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

Section 10
Changes in Perception and Cognitive Distortions

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

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On the last track we discussed three techniques for generating alternative interpretations with the phobic client.  Three techniques we discussed are generating alternative interpretations, dysfunctional thought records, and enlarging perspective. 

On this track we will finish our discussion regarding approaches to cognitive restructuring.  The focus on this track will be on decatastrophizing.  First we will discuss the technique of decatastrophizing and then discuss coping plans and the point/counterpoint technique.

#1  Decatastrophizing
To begin our discussion on decatastrophizing, let’s begin with a technique for helping a client develop the mindset of ‘So what if it happens?’  When anticipating a phobia stimulus, clients like Niles tend not to utilize all the information available, and rarely take into account past dire predictions having not materialized.  Therefore, the basis of decatastrophizing is to widen the range of information on which the client bases his forecasts. 

For example, Niles, age 41, was afraid of dying.  Niles’ phobia prevented him from enjoying a quality of life that he had previously enjoyed.  In treatment, I decided to push Niles to state the most extreme aspect of his fearful imagery, and then guide him through discussion to see even this outcome as less catastrophic then he had imagined.  Niles stated, "The worst is when I start thinking I’m going to have a heart attack."  How might you have responded to Niles?  I asked, "In your imagination, what happens after the heart attack?"   Niles answered, "I get this image of my heart stopping and my life just draining away from me!  I end up helpless and dying.  That’s about it.  Sometimes I think I have ESP." 

When asked if he had similar premonitions in the past with no results, Niles answered yes.  I explained to Niles that many phobic clients have similar images, yet rarely does the imagined event ever occur.  I stated, "I suggest you keep careful track of your images and see what happens."  Worried, Niles asked, "But what if it does happen?" 

I responded, "The fantasy is consistently worse than the reality.  Here’s an interesting example.  This client of mine had a recurring frightening image.  He was a business owner.  In his fantasy one of his key employees dies.  The client sees the business go downhill and he’s forced to do things he can’t do.  He then falls apart and has to be hospitalized.  In the fantasy he loses his business and his freedom. 

Well after about six months in treatment, believe it or not, it actually happened.  One of his key managers died.  And almost nothing else that he saw in the images happened.  It didn’t occur to him that other employees could take over tasks and that he could handle this better than he thought he could.  He had overlooked latent positive aspects.  Like yours, fantasy is nearly always worse than the reality when an event occurs.  The point is not to treat fantasies as real data." 

Niles looked confused.  Then he stated, "So, if by some chance I did have a heart attack, that wouldn’t necessarily mean I would die."  Clearly, I responded with ‘no it wouldn’t.’ 

The ‘so what if?’ strategy of decatastrophizing is almost a cognitive flooding procedure.  For this reason, the therapist may consider if there is enough time for the client to process the material and have some reduction in anxiety.  A policy I implement is to schedule an extended session for decatastrophizing.  How might you restructure a typical session with your phobic client in order to make it conducive to decatastrophizing? 

#2  Coping Plans
Next, let’s discuss coping plans.  If your client fears an inability to cope after you have attempted decatastrophizing, you might consider collaboratively developing a variety of strategies that the client can use to manage her phobia.  Regarding coping plans, you might consider stressing coping with the situation and not mastering it. 

Brenda, age 33, experienced social phobias.  We’ll discuss Brenda and her social phobia later on this course, but for the purposes of this track, let’s discuss the coping plans she developed.  First, Brenda implemented self distraction by focusing on other people’s body posture.  Next, Brenda focused on the task of conversing and behaving appropriately.  In addition to self distraction, Brenda used a coping technique with images where she turned negative images into positive ones.  Fourth, Brenda used a deep breathing exercise.  And finally, Brenda used each social incident to gather evidence about her thinking. 

Think of your Brenda.  How might your phobic client implement develop and implement a coping plan to use in the fear situation?

#3  Point/Counterpoint
Third, the technique of point/counterpoint lets the therapist combine all the strategies listed on this track in a general strategy.  In the point/counterpoint technique, the client and therapist switch back and forth between providing positive counterpoints to a client’s reasons of why a feared event is going to happen, why it is so terrible, and why the client would not be able to handle it.  Generally, four areas are covered in the point/counterpoint technique. 

The four areas are the probability of the feared event, its degree of awfulness, the client’s ability to prevent it from occurring, and the client’s ability to accept and deal with the worst possible outcome.  As you probably know, the point/counterpoint technique simply becomes a guided discussion regarding the phobia’s lack of validity.  You might consider presenting each counterpoint with strength and confidence. 

Think of your client.  How might you combine decatastrophizing and coping plans to produce a productive point/counterpoint discussion with your phobic client?

On this track we finished our discussion regarding approaches to cognitive restructuring.  The focus on this track was on decatastrophizing.  First we discussed the technique of decatastrophizing and then we examined coping plans and a method for combining both decatastrophizing and coping plans called the point/counterpoint technique.

On the next track we will discuss agoraphobia.  We will discuss the five principles of agoraphobia, indicative attitudes of agoraphobics, and how dependency leads to agoraphobia. 

- 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:
Erceg-Hurn, D. M., & McEvoy, P. M. (2018). Bigger is better: Full-length versions of the Social Interaction Anxiety Scale and Social Phobia Scale outperform short forms at assessing treatment outcome. Psychological Assessment, 30(11), 1512–1526.

Hofmann, S. G., Moscovitch, D. A., Kim, H.-J., & Taylor, A. N. (2004). Changes in Self-Perception During Treatment of Social Phobia. Journal of Consulting and Clinical Psychology, 72(4), 588–596.

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 10
What is a method for combining both decatastrophizing and coping plans? To select and enter your answer go to CEU Test.

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