254 ASSESSMENT AND INTERVENTION STRATEGIES
certain anxiety management strategies such as distraction, controlled breathing, and
progressive muscle relaxation can be temporarily introduced. It is important that these
strategies be employed briefly because they can interfere with full exposure to the fear
stimuli. In the end the effectiveness of exposure and response prevention will be weak-
ened if clients continue to rely on anxiety management. This would suggest that the
individual’s exaggerated threat appraisal of the physical symptoms of anxiety remains
intact.
Instruct Client about “Blocking” Strategies
A number of strategies can be used to suppress maladaptive coping behavior and
other forms of safety- seeking responses. First, the client can write down a list of self-
instructional coping statements that can be used as reminders of the benefits of prevent-
ing maladaptive responses and the costs of continued reliance on problematic safety-
seeking behavior. Second, individuals could develop a repertoire of competing activities
that interfere with performance of the maladaptive coping behaviors. For example, indi-
viduals who hold their breath when anxious could practice diaphragmatic breathing
or those who tend to overbreathe when anxious could focus on holding their breath
between exhalations. To compete with compulsive checking, an individual could imme-
diately leave the situation so that repeating a check becomes more difficult. For instance,
Maria was restricted to using mirrors only at certain times of the day and to refrain from
carrying a mirror in her purse. Considerable exploration will be necessary to develop a
repertoire of competing activities that would effectively block safety- seeking behavior. It
is likely that these competing responses will be quite idiosyncratic to the individual and
the specific safety- seeking behavior under consideration.
A third response prevention strategy that is probably the most effective in blocking
problematic coping responses is paradoxical intention. This involves having the client
engage in behaviors that are completely opposite to the safety- seeking response. For
example, a person who tries to rest whenever he feels anxious for fear that his pulse
rate is too high could engage in a high- energy physical activity when he feels anxious.
Someone who uses cognitive avoidance or distraction to deal with her anxiety could be
instructed to fully attend to the fear stimulus. And of course the person who relies on
escape and avoidance would be encouraged to remain in the fear situation. The client
who suppresses anxious feelings would be instructed to openly express his emotions,
whether they be fear or anger. It is likely that the deliberate performance of a behavior
that is opposite to the coping response will provide the most effective response preven-
tion.
And finally, the support and encouragement of family and friends can be a pow-
erful incentive to refrain from problematic responses to anxiety. With proper instruc-
tion from the therapist family members can serve as “coaches” to encourage exposure
and response prevention. Given Maria’s excessive reassurance seeking, family members
would need to be instructed on how to handle her requests for reassurance about her
physical appearance. Of course, involvement of significant others has to be monitored
carefully so that the person does not become a safety cue. Furthermore, the therapist
should provide verbal encouragement and be available by phone between sessions to
assist clients who might have difficulty blocking their maladaptive coping responses.