Cognitive Behavioral Strategies

Lynne S. Gots, Ph.D.
Licensed Psychologist

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When Therapy Does More Harm Than Good

By Lynne Gots, posted on July 2nd, 2012.

As a specialist in anxiety, I’ve seen countless people after they’ve gone through months—years, even—of ineffectual psychotherapy. Yet I’m surprised time and again by the inaccurate beliefs guiding the practices of so many mental health professionals. Some of their methods, which derive from unsubstantiated theories, can interfere with progress or even make anxiety symptoms much worse.

A psychoanalyst once told me how frustrating she found treating people with Obsessive-Compulsive Disorder (OCD). “They never get better,” she said.

Unlike her, I really enjoy working with people who have OCD, in large part because they often do make dramatic strides in treatment, and in a relatively short time. But I don’t doubt she didn’t see much progress.

A psychoanalytic therapist would encourage her patient to explore childhood experiences to uncover the allegedly unconscious forces behind symptoms. In theory, once a person figures out the deep-seated reasons for feelings of anxiety or for intrusive thoughts, distress will dissipate. In practice, however, this solution frequently becomes part of the problem.

People with anxiety strive above all to maintain control—over their physical sensations, their thoughts, and the outcome of events. Paradoxically, when they avoid upsetting situations, analyze every last detail of a thought, or try to figure out the reason for their worries—all common but counterproductive tactics—they become more anxious. These efforts backfire because they prevent the anxious person from learning to tolerate uncertainty and handle uncomfortable feelings. From a cognitive-behavioral perspective, developing a tolerance for uncertainty and acquiring the skills for coping with emotional distress are the primary goals of therapy.

Focusing on the whys can be problematic for two additional reasons. First, trying to figure out the origin of a worry can serve as an avoidance tactic, encouraging rumination (something people with anxiety already do too much of) over action. Second, emphasizing the need to understand where an anxiety issue originated gives undo credence to the thoughts.

Many people I treat have a type of OCD characterized by repugnant mental obsessions (such as the fear of being a child-molester or of committing a violent crime). They’ve become trapped by their thoughts precisely because they’ve attributed too much significance to them. We all have strange and sometimes disturbing ideas from time to time. If we don’t make too much of them, they usually just come and go. Not so if you have OCD.

Obsessive worrying starts with ordinary random thoughts. Say you’ve just read an article about the Sandusky trial. You’re appalled by the witness testimonies. You think, “How could anyone do that? I could never imagine doing that!” But then you start to wonder. “Why am I so interested in this case? Does that mean I unconsciously want to molest children?” The more you think about it, the more anxious you get. You try to push the thoughts out of your mind but they keep coming back. Thus are the seeds of a full-blown obsession planted.

In the interest of fairness, I should point out that psychoanalysts aren’t the only therapists who can make a problem worse by using counterproductive approaches. I’ve heard of cognitive-behaviorists who, apparently not having kept up with the current literature, advise patients to practice “thought-stopping”—visualizing a large stop sign or snapping a rubberband on the wrist whenever unwanted thoughts occur-—to short circuit disturbing cognitions.

This technique gained a fair amount of traction twenty or so years ago. I’m embarrassed to admit I myself recommended it to more than a few people back in the day. But we now know from the social psychology research on thought suppression that trying to push thoughts out of our minds only intensifies them. So it’s more helpful to make peace with unwanted mental intrusions than to engage in efforts to banish them.

Another misapplied behavioral method, one commonly recommended for managing panic attacks, is relaxation training. Sometimes practicing deep-breathing can be helpful, especially for controlling hyperventilation. But trying to relax often can lead to more tension in a person who fears the sensations caused by extreme anxiety. So learning to ride out a panic attack using “interoceptive exposure”—invoking symptoms such as dizziness or a rapid heart rate to practice allowing them to pass without trying to control them—is much more effective in the long run than trying to head off the feelings by attempting to relax.

If you’re not sure you’re benefitting from therapy, tell your therapist. Discuss the treatment plan and the rationale behind it. Gather information from the websites of credible organizations (no message boards, please) and don’t hesitate to inquire about the latest research. The process of psychotherapy is often more an art than a science. But if you think you’re making no progress or find yourself feeling worse, an unscientific approach may be the reason.


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Posted in Anxiety, Obsessive Compulsive Disorder, Psychotherapy, Techniques |

Got Anxiety? News from the ADAA Conference

By Lynne Gots, posted on April 16th, 2012.

My brain hurts. It’s overstuffed with the supersized servings of research data and clinical strategies I devoured during four days at the annual meeting of the Anxiety Disorders Association of America (ADAA). Each day I studied the catalogue of courses to decide which to attend, salivating at the rich array of workshops. It was like surveying the dessert table at a fancy Bar Mitzvah. I ended up sampling as many offerings as I could fit into my schedule until the last day, when just opening the meeting planner made me feel queasy.

And speaking of queasy, I picked up some useful tips on how to make the ultimate fake vomit and supplement it with YouTube vomit videos to provide realistic visual and sound effects when doing exposure therapy for emetophobia (the surprisingly common fear of vomiting). There’s even a site where you can customize the appearance of bodily emissions by typing in different ingested foods, and one where you can weigh in on the relative grossness of a gallery of vomit pictures. Who knew?  And if this is grossing you out, I can also help you with your overactive disgust reaction, having attended a workshop on the topic.

We anxiety specialists have so much fun!

I’ve been thinking about how to distill the volumes of information about anxiety into one pithy sound bite (a recommendation from the ethics workshop I attended on psychology and the media). Here’s what I’ve come up with:


It has a nice ring to it, and it’s paradoxical to boot, which fits with the mindfulness training I participated in.

But, in truth, learning how to accept anxiety (rather than fearing it and pushing it away) is a key component of all anxiety treatments across the spectrum of evidence-based practices.

For example, pure behaviorists define avoidance as a negative reinforcer (escaping from the aversive, anxiety-inducing stimulus relieves anxiety, thus making avoidance behaviors more likely to occur). Cognitive therapists emphasize the role of avoidance in perpetuating thinking errors such as catastrophic predictions about the outcome of an anxiety-producing situation. And proponents of the mindfulness and acceptance approaches suggest that experiential avoidance—turning away from negative emotions—promotes an unhelpful, judging state of mind that adds to the pain of anxiety.

So, no matter what mechanism you invoke to explain it, avoidance makes anxiety worse.

This isn’t news to anybody who’s come to me for treatment. But learning about the latest research and clinical applications from the academic experts in the field has made me eager to try out some promising new techniques.

In the meantime, I need something to settle my brain—a mental antacid, so to speak. Catching up on the latest episode of Mad Men should do just fine.





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Posted in Acceptance and Mindfulness, Anxiety, Behavior Change, Generalized Anxiety Disorder, Health Anxiety, Obsessive Compulsive Disorder, Phobias, Self-help, Social Anxiety Disorder, Techniques |

This blog is intended solely for the purpose of entertainment and education. All remarks are meant as general information and should not be taken as personal diagnostic or therapeutic advice. If you choose to comment on a post, please do not include any information that could identify you as a patient or potential patient. Also, please refrain from making any testimonials about me or my practice, as my professional code of ethics does not permit me to publish such statements. Comments that I deem inappropriate for this forum will not be published.

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