by Allison Reese, PsyD
John is a 15-year old-boy who entered therapy in hopes of finding some relief from feeling anxious on a routine basis. He has had little success making friends at school and is earning below average grades. Feeling as if “no one understands him,” he has little interest in wanting to play with other children. In addition, he experiences intense anxiety about being exposed to germs, reporting a deep-rooted fear of becoming sick. John has always remembered having a difficult time being in public areas where he feels that he may be exposed to “bacteria and filth.”
Last month, John stated he washes his hands until they are raw. He told of being at the bowling alley with his parents. Already anxious about being in a public place, he worried about touching bowling balls other people have used. He also witnessed a nearby couple sneezing and coughing. John routinely left the game to wash his hands in the bathroom. He reported his mother became upset with him because of this, and that she was “embarrassed” by his behaviors during the family outing. John said that his hand washing, frequent application of hand sanitizer, and leaving a situation when he “senses that a person may be ill” are behaviors that he has been doing since he was a child. However, he noticed a dramatic increase over the past few months and wanted some help because his family had become increasingly upset with him… something John couldn’t bear any longer.
Due to John’s increased anxiety at school and home, his parents brought him in for a therapeutic intake evaluation per his request. Although the process created some anxiety, he became more open to therapy after a couple of sessions. John was suffering from the classic symptoms of Obsessive-Compulsive Disorder and needed to experience immediate relief due to the intensity of his symptoms.
Cognitive behavioral techniques are often the first mode of action used with clients in situations like this, where the amount of anxiety appears to overwhelm a person in all they think and do. Cognitive Behavioral Therapy, or CBT, is helpful with focusing in on key cognitions or behaviors that create discomfort for the client in hopes of reversing the process, generating some symptom relief. This style of therapy is also traditionally used with the more “challenging” clients who suffer from mood disorders or more deep rooted characterological/personality issues in order to help an individual positively re-shape core beliefs about themselves.
CBT provides a solid structure where the client is able to evaluate their fears and generate less dysfunctional and more positive, alternate ways of thinking about the world. Various therapeutic tools are utilized to help facilitate the process (e.g., detailed thought records and recognizing distortions in thinking worksheets). Mapping out how a specific situation triggers uncomfortable thoughts, feelings, and unwanted behaviors can help a person become more aware of themselves in a multitude of ways. For example, John was able to articulate and map out what situations triggered his anxious thought and feelings, which led to his compulsive behaviors (e.g., hand washing). It is important to help a client recognize and challenge their distortions in cognitions, like an “all or nothing” way of thinking.
Although this therapeutic process is sometimes difficult, it is necessary for someone who becomes consumed by the cycle of anxiety. If John never challenged his belief of literally becoming sick by being in public places, he could further alienate himself with friends and family. This ultimately could be detrimental to his academic and social performance as an adult, and is something that needed to be addressed sooner versus later for John.
Working together to challenge/reject the “negative” core beliefs and automatic thoughts a client creates within him/herself to generate more realistic beliefs and cognitions is the goal towards positive change and symptom relief. There are various progressive techniques that can be used in therapy to help facilitate the process of challenging anxious cognitions. For example, guided visual imagery is a helpful tool where the individual visualizes their fear in thoughts, and confronts the uncomfortable feelings associated with that fear. Further, systematic desensitization methods are useful with slowly, physically exposing a client to their fears (e.g., germs, snakes, etc.) in hopes of becoming essentially desensitized to the stimulus. Routine worksheets and homework assignments can also greatly help provide a more concrete structure in reducing uncomfortable thoughts and emotions.
In this case, John worked together with his therapist on a weekly basis for five months utilizing this model. He made considerable progress decreasing his fears of bacteria and filth as well as his overall anxiety levels. Cognitive behavioral therapy has proven helpful particularly in cases where acute/chronic anxiety or depression are the primary concerns. Challenging a person to look deep within the “core” of their issues is a painful process, but the rewards can be priceless.