Brief but intensive treatments are proving to be effective for many anxiety disorders
By Claudia Wallis
Psychotherapy is not what most people think of as a quick fix. From its early Freudian roots, it has taken the form of 50- to 60-minute sessions repeated weekly (or more often) over a period of months or even years. For modern cognitive-behavioral therapy (CBT), 10 to 20 weekly sessions is typical. But must it be so? “Whoever told us that one 50-minute session a week is the best way to help people get over their problems?” asks Thomas Ollendick, director of the Child Study Center at Virginia Tech.
For nearly 20 years Ollendick has been testing briefer, more intensive forms of CBT for childhood anxiety disorders and getting results that closely match those of slower versions. His center often has a waiting list for treatments that include a four-day therapy for obsessive-compulsive disorder (OCD) and a three-hour intervention for specific phobias (such as fear of flying, heights or dogs). Around the U.S. and Europe, short-course therapies for anxiety disorders have begun to catch on, creating a nascent movement in both adult and child psychology.
The idea originated with Swedish psychologist Lars-Göran Öst, now professor emeritus at Stockholm University. Some 40 years ago Öst got the impression that not all his phobia patients needed multiple weeks of therapy and decided to ask if they would like to try a single, three-hour session. His first taker was a 35-year-old spider-phobic woman. “She lived five hours away, so she was happy,” he recalls, to be treated in one go. He later showed the efficacy of the approach in a clinical trial, although it took four years to recruit 20 participants. “People with a specific phobia rarely apply for treatment,” he explains. “They adjust their lives [say, avoiding spiders] or think they can't be helped.” Öst went on to work with a team in Bergen, Norway, to test an intensive therapy for OCD known as the Bergen four-day treatment. By the early 2000s Ollendick was adapting brief therapies for adolescents and kids.
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The details vary, but the quick treatments have some common features. They generally begin with “psychoeducation,” in which patients learn about their condition and the catastrophic thoughts that keep it locked in place. In Bergen, this is done in a small group. With children, the lessons may be more hands-on and concrete. For instance, Ollendick might help a snake-phobic kid grasp why the creature moves in a creepy, slithering way by having the child lie on the floor and try to go forward without using any limbs.
A second part usually involves “exposure and response prevention,” in which patients confront in incremental steps whatever triggers their anxiety: perhaps shopping, for agoraphobics, or having dirty hands, for people with OCD. With support from the therapist, they learn to tolerate it and see it as less threatening. Patients leave with homework to reinforce the lessons. Parents may be taught how to support a child's progress.
How well do these approaches work? A 2017 meta-analysis by Öst and Ollendick looked at 23 randomized controlled studies and found that “brief, intensive, or concentrated” therapies for childhood anxiety disorders were comparable to standard CBT. With the quicker therapies, 54 percent of patients were better immediately post-treatment, and that rose to 64 percent on follow-up—presumably because they continued to practice and apply what they had learned. With standard therapy, 57 percent were better after the final session and 63 percent on follow-up. The severity of symptoms and whether the patient was also taking antianxiety medication did not seem to impact outcomes.
An obvious advantage to quick therapy is that it accelerates relief. Children with panic disorder, for instance, may refuse to leave home for fear of triggering an episode of shortness of breath, a racing heart and nausea. “They start to avoid places like the mall, the movies, the school dance,” says child psychologist Donna Pincus of Boston University. Pincus developed an eight-day treatment for the disorder as an alternative to three months of CBT, which, she observes, “is a long time if you are not going to school or are avoiding doing things that are fun or healthy.”
Making these briefer therapies more widely available could help address the sad fact that only about a third of patients with anxiety disorders get any kind of treatment. A weeklong therapy could be completed over a school or work vacation. Rural patients who cannot find CBT nearby could be treated during a short out-of-town stay. The intensive approach requires special training and a big shift for therapists—and health insurers— accustomed to the tradition of 50-minute blocks. But is there really anything sacred about that?
A very useful self-help method for managing and controlling OCD, which is pioneered by many organisations who work in this area, is Professor Jeffrey Schwartz' Four Step Method. The Four Steps are: Relabel, Reattribute, Refocus and Revalue.
In children, specific phobias can be short-term problems that disappear within a few months. In adults, about 80% of new phobias become chronic (long-term) conditions that do not go away without proper treatment.
The most effective treatments are: Exposure therapy. This therapy focuses on changing your response to the object or situation that you fear. Gradual, repeated exposure to the source of your specific phobia, and the related thoughts, feelings and sensations, may help you learn to manage your anxiety.
Phobia and OCD differ according to how stimuli are processed. In phobia, the complete category of object is feared (e.g. big and small spiders are feared), while in OCD specific types of objects are feared, mostly for their symbolic meaning (e.g. germs may be feared on glue and mud, but not on door handles).
Cognitive behavioral therapy (CBT), a type of psychotherapy, is effective for many people with OCD . Exposure and response prevention (ERP), a part of CBT therapy, involves exposing you over time to a feared object or obsession, such as dirt. Then you learn ways not to do your compulsive rituals.
Some clients may be familiar with the “3 C's” which is a formalized process for doing both the above techniques (Catch it, Check it, Change it). If so, practice and encourage them to apply the 3 C's to self- stigmatizing thoughts.
Erythrophobia. Erythrophobia, the fear of blushing, can be a much harder phobia to treat than other types. Blushing is a natural bodily response in which blood is more pronounced in areas such as the cheeks or ears. Oftentimes, erythrophobia has its origins in fear of embarrassment.
1. Social Phobia: Fear of Social Interactions. Also known as Social Anxiety Disorder, social phobias are by far the most common fear or phobia our Talkspace therapists see in their clients.
Exposure-based treatments, including in vivo, imaginal, and virtual reality exposure, have been found to be effective for specific phobia (Wolitzky-Taylor et al., 2008), and several studies have found very high response rates (≥80%) to in vivo exposure in particular among treatment completers (Choy et al., 2007).
It can be used to develop practical ways of dealing with your phobia. One part of the CBT treatment process that's often used to treat simple phobias involves gradual exposure to your fear, so you feel less anxious about it. This is known as desensitisation or exposure therapy.
The most often prescribed medication for phobia is what is known as a benzodiazepine. These are medications such as Xanax, Ativan, and Klonopin. Benzodiazepines are intended for acute anxiety, meaning a discreet anxiety episode or a panic attack.
Treating simple phobias involves gradually becoming exposed to the animal, object, place or situation that causes fear. This is known as desensitisation or self-exposure therapy. Each phobia is different and no single programme will work for everyone.
Some common obsessions that affect people with OCD include: fear of deliberately harming yourself or others – for example, fear you may attack someone else, such as your children. fear of harming yourself or others by mistake – for example, fear you may set the house on fire by leaving the cooker on.
Mysophobia is a specific phobia, meaning that it's due to a particular situation. People with mysophobia may also suffer from obsessive-compulsive disorder (OCD). People with OCD take comfort in repetitive, irrational thoughts and urges.
Navigating through The Four Steps: Relabel, Reattribute, Refocus, and Revalue. In dealing with intrusive thoughts or compulsive urges characteristic of OCD, Dr. Schwartz's four steps serve as a roadmap guiding you toward healthier responses: Relabel: Recognize your obsessions and compulsions as symptoms—not reality.
The OCD cycle consists of four stages: obsessions, anxiety, compulsions, and temporary relief. Often called a vicious cycle or feeling stuck in an OCD thought loop of “wrongness,” once the OCD cycle is established, it can be hard to break out of.
Within the stepped care model, we are a secondary care specialist service offering assessment, formulation, and psychological intervention (individual and groups) to clients with complex levels of mental health difficulties.
Results. A four-factor solution provided adequate but imperfect fit across age groups, with comparable indices to the only previous OCD CFA: factor 1 (aggressive/sexual/religious/somatic/checking); factor 2 (symmetry/ordering/counting/repeating); factor 3 (contamination/cleaning), and factor 4 (hoarding).
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