Question 1

When doing cognitive restructuring with clients who tend to ruminate and obsess over things, it's common for them to use the cognitive techniques as fuel for the rumination and obsession. How do you avoid that?

David A. Clark · Accepted Answer

I've seen this happen a few times, especially in OCD. For me, the tell-tale sign that cognitive interventions are being used to neutralize obsessive thinking, rumination, or even worry is when the interventions are used to escape or avoid negative emotion, especially anxiety. When this happens, I point out that the intervention has ceased to be therapeutic, and that the client should stop using the intervention. I might then switch to an exposure-based intervention that requires the individual to confront and then accept their negative emotion.

Question 2

I have a client who has overcome contamination OCD and we are now noticing his OCD is shifting into relationship OCD- over reading text, catastrophizing and I'm unsure what would be helpful- there is always an impending feeling of loss and doom.

David A. Clark · Accepted Answer

It's very common in OCD to see limited generalization of treatment effects from one obsessive content to the next. This makes it difficult because many individuals do shift from one obsessional content to another. They tend to believe "this is a new obsession; it's more real and powerful than my old obsessions. Therefore, I can't apply what I learned previously to this new obsession." In this case, I reintroduce the same CBT interventions from the past but help the client modify them so they're able to see how they apply to the new obsession. In terms of the "impending feeling of loss and doom", I take a page out of acceptance and commitment therapy, emphasizing that thoughts (or feelings) are thoughts or feelings and not facts. There is a difference between a "prediction or anticipation" of loss and doom, and the actual occurrence of loss and doom. The goal is to get the client to the point where the feeling of impending doom and gloom is not taken as validation of the obsessive thought.

Question 3

In the age of the pandemic and varied opinions about risks associated with COVID-19, how can therapists help patients determine the difference between a real and perceived threat?

David A. Clark · Accepted Answer

This is a great question and one that confronts every therapist, especially when treating individuals with fear of physical contamination or health anxiety. The first point I try to make is that threat can not be dichotomized into "purely imagined" and "purely realistic" threat. All perceived threat, no matter how far-fetched, has an element of possibility (i.e., risk), and when it comes to anxiety, it's always about threat in the future that "could happen" and not what will happen. Even the fear of death, which is a certainty for all of us, is usually about having an early death. So this is my first point. Making a distinction between perceived and realistic threat is not helpful. Second, I find identifying cognitive errors, exploring the costs/benefits of threatening thoughts, and generating alternative perspectives on possible threat the most helpful cognitive interventions for altering biased thinking about threat. If the therapist takes this approach, the effects of the pandemic become less relevant. For example, the therapist working with a client who believes "I cannot venture outside my home because I might contract COVID" could explore the costs/benefits of this belief, and whether there are other ways of perceiving the situation that could lead to less anxiety and a better quality of life. Doing evidence gathering on the probability of contracting COVID would be counterproductive.

Question 4

What role does trauma play in creating an anxious mind?

David A. Clark · Accepted Answer

Trauma can be either a distal or proximal factor in the origins and persistence of anxiety. After experiencing an actual personally significant threat or danger, an individual's beliefs about the world change, so there is a higher expectation of danger and safety seems much more elusive. As well, survivors of trauma often exhibit a change in their beliefs about their personal vulnerability and ability to cope. Beliefs about helplessness and vulnerability are more readily activated by a range of situations that may become associated with the original trauma. A threat-based attentional bias is evident so that information congruent with threat is more readily encoded and interpreted. In sum, trauma can play an important role in creating and maintaining an anxious mind. However, it must be remembered that many people with anxiety problems have not experienced trauma, so it is neither a necessary nor sufficient factor in creating an anxious mind.

Question 5

Is it important to work through and understand the cause of anxiety before trying to treat it?

David A. Clark · Accepted Answer

Many clinicians think that once anxiety has been identified as the primary presenting problem, it's simply a matter of applying the right set of techniques to achieve meaningful change. Then there is the opposite camp, who believe a long and protracted analysis is necessary before offering treatment. As a CBT therapist, I stand somewhere in the middle between these two extremes. I believe it's important to do a time-limited (2-3 sessions), focused assessment that provides the information needed to develop an individualized cognitive case formulation that guides the creation of treatment goals and subsequent intervention. San Francisco CBT psychologist Dr. Jacqueline Persons has written extensively on CBT case formulation.

Question 6

What does depressed thinking look like in comparison to the thinking of people who aren't experiencing depression?

David A. Clark · Accepted Answer

There is a large research literature on negative self-referential thinking in depression. To summarize, the main differences between depressed and nondepressed negative thinking are: (a) higher frequency, (b) greater emotional intensity, (c) stronger belief in the veracity of the negative thinking, (d) presence of cognitive errors (overgeneralization, personalization, etc), (e) greater ease of encoding and retrieval, and (f) closer proximity to core aspects of self-definition.

Question 7

How do you help someone when their negative thoughts and beliefs feel correct?

David A. Clark · Accepted Answer

Most treatment-seeking individuals report that their negative thoughts and beliefs "feel correct". They may readily see the irrationality of their negative thinking, especially when they're not feeling distressed or they're sitting in a therapy session. I start by providing psychoeducation on the relation between thought and feeling. I use examples from the client's own experience in which a feeling turned out to be misleading or false. For example, have you ever felt anxious, had this terrible feeling that everything would go wrong, and then later the situation turned out okay? Or, were there ever times you felt calm, relaxed or happy and felt like life was good and then something bad happened? The point I'm making is that you can't trust your feelings. Instead, you have to test out your thoughts and beliefs against reality. I then teach clients cognitive restructuring as a way to shift from "emotion-based" validation of their thinking to a "reality-based" validation of their cognitions.

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