Behavioral Interventions 253
cL i e nT: I’ve been doing these things for years but the anxiety seems to always come
back.
Th e r a p i sT: Derek, that’s an important observation that you just made. So you find that
trying to relax or seeking medical advice calms your anxiety for a while but then it
comes back just as strong as ever.
cL i e nT: That’s exactly what happens.
Th e r a p i sT: It’s kind of like the old adage in reverse “short-term gain but long-term
pain.” Responses like trying to relax or seeking reassurance may work in the short
term but over time they actually contribute to the persistence of anxiety. They pre-
vent you from learning to tolerate anxiety and that nothing terrible will happen to
you because of the physical symptoms of anxiety. By artificially cutting short the
anxiety, it doesn’t have a chance to disappear naturally and you never have a chance
to learn that your fearful thoughts about chest pain and heart attacks are based on
exaggerated misunderstandings about risks to your health.
cL i e nT: Are you saying that going to the doctor or trying to relax are bad, that these
things actually make me more anxious?
Th e r a p i sT: Yes, that is exactly what I am saying. These coping strategies prevent you
from actually learning ways to deal with faulty beliefs about risks to your health.
And so the anxiety you have over chest pain and heart attacks continues unabated.
You recall that earlier we talked about the exposure exercises as an important way
to learn how to let anxiety decline naturally. It is also very important to eliminate
some of these coping strategies like rest, trying to relax, or seeking medical reas-
surance that artificially interrupt the anxiety response. So while you are doing the
exposure exercises, I would also like to work with you on ways to reduce these
problematic coping behaviors. We use procedures called response prevention which
focus on suppressing certain maladaptive responses. Would you like to look at some
strategies we could use to reduce or even eliminate these problem behaviors and
build up better responses to the anxiety?
cL i e nT: Sure, this sounds like a good idea.
Prepare Client for Heightened Anxiety
Individuals must be forewarned to expect an immediate increase in anxiety with pre-
vention of safety- seeking responses and prolonged exposure to fear stimuli. Although
individuals will differ in the duration of peak anxiety, some reduction in anxiety should
be evident after 30–60 minutes of exposure. However, continued prevention of mal-
adaptive coping and neutralization may be necessary for several hours after an exposure
session. For example, individuals with obsessive fears of contamination can engage in
washing and cleaning rituals that take hours to complete. In such cases the response pre-
vention phase of an exposure homework assignment can extend over a 2–3 hour time
period. The approximate duration of a response prevention session should be discussed
with clients. Most often clients will be encouraged to continue with their response pre-
vention until their anxiety reaches the mild range.
There are times when an individual’s anxiety is so intense over a prolonged period
of time that she refuses to engage in exposure and response prevention. In such cases