8 Strategies That Work!
Next let's explore some specific strategies implementing the preceding 10 Principles.
I use the trial-and-error method to check on strategy and tactics rather than thinking there is one magic overall guiding force in therapy. For example, one patient's problem was conceptualized as fear of being controlled. One strategy used in therapy was for the client to "gain control by giving up control."
Gain Control by Giving Up Control - 4 Tactics
Here are four tactics I use:
1. Relaxation: "Letting go of control of your muscles causes you to feel more in control."
2. Acceptance of anxiety: "Not trying to fight and control your anxiety makes you feel more in control."
3. Agreeing quickly to others' requests: "Choosing to let others be in control puts you in control."
4. Accepting others as they are: "Trying to control others makes you feel out of control."
Here is a review of 8 commonly used strategies with an anxious client. Use it as a checklist or a review of treatment options. While I explain the list, think of clients with a general anxiety disorder, phobia, panic attack etc. Perhaps this will help you to refocus your session if progress is slow. In some cases, conceptualization, choice of strategy, and tactic are developed early in treatment; In other cases, these three evolve over a period of time.
8 Strategies with an Anxious Client
♦ 1. "Go with the Flow."
The specific tactic to use with a client depends on the strength and intensity of his anxiety. I do not encourage a client to approach frightening situations all at once. I find out which part of the client's anxiety formulation is weakest and attack that part. When the patient is highly defended against learning new material, an indirect approach may have to be used by providing information and using stories and metaphors. For example, Devin was ashamed of going to therapy. Without directly talking about therapy, I talked about the importance of education and of bettering oneself. This approach seemed to alleviate Devin's concerns, where the direct approach did not work.
♦ 2. "No Time is like the Present."
In general, as you know, you can design a strategy that allows a problem to be worked on in the session. This strategy also involves having a client approach, in the here-and-now problems that he or she has been avoiding. A speech-anxious client outlined her speech in the session and practiced giving a few minutes of it. It is always better to elicit and restructure a client's cognitions when they have the motivation, that is, thoughts that the patient is having in the session. Talking about the past or the future is rarely as productive as focusing on the present.
♦ 3. "You Don't Know unless You Try."
Another strategy is to encourage the client to try. One standard lead into this process is "What will you learn if you go versus what will you learn if you don't go?" can be applied to a variety of situations. One client wanted to avoid a wedding where she might run into an old boyfriend. Using this strategy she decided to go. At the wedding, she found that she no longer was emotionally overwhelmed or anxious about seeing her old boyfriend.
♦ 4. "When You're off Track, Take the Opposite Track."
If I am not able to help the client modify a situation for whatever reason, I find a useful strategy is to reverse and help the person accept the situation. For example, a therapist who was making little progress in helping the client modify his expectations of getting cancer, reversed his approach by stating "Okay, let's say you're going to get cancer. What will you do then?" Another way of stating the strategy is: "If you can't beat them, join them."
♦ 5. "Client Persistence."
A general strategy with the anxious client is to persist in helping him overcome his fears. The patient often needs this persistence to learn new ways of thinking and acting. The therapist, by not getting frustrated and giving up, is modeling the important strategy of patience. Such patience is particularly necessary in dealing with the obsessively anxious patient and with the client who has trust issues.
♦ 6. "Divide and Conquer.'
You focus on the components of the client's anxiety that have the least resistance. I tell the client that his anxiety is made up of three parts: his thinking, his feeling, and his actions. The most sensible approach is to work on the parts that are most modifiable. If the patient has a behavioral problem, my therapy focuses on thoughts and feelings; if he has a thinking problem, therapy focuses on thoughts and behavior. Because anxiety is primarily a feeling problem, therapy focuses on thoughts and behavior.
♦ 7. "Do the Unexpected."
Cognitive therapy often emphasizes encouraging a patient to do the unexpected, to surprise himself, to step out of character. This strategy is presented as one of the best ways to defeat anxiety. Many patients, when given the homework "surprise yourself," will return with a number of examples of occasions when they have taken specific risks and surprised themselves.
---Case G: A seventy-year-old man that has previously been in long-term therapy
---Conceptualization: Wants intellectual stimulation as well as relief.
---Strategy: Support patient's choices.
---Tactic: Use teaching stories and other forms of intellectual stimulation to get points across.
♦ 8. "Simplify, Simplify, Simplify."
The strategy of simplifying is used throughout therapy. We will talk about this in more detail later. One patient had six years of psychoanalytically oriented therapy, which gave her much insight but little help in managing her anxiety. Although she knew this, she still had a tendency to overcomplicate her problems. Throughout therapy, the strategy of simplification was used. One of her most effective anxiety reducing tactics was the self-instruction, "When anxious, take constructive action."
Some related strategies are: "Specific is better than vague," and "Concrete is better than abstract." Many therapists and patients have a tendency to become lost in tangential and overly abstract discussions that are rarely helpful to the patient. The strategy of simplifying helps to counter this tendency.
Peer-Reviewed Journal Article References:
Boswell, J. F., Iles, B. R., Gallagher, M. W., & Farchione, T. J. (2017). Behavioral activation strategies in cognitive-behavioral therapy for anxiety disorders. Psychotherapy, 54(3), 231–236.
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.
Villarosa, M. C., Moorer, K. D., Madson, M. B., Zeigler-Hill, V., & Noble, J. J. (2014). Social anxiety and alcohol-related negative consequences among college drinkers: Do protective behavioral strategies mediate the association? Psychology of Addictive Behaviors, 28(3), 887–892.
Online Continuing Education QUESTION
4: What is the "Divide and conquer" intervention technique? To
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