Medication is certainly an option, but it's not the frontline intervention.
Some of the key strategies within a cognitive behavioural framework include psychoeducation
about anxiety; cognitive restructuring and exposure.
These strategies tend to be used in conjunction, rather than entirely separate from one another.
Psychoeducation involves educating clients about anxiety.
This would include talking about the fact that anxiety is normal, that it is often adaptive
or helpful, and that we understand it to consist of three separate but interrelated systems
– the cognitive, behavioural and physiological systems.
I would usually go through a cognitive-behavioural model such as the one we looked at before.
I'd probably talk about some of the theories about how anxiety develops.
All of this is helpful in giving people a general idea of how anxiety works – but
then, I'd be working with the client to come up with a very personalized formulation or
way of understanding how their anxiety has developed and is being maintained.
Cognitive restructuring requires that the client understand the importance of thoughts.
Once this has been explained – typically using the ABC model
– which, by the way, is an example of psychoeducation – we would be asking
the client to start identifying the unhelpful thoughts that are making them anxious.
The most common way of doing this is by having clients complete a weekly thought diary.
Next, we work with our clients to help them evaluate the evidence for and against the
likelihood of these thoughts being accurate.
This is absolutely not about clinicians telling clients that their anxious thoughts are inaccurate
or incorrect – rather, it is about helping our clients to view their thoughts as theories
to be tested, as opposed to facts that are true.
So, when I am working with anxious children, we use a cognitive approach that we call the
Scientific Approach, where kids are encouraged to think of themselves as scientists, whose
job it is to evaluate the evidence for and against their hypotheses (or anxiety-provoking
thoughts).
The kinds of questions we teach kids to ask themselves in gathering evidence include:
"are there other ways of thinking about this situation?" and "what advice would
I give a friend who was in the same situation and having the same worried thoughts?".
With adults, the cognitive equivalent is known as Socratic questioning.
The behavioural strategy of Systematic Desensitization or Exposure aims to address the avoidance
of feared stimuli that tends to go hand-in-hand with anxiety.
Cognitive restructuring is often – though not always – used in conjunction with exposure.
This strategy is based on the psychological principle of habituation and involves deliberately
and repeatedly placing yourself in anxiety-provoking situations that would normally be avoided.
Developed by Wolpe (1958), desensitization can be either imaginal (that is where the
client is asked to imagine a series of increasingly anxiety-provoking situations) or in-vivo (i.e.,
where the client actually places him or herself in increasingly anxiety-provoking situations.
Treatment begins with the construction of a list of situations that provoke increasing
amounts of anxiety – a hierarchy.
Typically, in the past, relaxation techniques have been taught in conjunction with the use
of desensitization.
The rationale for using relaxation techniques was two-fold.
To begin with, relaxation was used to reduce the anxiety response that would typically
be elicited by either the imagination or the actual experiencing of the avoided situation/stimulus.
Second, relaxation was believed to improve a client's ability to imagine a feared situation.
Today however, relaxation techniques are far less commonly used in conjunction with desensitization.
Indeed, most researchers and clinicians now believe that the use of relaxation strategies
in this particular context constitutes a subtle form of avoidance.
The current thinking among most cognitive-behaviourally-oriented therapists is that anxious clients need to
fully experience their anxiety and realize that it is not going to harm them; and that
the teaching of relaxation techniques for specific use in working through an exposure
hierarchy actually hinders this process.
As we previously noted, the aim is to fully experience the anxiety that would normally
result in avoidance & to realise that you can handle both the situation & the anxiety that it provokes.
Each of the situations that make up the hierarchy needs to be experienced (either imaginally
or in real life) repeatedly until the fear response has been extinguished.
The most common behavioural response to anxiety is avoidance.
Avoidance means that the individual misses out on the opportunity to discover that he or she
actually can cope with that feared situation.
Instead, avoidance serves to strengthen and reinforce anxiety.
Let's have a look at the steps involved in developing an exposure hierarchy.
Identify the feared situation. Break the feared situation down into as many
different component parts as possible (identify variables that make a difference to how anxiety-provoking
a situation is). Then list the components as specifically as possible
and rate each from 0-100 in terms of its difficulty. Rearrange the items in order of increasing
difficulty. And finally, implement the hierarchy
Let's look at an example exposure hierarchy for a child who is currently fearful of sleeping
in their own bed.
As you can see in this hierarchy, each step is becoming a little more difficult than the preceding
one.
The child would start on the first or bottom step and they would practice this step every
night until they felt confident to go up to the next step, and so on.
For example, the first step here is for the child to "Sleep on a mattress beside mum
& dad's bed".
The next step is to "Sleep on a mattress outside mum and dad's bedroom door".
Then, have mum or dad sit with me until I fall asleep in my own bed and have a night
light on.
Have mum or dad sit with me for 10 minutes and have a night light on.
Sleep in my room with a night light on.
Sleep in my own room with the hall light on.
Then finally, sleep in my own room
with no light.
An exposure hierarchy is intrinsically rewarding – by the time a person gets to around about
the third step, they are feeling really good about what they have already achieved, and
beginning to think that maybe, just maybe, they can get to that top step.
However, because by definition, we are asking clients to do things that they find anxiety-provoking,
it is also very common – certainly when you are working with children and adolescents
– to link an exposure hierarchy to an external reward system, in which they can earn small
rewards for working on their hierarchy.
I want to end with this question.
What if you know someone with an undiagnosed mental health problem?
People are more likely to seek help from a friend or family member than from a professional.
Here are some resources you may find useful to assist anyone.
https://psychcentral.com/lib/where-to-get-help-for-depression/
Your doctor or General Practitioner Counselling Services and Psychology Clinics
Online, e.g., www.beyondblue.org.au ; Lifeline: www.lifeline.org.au (Phone 13 11 14 in Australia)
APS website www.psychology.org.au For other 24 hour Help lines check online for one in your area or contact your local general practitioner / doctor.
For more infomation >> Forecast Focus for April 4 - Duration: 3:59. 
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