoughts is a necessary step in correcting distortions.  The client frequently finds that increasing self-awareness is sufficient to start correcting his or her thinking errors.  Self-awareness allows the client to distance him or herself from faulty thinking and develop a more objective perspective toward a situation.  

As the client begins to collect automatic thoughts, the therapist gains a greater understanding of the client’s vulnerability and of the specific schemas that control his perception of a feared situation.  Therefore, this track will focus on techniques for developing self awareness.  Three techniques for developing self awareness which we will discuss are eliciting automatic thoughts, self observation, and in vivo exercises. 

As you listen to this track, may I suggest considering your phobic client?  In what ways could these techniques be implemented in your treatment plan?  How might he or she benefit? 

Unlike the depressed client, who brings his depression into the office, do you find that the anxious client is often free of anxiety in the office?  For this reason, I find it productive to be creative in helping the client catch the thinking behind his anxiety.

Three Techniques for Developing Self-Awareness

#1  Eliciting Automatic Thoughts
A standard way for the therapist to elicit automatic thoughts is to use a marker board or a chalkboard.  The client usually gives two or three frightening thoughts when asked directly about his fears.  When the therapist puts these on the board, this visual reminder triggers the client to look for less obvious thoughts.  I find it helpful to continue to probe past the first few responses.  By repeatedly asking the client for his thoughts and waiting for him to identify them, more meaningful ones may start to emerge.  The thoughts can then be rated according to how much fear the client associates with each.  

Often thoughts the client comes up with last are the most frightening.  The client’s holding back is usually due to cognitive avoidance.  Most clients find that seeing their thoughts on the board is less frightening than they expected and thus are stimulated to overcome their avoidance and search out other frightening thoughts.

Janet, age 39, after seeing some of her fears on the board, said, "What I’m really afraid of is getting old.  If I get old, no one will want me and I’ll be alone!  That’s what I’m really afraid of!"  Because clients experience many of their fears in the form of pictures, clients often respond well when their fears are illustrated with stick figures or symbolic drawings.

#2  Self Observation
The primary function of the board is self observation.  With this perspective, the client is able to distance him or herself from his or her thoughts and behavior.  You might also consider using the board to conceptualize a client’s problems and choose possible strategies.

Another method of fostering self observation is having mirrors in the office to help clients become aware of their thinking.  Floor-length mirrors and small shaving mirrors can be used.  A mirror can be a "social window" where a client sees his presentation of his social self.  Upon looking in the mirror, the client may identify anxiety-producing thoughts that he previously was unaware of having.

The client can be asked to free-associate at a rapid pace those thoughts that come to mind while looking in the mirror.  Janet, who was afraid of growing old, also had severe social anxiety.  While implementing free association, Janet had a stream of thoughts about being ugly and unattractive—from "fat thighs" to her "odd-shaped body."

I also asked Janet to complete sentences to help identify associations; for example, "Being rejected would mean —;" or "Making a fool of myself would mean —."  Similarly, I asked for memory associations to the anxiety and found that these associations helped to identify underlying beliefs and major concerns.

#3  In Vivo
I find it helpful to also use places near the office for in vivo exercises.  You might consider going with your client to a restaurant or store to help him or her become aware of his or her thinking.

For example, Jason, age 26
, had fears of public incompetence.  Jason and I played video games in a nearby fast-food store.  During this interaction, I was able to observe Jason’s cognitions when they were actually occurring.

Would you agree that therapy sessions can be held in a variety of places, such as a gym, the beach, a crowded area, or other situations that a client finds anxiety provoking?

The general rule is for the client to do as much anxiety-provoking activity as possible during the session.  Such activity might include writing letters, filling out applications, and writing outlines for speeches.  Because many anxious clients fear making phone calls, having to do so is a rich source of anxiety-producing thoughts.  A phone call can be taped, and the client can identify his automatic thoughts when it is played back.  

For example, Hanna, age 41, was putting off making a call to set up an appointment with a creditor.  I suggested Hanna record the conversation.  By reviewing the call she made in the office, Hanna was able to identify her fearful thoughts of "not wanting to bother others" and her imagery of herself as being "a small, helpless child."

What other technical aids might you implement with your client?  Could another particularly useful tool be a set of walkie-talkies?  Perhaps if your client feels safe with you, he or she may not have any significant anxiety if you accompany him or her.  For this reason, when a client is afraid to be out alone, walkie-talkies can keep him in touch with the therapist and allow him to report automatic thoughts. 

Think of your phobic client.  Could these techniques help him or her with developing self awareness?

On this track we discussed developing self awareness.  Three techniques for developing self awareness which we discussed are eliciting automatic thoughts, self observation, and in vivo exercises. 

On the next track we will discuss directing clients.  Methods for directing clients include active affective statements, replacing ‘why’ with ‘how’, experiencing feelings, and fostering honesty.

- 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.

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.

McManus, F., Surawy, C., Muse, K., Vazquez-Montes, M., & Williams, J. M. G. (2012). A randomized clinical trial of mindfulness-based cognitive therapy versus unrestricted services for health anxiety (hypochondriasis). Journal of Consulting and Clinical Psychology, 80(5), 817–828.

Querstret, D., Morison, L., Dickinson, S., Cropley, M., & John, M. (2020). Mindfulness-based stress reduction and mindfulness-based cognitive therapy for psychological health and well-being in nonclinical samples: A systematic review and meta-analysis. International Journal of Stress Management. Advance online publication.

Shikatani, B., Fredborg, B. K., Cassin, S. E., Kuo, J. R., & Antony, M. M. (2019). Acceptability and perceived helpfulness of single session mindfulness and cognitive restructuring strategies in individuals with social anxiety disorder: A pilot study. Canadian Journal of Behavioural Science / Revue canadienne des sciences du comportement, 51(2), 83–89.

Online Continuing Education QUESTION 6
What are three techniques for developing self awareness? To select and enter your answer go to CEU Test.

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