CHANGING THE ANXIOUS MIND

13 Pages·2015·0.3 MB·English

Changing the Anxious Mind ‐Rapidly
1 Reid Wilson, Ph.D.
CHANGING THE ANXIOUS
MIND — RAPIDLY Anxiety Disorders Treatment Center
421 Bennett Orchard Trail
Chapel Hill, NC 27516
Anxiety & Depression Conference [919] 942-0700
April 9, 2015
Miami [email protected]
www.anxieties.com
Reid Wilson, PhD www.PlayingWithAnxiety.com
Chapel Hill
Disclosures
4
Video clips courtesy of
Trade books with the following publishers
• Harper
 Psychotherapy.net
• Bantam
 Series: Strategic Treatment of the Anxiety Disorders
• HCI Books
• Pathway Systems
 Milton H. Erickson Foundation
DVDs
• Psychotherapy.net
Shorter treatments 5 Efficacy of briefer treatments 6
 PTSD
 support a stepped care approach
 8 90-120-min. sessions over 4-6 weeks = 10-15
 skilled CBT therapists can see more clients weekly or twice-weekly 90-min. sessions (Simon et
al., 2008)
 may entice more people into care
 OCD
 reduce attrition rates  2 meta-analyses –psychosocial treatments –longer
txmay not Improve on shorter tx(Abramowitz, 1996;
Rosa-Alcázar et al., 2008)
Reid Wilson, PhD, anxieties.com 1
Changing the Anxious Mind ‐Rapidly
 Panic disorder 7 Sudden gain 8
 5 txsessions + 2 booster sessions over 3 months
(6.5 contact hours) = 12 weekly sessions + 2  SAD–15 of 67 subjects (22.4%). (Bohn, Aderka,
booster sessions (Clark, Salkovskis, Hackmann, Schreiber, Stangier, Hofmann, 2013)
Wells, Ludgate, & Gelder, 1999)
 TransdiagnosticCBT group–17 of 98 subjects
 2-day individual tx(10 subjects), 9 contact hours.
(17.3%) (Norton, Klenck, & Barrera, 2010)
90-100% reached non-clinical levels (Deacon &
Abramowitz, 2006)  panic disorder–10 of 43 subjects (43%) (Clerkin,
 5-session panic disorder intervention (series of Teachman, & Smith-Janik, 2008)
studies –Otto et al., 2012)
GAD client
10
Detachment through reappraisal
 “Maybe it’s this and not that”
Paradoxical intention Step back
 Seek out clumsy, awkward, unsure,
insecure
Provocative frame of reference
 An understanding of the problem in such
a way as to approach it
11 12
Want it Step forward
Reid Wilson, PhD, anxieties.com 2
Changing the Anxious Mind ‐Rapidly
OCD WASHER
13
• 200-300 hand-washings per day
• 12 years
Be cunning
Look for any signs that they can dissociate
from the content. Work that.
• “In my mind…”
• “Naïve question: so why don’t you just not
wash, since you know it’s in your mind?”
14
DETACHMENT & OWNERSHIP Ownershipby linking with outcome picture
• Challenging the difference between what • She can’t get behind “I want this”
Disorder tells her to be afraid of & what
• But totally gets behind “I want the outcome”
she’s actually afraid of. She is just plain
scared. Perfect.
[Again] The work is alwaysmoment-by-
• Therefore, we can [but don’t have to] go to
moment
the highest item on Disorder’s list. And why
not? It’s a meaningless hierarchy.
• She picks the dirtiest spot on the floor to [Again] “It is totally understandable that you
want to resist, but…”
touch. Ownership in the protocol!
15 16
FRAME UP THE ACTION
Youbring the frequency
Make the Disorderbring intensity & duration
— Your mind is going into alarm, as though
Give all the work to the Disorder there is chaos
• “What we are doing is changing your
— You are now one of the First Responders
mindset. It doesn’t matter whether your
uncertainty is strong or your anxiety is strong.
It matters that you ask for OCD to makeit — First Responders are trained to go into
strong.” action on cue
17 18
Reid Wilson, PhD, anxieties.com 3
Changing the Anxious Mind ‐Rapidly
Opening moves 20
Hebb’sLaw: neurons that fire together, wire
together  Get rapport
 Nature of problem
Self-messages that motivate or command
Short & sweet  Coping behaviors/safety behaviors
 Avoidances
• “I’m doing this for my family”
19
Chunk it up 21 22
Humor begins dissociation
 Be explicit regarding symptoms –then
 “…lock me up in a small place”
package them& move them up into theme
= easier  “…I have the combination here
somewhere…”
 Here:
 restriction & suffocation fears
23 24
Listen for/address beliefs
Establish their goals
“How do you get better?”
(you won’t hear this) She believes it is “in
Educate on habituation
subconscious”
Reid Wilson, PhD, anxieties.com 4
Changing the Anxious Mind ‐Rapidly
25 26
Normalize fearful response
“What symptoms… concern
you?”
“That makes perfectly good sense to me”
Challenge distortions (of
course)
27 Establish contract 28
The shoulder shrug
 “Focus on tolerating suffocation & feeling
“I think you are making an error in logic”
trapped”
The hand wave  “First, we have to be on same page”
“You are adding a problem. Anything  “How could that be useful to you?”
we can do to remove the problem…”
 from “I can’t tolerate this” to “I can handle
this”
Rating List
“NOT removing symptoms” 29 30
Interoceptive Exposure
__ __ Breathing thru cocktail straw
"Had trauma in past –predicting trauma in
__ __ Breathing thru cocktail straw while wearing nose plug
future”
__ __ Standing inside storage box -top opened
Introduction to interceptive exposure __ __ Standing inside storage box -top closed
__ __ Scarf tight around neck
 "We’ll only do what makes sense to you” __ __ Wearing 2 tight sweaters
__ __ Breathing thru painter’s mask
__ __ Breathing thru painter’s mask –wearing nose plug
__ __ Wearing pillowcase over head
Reid Wilson, PhD, anxieties.com 5
Changing the Anxious Mind ‐Rapidly
__ __ Wearing pillowcase over head -taped closed 31 1st interoceptive exposure (IE) 32
around neck
__ __ One hand bound to arm of chair
Use exposure to reappraise
__ __ Both hands bound to arms of chair
__ __ Hands bound by side
 Interpretation —not experience —brings
__ __ Legs bound to chair
distress
__ __ Zipped up in sleeping bag
 Using IE to immediately challenge belief
__ __ In a sleeping bag head-first
__ __ Wearing a nose plug
“Let's see if we can understand” 33 34
Keep clarifying moment-by-
“Are you telling me you can undo it just moment goals
like that?” [snap finger]
“I can handle being uncomfortable & scared”
Time 2: “How did you do that?” [from 8
sec. to 30 sec.] Link misinterpretations together
“Also, I kept in mind that I was in control
“This is like your heart...”
of it”
“What point of view are you 35 Introduction of “I want this” 36
adopting?”
Two voices
Changed her perspective within 30 minutes!
 Notgetting rid of being scared
Manifest within self-talk
 Changing interpretation & adding point
 “Some fears I have are unfounded” of view –in the moment
 “I can handle more than I think I can at How does body respond to message of
this moment” “I don'twant this?”
Reid Wilson, PhD, anxieties.com 6
Changing the Anxious Mind ‐Rapidly
37 38
“Voluntarily choose the
experience”
scarf
 “50” is fine, because she has Convert involuntary to voluntary
already incorporated interpretation!
“Treatment is aggressive”
39 40
Plant seeds of future
provocative work
 “…a box, a sleeping bag, a pillowcase, Debrief homework practice
some packing tape…
“So that... you can say, ‘been there, done
that’”
41 42
“Give yourself (helpful) The possibility of conscious-
messages” unconscious integration
 Reminders of new interpretation
o After she describes trauma driving in
 “There is enough air in here”
Chicago (not shown), has one other
 Commands
traumatic memory
 “Don’t leave --Stick it out”
 Motivational messages
Reid Wilson, PhD, anxieties.com 7
Changing the Anxious Mind ‐Rapidly
43 44
1. Face your fears in small ways that you have
Ask them to generate a list of
control over. Gradually do these things longer
principles from their experiences
& then do the harder things.
with you
2. Talk yourself through it in a really strong,
commanding voice
Always look for opportunities to
3. Talk to your primitive brain. Let it overreact, &
move to higher level of abstraction
then say, “I like your expression, but you don’t
have to juice me up so much next time. I’m
fine. Save that for real situations.”
45 46
Challenge their safety
behavior
This is not habituation —
 “What’s the intention of the practice?”
This is change through single
set of experiences, plus insight  Safety behaviors are manifestation of
related to them belief that “I can’t handle it otherwise”
Chart 1: Practice Creating Symptoms
47
Type of Possible
Task Instructions
Sit Back symptoms symptoms
Stare at Pick a spot on an empty
 Let them decide what they are willing to do spot wall & stare at it without
moving your eyes.
Stare at Stare at a light for 30 Detachment
light seconds, then look at a from self,
Detached
blank wall. seeing spots,
Feelings
What voice responds best to Stare in Look at your face in the visual
mirror mirror. Choose one spot, distortions
threat? such as the bridge of your
nose, & remain gazing
there, without moving your
eyes.
Reid Wilson, PhD, anxieties.com 8
Changing the Anxious Mind ‐Rapidly
Type of Possible
Type of Task Instructions Possible symptoms Task Instructions symptoms
symptoms symptoms
Breath holding Take a deep Shortness of
Step-ups Take one step up onto a breath & hold it. breath, heart
stair, & immediately step 30 seconds. racing
down. Do this repeatedly
at a fast rate (enough to
get your heart racing). 1-
2 minutes. Breathe through Breathe through Breathing
Breathing straw thin straw for one difficulties,
Heart Heart racing, Symptoms minute. Then 2 choking feelings
Symptoms sweating minutes. Don’t
allow air through
Any brisk Walk up & down stairs, your nose.
exercise or use an aerobic (slightly pinch
exercise machine. 1-2 your nostrils
minutes. together if
needed.)
Type of Possible
symptoms Task Instructions symptoms Type of Task Instructions Possible
symptoms symptoms
Roll head Drop your chin down to your chest &
roll your head to the right. When you
Spin Stand & turn around quickly
get to your shoulder, move your head
across to your left shoulder (don’t roll standing (do this near a wall, chair or
toward your back), & continue rolling up couch in case you need to
down to your chest. 1 minute. Seeing catch your balance) 1 minute
spots,
dizziness
Spin in Spin yourself in a swivel Seeing
Dizziness Shake head Lower your head slightly & shake it Dizziness chair chair. Have someone else spots,
from side to side for 30 seconds spin you. Stand. Walk dizziness,
around. 1 minute faintness
Walk in circles Walk around in a small circle, about 3
feed in diameter (do this near a wall, Seeing
chair or couch in case your need to spots, Hyper- Breathe deep & fast. Exhale
catch your balance) 1 minute dizziness, ventilate with a lot of force. 1 minute
faintness
Chart 2: Practice Creating Symptoms
Actual Intensity of Fear level
Type of Task Suggested time sensation 53 54
Symptom time Low Med High Low Med High
Detached Stare at a spot 2 minutes
Feelings Stare at a light 30 seconds +
Stare in the mirror 1 minute
Heart Step-ups 1-2 minutes
Symptoms Brisk exercise 1-2 minutes
Breathing Hold breath 30 seconds
Symptoms Straw breathing 1 minute
Roll head 1 minute
Shake head 30 seconds
Dizziness Head between knees 30 seconds
Walk in circles 1 minute
Spin standing up 1 minute
Spin in chair 1 minute
Hyperventilate 1 minute
Reid Wilson, PhD, anxieties.com 9
Changing the Anxious Mind ‐Rapidly
Interoceptive Exposure in
55 Adding Interoceptive Exposure 56
Office or at Home to In-vivo Exposure
 Hyperventilate while sitting in car
 Do practice 5-8 times in a row
 Run in place in closet
 Do it several times a day
 Walk briskly in mall
 Therapist might have to leave room
during practice to provoke distress  Drink coffee at party
 Wear tight scarf at work
OCD Repeater
 10 years old –NYC trip
 “Let me make sure I understand…”
 Then “Am I dying? Do I have cancer? Tumor?”
What’s the biggest fear?
 Now is worst it’s been
 Me: “So I gottaget rid of it”
 Creeping into work: being late
— Closing car door  Me: “But then you can’t do what you love”
— Going to sleep
—Walking in & out of
— Changing clothes
room
57 58
Resource: focused at work –pride
- Me: “Good news”
“I’m going to take you in a different direction”
 End Picture –Motivation
- Me: “I want my mind back… my day back”
- “Don’t want to feel like I’m going to go
crazy constantly”
- “…just be happy & excited”
59 60
Reid Wilson, PhD, anxieties.com 10