Tag Archives: exposure

A cognitive behavioral understanding of social anxiety disorder

By Brad Imhoff August 8, 2022

“Don’t let anxiety drive the car,” I learned to tell myself.

I was standing in the hallway of the hotel’s conference center where our state counseling association was hosting its annual conference. I had co-presented with my professors at the conference a handful of times before, but I viewed them as experts who could handle anything that came up during our presentation. There was comfort in that.

Now here I was as a doctoral student about to present a 60-minute session as lead presenter for the first time. The anxiety I had tried fending off for the past several hours (and, let’s be honest, past several days) rushed over me like a tidal wave as I looked at my watch and saw the presentation was scheduled to start in 15 minutes.

My stomach was in knots, my hands were ice cold (yet sweaty), and my thought process went something like this: “They all know so much more than I do; what am I doing here? They’ll see I’m a fraud and don’t belong. What if I run out of things to talk about? What if they ask questions and I have no answers? Great, now I’m sweating. They’re going to see I’m sweating and know I’m nervous. The sweat is fogging up my glasses and now I can barely read my notes. Do I have enough notes? What if I run out of material and have nothing to say after 20 minutes? How embarrassing. They’re going to judge me. Why am I doing this?”

Anxiety was absolutely driving the car.

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Social anxiety disorder

As its name implies, social anxiety disorder can be understood as an intense fear of, and overwhelming distress in, social situations. Situations that involve scrutiny, being observed, and real or perceived evaluation create extreme discomfort and dread for individuals with social anxiety. Common examples that trigger social anxiety for these individuals include speaking or performing in front of others, interacting with unfamiliar people, dating, being interviewed, initiating conversation and being at the center of attention. The underlying concerns are largely centered on judgment, negative evaluation and the potential for embarrassment. There is a persistent worry about appearing inadequate, humiliating oneself or being evaluated as awkward, boring, weird or any number of other negative descriptors.

As if the discomfort associated with social situations were not enough, social anxiety disorder also involves a fear of exhibiting anxiety symptoms. There is anxiety about being anxious. People who are overly anxious often sweat, blush, tremble or stumble over their words and fear that others will notice this and judge them for it. They may have racing thoughts, a quickened heartbeat, muscle tension or a dry throat, all of which can impede functioning at their best. When this happens, they become hyperaware of their internal experience and focus less on the task at hand and what is going on externally.

Take, for example, someone who is on a first date or someone interviewing for a job. They might have sweaty palms from feeling anxious and then be consumed by worry about having to shake hands. Rather than mentally preparing for a positive greeting or being excited about an introduction, the person might ruminate on the thought, “If I shake hands, they’ll feel the sweat and think I’m gross, but if I don’t shake hands, they’ll think I’m awkward.” This creates the sense of a no-win situation that might lead a person to avoid such situations altogether.

Another example is a young student who raises her hand to participate in class and feels her face getting warm as she begins blushing. She is rehearsing in her mind what she wants to say but now turns her attention to the anxiety symptoms she is experiencing — worried that others might notice them too. Her embarrassment intensifies and her fears are actualized as her peers giggle and comment on how red she is turning. Not only does she feel anxious about speaking up, but it is confirmed to her that her anxiety symptoms are on full display for others to see and judge. She decides it is safer to just not raise her hand in the future.

Many readers can relate to these scenarios because most people experience anxiety in some social situations. It would be rare to go on a first date, present in front of an audience or go into a job interview without feeling some level of anxiety. With social anxiety disorder, however, the anxiety is excessive and out of proportion to the situation. Furthermore, the anxiety creates extreme distress or impairment. That is, it gets in the way of typical functioning.

Individuals are very likely to use avoidance behavior to not have to engage in social situations or they may tend to escape situations once in them (e.g., leaving a social gathering shortly after arriving). Social situations feel as if they are being endured and survived as opposed to enjoyed. This can create various challenges related to employment, educational opportunities and relationships. When anxiety gets in the way of life in this way, treatment with a professional is warranted.

When considering the treatment of social anxiety disorder, I tend to conceptualize it as a three-pronged approach that involves understanding the disorder, learning to accept and value oneself, and reconstructing the reality clients have built for themselves. The latter two processes are very much intertwined, and all three are fluid and ongoing as clients learn about their anxiety, discover new ways of thinking about themselves and begin to engage the word differently. As they do all of this, they are practicing new skills with an aim toward interacting and functioning more effectively in their daily lives.

Understanding the disorder

Understanding social anxiety disorder begins with psychoeducation. This process is very reciprocal, however, because counselors learn from clients too. Clients who struggle with social anxiety are well aware of the discomfort associated with it, having experienced it daily for much of their lives. Still, counselors can work through the features, symptoms and diagnostic criteria with them to help put a name and label to their experiences.

While this is being done, clients are asked to share how the various features of the disorder have played a role in their lives. This becomes a parallel process of educating clients on the ins and outs of social anxiety disorder while they educate counselors on their individualized experience with it. This joint effort builds rapport and trust and sets the tone for a collaborative partnership throughout treatment. It also helps normalize the challenges clients have encountered due to their anxiety, puts a name to what they have experienced and may help them feel less alone in the struggle.

According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, the onset of social anxiety disorder occurs most often between the ages of 8 and 15, and people go an average of 15-20 years experiencing symptoms before receiving treatment. This means clients have likely avoided and missed out on many opportunities going back well into childhood.

The counselor should explore these opportunities. Doing so can be beneficial for several reasons. First, it gives a clearer understanding of the disorder’s role throughout clients’ lives and how it has affected their quality of life. Second, it offers insight into the areas each individual client may struggle with most — at work, in school, initiating friendships, building intimate relationships and so on. Finally, the historical challenges and missed opportunities can provide motivation for truly engaging the therapeutic process now. Building this motivation can be especially important when it comes to the gold standard for anxiety treatment — exposure (discussed later in the article).

I like for clients to consider this question: “In light of all the missed opportunities you have described, I wonder what life will be like moving forward if anxiety continues to lead the way?” With an eye toward collaboration, motivation and building hope, the counselor may follow up with, “I want to help you take back control from this anxiety.”

When anxiety leads the way and controls our behavior, it becomes problematic. It creates impairment. Anxiety itself, however, is actually healthy and helpful. Being anxious about an important exam motivates us to study for it. Having anxiety about an upcoming business presentation focuses our preparation and encourages us to give it due attention. Feeling anxious about an upcoming networking opportunity might indicate that we value relationships and view social connection as important.

Part of educating clients is helping them understand the benefits of anxiety and learning to distinguish helpful anxiety from the excessive anxiety they experience. The former motivates us and helps us prepare, whereas the latter paralyzes us into inaction.

Don’t let anxiety drive the car

Back to the opening story. The anxiety had stopped being helpful long before my presentation began. It was excessive and paralyzing at times. When I was anxiously preparing to begin a conference presentation, I would start implementing a handful of interventions to try to get rid of the anxiety. I would quickly run through them, expecting one to be the magic pill that would make me feel better. It was not a helpful way to view anxiety, and when none of the interventions made it disappear altogether, I was left feeling even more anxious. I had a combative relationship with the anxiety; it was overwhelming me, and I was fighting as hard as I could to make it go away. Only when I accepted that it was going to be there did I experience some level of freedom from it.

“Don’t let anxiety drive the car” was the phrase and visual that came to my mind. It became my imagery for managing anxiety. Anxiety was coming along for the ride — there was no doubt about that — but it did not have to be all-consuming and control where we went, whether we went at all or how we got there.

Instead of creating an inner conflict that I was battling and trying to overcome, I began to externalize the anxiety and invite it along. I had a mental image of me sitting in the driver’s seat and opening the passenger door to welcome it. Essentially, I was saying, “I know you’re going to be there, so get in and let’s go.”

Externalizing the anxiety and inviting it along meant that I was no longer fighting against it and consistently losing. Rather than fearing the symptoms and engaging the racing thoughts, I could simply acknowledge them, accept that they would be there and make the decision to continue forward anyway. To keep things light and in perspective, I might even say to the anxiety, “It sure would be nice to just put you in the trunk.” For some anxiety-inducing situations, that can be a good way to monitor its severity. Is it tucked away in the trunk and mostly out of mind? Is it in the back seat just riding along? Or is it sitting in the passenger’s seat trying to grab the wheel and take control?

Once we understand that anxiety is not something that is going to disappear, we can turn our attention to navigating our lives despite its presence. We can learn how to lessen its impact and manage it when it becomes excessive and unhelpful.

Acceptance of oneself

If I think poorly of myself, it naturally follows that I will expect others to think poorly of me too. How could I expect others to view me in high regard if I do not see myself that way in the first place? This is important because social anxiety is largely focused on how we think others perceive us, which leads to the presence of anxiety when around others.

Therefore, the second prong to the treatment approach is to help clients better accept and value themselves. Counselors can explore with clients their natural dispositions and work with them to understand and value their individual strengths and personalities. People with social anxiety may long to be extroverts or overvalue outgoing personalities, despite themselves being quiet observers who are rejuvenated by alone time and drained by social interaction. It is important to recognize these tendencies, not only to manage client expectations but also to highlight the value of these tendencies and reframe them. A client who puts herself down for being too reserved may learn to recognize how this plays a role in her being such a good listener with her friends. A client who longs to be more outgoing may learn to recognize how his quieter demeanor has made him more observant and intuitive.

It is also possible that social skill development is necessary for some clients. Areas may exist in which clients can improve their role in social interactions. Those who have social anxiety have spent years avoiding social situations and have not practiced and honed their skills in the way that others who are more socially comfortable have. Take, for example, a child who plays a sport or musical instrument. If this child shows up to practice two days each week while all the other children practice five days per week, those who have practiced more will have developed better skills. Similarly, an individual who has not had much practice in social situations may need to develop and practice skills that have not regularly been used. The counseling relationship is an opportunity for clients to become more competent with initiating conversation, recognizing social cues, speaking clearly, making eye contact, practicing how to show interest in others through prompts and questions, and any number of other social skills. With improvement of skills and competency comes more confidence.

Self-esteem activities are another useful tool in the process of helping clients accept and value themselves. One that I particularly like is having clients consider five different aspects of themselves: physical, spiritual, emotional, intellectual and social. Clients are asked to identify personal characteristics within each area that they value and appreciate in addition to identifying some areas for growth. Using this approach makes the abstract concept of self-esteem more concrete and can help clients create a more balanced and holistic view of themselves. As counselors observe this process, they can also keep an ear out for particularly negative language or self-talk.

Reconstruction of reality

Throughout the steps noted in the previous sections, clients are beginning to understand themselves better and view themselves differently. The third prong to treatment — helping clients reconstruct their reality — continues this effort. Here, clients really begin to explore their self-talk and maladaptive behaviors.

This process is easier said than done. Clients often come to us with low self-esteem, and there is no switch to flip to instantly have them think better about themselves. To emphasize it as an ongoing process, counselors can present it as “chipping away” at old ways of thinking and starting to entertain new ones.

Negative self-talk: One of the first steps in this process is exploring our clients’ negative self-talk and inner critic. This is that voice in our mind that continually criticizes us for not being good enough. It is hard to develop a healthy sense of self with such a critic living within.

To emphasize the importance of healthier self-talk, counselors might pose the following scenario to a client: “I want you to think about the person you love most in this world. It could be your child, your partner, your niece or nephew, or any person you just absolutely love. Now, tell me how that person would develop mentally and emotionally if you talked to them the same way you talk to yourself.”

Often, this becomes a rhetorical question that, in my experience, generates tears for many people. They recognize that they would never talk so harshly and critically to someone they love, and they recognize their loved one would not develop into a healthy, confident, high-functioning person if they did. This helps make clear the connection between our self-talk and our self-esteem. If we want to be healthy and confident, it is helpful to talk to ourselves in a way that promotes that.

Again, this does not mean our clients will flip a switch and miraculously begin thinking only in helpful and healthy ways, but it does lay a foundation for monitoring their thought processes; identifying negative, unhelpful self-talk; and beginning to choose kinder ways of speaking to themselves.

Monitoring negative self-talk becomes another collaborative process. Counselors can prompt discussion by simply asking about it (“What were you telling yourself in that moment?”) and by pointing it out in the present (“I am hearing a lot of negative self-talk as you discuss this. Can we pause to look at that?”). This process teaches clients how to train their own ears to catch it as well. They can begin to monitor their self-talk outside of the counseling office and use interventions such as thought records that they write down and bring back to session. When reviewing such records, counselors can help clients brainstorm new thoughts to interject as healthier ways of thinking. Over time, this practice can give rise to clients monitoring and replacing negative self-talk in real time on their own.

Core beliefs: To further enhance the treatment process, counselors would do well to connect their clients’ thoughts to the idea of core beliefs. Core beliefs are those that develop early in life and become deeply held, foundational views of ourselves, others and the world in general. These tend to take the shape of absolute statements such as “I am _____” or “The world is _____.” Everyone has both positive and negative core beliefs, but the negative beliefs tend to be more prominent, especially for people experiencing enough distress in life to seek counseling.

Early childhood interactions, especially with caregivers, play a significant role in the development of these beliefs. Take, for example, a client who as a child was told by her parents that she was always in the way, she was a “mistake baby,” and they wished they had never had a kid. A profoundly negative message such as this is repeated in various ways throughout the client’s life, so she develops the belief that “I am worthless and unlovable.” One can imagine the implication of this belief on her thoughts and how it interferes with developing healthy relationships throughout life. A second example might be a client who experienced significant traumas early in life and develops a belief that “the world is unsafe and dangerous” or “people are manipulative and untrustworthy.”

Clients are generally not going to walk into the counseling office and tell us their core beliefs. They are usually unaware of this concept, and their beliefs operate more implicitly. Clients’ thought processes and self-talk very much lend insight into what their beliefs may be, however. As we listen to clients share stories about their day-to-day lives, recall memories from their past and especially make “I” statements, we can hear how their language is shaped by core beliefs about being unlovable, incapable, inadequate and so on.

I like to think of core beliefs as root systems. Any flowering plant needs a healthy root system to produce healthy flowers or fruits. An unhealthy root system will lead to unhealthy plants. Similarly, a client’s negative core beliefs will naturally result in negative thought processes. So I want to help my clients reevaluate their root systems, or core beliefs, to establish a healthier foundation that can give life to healthier thoughts about themselves and the world around them.

When working with clients on restructuring how they perceive themselves and others, we cannot expect an immediate switch from negativity to positivity. They have spent their entire lives with these negative core beliefs as a foundation and, once made aware of them, can often provide significant evidence as to why they think their beliefs are true. Our job is to help clients chip away at those unhelpful core beliefs and begin to find a healthier balance.

We can do so by helping them discover alternative ways of thinking about themselves and then intentionally looking for evidence to support those newer, healthier ways of thinking. This evidence might come from a reinterpretation of past experiences or be found by intentionally looking for it moving forward. For example, a compliment from one’s boss may no longer be shrugged off as obligatory and undeserved, but instead lead to ownership of a job well done — thinking to oneself, “I did do good work on that project. I’m glad it was recognized.” The new evidence and ways of thinking begin to plant the seed of a new core belief of “I am capable” or “I am enough.”

Exposure: The previously discussed interventions for helping clients view themselves differently build motivation and courage for what comes next — exposure. Exposure is generally considered the gold standard for anxiety treatment, which often comes as bad news for those who experience anxiety. It can be hard to hear that engaging in the very situations that create anxiety is ultimately the best way to reduce that anxiety. Avoidance feels safer in the short term, but it impedes us in the long term.

The inconvenience of this reality is why I like to start treatment with understanding the disorder and developing a better acceptance and valuing of oneself. As we do these things and establish a strong counselor-client relationship, clients grow more willing to expose themselves to situations that require a lot of bravery.

Exposure therapy does not mean identifying what causes our clients the most anxiety and having them jump right in. On the contrary, it is a process of identifying situations that cause varying levels of anxiety and working through them systematically. We can help our clients create a list of situations that create anxiety for them and rate them on a 1-to-10 scale. At the bottom of the list (1) is something that evokes mild anxiety symptoms; at the top (10) is a situation that causes significant anxiety.

These lists are extremely individualized, but examples may include waving to and saying hello to a neighbor across the road as a lower anxiety situation and attending a networking event where the client doesn’t know anyone as a higher anxiety situation. Between the two are many situations that induce increasing levels of anxiety that can be worked through one at a time, from least frightening to most frightening.

Clients work through the list systematically with the support of the counselor. It may begin with simply visualizing the scenario together in the counseling session and thinking through how it might go, discussing what clients feel as they think about it, and talking about how to best approach the real scenario outside of the counseling office. This imaginal exposure can introduce clients to the process, allowing them to first navigate it from a distance and deal with some of the feelings associated with it prior to engaging the real scenario.

The idea behind exposure is that clients learn to engage situations that make them uncomfortable as opposed to continuing patterns of avoidance behavior. As they do so, they build a tolerance for discomfort and learn to take control of the anxiety, moving forward even with it present. Successfully engaging situations will help develop a sense of accomplishment and self-efficacy that motivates them to continue working toward more challenging situations.

Clients will also notice a reduction in anxiety symptoms if they engage situations many times before moving on to a more challenging one. Clients do not need to feel 100% comfortable and confident before engaging the scenarios or moving on to the next one, however. They may need to learn that the anxiety will sometimes come along for the ride. Clients just need to make sure it isn’t driving the car.

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Brad Imhoff earned his doctorate in counselor education from Ohio University and currently serves as the director of the online Master of Arts in addiction counseling program at Liberty University. His scholarly interests include the understanding and treatment of social anxiety disorder, substance and behavioral addictions, and counselor well-being and self-care. Contact him at bimhoff@liberty.edu.

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

How COVID-19 is affecting our fears, phobias and anxieties

By Lindsey Phillips March 2, 2021

When faced with a new, unknown virus, our anxiety can take over, and we often assume the worst. We indulge our fears. We panic. The uncertainty overwhelms us, exacerbating old anxieties and fears and creating many new ones.

If this reaction sounds familiar, you were likely alive when HIV, the virus that causes AIDS, elicited widespread fear and anxiety in the 1980s. In fact, the HIV/AIDS and new coronavirus/COVID-19 outbreaks share many similarities: an inadequate government response, the stigma attached to having the virus, the disproportional impact on underrepresented groups, and initial confusion over how the viruses are transmitted.

At the onset of the AIDS crisis, people incorrectly assumed that they could get HIV by kissing another person. Michael Soderstrom, a licensed professional counselor at Houston OCD Counseling in Texas, remembers his own anxiety when first hearing about HIV and AIDS. He says he didn’t want to sit on a public toilet for fear of contracting HIV.

There’s no doubt that the COVID-19 pandemic has changed us. The question is, in what ways will it continue to change us? Will we ever shake hands again? Will we wear masks each year during flu season? Will we learn from the lessons of previous health crises? One thing is clear already: The pandemic is reshaping not only people’s fears and anxieties but also how counselors are having to approach treatment.

Fear of contamination and harming others

What about people who wrestled with contamination fears before this pandemic? Have they experienced an increase in symptoms? Soderstrom, an American Counseling Association member who treats obsessive-compulsive disorder (OCD) and other anxiety disorders, has observed that his clients who fear contamination from blood, semen or bodily waste have not gotten worse, because quarantine largely takes them away from exposure to these “contaminants.” But he has noticed an increase in clients who worry about contracting diseases, getting sick or dying, as well as those with perfectionist tendencies who struggle with the fact that COVID-19 ultimately lies outside their control. The thought that they could contract the disease regardless of how carefully they follow safety precautions terrifies them, he says.

The pandemic has even given rise to a new phobia — coronaphobia, the fear of contracting COVID-19.

People with OCD are also at risk of backsliding right now because the isolation, heightened stress and uncertainty associated with the pandemic can lead to depression and generalized anxiety, which fuel OCD-related symptoms, says Soderstrom, a member of the International OCD Foundation and OCD Texas. He has seen several new clients who had previously dealt with OCD symptoms on their own, but their symptoms became unmanageable during the pandemic, causing them to seek professional help.

To some degree, everyone is concerned about cleaning and sanitizing right now, so when do these thoughts and behaviors cross over into becoming a problem? Soderstrom asks clients who struggle with contamination fears to establish a safety practice based on guidelines from a trusted health organization such as the Centers for Disease Control and Prevention (CDC). He also has clients record how often they are cleaning surfaces to help them recognize if their behavior is becoming problematic.

If clients realize they are going beyond the CDC guidelines and washing their hands obsessively, Soderstrom has them establish rules on when they should wash their hands, such as after using the bathroom or sneezing. He also encourages them to limit themselves to washing with soap and water for 20 seconds. At first, these clients may feel the need to also wash their hands every time they touch the front door because it could be contaminated. Over time, Soderstrom may ask them to simply “water wash” their hands after touching the front door. This fulfills their emotional need without the full brunt of soap and water. These ground rules serve to keep people anchored in reality because someone who wants certainty can always find a reason to wash or clean, he adds.

Soderstrom has also noticed an increase in clients who worry about infecting others with the coronavirus. These clients struggle with what is known as “harm OCD”; they are the same people who worry about hurting or killing someone with their actions, he explains. To illustrate, these clients might grab a doorknob and think to themselves, “I hope I have the COVID-19 virus and will give it to my mom.” But then they quickly reject this thought and obsessively clean the doorknob out of fear that they will actually give their mother the virus.

Over-responsibility is a substantial issue with OCD, Soderstrom continues. Some clients feel responsible for not protecting others from the coronavirus, so they are constantly cleaning commonly touched surface areas such as car-door handles before others use them.

With these clients, Soderstrom often uses a responsibility pie exercise. If a client is worried about giving their older parent the COVID-19 virus and killing them, then he would ask, “What are all the other ways they could get COVID-19? How many times have they been to the store? How many times have other people come over to their house?” This exercise helps clients realize that assuming full responsibility for the possibility that someone else could get COVID-19 is not realistic, he explains.

Soderstrom also finds this exercise personally helpful. Whenever he has intrusive thoughts about the possibility of getting COVID-19, he asks himself, “What ways could I get the virus? If I did get the virus, who would be responsible — me, the government or the people I’m around?” Thinking through these questions helps him realize that even if he did get COVID-19, it would not automatically mean that he had been irresponsible or was a failure. Because myriad factors are at play, he knows he can only do the best he can to stay safe; the rest, ultimately, is outside of his control.

Relationship and separation anxiety

In the coming months, Rocio Morris, a licensed mental health counselor and the assistant clinical director at the Bougainvilla House in Fort Lauderdale, Florida, believes counselors will see an increase in relationship issues. She has already noticed that more of her clients are coming to therapy because of attachment and communication issues within the family. For example, one of Morris’ clients is in a codependent relationship with her mother, and the mother’s anxiety over the pandemic is in turn affecting her. The mother constantly worries about the family contracting the virus, which only serves to increase the daughter’s anxiety.

In addition, a few of Morris’ clients are having identity crises because they are isolated and trying to figure out who they are in the absence of their normal support networks. One client in particular is actively grappling with her sexual orientation, but she is doing this alone in a home with a mother who is unsupportive and two young siblings. Before the pandemic, this client would have found support through school activities or by hanging out with friends who were having similar experiences. Now, she feels trapped and all alone in her house.

To complicate matters, the client has a history of self-harm. Morris, an ACA member who specializes in working with teens and adults struggling with anxiety, depression, behavioral issues and life transitions, is working to cultivate the client’s inner strengths to help her through this challenging time. For example, because the client is artistic, Morris has encouraged her to use expressive coping techniques. So, when the client feels the urge to harm herself, she opts to paint that part of her body instead.

Morris, owner of the private practice Reimagine Life Counseling Services, thinks these types of relationship issues are likely to increase. Once pandemic-related restrictions are lifted, some people will be anxious to leave home or to be apart from certain family members, whereas others will start dealing with the outcome of being stuck in a toxic environment for months on end, she says.

Soderstrom believes counselors may see an increase in clients who are panicked about leaving home and being away from family members because they have grown more attached during the pandemic. “It’s like a part of who we are didn’t get exercised [during the pandemic] and got out of shape,” he says. “We have to exercise that part of ourselves again to be our full selves. … We have to reexperience fear. We have to reexperience doubt. We have to reexperience … emotional isolation outside the house.”

Soderstrom knows how much isolation can affect someone’s social anxiety. A few years ago, he had an extroverted client who lived overseas with his father for an extended period of time. The client mostly stayed isolated inside his apartment because he didn’t speak the local language. When he returned to the United States, he came to see Soderstrom because he had developed social anxiety about reconnecting with his friends. The extended break from his social activities had affected his self-confidence, and he found it easier to avoid his friends, which only reinforced his anxiety, Soderstrom says.

With Soderstrom’s help, this client overcame his anxiety, but Soderstrom worries that once the need for physical distancing finally passes, more people will struggle with social anxiety and panic disorders because they too have been isolated for extended periods of time. He predicts that some people will find social situations such as going to the mall or being around large groups of people triggering at first.

“Because this [pandemic] is such an individual experience for everybody, people are going to come out of this or move forward from this with different [experiences], such as losing somebody or experiencing trauma in the home,” Morris observes. These differences will affect how people learn to interact with one another again, she adds.

Confronting, not avoiding, anxiety

Clients often come to see Andrea Batton, a licensed clinical professional counselor and the clinical director at Maryland Anxiety Center, and ask her to “get rid of their anxiety.” No one wants to feel anxious or afraid all the time, of course, but the treatment goal isn’t to completely eradicate these feelings, she says. Batton, an ACA member who specializes in treating anxiety and OCD-related disorders, explains to clients the adaptive nature of these emotions, which includes informing us about our environment and helping us to survive. The point of counseling is to learn how to respond to these emotions in more helpful ways, she says.

Similarly, Soderstrom advises his clients not to ignore these thoughts and feelings but rather to be curious about them. Too often, he says, clients try to run away from these thoughts. “We try to control thoughts by either getting rid of the trigger or avoiding the trigger,” he explains. His goal is to get clients to embrace their emotions by capturing the thought and refocusing their energy back into their body or on another thought they value more.

So, if an adult child is eating lunch with their father and they have an irrational fear that they have the COVID-19 virus and just gave it to their father by hugging him, they can pause and acknowledge this intrusive thought as one that may feel true but isn’t. They can ground themselves by shrugging their shoulders, remind themselves of the low likelihood they are giving their father the virus, and refocus their attention on what they will discuss during lunch.

“The art of refocusing gives us ultimate power,” Soderstrom says. “It’s the moving on or refocusing on something we value or something that’s important that teaches us to devalue whatever the [intrusive] thought was rather than avoiding it.”

Although this isn’t the intent, physical distancing guidelines are encouraging many people to avoid the stimuli that trigger their anxieties or fears, and this can have serious repercussions on their overall progress, says Batton, a member of the International OCD Foundation and a board member for OCD Mid-Atlantic. Some school-age children, for example, struggled to go to school before the pandemic because they wanted to avoid situations that might trigger worries about having a panic attack or a specific phobia such as a fear of vomiting. Virtual classes — which have become common during the pandemic — serve to reinforce avoidant behavior.

“Avoidance is a compulsive behavior that reinforces the notion that there is danger at school,” Batton says. So, she wants to see these students return to in-person instruction full time. The same goes for clients who want to avoid work or other settings that trigger anxiety, phobias, or OCD-related worries or fears.

Counselors will have to work with their clients to figure out plans to ease them back into these spaces once it has been deemed safe to do so, Batton continues. “We don’t want anxieties, worries and fears to limit your life,” she says. “We want you living in accordance with your values [and] life goals, not [with] what anxiety tells you to do or your fears tell you not to do.”

Reappraising negative thoughts

When people are triggered, their mind automatically goes to worst-case scenarios, says Batton, a member of the Anxiety and Depression Association of America. When clients struggle with worst-case-scenario or all-or-nothing thinking, also known as “thinking traps,” counselors can help by teaching them how to respond to their thoughts more rationally, she continues.

Cognitive reappraisal isn’t about “looking on the bright side” or trying to be positive, Batton notes. Instead, counselors should help clients consider other possible explanations and look at what else might be going on. For example, if a student is struggling in a virtual class, they may start to think, “I’m going to fail the class. Everyone else understands the material. I’m stupid.” These thoughts will only make the student feel more anxious about the class, so they will dread doing homework or even avoid going to the class again, thereby reinforcing these less rational thoughts, she explains.

Batton’s goal instead is to teach the student to take a step back and consider what else could be true about the situation. Maybe the other students are also confused. Maybe the class is difficult. Maybe the student won’t get an A in the class, but they will still pass. After challenging the negative belief, the student can engage in more adaptive and helpful behaviors such as starting a study group or speaking with the teacher about how to improve in the class.

This cognitive reappraisal technique helps clients change the way they respond to intrusive thoughts over time. “When you’re having more rational thoughts, you’re going to feel more neutral. You’re not going to feel as anxious. You’re not going to feel discouraged … or afraid,” Batton explains. These neutral emotions and rational thoughts lead to more productive behaviors, which in turn fuel more rational thoughts.

Morris says many of her clients are falling into thinking traps when it comes to the pandemic. She often relies on thought-stopping exercises to help them get unstuck and move forward. If a client is afraid to leave their house because they may get the COVID-19 virus, she helps them identify the trigger and stop the negative thought before it snowballs into a physical reaction. She asks the client, “What is one small thing you can do to feel more in control?” Maybe they could put on a mask and go for a careful walk around their neighborhood rather than locking themselves inside their house.

Morris also shows clients a few common thinking errors such as negative labeling (e.g., “I’m stupid.”), blowing things up (e.g., “This pandemic will never end. I’m going to live alone forever.”) and self-blaming (e.g., “My neighbor has COVID-19. I probably gave it to them.”). She then asks them to identify which ones they are experiencing. This helps initiate the conversation and individualize the coping skills the client needs to respond to these thoughts, she adds.

Soderstrom helps his clients engage in logical, rather than emotional, thinking by asking Socratic questions. For a client who worries that they didn’t clean the doorknob well enough and may be responsible for giving their family the COVID-19 virus, Soderstrom would simply ask, “Would you bet $10,000 that if a scientist came and swabbed the doorknob, they would find the virus? What’s the evidence for this thought? What would you tell your friend if they were in a similar situation?”

He also asks clients to complete a thought record that consists of seven columns: the situation/trigger, feelings, unhelpful thoughts/images, facts that support this thought, facts that challenge this thought, an alternative (more balanced) perspective and the outcome. This activity anchors clients and pulls them away from black-and-white thinking, he says.

Rethinking exposure therapy

As Batton points out, exposure therapy is the backbone of clinical treatment for anxiety and obsessive-compulsive and related disorders. But not all exposures are possible during a pandemic. Asking a client with social anxiety to go to a large party is bad therapy right now, Batton jokes.

For that reason, counselors have to get creative with their exposure ideas. For example, Batton is using a HIPAA-compliant version of Zoom and Bluetooth to “ride along” with her clients who have driving phobias. This allows her to still see clients’ facial expressions, such as a clenched jaw, while she coaches them during the exposure. When she has a client with compulsive bathroom rituals, she sets a timer and virtually watches them brush their teeth to limit how long they engage in this behavior. Batton also helps clients with emetophobia (a fear of vomiting) by making fake vomiting noises together during the virtual session, sharing her screen to look at photos of vomit and watching video clips of other people vomiting.

Regardless of how the exposure occurs, the goal is to initiate those intrusive thoughts and anxieties to help clients realize that their worst fear is unlikely to occur. Through this experience, they don’t “unlearn” the fear. Instead, they gain “new safety learning” or inhibitory learning (i.e., learning that the feared stimuli and their emotional response to it are safe) and habituate to the thoughts and uncomfortable feelings, Batton explains. The fearful thoughts lose their power and diminish over time, she adds.

Before the pandemic, Soderstrom rarely went into clients’ homes to do exposure therapy. Now, with the transition to telebehavioral health spurred by the pandemic, he regularly enters clients’ homes virtually and works on their phobias and anxieties in real time. For example, one client fears losing control and accidentally stabbing her grandmother. Previously, as part of treatment, he would ask the client to take a plastic knife and sit beside her grandmother or hug her as a homework assignment. Now, he can observe her while she actually performs this exposure exercise.

Soderstrom is also finding inventive ways to help clients focus on their core fears. For example, he’s asked clients with social anxiety to call someone on the phone and post new videos on TikTok.

Virtual exposures have actually expanded Soderstrom’s options for treatments because, as he points out, “so many obsessions/compulsions are done inside the house.” So, he plans to continue virtual exposure sessions even after he returns to having in-person sessions. He likes that the virtual exposure sessions provide him with visual, not just written, evidence of clients’ progress.

Batton finds that virtual exposures have provided cost-effective treatment options for her clients. Before the pandemic, she had to charge a travel fee every time that she conducted an in-home visit to do exposure work. Because of the pandemic, and thanks to telebehavioral health, in-home visits have been eliminated, and because exposure therapy is typically as effective virtually as it is in person, she plans to continue this practice on occasion after the pandemic-related restrictions end.

Counselors’ own fears (and hopes)

At the beginning of the pandemic, Soderstrom worried he would lose his connection with his clients. He thought he wouldn’t be as effective as a therapist because of the physical distancing restrictions. But Soderstrom was happy to learn his fears were unsubstantiated. He just had to adjust his technique and become more vulnerable with his clients.

With telebehavioral health, clients may not be able to pick up on the counselor’s body language, or they may not feel comfortable being vulnerable themselves, Soderstrom says. He finds that being open and honest about the way he is feeling often elicits clients to be more open with him. For example, he recently told a client, “Sometimes, I feel like it’s hard to do treatment right now.” This prompted the client to share that they also found therapy difficult. The client hadn’t been able to finish their therapeutic homework assignments that week and had even considered quitting therapy. Soderstrom reassured the client that they weren’t alone in this feeling.

Morris believes that counselors need to keep suicidality on their radars in the coming months and years. The suicide rate among teenagers has already been rising, and one must assume that the job losses, isolation and loss of life resulting from the coronavirus pandemic will only push that rate even higher, along with suicidal ideation among both teenagers and adults, she says.

Morris emphasizes the importance of counselors doing more outreach during these times. She recently hosted a webinar for a local high school on how COVID-19 is affecting teenagers and discussed the warning signs of suicide as a preventive measure. By providing psychoeducation, she hopes to normalize conversations about suicidal ideation and prevent future suicides.

Batton’s biggest fear for the profession itself is that many counselors will choose to engage with clients exclusively through telebehavioral health even after the pandemic danger has passed. She acknowledges that returning to in-person sessions may not be easy or straightforward for many clinicians, especially if they had to break the lease on their office spaces. But she hopes most counselors will find a way to return to an office in some capacity. Batton longs to see clients and counselors interacting in person again, in part because in-person sessions are beneficial for clients who struggle with certain fears and anxieties such as social phobias, she says.

Morris shares Batton’s concerns about the possibility of counselors not returning to their offices. She’s currently hiring counselors for her clinical office and has found many of them are still fearful of providing in-person sessions, even after taking the appropriate precautions of wearing masks and sanitizing between sessions. Morris acknowledges that the whole process has been unsettling for many clinicians. First, they had to quickly adapt to moving their practices online; now they are being told they can go back into the office with safety precautions. She wonders, “How long is it going to be before counselors feel comfortable again with face-to-face sessions?”

Soderstrom says some of his clients are worried about the potential consequences of the prolonged suffering experienced over the past year because of the pandemic. Others with anxiety disorders and OCD fear that if their situation gets too tough, they might implode or incapacitate themselves with worry. He reassures them that humans are strong and can adjust to even the worst circumstances — just as they have done before.

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.com.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Living with — and beyond — OCD

By Bethany Bray January 24, 2020

In popular culture, obsessive-compulsive disorder (OCD) is often portrayed through characters who can’t bring themselves to step on cracks in the sidewalk, who are germaphobes, or who are obsessed with cleanliness and organization. These “hang-ups” are often played for comic effect.

“There’s a huge misconception that OCD is cute and quirky,” says Shala Nicely, a licensed professional counselor (LPC) with a practice in Marietta, Georgia, who specializes in treating OCD and related disorders. “There’s nothing further from the truth. That [stereotype] keeps people from seeking help. They think they just need to ‘get it together’ and deal with it.”

In reality, OCD can be debilitating, says Nicely, who has lived with the disorder since she was a child. Individuals with OCD are haunted by unwanted and invasive thoughts that are often self-critical, fear-inducing or disturbing. One of the classic portraits of OCD is the person who won’t touch a doorknob without a sleeve pulled over their hand out of fear of contracting germs. But that is only the tip of the iceberg when it comes to the different types of compulsions — whether external, such as repeated hand-washing, or internal, such as rumination — that individuals with OCD feel subjected to in order to keep themselves safe.

OCD can be “hell on Earth,” Nicely asserts.

“It puts people in absolute misery. It makes people’s lives smaller and smaller and smaller,” she says. “Having OCD is like living with an abuser 24/7. It’s incredibly mean, it’s very critical, and [it] can be violent. It is being yelled at by your own brain and you can’t get away from it.”

The tipping point

Justin Hughes, an LPC who owns a private practice in Dallas, specializes in treating clients with OCD, anxiety and other mental health issues. He says many of his clients seek treatment because they are overwhelmed by intrusive thoughts or because their compulsions and routines are interfering with their daily life — taking up enormous amounts of time and causing them stress or even physical pain. Other clients come to treatment because a parent, spouse or loved one noticed the toll that OCD was taking on the person and expressed concern.

Karina Dach, who specializes in treating OCD and anxiety at her private practice in Denver, says clients sometimes come to counseling knowing that “something doesn’t feel right” but without realizing that they have OCD. “They may say things like, ‘I feel stuck,’ ‘My brain won’t let me move on,’ or ‘I can’t stop thinking about this or imagining this.’ They might feel like something is wrong with them or worry that these thoughts and fears mean something bad about their character or them,” explains Dach, an LPC and licensed mental health counselor.

Clients who come to counseling with OCD may be struggling with self-criticism and intense feelings of shame, guilt, anger, worry and fear, Nicely adds. Intrusive thoughts are common with OCD, and for some people, these thoughts can involve the idea that they might somehow end up killing, injuring or sexually molesting someone, including their loved ones. As these thoughts repeat themselves over and over, the individual may begin to believe the content of these thoughts and feel a deep sense of shame or embarrassment.

In fact, clients struggling with OCD may be hesitant to share the worst of their intrusive thoughts because they can involve things that are criminal or dangerous. “Some [individuals with OCD] really do think they might be a closet murderer. They’re afraid to share that, [thinking that] they might get in trouble,” Nicely says.

Given that insight, Nicely says, counselors should not hesitate to follow up conversations about intrusive thoughts and worries in session by asking clients if there is anything else they have been too scared to share. These clients should be reassured that counseling is a safe and confidential place to share whatever they are going through, Nicely adds.

Obsessions + compulsions

The National Institute of Mental Health reports that an estimated 1.2% of U.S. adults experience OCD each year. This prevalence is higher for females (1.8%) than for males (0.5%). The lifetime prevalence of OCD in the U.S. is 2.3%.

Jeff Szymanski, a clinical psychologist and executive director of the International OCD Foundation, notes that even though the prevalence of OCD is not increasing, mental health practitioners may see more people who struggle with the disorder in their caseloads in the future because of a gradual, general increase in awareness and a reduction of stigma regarding
the disorder.

OCD is characterized by two components: 1) recurring and intrusive thoughts (obsessions) and 2) excessive urges to perform certain actions over and over again (compulsions) to prevent or counteract the recurring thoughts. The types of obsessions and compulsions that individuals with OCD can experience are wide-ranging.

Not all recurring thoughts can be categorized as OCD obsessions, Szymanski stresses. “Obsessions in OCD are also ego-dystonic, meaning that the individual doesn’t like or want them. … Some recurring thoughts people like to have,” he says. “In lay language, people say things like ‘I’m obsessed with baseball.’ This means they like baseball. They may even spend a lot of time ‘compulsively’ following baseball. But this doesn’t interfere with their life, and it is something that is invited, not something they are trying to get away from.”

OCD-related obsessions can include unwanted sexual thoughts, religious obsessions, fear of contamination (by dirt, germs, chemicals or other substances), fear of losing control of yourself, fear of being responsible for harm to oneself or others, fear of illness, and myriad other concerns. Compulsions can involve:

Washing and cleaning tasks (including personal hygiene)
Checking behaviors (such as checking news headlines over and over to ensure that nothing terrible has happened, or checking multiple times that a door is locked)
Repeated actions such as blinking or tapping
Performing certain actions multiple times (e.g., opening and closing doors, going up and down stairs)
Asking questions (possibly to include the same or similar questions over and over) to seek reassurance
Internal actions such as repeated prayers, counting rituals, and repeated mental review or replaying of past scenarios and interactions

(Get an in-depth explanation of OCD from the International OCD Foundation at iocdf.org/about-ocd.)

“If a counselor begins hearing the exact same things [from a client in session], worded or behaved in similar ways, this is a good indicator [of OCD] to watch out for,” Hughes says. “Many of my clients are good at exactly quoting themselves on what they’ve said before. Obsessions are repetitions on a theme; if you get good at catching the theme, you can usually spot an obsession miles away.”

Compulsions can also involve avoidance behaviors. For example, Dach once had a client, a new mother, who was experiencing intense thoughts and fears about harming her baby. She would avoid interacting with her child — particularly being in the bathroom with the child while he was being bathed — because she felt it was safer to be away from him.

OCD-related avoidance can spill over into the life choices that clients make, such as where they work or live, what their hobbies are or even the words they use, Dach says. Individuals with OCD sometimes exercise another form of avoidance — breaking up with a partner because they fear the doubt, uncertainty and risks involved in having a relationship. However, they soon find that ending the relationship doesn’t quell their rumination, Dach notes.

Individuals with OCD “operate on a risk-adverse level,” explains Dach, a member of the American Counseling Association. “You find them checking a lot, asking for reassurance, accommodating their fears and compulsions. … It’s terrifying and it takes over people’s lives. We see OCD as this mental bully. You are a complete prisoner to your fears. People with OCD just want to protect themselves and their loved ones.”

Obsessions are often a reflection of a person’s deeply held values, such as being a good parent, keeping their family safe, or being a good person, Dach notes. Focusing on these values can be a source of leverage when counseling clients with OCD. When working with the new mother who had intrusive thoughts about harming her child, Dach talked with the client about how her fears were based in the values she possessed of wanting to connect with her child, be a good mother and keep him safe.

“If you can find what the client’s values are, that can be very powerful,” Dach says. “Maybe you fear rejection and failure but value excelling in a career. Finding those values can make a really clear [therapeutic] path to work on and find motivation.”

Several of the counselors interviewed for this article recommend that practitioners use the Yale-Brown Obsessive Compulsive Scale to assess clients for OCD and to get a full evaluation of clients’ obsessive thoughts and compulsive behaviors. If clients identify numerous behaviors and thoughts that they experience from the assessment’s detailed checklist, counselors should work with them to “triage,” creating a plan of care to address their most pressing or concerning issues first, Nicely says. Seeing the fearful thoughts and tortuous behaviors that they’ve been experiencing included on the checklist can serve to normalize clients’ experiences and demonstrate that they aren’t alone in their struggles, she adds.

Distinguishing OCD

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders categorizes OCD under a cluster of diagnoses that also includes body dysmorphic disorder, hoarding disorder, trichotillomania (hair-pulling disorder) and excoriation (skin-picking) disorder.

OCD can be complicated to identify because the disorder often co-occurs with other issues such as bipolar disorder, anxiety-related disorders, depression, eating disorders and substance abuse, notes Nicole Hill, an LPC who co-authored an ACA practice brief on OCD. Because clients with OCD often struggle with multiple presenting concerns, the disorder can be hard to pinpoint. In addition to delving into these clients’ distress, counselors should complete full biosocial assessments to get a clearer picture of their life and family history, social landscape, early childhood experiences and other contextual factors, says Hill, a professor and dean of the College of Education and Human Services at Shippensburg University in Pennsylvania.

Although there is no one particular cause of OCD, research indicates that there may be a number of contributing or correlating factors, including genetics and family-based factors, autoimmune issues, and the brain structure involved in transmission of serotonin. Being aware of the client’s full context — especially whether other family members have OCD — can provide counselors a better understanding of the person’s experience and risk factors, says Hill, an ACA member who co-authored a chapter on OCD and related disorders in the 2016 book Diagnosing and Treating Children and Adolescents: A Guide for Mental Health Professionals.

OCD is easier to pinpoint in clients who describe overt compulsive behaviors, such as checking the weather forecast repeatedly. Asking questions to probe the depth and root of clients’ fears can help uncover mental compulsions that aren’t as immediately noticeable, such as mentally reviewing the activities of their day over and over again, repeating a conversation or a word to themselves a certain number of times, or saying a certain prayer repeatedly, Dach says.

To probe clients’ experiences, Dach suggests counselors begin by asking how they deal with stress and anxiety. It is certainly normal for people to experience anxiety from time to time, and it is true that individuals with anxiety disorders may be confronted by intrusive thoughts, ruminate, and perform certain coping behaviors. With OCD, however, the worry, fear and compulsive behaviors become so all-encompassing that they impair the individual’s ability to function. For example, most people wash their hands to keep from getting sick, but individuals with OCD may wash their hands a certain number of times, for a certain length of time, or until it feels “right” to them, Dach says.

“We all have this inner voice that’s telling us what’s safe and not safe. But someone with OCD has a faulty alarm system. They’re more vigilant. A whole battle can be happening internally on what’s safe and what it takes to be safe,” Dach explains.

To uncover compulsions that are internal (and, thus, less apparent to others), Dach suggests asking clients questions along the following lines:

Are there words or statements that make you feel better or that you say to yourself? Do you do something a certain number of times in your mind until it feels right?
When you’re lying in bed, is that when your mind wanders the most? What are you thinking about? Is it about your day and what you could have done differently? What you
did wrong?
When you enter a room, what’s the first thing you do? Do you beeline straight to where you need to go, or do you scan the area first to feel safe?

From there, Dach suggests asking clients what would happen if they weren’t able to complete whatever action they felt compelled to perform. “If there is clear distress in their answer, that may indicate OCD,” she says.

Another indicator that OCD may be present is if the client doesn’t respond to methods that counselors typically use to help individuals with their negative thoughts, says Hughes, the Dallas-Fort Worth advocate for OCD Texas, a regional affiliate of the International OCD Foundation. “If a client isn’t improving from certain methods — especially things like cognitive restructuring in cognitive behavioral therapy — this is ‘Getting Stuck 101’ and needs further assessment,” Hughes says. “Most of my clients have had prior experience with a counselor who had no idea how to treat OCD from an evidence-based way and approached it the same as regular old automatic negative thoughts. This is not typically helpful.”

OCD is disruptive, not only to the individual’s ability to function but also to their family life, says Hill, whose past clinical work included treating juvenile clients with OCD via play therapy. Parents and families often restructure their routines or make accommodations to work around a loved one’s compulsive behaviors, especially if the individual with OCD is a young child. OCD behaviors can be very concerning to parents and, in some cases, embarrassing in public situations. In making accommodations, the family typically feels like they are doing what they can to help the person, but that approach is actually counterproductive, Hill says. In reality, accommodating or yielding to OCD behaviors can exacerbate the issue.

Counselors shouldn’t hesitate to involve a client’s family in OCD treatment (if applicable and with the client’s consent) or to reach out to collaborate with social workers, family counselors or other professionals who may be working with the family, Hill says. Counselors can play a vital role in educating parents and family members about what an OCD diagnosis entails and clarifying the therapy goals for their loved one. They can also offer helpful, nonaccommodating ways to intervene when the person’s OCD spikes. Hill says that in her past work with juvenile clients, she often saw the severity of OCD decrease when she used filial play therapy with children and parents. This approach served to bolster their relationship, problem-solving skills and communication patterns. It also instilled a focus on positive behavior and empowering the child, she says.

Working with other treatment providers

Research has shown that a combination of therapy and psychiatric drugs, especially exposure and response prevention (ERP) therapy and serotonin reuptake inhibitors, can be particularly helpful to people with OCD.

“Attending to clients’ socioemotional and cognitive issues [in counseling] will be helpful, in addition to medicine,” Hill says. “Research consistently shows that the both/and approach is best, with medication and therapy.”

Medicine can “turn down the volume” on clients’ OCD so that therapy can help them manage their rituals and compulsions, says Nicely, who estimates that three-quarters of her clients take medication. Eventually, if clients and their prescribers agree it is the best course of action, their medications can be tapered back as their coping skills are strengthened in counseling.

Although professional counselors cannot prescribe medications, they must always consider their clients’ use of medications — and be proactive in working with clients’ medication prescribers — when looking at the whole picture of treating OCD. With clients’ consent, counselors can check in with these other treatment providers about clients’ symptoms and progress in counseling.

“I always worked on a team with other professionals,” says Szymanski, who was previously the director of psychological services at McLean Hospital’s OCD Institute in Massachusetts. “It is important to ensure that some time is spent coordinating care and that everyone’s work is complementary and not getting in the way of each other. It is equally important to inquire from the client how the team format is working for them and to ask them for specific feedback and encourage them to give direct feedback to each of their team members.”

Coordinating care among multiple treatment providers can be challenging, but it is worth it to work toward the best outcome for the client, Hughes asserts. Even imperfect, one-way communication stands to benefit the client.

“Although seamless communication and record exchange between providers is likely ideal, it just rarely happens in real life,” Hughes says. “In complex cases, it is almost unheard of for me to not [reach out to] another provider that is connected somehow to shared treatment concerns. I think we need to be realistic about other providers’ schedules and to communicate what we can, how we can. This often looks like me leaving a psychiatrist a voicemail after release is given and not hearing back, but at least they have the information.”

In addition to professionals who prescribe them medications, clients may be seeing other practitioners for treatment of issues such as depression and substance abuse that often co-present with OCD. This offers opportunities not only to coordinate care but also to make other health care professionals who do not specialize in OCD treatment aware of the disorder’s nuances. These professionals can also be alerted to the pitfalls of inadvertently undermining the client’s work in counseling by feeding their compulsions through accommodation or reassurance, Hughes says.

Many other comorbidities in clients will often improve by treating their OCD first, Hughes adds.

Exposure and response prevention

Research has identified ERP, a type of cognitive behavior therapy, as the most helpful and effective therapeutic method for treating OCD. All of the counselors interviewed for this article recommend its use with clients who have OCD. The International OCD Foundation refers to ERP as the “gold standard” for treating OCD and more helpful than traditional talk therapy methods.

In ERP, clinicians use gradual exposure to desensitize clients to the OCD-related thoughts, compulsions, situations or objects that are invoking fear and worry in them. With each exercise, the client works to overcome a triggering thought or scenario without responding with a compulsive action. This is the “response prevention” part of ERP. Exposure work is done both in session with a counselor and outside of session as homework for clients to complete on their own.

Counselors should be aware that clients’ OCD is likely to spike as they begin ERP treatment, Nicely says, because it removes the compulsions that have given them reassurance in
the past.

Over time, ERP empowers clients to confront thoughts and situations that they often would have tried to avoid previously, Dach says. “When someone has intrusive thoughts, they tend to [try and] push them away, and it effectively boomerangs. Pushing things away and trying to avoid them only empowers [the OCD] and gives it too much value,” she explains. “This [ERP]
puts them in the driver’s seat. They are the driver, instead of the fear deciding their choices.”

With the new mother mentioned earlier in this article, Dach used incremental exposure exercises to help her overcome her fear of harming her baby. At first, the baby was left outside of the counseling room with a caretaker while the client met with Dach. They started small, exposing the client to words that were triggering, such as “baby” or “bathing.” As the client progressed, Dach asked her to bring the baby into sessions. Even taking the baby out of his car seat and putting him on her knee was triggering to the client at first, Dach recalls. Dach would talk the client through each exercise, asking her throughout to monitor her level of distress on a scale of 1 to 10.

Eventually, the client graduated to exercises that included changing the baby’s diaper in session. In time, the client was able to work toward bathing her child at home, which had been one of her most fear-inducing obsessions.

Giving clients exposure assignments to work on between sessions is a critical part of ERP, Dach says. This can include creating a “worry script” in which clients write out imagined worst-case scenarios for themselves. For example, for one client, the scenario might involve going to the mall or another public place and losing control of themselves so that they vomit or yell and cause a scene, Dach says. The client imagines everyone staring at them, the client dying of embarrassment and then being banned from the mall. The client writes out all of the details of what they are feeling, seeing and experiencing in this imagined scenario. Next, the client reads or rewrites the story script repeatedly or records themselves reading it and listens to the recording over and over, Dach explains.

“It’s like watching a scary movie 1,000 times. It might be scary when you watch it the 1,000th time, but [it’s] not as terrorizing as the first time,” she says.

Dach uses the metaphor of working at a garbage facility to explain the effectiveness of ERP: On your first day, you notice the smell of the garbage and it’s so disgusting to you that you can’t even eat your lunch. But the smell bothers you less and less as you return to work each day and, eventually, you barely notice the smell at all.

ERP is granting permission “to open the doors to your dungeon and hang out with all these skeletons that you’ve got hiding in there,” Dach says. “If you grab your sleeping bag and pillow and hang out in there, eventually you’ll be more comfortable being around them.”

Hughes recalls one client with OCD who was struggling with severely distressing thoughts about harming her children. The client had no history of harm or abuse. Over time, the client found it difficult to differentiate between reality — that she would never intentionally hurt her children — and her intrusive thoughts about having impulses to stab her children, Hughes says.

“She knew [these fears] were irrational, yet it felt so real to her,” Hughes says. “As can be very typical, the stress also took a toll on most every area of her life, [including] making work difficult.”

ERP work began with small exercises the client learned to conquer while staying present with her distress and without turning to compulsions, Hughes says. The client was able to integrate ERP assignments into her daily life with the support of her loved ones, church community and her own desire to be able to engage with her family without fear of harming them.

She soon graduated to script writing and larger exposures that involved holding knives and stating her feared thoughts aloud (appropriately and not in front of her young children), Hughes says. For example, the client would work outside in the family garden and repeat to herself the worst-case scenario she had written in her scripts: “I’m wanting to use these yard tools to kill my daughters.” Later, she added more distressing content: “I want to stab them, and I’ll get arrested and divorced and be hated by my kids.”

Other exposures involved holding a butcher knife firmly for 15 seconds at a time (and eventually longer) while repeating her scripts. Over time, the client worked toward being home alone with her children, bathing her children, and ultimately cooking for her children (including using knives) while her husband was out of town.

Now the client’s OCD symptoms score so low on the Yale-Brown Obsessive Compulsive Scale that she would be considered subclinical, Hughes says. “In relapse prevention planning, [this client] understands the chronic nature of OCD and the necessity of staying on top of her good progress, with the plan to follow up at occasional intervals for ‘booster sessions,’” Hughes says. “I gain so much joy from stories like these.”

Tolerating uncertainty

ERP is effective because it empowers clients to tolerate the uncertainty that is at the core of their fear and worry, Nicely explains. The crux of the problem is not a client’s worry over contracting HIV or stabbing their husband, she says, but tolerating the uncertainty of whether or not those fears might happen.

“The hallmark question of OCD is ‘what if’ and having doubts,” says Nicely, the author of the 2018 book Is Fred in the Refrigerator? Taming OCD and Reclaiming My Life. Treating only the content of a client’s worries without teaching the client to tolerate uncertainty will simply lead the OCD to surge (or resurge) in another area of the client’s life, Nicely notes.

For ERP to be effective, it requires commitment and trust between the client and practitioner. Nicely explains to each client that the work requires a cognitive shift — that trying to avoid anxiety and OCD triggers actually makes them worse.

In working with clients with OCD, Nicely uses the acronym JOY: Jump into anxiety, opt for greater good, and yield to the anxiety. Nicely goes into detail about this method in the 2017 book she co-authored with Jon Hershfield, Everyday Mindfulness for OCD.

She asks clients, “What if we didn’t push the anxiety away? What if we brought it toward us? Can you handle it?” Then she points out an example of how the clients are already handling uncertainty by taking the first step of coming to counseling. Bringing anxiety toward them is equal to taking away OCD’s power, she explains.

Nicely books a double session with clients for their first exposure treatment. After the exposure work, they process what happened together. Nicely asks questions such as: Was it as hard as you thought? What did you learn? Did you learn that this is something that you can do to get your life back?

“If you do [triggering things] over and over again, then the brain begins to learn that these things aren’t the problem,” Nicely says. “The reason that our brain is putting these thoughts up front is because we’re reacting to them. The brain is learning when you’re allowing it to stay at a high level of anxiety.”

“OCD is a biological issue,” she says. “Our brains [in those with OCD] are structurally and functionally different than those without OCD. You can’t think your way out of this. It’s a brain disorder, and ERP changes the way our brain functions.”

Nicely uses a concept she calls “shoulders back” with both herself and her clients. She says that squaring one’s shoulders can serve as a physical reminder that whatever a person’s OCD is telling them, it doesn’t matter, and they can act as if it’s irrelevant.

“Ultimately, we want people to hear all of this [OCD triggers] in their heads and go on and have it bother them less and less,” Nicely says. “We want them to live in a world of uncertainty and not have it bother them and act as if their intrusive thoughts don’t matter.”

It can also be helpful for clients to imagine what their OCD “monster” looks like or even to give it a name. Nicely does that herself, even speaking to her OCD when it begins to surge. Nicely thinks of her OCD as something that will always be a part of her. It’s something that, at its core, wants her to feel safe.

“It’s exceptionally important [for clients] to realize that OCD is part of them, but it is not them,” she says. “That will help them to conceptualize the process. Think of it as something that has been torturing you. Talk back to it and tell it where you want it to go.”

Reassurance

The compulsions associated with OCD often arise out of a person’s urge to find reassurance and feelings of safety, Dach says. As helping professionals, counselors’ natural reaction may be to try to comfort these clients by telling them that their worst fears will not come true. But in the case of clients with OCD, offering reassurance is actually doing harm and reinforcing behavior, Dach stresses.

“No one knows whether or not the fear will happen — not the therapist [and not] the client. But the client will search and search and search for reassurance, an illusion of security and control,” Dach says. “If a practitioner gives them reassurance, they’re making the condition worse.”

When Dach finds clients asking questions as a means of seeking reassurance in sessions, she explains that she will answer questions to provide education or information but not for the purposes of offering reassurance. “It may be a hard pill to swallow, but we [counselors] need to sit with their uncertainty together and model what it looks like to sit with distress,” Dach says.

When clients express anxiety over the possibility of vomiting in a public place or some other OCD-related fear coming true, counselors shouldn’t reassure them that it won’t happen, Dach says, because there is no way to ensure that it won’t. Instead, she says, counselors can respond with questions such as, “If you did vomit, what’s the worst thing that could happen? What would it feel like? How do you know it’s going to happen?”

“The possibility is there, but the probability is low,” Dach says. “I can’t tell [the client] whether or not something is going to happen. The best we can do is put ourselves in a situation [via exposure] to learn what’s going to happen. Then I offer to lean into that discomfort [with the client].”

On the same team

There is sometimes a misconception among mental health professionals that exposure work can traumatize clients, but that simply isn’t true, Dach stresses. Therapy with a practitioner specially trained in ERP is hard work — it’s asking a client “to walk into their worst nightmare and have a party” — but it’s also incredibly effective and rewarding, she says.

“This is an extremely collaborative intervention. We’re on the same team. It’s not forcing [clients] to do things. It is asking them to get close to the thing they’re afraid of the most. You [the counselor] are there to offer gentle pushing, but it’s all choice-based,” Dach says.

Nicely and Hughes say that clients with OCD tend to be incredibly brave and also deeply caring. It is inspiring, Nicely says, to watch clients tackle such hard things in therapy and become more resilient.

“For many reasons, I love work with clients who have OCD,” Hughes adds. “I have found that they are some of the kindest, hardest-working and most conscientious individuals on this planet. This is where I believe many of their personality strengths arise once [they move] through pathology. It is a joy every day to see recovery, growth and maturity bloom out of suffering.”

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The International OCD Foundation offers a wealth of resources and information on its website, iocdf.org, as well as training programs, an annual conference, and local affiliates around the country.

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Contact the counselors interviewed for this article:

Karina Dach: anxietyocdcounseling.com
Nicole Hill: NRHill@ship.edu
Justin Hughes: justinkhughes.com
Shala Nicely: shalanicely.com

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OCD is not an adjective

It’s not uncommon for people to describe themselves in casual conversation as “obsessed” with a television series or “OCD” about the way they organize their closet.

Professional counselors can be agents of change when it comes to casual use of the language related to obsessive-compulsive disorder (OCD), says Shala Nicely, a licensed professional counselor in Georgia who specializes in treating the disorder. She encourages counselors to be mindful of their own language and to gently correct those who misuse OCD-related terms.

One place to begin: Stop using OCD as an adjective, she says. Someone might be meticulous or detail-oriented or neat, but he or she is not “OCD.” To say “I’m so OCD” about something can discourage people who really do have OCD from seeking treatment, especially if that offhand pronouncement comes from a mental health professional, Nicely says.

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

Letters to the editor: ct@counseling.org

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

More than simply shy

By Bethany Bray July 29, 2019

Social anxiety is different from — and much more than — simply being shy or introverted or having poor social skills. Even so, people who live with social anxiety often find the disorder trivialized or minimized by others, including some mental health professionals, according to Robin Miller, a licensed professional counselor (LPC) and a member of the American Counseling Association.

“Shyness doesn’t necessarily have a negative impact on someone’s life. That’s an important thing to remember from a clinical point of view,” explains Miller, who specializes in working with adults with anxiety disorders at an outpatient practice just outside of Milwaukee. “Many of my clients get a pat on the head from people and [comments such as], ‘You’re just shy. You have nothing to worry about.’ But you wouldn’t get that for [symptoms of] posttraumatic stress disorder or other mental health issues. You wouldn’t say there’s nothing to worry about.”

Most of all, clients with social anxiety need support and reassurance as they try to discontinue old patterns and behaviors that they have adopted to cope with the paralyzing fear that often accompanies the disorder, says Brad Imhoff, an LPC who was diagnosed with social anxiety disorder in 2012 as he was working on his doctorate.

One characteristic of social anxiety is a constant feeling of apprehension regarding social situations. It is difficult to express just how oppressive and pervasive that feeling can be, says Imhoff, an assistant professor of counseling at Liberty University who lives in central Ohio and teaches in the university’s online program. “You carry this feeling of ‘I just can’t do this’ all the time,” he says. “As human beings, we’re social. And apprehension in every one of [those social situations] can be overwhelming.”

Imhoff, a member of ACA, says he recognizes the irony of his career choice: a person with social anxiety who speaks regularly to rooms full of people, both as a counselor educator and as a frequent presenter at conferences, including giving a session on social anxiety at the ACA 2019 Conference & Expo in New Orleans.

Imhoff has learned to navigate the challenges of social anxiety since his diagnosis, but he acknowledges still feeling anxious before speaking engagements. “The question is, how do I manage it and not let it get in the way of life?” he says. “I will have to manage this, to some extent, for my entire life and not let it get to the extremes it has in the past.”

Navigating life through avoidance

Social anxiety is one of a number of related issues — including specific phobia, panic disorder, separation anxiety disorder, generalized anxiety disorder and others — that fall under the anxiety heading in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

Called social phobia in decades past, social anxiety disorder is characterized by persistent fear over social or performance-related situations, according to the National Institute of Mental Health, which cites diagnostic interview data to estimate that 12.1% of U.S. adults will experience social anxiety disorder during their lifetime. Among adolescents ages 13-18, the lifetime prevalence is 9.1%. For all ages, social anxiety disorder is more prevalent in females than in males.

Researchers have not singled out a specific cause for social anxiety disorder, pointing instead to a combination of biological and environmental factors as contributors. Genetics appears to play a large role in many cases, as can negative childhood experiences such as family conflict or being bullied, teased or rejected by peers. It is also believed that individuals who have an overactive amygdala may experience more anxiety in social situations.

According to the Center for the Treatment and Study of Anxiety at the University of Pennsylvania, “Social anxiety disorder can affect people of any age. However, the disorder typically emerges during adolescence in teens with a history of social inhibition or shyness. The onset is usually accompanied by a stressful or humiliating experience, and the severity varies by individual. … There is a higher incidence of social anxiety disorder in individuals with first-degree relatives affected by other panic and anxiety disorders. However, there is no one gene that explains this biological trend. General findings indicate that personal experiences, social environment and biology all play a role in the development of the disorder.”

People often experience symptoms of social anxiety disorder to varying degrees across the life span, according to the center. Symptoms may lessen for stretches of time and then worsen during periods of change or stress, such as a job transition or when dealing with feelings of grief and loss.

What sets social anxiety apart from general anxiety is not only the social component but also an intense fear of judgment by others, explains Holly Scott, an LPC whose Dallas private practice is a regional clinic of the National Social Anxiety Center. People with social anxiety often harbor strong and pervasive feelings that others will notice their anxiety and judge them, which triggers avoidance behaviors, she says.

At the same time, there are nuances to the diagnosis, and social anxiety can look different in each client, Scott adds. For example, someone may be fine with public speaking and yet not be able to walk into a room in which they don’t know anyone.

“People think it’s not treatable,” Scott says. “Clients label it as ‘this is just the way I am, and I can’t change the way I am.’ It can be difficult to treat or to find a qualified practitioner, but it is treatable.”

Imhoff says he has read that on average, people go 15 years before seeking treatment for social anxiety. Counseling itself is a social interaction, he notes, and people with social anxiety may avoid treatment out of a fear of the close interaction or of being scrutinized by a practitioner.

Because people with social anxiety typically adopt avoidance as one of their coping mechanisms, and perhaps because of the way that social anxiety tends to get minimized or passed off as simply being introverted or shy, these clients often live life without seeking treatment until they reach a breaking point. As Imhoff points out, people can self-manage their social anxiety for an extended period of time by maintaining the same small circle of friends and following certain behavioral patterns such as always using the self-service checkout line at the grocery store.

Living with social anxiety is their reality, Imhoff explains, and they “forge ahead until something causes [them] to realize it’s more significant.” For Imhoff, that “something” was the impending scrutiny involved in defending his doctoral thesis.

“For social anxiety, it’s possible to navigate life with avoidance and survive for a long time. Then something comes up — a life change, such as entering the workforce — that causes them to need help,” he says. “A lot of these safety behaviors aren’t being done consciously. They are things we’ve done throughout our lives to find safety.”

Assessment and core beliefs

Avoidance behaviors are one of the biggest red flags that a client might be dealing with social anxiety, Miller says. These behaviors can extend to staying in situations in which the person is unhappy yet comfortable, such as a bad romantic relationship, a toxic friendship or a job that the person doesn’t enjoy or isn’t advancing in.

Other indicators include rumination and overthinking social experiences. This can include asking oneself over and over again, “What did that person think of me?” Miller explains, whether it’s an interaction with a neighbor while walking the dog or a yearly performance evaluation with one’s supervisor.

Counselors should be aware that social anxiety often co-occurs with other mental health issues such as depression and substance abuse (which often becomes a coping mechanism) that may need to be treated first or in tandem with the disorder, Miller adds. In addition, other issues such as grief may be complicating a client’s social anxiety. “They’re not always struggling with one thing. Make sure you’re working on what they’re struggling with the most,” Miller says.

Scott suggests asking clients at intake about how they deal with social situations and how often they go to gatherings or parties. Are they uncomfortable introducing themselves to new people, making a phone call or using the restroom in public places? If Scott hears symptoms that might indicate the presence of social anxiety, she uses a questionnaire (she recommends the Liebowitz Social Anxiety Scale, available at nationalsocialanxietycenter.com) to pinpoint the client’s fear level and to identify goals to focus on in therapy.

It can also be helpful to identify a client’s core beliefs and values and how those are affecting the person’s choices and behaviors, Imhoff says. People with social anxiety often carry a core belief that they’re inadequate or inferior, which spurs a fear of being judged, he explains. These clients frequently place weight and focus on situations that seemingly confirm their core belief and discount those that might disprove it. They might ruminate over a conversation with a colleague that didn’t go well, for example, without giving any consideration to all of the past conversations that did go well, Imhoff notes.

“They move through life paying very close attention to and taking to heart scenarios that confirm their core belief,” he says. “It’s important to help the client take off the blinders. Talk through ways they are competent, and get to the root of their concerns. Be aware of the multitude of their experiences and not just those they struggle with.”

To identify core beliefs, counselors can listen for themes in the way that clients talk about themselves, other people and the world. These themes can suggest deeply held beliefs to challenge or to explore further in therapy. Having clients work on thought journals can also be helpful in finding patterns, Imhoff says. He also suggests using a prediction log, in which clients name upcoming social scenarios that make them anxious and describe what they assume will happen. After the scenario occurs, clients can look back at their predictions with the counselor to talk through how accurate these foresights were.

After core beliefs and values have been identified, the counselor can work with clients to reframe their perspective around new core beliefs. For example, clients who place value on providing for their family could focus on that value to help them overcome their anxiety and discomfort over applying for a new job.

“Look for evidence that supports their new core belief,” Imhoff says. “If their belief is ‘I am capable,’ have them write down even the most minor piece of evidence [in a journal]. It makes it concrete and documented so they can refer back to it and talk it through with a counselor.”

From there, the counselor can work with clients on challenging cognitive distortions and black-and-white thinking, Imhoff suggests. Acceptance and commitment therapy (ACT) can be helpful, as can guiding clients to adopt a growth-focused orientation. With that mindset, every social interaction becomes an opportunity to learn rather than a pass-fail situation, Imhoff explains.

Clients with social anxiety may also feel that they’re failing because they can’t assume an extroverted, life-of-the-party façade. Counselors can help these clients learn that there is a continuum of social skills, Imhoff says. For example, perhaps they got through a work meeting and contributed their thoughts despite having a shaky voice and sweaty palms. “Work on [helping them realize] that it’s not black and white, it’s not all success or failure. There’s an in between for almost all scenarios,” he says. “Help them to recognize that in all social interaction, there is ebb and flow. It’s not a pass-fail exercise but an opportunity to connect with someone and learn moving forward.”

Additionally, ACT techniques can help clients learn to accept their anxiety rather than trying to get rid of it or avoiding triggering situations. Imhoff uses the imagery of “keeping anxiety in the passenger seat because I know it’s coming along but not letting it take control of the wheel.” Clients can learn to say, “There you are anxiety; I knew you were coming,” even as they move on with life and navigate situations they previously would have avoided.

Scott regularly uses cognitive restructuring and cognitive behavior therapy (CBT) with her clients who have social anxiety. She also uses a mindfulness technique called curiosity training that helps clients label their anxious thoughts as “background noise.” With this technique, users try to adopt an approach of curiosity about and interest in what is being said by others rather than assuming that others are judging them.

“In any situation,” Scott says, “whether they’re having a conversation, public speaking or sitting somewhere having lunch, they’ve usually got a constant dialogue going in their head. [It’s] self-criticism about how people must be thinking of them: ‘They don’t like my clothes’ or ‘I just stuttered while speaking.’ Curiosity training helps keep your mind on the present and learn how to pull your mind back when it starts wandering.”

Elizabeth Shuler, an LPC who has been working as an international school counselor in Amman, Jordan, for four years, recommends mindfulness techniques. She has often used Kristin Neff’s self-compassion practices in addition to dialectical behavior therapy, meditation and yoga for clients with social anxiety, both when she was in private practice in Colorado and Wyoming and currently in her work with adolescents and adults at her school.

“When we dig into their fears, most clients with social anxiety are really afraid that other people will agree with their own negative judgments of themselves. They’re worried that they will be proved right,” says Shuler, an ACA member. “I had a client who walked through the office the same way every day to avoid the people he was afraid of interacting with and had panic attacks when his route had to change or people he was avoiding crossed his path. These types of behaviors are meant to stave off panic but end up reinforcing it. My role as a counselor is to help clients see how these behaviors are actually making their panic worse and help them to slowly replace them with more helpful behaviors.”

Exposure

Exposure techniques are often central to treating social anxiety because they gradually reintroduce clients to anxiety-provoking situations in a healthy way.

Miller is trained in exposure and response prevention and finds it a powerful tool for working with clients with social anxiety. The behavioral technique requires clients to put in a lot of work themselves outside of sessions. The counselor collaborates with the client to develop a hierarchy of exposure based on the client’s needs and treatment goals and supports the client throughout the process.

As Miller explains, exposure assignments start small and build over time as clients become comfortable with each homework task. She describes this as a “Goldilocks situation” — not too much challenge and not too little, but just the right amount, tailored to each individual client. Miller says she emphasizes to clients that the treatment is in their hands — they have to do their part to experience a successful outcome.

“A lot of people have anticipatory anxiety, but once they do it [complete the exposure assignment], they’re OK,” Miller says. “A lot of people get over that hill of worry. They do it for a week or two and realize they can do it. Trust between a client and clinician is huge because we’re asking them to do really scary things.”

Miller often gives clients who are early in treatment the assignment of calling multiple businesses to ask what their hours are. Clients might have to overcome feeling a little foolish because that information is readily available on the internet, she notes. However, the goal is for clients to complete the task without falling back on habits they formed to avoid social situations, such as relying on technology in lieu of having personal interactions. Clients repeat the task over and over until they no longer feel anxious about picking up the phone and making a call, she explains.

Once they’ve mastered that task, clients might move on to going inside a store and asking a question in person. Or they might switch to walking their dog in their neighborhood during a busy time of day and saying hello to at least one other person during each walk.

As clients complete each task and return to their next counseling session, they process these interactions with Miller, discussing how the interactions felt to them and what went right or wrong. “Sometimes the client will come in and say, ‘I’m so bored with this.’ I say, ‘Great! That means it’s time to move on to something bigger,’” Miller says. “You need repetition with assignments. You need to do [tasks] over and over for your brain to get used to it. … The more you do it, [the more] it overwrites [old] patterns and anxious feelings.”

As a practitioner who specializes in treating social anxiety, Scott has a laundry list of exposure assignments that she uses with clients, ranging from making eye contact during a shopping trip to asking for directions from a stranger to calling into a radio talk show to singing karaoke. As clients progress, it can be helpful to assign them tasks that are certain to create some level of discomfort or awkwardness, such as going into Starbucks and ordering a hamburger, she says. This can be especially hard for clients who have a strong fear of being judged by others, but dealing with the responses they receive desensitizes these clients over time as they repeat the tasks.

Miller acknowledges that counselors may need to provide their clients with some ongoing motivation during exposure work. If clients come to session without completing their assigned tasks, she suggests asking leading questions to find out if they are avoiding the work or genuinely struggling to make it a priority among their other challenges.

“Who wants to go home and do anxiety-provoking things?” Miller says. “[We] have to find a way to motivate them. We want them to feel empowered to go out and do [an assignment]. Remind them that they’re in pain because something is not changing. … You can’t snap your fingers and make this go away. It’s going to be hard work and take time.”

It can be useful to circle back and remind clients of their core beliefs and the goals they want to achieve. For example, consider clients who say they ultimately want to start a family but whose social anxiety prevents them from entering the dating scene and potentially meeting a partner.

“They may not see how calling a drugstore [as an exposure assignment] is getting them to be able to date. But remind them that they’re building a foundation to be able to do that,” Miller says. “It may not have an immediate payoff, but the easier these things become for you, everything builds.”

Miller often uses the metaphor of training for a marathon to keep clients motivated. You don’t run 26.2 miles right away, she tells them. You start with one or two miles and then keep adding more distance, mile by mile.

Social skills

In addition to exposure work and cognitive restructuring, the counselors interviewed for this article recommend social skills training for clients with social anxiety. Avoidance behaviors may have kept these clients from learning and practicing social skills that are commonplace among their peers who do not deal with social anxiety.

“If you’ve been avoidant for years, you miss out on learning from all of the social interaction that others have had,” Miller says. “Sometimes they’ve built a life to minimize their pain, their anxiety.”

Goal setting and planning ahead, with support from a counselor, can help these clients navigate situations that are foreign to them and that naturally provoke anxiety. Miller suggests troubleshooting with clients. For instance, if their office holiday party is coming up, a counselor can talk through expected behaviors with clients and work on small talk and other exercises to help them get through the evening.

Setting realistic goals can also be comforting, Miller adds. “[They] don’t have to go in and work the room, [but] if they haven’t had a lot of social experience, they may not realize what’s expected,” Miller says. Instead, clients might set a goal of talking to three people whom they already know. Maybe at next year’s party, they can increase that goal from three people to five people.

Miller also reminds clients that a certain measure of social anxiety is simply part of being human. Even she, a therapist who makes a living talking to people, acknowledges sometimes being uncomfortable in social situations.

Kevin Hull is a licensed mental health counselor with a private practice in Lakeland, Florida, who specializes in counseling children, adolescents and young adults on the autism spectrum. Social skills training, along with group therapy, plays a large role in the work Hull does with clients around social anxiety, which he says often goes hand in hand with autism.

In individual counseling sessions, Hull uses puppets with clients to role-play social situations and work through what is expected. For example, Hull might instruct clients to verbalize a food order to his puppet without the usual help from mom or dad or ask his puppet for help finding a certain building on a school campus. Afterward, they process the experience together and talk about the emotions clients felt as their puppet had to interact and ask questions.

Humor can also be a great tool for overcoming the fear associated with social anxiety, says Hull, a member of ACA. He often shows clips of TV shows or movies (via YouTube) in client sessions as a lighthearted way of starting conversations about what is and isn’t appropriate when it comes to social skills. Particularly popular with clients are scenes with The Big Bang Theory’s Sheldon Cooper wrapping himself in bubble wrap to stay safe or wearing a second set of “bus pants” over his work outfit when taking public transportation. Another favorite is the title character in How the Grinch Stole Christmas, who initially can’t stand being around the Whos but ends up transforming over the course of the story.

“Using humor is a great thing to counter the fear,” Hull says. “When you can laugh at something, that gets people opening up and listening.”

Group work

Group therapy — a format in which clients are expected to interact with others and contribute to a discussion — would seem to be a nightmare for individuals who are socially anxious. But that’s not necessarily the case, according to Hull.

Although it can take clients some time to warm up to the idea, group therapy can play a powerful role in imparting the skills needed to navigate social anxiety, says Hull, an assistant professor and faculty adviser in Liberty University’s online master’s counseling program. In addition to helping participants sharpen their social skills, group counseling can instill perspective — something with which Hull’s clients who are autistic sometimes need extra help.

“With autism, clients have a hard time putting themselves in others’ shoes, so group is a great way for them to hear from the mouths of peers [and] hear them talk about what they’re going through,” Hull says. “Maybe someone [in group] had to ride a different bus than usual. It was terrifying at first, but they were OK and actually ended up talking to the person they sat next to.”

The group format, in which participants take turns offering comments, can model and teach the back-and-forth “tennis match” that is the basis of healthy conversation, Hull adds. It can also help clients learn to tolerate and listen when someone is talking about a subject that doesn’t interest them — a circumstance that previously would have triggered their fight-or-flight response and caused them to exit the situation.

Hull often has group participants speak for five minutes each on something they are passionate about. Afterward, he urges all of the group members to ask questions or make a comment about what was said.

“This is really hard with autism. If they don’t like something, it’s utterly meaningless to them,” Hull says. “This has them put themselves in others’ shoes and imagine how it’s like [something that they] like. This can transfer to social situations outside of group, such as a dinner party where other people are talking about whatever. Can you listen and learn something? It’s teaching their brain to overcome fear and learn a new normal. Everyone is scary when you first meet them, but you can do it. If you can do it in group, it’s the same as at school or a new job.”

Hull also uses video games in sessions as a way for participants to learn about group dynamics, leader/contributor roles and overcoming frustration (see sidebar, below).

It is important to prepare individuals with social anxiety for the group setting as much as possible ahead of time. Hull often shows clients the group room at his office (or emails them photos of it) and explains the format and what sessions will entail before they join group counseling.

“I walk back to the [group] room with the client and their caregiver before a group session so they can see it,” Hull says. “I explain, ‘Everyone who is coming here feels what you feel, and they’re all struggling with this.’”

When new clients join a group, he never makes them introduce themselves or speak right off the bat. He also allows them to bring anything that might boost their courage, such as a favorite stuffed animal or even a parent in the cases of younger clients. With social anxiety, it is important to allow clients to warm up and contribute at their own pace, he says.

“I can see group members five or six sessions in and they haven’t talked yet. I never stop trying to get them to engage or open up, even if all they can do is a head nod or fist bump,” Hull says. “[I emphasize that] I’m just happy they can be in the room.”

Hull acknowledges that group counseling isn’t a fit for every client who struggles with social anxiety. Social anxiety falls on a spectrum, and for some clients, the disorder is so severe that a group setting would be too much, he says. It is important to continue individual sessions with these clients, with group counseling becoming a possible long-term goal for some of them, he says.

When it comes to group counseling and social anxiety, it is crucial to take things step by step and to celebrate little victories, Hull emphasizes. With clients on the autism spectrum “the victories are fewer and far between,” he acknowledges, “but when they happen … you feel like you’ve won the Super Bowl.”

The long haul

Hull says that counselors should view social anxiety as a process rather than something to “fix.” Neuroscience tells us that the brain responds better to slow and steady change rather than forced or rushed adaptation. This is especially true for clients who struggle with social anxiety in addition to neurodevelopmental issues, past trauma or other mental health diagnoses, Hull notes.

Something else that counselors should avoid is projecting their assumptions onto clients with social anxiety. Just because the counselor went to prom as a teenager doesn’t mean that should automatically become a goal for every teenage client or, for that matter, even be considered the rite of passage that it once was, Hull says.

Counselors should really get to know their client’s world first before doing anything else, Hull says. “Avoid putting your agenda or perceptions on a client. We often see the potential in our clients, and it’s hard not to say, ‘Just do it!’ It can be discouraging and slow going at times, [but] be patient.”

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Technology and social anxiety: A double-edged sword

We live in a world where a person can text a happy birthday message to a friend, order a week’s worth of groceries for delivery and apply for a loan with the click of a button — all without having to speak to another human.

So, when it comes to social anxiety, technology can be a double-edged sword. Clients can certainly use it as an easy escape route to avoid social situations. At the same time, mental health practitioners can use it as a teaching tool with clients and as a bridge to overcoming long-held behavioral patterns.

“As great as it can be, technology can be part of avoidance,” says Robin Miller, a licensed professional counselor (LPC) who specializes in treating adults with anxiety. “Learn how to have conversations [about technology]. Make sure a client isn’t too reliant on it and unable to do things in a more social, direct way.”

Miller suggests that professional clinical counselors ask clients about their technology use at intake along with other questions about avoidance behaviors. Counselors can prompt clients to provide examples of situations where they feel most anxious and then listen for overreliance on technology, such as texting to ask someone out on a date or habitually using the self-service checkout line when shopping.

Social media can also exacerbate the assumption of judgment that often accompanies social anxiety, Miller adds. Clients who see photos and posts about friends’ and peers’ vacations, children or happy life events may come to believe that their lives pale in comparison.

Elizabeth Shuler, an LPC and an international school counselor, agrees. She says social media has created a new layer of social anxiety “centered around likes, comments and followers” in many of the adolescents with whom she works.

“I see students every day who are upset — to the point of panic attacks — that they’ve lost followers or that no one is liking their Instagram pictures. Instead of being afraid of being seen as stupid, these kids are afraid of not getting likes. It is a whole new world of judgment that has been unleashed on our teens, and it is taking a toll,” Shuler says. “However, many people who find face-to-face interaction intimidating can benefit from starting with digital interactions. Using texting, video and other digital means of conversation can help people with social anxiety learn social skills and give them a chance to practice new skills in a safer, lower stakes environment.”

Kevin Hull, a licensed mental health counselor in private practice, finds technology — specifically, video games — a natural tool for working with his young clients, many of whom are on the autism spectrum. In group counseling, Hull uses multiplayer games such as Minecraft to introduce clients to interacting and working together in a way that provokes less anxiety than face-to-face conversation might. Group members take turns being a “foreman” and leader in Minecraft sessions. The group learns to communicate and work together while dealing with frustrations and the nuances of the leader/contributor roles. “If technology wasn’t there, these kids would be even more regressed,” Hull says.

Conversations about technology use can also be an important part of social skills training in counseling, Hull adds. For example, young clients might claim that they are “dating” someone when they are actually just texting or playing video games together over the internet.

Hull often talks with clients about how texting is a good place to start communication but that it should not become their be-all, end-all. He’ll say to the client, “It’s great you’ve made a connection through texting, but what about the next level? Your brain’s process to communicate in text is the same as in speech. It’s just a different route.”

— Bethany Bray

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Social anxiety and college

The transition to college — leaving home, living with a roommate and establishing a new social circle, all while navigating academic responsibilities — doesn’t have to be paralyzing for students with social anxiety. Read more in our online exclusive, “Heading to college with social anxiety.”

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Contact the counselors interviewed for this article:

Kevin Hull: kbhull@liberty.edu
Brad Imhoff: bimhoff@liberty.edu
Robin Miller: 262-542-3255 ext. 379
Holly Scott: hollyscottpllc@gmail.com
Elizabeth Shuler: ewambeke@gmail.com

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

Letters to the editor: ct@counseling.org

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Putting PTSD treatment on a faster track

By Bethany Bray August 27, 2018

An exposure-based therapy method has shown to reduce the symptoms of posttraumatic stress disorder (PTSD) in just five sessions, according to researchers.

Written exposure therapy (WET) consists of one 60-minute and four 40-minute sessions, during which clients are guided to write about a traumatic event they have experienced and the thoughts and feelings they associate with it. Researchers recently tested the method’s effectiveness alongside cognitive processing therapy (CPT), a more traditional talk therapy method that typically involves more than five sessions. Clinical trials were conducted at a U.S. Department of Veterans Affairs (VA) medical facility with adults who had a primary diagnosis of PTSD.

The researchers’ findings, published in JAMA Psychiatry this past spring, suggested that WET was just as effective as CPT in reducing PTSD symptoms.

“WET provides an alternative [treatment] that a trauma survivor might be more likely to consent to, especially if verbalizing the trauma narrative causes a sense of shame or guilt,” says Melinda Paige, an American Counseling Association member and assistant professor at Argosy University in Atlanta whose specialty area is trauma counseling. “The more evidence-based options the trauma counselor has to consider, the more options can be offered to the client. WET provides an option for written expression rather than verbal and a shorter length of treatment, which may be preferable to survivors, including [military] service members.”

“Effective trauma treatment is the antithesis of the traumatic event itself in that survivors experience person-centered core conditions such as congruence/genuineness, nonjudgement and empathic understanding, as well as a sense of control over their recovery experience,” adds Paige, a member of the Military and Government Counseling Association (MGCA), a division of ACA.

MGCA President Thomas Watson agrees that the addition of another method to a trauma counselor’s toolbox will only benefit clients. “Those involved with service delivery to service members and others diagnosed with PTSD are always enthusiastic about how applied, evidence-supported treatment approaches have the potential for effective and ethical positive change,” says Watson, an ACA member and assistant professor at Argosy University in Atlanta. “An obvious goal of the WET approach is to implement effective treatment options that are efficient for both client and clinician.”

The research study involved 126 male and female participants, some of whom were military veterans and others who were nonveterans. The participants were randomly sorted into two groups: those who received five sessions of WET and those who received 12 sessions of CPT.

“Although WET involves fewer sessions, it was noninferior to CPT in reducing symptoms of PTSD,” wrote the researchers. “The findings suggest that WET is an efficacious and efficient PTSD treatment that may reduce attrition and transcend previously observed barriers to PTSD treatment for both patients and providers.”

The researchers reported that the WET group had “significantly fewer” dropouts (four) than did the CPT group (25).

This factor is another reason for counselors to consider using WET, Paige notes. “Maintaining a survivor’s physical and emotional safety and doing no harm by utilizing evidence-based and minimally abreactive trauma reprocessing interventions is essential to trauma competency. Therefore, WET may be a less invasive and more tolerable exposure-based PTSD treatment option,” she explains.

At the same time, Benjamin V. Noah, an ACA member and past president of MGCA, was discouraged to see that the study excluded PTSD clients who were considered high risk. Individuals had to be stabilized by medication to be included in the clinical trials.

“Many of the veterans I have worked with dropped their medications [because] they do not like the side effects. Therefore, I believe the study overlooked veterans that may be higher risk,” Noah says. “Additionally, a high risk of suicide was an exclusion for being in the study. Again, this leaves out those veterans who need help the most and could benefit from a short-term approach.”

Noah, a licensed professional counselor in the Dallas area whose area of research is veteran mental health, has used written therapy methods in his own work with veteran clients and has found the methods helpful. A therapy session provides a safe and supportive environment for clients to write about traumatic experiences – particularly clients who may be trigged by the exercise when alone, he explains.

“I have had veterans triggered doing [writing] as homework; keeping the writing in session acts as a safety measure for the [client]. Helping veterans resolve their event or events — which I call the ‘nightmare’ — that led to PTSD has been a focus of my work since I was able to put my own nightmare to bed,” says Noah, a U.S. Air Force veteran and a part-time faculty member in the School of Counseling and Human Services at Capella University.

WET is one of many methods that should be considered by clinicians working with clients who have PTSD, Noah adds.

“I would like to see more research within the VA and National Institute of Mental Health on the use of Viktor Frankl’s logotherapy, solution-focused brief therapy, sand tray therapy and other approaches that counselors are using in their work with veterans,” Noah says. “There are articles focusing on other approaches, but these tend to be the experiences of a few counselors and do not have the research rigor used by [the WET study researchers]. I do applaud the authors for showing the efficacy of a brief therapy approach for use with veterans, and I do plan to look deeper into written exposure therapy and perhaps use it in my future work with veterans.”

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Find out more:

Read the research in full in JAMA Psychiatry: jamanetwork.com/journals/jamapsychiatry/article-abstract/2669771

From the National Institute of Mental Health: “A shorter – but effective – treatment for PTSD”

Related reading from Counseling Today:

“Controversies in the evolving diagnosis of PTSD”

“Informed by trauma”

“Exploring the impact of war”

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.