Supporting Self-Determination in the Treatment of Anxiety and Eating Disorders
Supporting Self-Determination in the Treatment of Anxiety and Eating Disorders
Abstract and Keywords
This chapter discusses anxiety disorders and eating disorders, specifically bulimia nervosa. It covers the effective therapeutic approaches to anxiety disorders, while simultaneously showing these therapies are effective when used in an autonomy-supportive way. This chapter presents a handful of clinical examples that illustrate the self-determination principles and the treatments which require attention to motivational issues, clinical-technical skill, warmth, and sensitivity.
In this chapter we focus on anxiety disorders, but because there are important areas of overlap between techniques targeting anxiety and those targeting eating disorders, we also mention eating disorders, especially bulimia nervosa (the binge-purge syndrome). Our goal is to cover the demonstrated effective therapeutic approaches to anxiety disorders while showing that these therapies are most effective when practiced in an autonomy-supportive way. Further, although the therapies are quite structured and even prescriptive, they are quite consistent with SDT at their core.
Generalized anxiety disorder is a syndrome characterized by persistent experiences of worry and physical tension. The worry and tension are often focused on one or more major life issues, such as finances or success at work or school. Data suggest that the genetic basis for the disorder overlaps considerably with that for depression (Kendler et al. 1992).
Panic disorder involves the frequent experience of gripping bouts of fear that come out of the blue several times a week. Physical symptoms of anxiety (such as a racing heart and shortness of breath) are key aspects of panic attacks. During a panic attack, the sufferer may believe that he or she is having a heart attack and is about to die, and indeed, panic attacks are a major source of visits to hospital emergency rooms. People who suffer from severe panic disorder may become agoraphobic (afraid to go out of the house) because they (p.143) worry that a panic attack may hit at any time and want to be in a safe place when it hits.
Social phobia (also known as social anxiety disorder) involves fear and anxiety in social settings. The patient with alcohol abuse problems, described in the last chapter, had this diagnosis. For such individuals, social settings in general provoke anxiety; patients are often concerned that they may not know how to act or what to say and that others will form bad impressions of them. Attending parties, interacting with authority figures, asking others out for dates, eating in restaurants—all of these things can be very difficult for the person with social phobia. For some patients, a specific social situation, such as public speaking, is problematic. Some men with social phobia develop difficulty urinating in public bathrooms because of a performance-based social fear (for example, “What will everyone think if I'm standing here at the urinal but can't urinate?”).
Obsessive-compulsive disorder is characterized by repetitive and unwanted thoughts about things like contamination and danger as well as an attendant, irresistible need to engage in some ritual related to the obsession. Common manifestations of the disorder are obsessions regarding germs and dirt, with attendant compulsive rituals of excessive washing and cleaning. The disorder can become so severe that the obsessions are overwhelming and the rituals absorb most of the patient's time and even money (for example, showering or cleaning for hours each day or discarding major appliances, such as a washing machine or microwave, because of the belief that they have become contaminated).
Post-traumatic stress disorder (PTSD) is an anxiety syndrome that develops in the wake of a discrete, rather severe life trauma, such as combat, a natural disaster (for example, earthquake, hurricane, or tornado), an accident (for example, a motor vehicle accident), or a physical assault (for example, rape). The anxiety syndrome includes such features as anxious preoccupation with the trauma, nightmares about the trauma, and a heightened startle response. PTSD was misdiagnosed in the man described in Chapter 7 who suffered from severe depression (at the same time that he was misdiagnosed with bipolar disorder). As with other anxiety disorders, there is evidence that selective serotonin reuptake inhibitor (SSRI) antidepressant medicines can provide some relief. Specifically regarding PTSD, Zoloft (sertraline) has received approval by the Food and Drug Administration as effective for PTSD, especially for women.
Patients with any of these anxiety disorders tend to respond to cognitive-behavioral approaches, which emphasize behavioral confrontation with feared things (this leads to habituation to the feared things, in other words, to (p.144) becoming less afraid of them), as well as the correction of any exaggerated anxiety-related thoughts that may be contributing to the symptoms. For example, a man with social phobia may begin to force himself to speak in public and ask women for dates, even though these things produce intense anxiety. When in a social situation, though his impulse is to flee, he endeavors to prevent this behavioral response. Throughout this process, he monitors his thoughts (cognitions) and works to make sure that his thoughts correlate with objective information. If he thinks, “Everyone is looking at me, and they think I'm ridiculous,” his cognitive task is to evaluate whether this is really so. He then looks carefully at the people around him to see if they actually are all scrutinizing him, and typically he finds that few are even looking at him. If anyone happens to be looking at him, he checks their facial expression and posture to see if there is any clear evidence that they think he is ridiculous. He usually cannot find any such evidence and instead finds that they are looking at him only because he is looking at them!
Or consider someone with obsessive-compulsive disorder (OCD) that combines extreme fear and disgust of germs and dirt with rituals involving washing and cleaning. Behavioral confrontation (also known as exposure) would involve things like the patient and therapist sitting within a few feet of an office trash can, then sitting next to it, then touching its outside first with one finger and then with the whole hand, then putting one's hand in the trash can, and so on, all the while resisting the intense urge to flee and go through washing rituals (response prevention). Note the incremental nature of this process—confrontation or exposure begins with a relatively mild stimulus (like sitting a few feet from a trash can) and then progresses in stepwise fashion. Note also the improvisational and collaborative nature of this approach—for one patient, a therapist might focus on trash cans (and the therapist collaboratively does the exercise along with the patient); but for the next patient, the therapist might focus on obsessions about symmetry and counting. For example, the therapist might encourage the patient to walk through a store or mall and purposefully violate rules of symmetry and counting developed by the patient (for example, “the number of steps from one place to another must be odd and divisible by seven, and if not, then the route must be retraced”). For an OCD patient of this type, exposure would involve violating the rule, and response prevention would mean not retracing the route after the rule had been violated. Cognitive correction for OCD patients might involve trying to find actual evidence for the thought “If I am near trash, especially if I touch it, I will definitely get extremely ill,” or “If I violate counting rules, it will cause a catastrophe.” Through constant practice of these behavioral and cognitive techniques, (p.145) and with the encouragement and coaching of a cognitive-behavioral therapist, patients with anxiety disorders often experience considerable relief (perhaps particularly if they are also on an appropriate medicine; again, for many mental disorders the optimally effective treatment package includes the simultaneous administration of medicines and of extremely specific forms of psychotherapy).
The following clinical anecdotes illustrate these approaches and their compatibility with self-determination principles. Here, as always, the combination of technical-clinical skill along with attention to the patient's motivation via autonomy support creates the optimal intervention package.
Case 1: Post-Traumatic Stress Disorder
A healthy and resourceful woman, S. C., was on her way to drop off her child at school, taking her usual route through a residential area with a low speed limit. She approached an intersection with a four-way stop sign; she had never had reason to notice, but a fence and bushes obstructed the sight lines for cars that were coming from her right to the left. So she never saw the van that ran the stop sign at high speed and barreled in to the right side of her car (not, that is, until minutes later, when she came to). Both S. C. and her child were wearing seatbelts; fortunately, her child was virtually unscathed—no more than a little bruised. She, too, was relatively fortunate—on impact, she banged the left side of her head and her left shoulder on the driver's side window and door. She was unconscious for two minutes and her shoulder was badly bruised. She was taken to the hospital, where it was determined that neither injury would result in any lasting problems.
S. C.'s recovery was swift and uneventful, and she was soon ready to resume her normal activities and routines. One morning she got in her new car to take her child to school and then on to work, when she was overwhelmed by fear and anxiety. She had intense visual images of the scene of her accident (actually, its aftermath; she could not recall the accident itself) and could not seem to make these images go away. She had trouble catching her breath, her heart was racing, and she was shaky. She sat in the car in her driveway for a minute or so, deciding what to do. Should she call a friend to come take her child to school? Then how would she get to work? Should they just both stay at home?
Still quite anxious, S. C. decided that she could probably manage, started the car, and pulled out of the driveway. As she approached the intersection of the accident, even from quite far away, she felt her anxiety escalating intensely. She decided that she could not face that intersection and took an alternate, (p.146) much longer route to the school and then to work. On her way home that day, a similar scenario occurred: C. S. was very anxious but managed to return home by avoiding the intersection.
That night, S. C. dreamed of an awful car accident in which her child was badly injured. She did not sleep well, and the next day she was preoccupied with the accident as well as with the thought that something awful could have happened to her child.
S. C. hoped that over time this problem would fade, and in the meantime, she limited her driving to essential trips. She began to walk to the grocery store, even though it was a considerable distance and she felt embarrassed about pushing the grocery cart through her neighborhood to her home. A resourceful and strong woman, S. C. felt undercut by her fear of driving and began to doubt and blame herself for the problem. She was often on edge, and this was affecting her relationships with her daughter, friends, and coworkers. Her symptoms continued essentially unabated: she experienced high levels of anxiety while driving, avoided driving and associated stimuli (for example, movies in which there might be car accidents), was preoccupied with the accident, and had nightmares about car wrecks.
For a few weeks, S. C. put up with these symptoms. Then she decided that she wanted help and told her family physician about the problem. The physician was unsure about whether medicines would help (this case occurred before Zoloft had FDA approval as helpful for PTSD in women) and referred her to a clinical psychologist whom she trusted. The psychologist, P. W., quickly diagnosed PTSD; he also screened for other disorders and noticed possible depressive symptoms, such as self-blame, feelings of sadness, problems in concentrating, and sleeplessness.
The psychologist told S. C., “You've been through something traumatic, and when people go through these things, they sometimes develop an anxiety reaction called post-traumatic stress disorder, or PTSD. People with this syndrome experience flashbacks and nightmares about the trauma; they may be thinking about the trauma a lot, and they may feel on edge and tense much of the time. I believe that you have developed PTSD in response to the car accident. You've also told me about some other problems—trouble sleeping, difficulty concentrating, negative mood—that are common signs of depression. It's possible that depression is a separate problem for you, or it's possible that the depression symptoms stem from the PTSD and will go away as the PTSD goes away. There are safe and effective treatments for PTSD and for depression that we can discuss. But first, let me ask you, which problem would you want to work on first—which do you find most troubling?”
Here, the clinician showed reasonable attention to the perspective of the (p.147) patient, made a good start with rationale provision by explaining his view of diagnoses in clear and accessible terms, showed clinical-technical skill in arriving swiftly at an appropriate diagnosis and in detecting the additional possibility of depression; and provided some choice by asking S. C. which problem she would prefer to prioritize.
The patient answered, “My big problem is definitely with the car accident and PTSD. I really think the only reason I'm having trouble with sleep and concentration and all that is because of the accident.”
Using language reminiscent of the motivational interviewing technique of reflective listening, P. W. responded, “So, you feel that the depression is only a consequence of the PTSD.”
S. C. replied, “Yes, I'm pretty sure of that. What can I do about the PTSD?”
“I can think of three choices,” he said. “One choice would be medicines, antidepressant medicines. Even though the name is ‘antidepressant,’ the same medicines are sometimes used for other things, including anxiety reactions. I've talked to some people who believe that antidepressants were helpful to them for PTSD symptoms. But I'm not aware of any controlled clinical trial with antidepressants for PTSD showing that they are effective. A second choice is a specific form of psychotherapy called cognitive-behavioral therapy. It involves facing up to the trauma in various ways and correcting thinking patterns about the trauma that may be causing emotional distress.”
The patient interrupted, “You said facing up to the trauma. I'm not sure what that means.”
The clinician said, “Well, it means gradually confronting everything about the car accident that currently makes you anxious. For example, we would work together to increase your driving, even driving near and eventually through the intersection where the accident occurred. We may agree for you to visit the site of the accident on foot. Perhaps we would arrange more conversations about the accident between your daughter and you; or maybe you would visit the hospital where you went after the accident. All of these things will be challenging, but we'll work up to them together in a gradual way so that they won't be overwhelming. The idea of it all is that if you do enough of this facing up to the trauma, you essentially just get used to it, and it stops being anxiety-provoking.”
Nervously, S. C. said, “You said there was a third option.”
“Well, it's actually not a completely separate option,” said P. W. “The approach here would be to get all possible benefits by doing options one and two simultaneously. In other words, take the medicine and do the cognitive-behavioral therapy. I should mention that at this point in time, the cognitive-behavioral therapy appears to have the best scientific support behind it; but (p.148) adding the medicine to the therapy might increase the therapy's benefits somewhat. The other advantage of having the medicine is that, because it's an antidepressant, it might help you with sleep and mood.”
Throughout this exchange, the clinician paid reasonable attention to both clinical-technical skill and to self-determination principles. On the count of clinical-technical skill, he summarized the treatment options that are most effective for PTSD. On the count of self-determination principles, he offered as much choice as is possible given his understanding of the scientific literature, and he provided a brief rationale for the ideas and techniques behind cognitive-behavioral therapy. Rationale provision is particularly crucial here, because the patient was being asked to confront very painful and scary material (the experienced trauma). Thus, the logic of doing so needed to appear quite clear. In addition, the clinician attended to the patient's perspective by acknowledging that confronting the trauma would be difficult and by reassuring her that it would be a relatively gradual process. He also supported the patient's needs for relatedness by sympathizing and stating that he was there for the patient and that they would work on the problems together.
The woman agreed that the combined drug and psychotherapy approach sounded best but said that the “confronting the trauma” idea made her a little scared. The clinician responded that he would probably feel the same way if he were in her shoes and that feeling anxious and scared was a natural reaction—indeed, an important part of the therapy—because in order to get used to something scary, it stands to reason that one would need to go through some fear, at least at first. A prescription for an antidepressant medicine was arranged, and S. C. began taking the medicine a few days after the first interview. She returned a week after the first interview to begin the cognitive-behavioral therapy.
At this session, P. W. first checked in with S. C. about PTSD and depressive symptoms. The patient stated, “I feel good that there's a plan in place and that treatments are being started, but on the other hand, I really don't feel very different. Driving is still a big problem; so are nightmares. My sleep is still not good.” He explained that both the medicine and the cognitive-behavioral therapy would take time to affect her symptoms; whatever benefits occurred in response to medicines would, in all likelihood, be apparent in around four weeks, and usually, some relief from cognitive-behavioral therapy would occur within eight weeks or so.
The clinician then offered another overview of what cognitive-behavioral therapy involves—behavioral confrontation of the feared and avoided things associated with the accident, as well as an examination of and, if needed, changes in thinking patterns related to the accident. As a first step, P. W. (p.149) suggested that the patient make up a list of feared situations and stimuli associated with the car accident. In generating the list, S. C.'s perspective was prioritized—she was the one developing the list based on her own feelings and views, and the therapist was simply assisting her (for example, in helping make it more detailed). Also, it was a collaborative process, with patient and therapist working together on a joint project, in keeping with the self-determination principle of autonomy and relatedness need-fulfillment. Her initial list looked something like this:
- Being anywhere near the scene of the accident, especially if driving
- Vans (her car was hit by a van)
- Any television show or movie with car accidents
P. W. said, “Let's work with this list for the moment. You listed driving as a difficult situation, but driving is a pretty general process, including lots of specific behaviors. For example, where do you keep your car keys?”
“In my purse usually.”
“So what about that? Taking the keys from your purse—that's part of driving, or at least a necessary step toward it; does taking the keys from your purse make you anxious?”
The patient said, “Actually, yeah, it does; not the same kind of anxiety as when I'm actually driving, but yes, I can notice anxiety then.”
Together, the patient and clinician went on to break down the category of “driving” into smaller parts, such as taking her keys out of her purse, opening the car door, starting the engine, backing out of the driveway, turning a certain direction to go to work or elsewhere, and so on. For each of the other things on the list (for example, ambulances, vans, shows containing car accidents), they performed the same process of breaking the item down into specifics.
S. C.'s list was now longer and more detailed. At this stage, the therapist is in an ideal position for choice provision. As a preliminary step, P. W. said, “Now that we have a pretty full list here, let's go through each item, and I'd like you to assign each item a score from 1 to 10, in terms of how anxious it makes you feel. A rating of 1 means it doesn't make you very anxious at all, and a rating of 10 means it gives you intense anxiety, at or near the highest anxiety level you've ever experienced.” Some of S. C.'s ratings were:
- Actually driving through the accident intersection: 10
- Driving within one hundred yards of the accident intersection: 9
- Being at the scene of the accident on foot: 8
- (p.150) Seeing a car accident scene in a movie or TV show: 7
- Driving in traffic, away from the accident scene: 7
- Driving when there's little traffic, away from the accident scene: 6
- Backing out of the driveway: 5
- Seeing ambulances: 4
- Seeing vans: 3
- Getting in her car and putting on the seatbelt: 3
- Taking her car keys out of her purse: 2
P. W. then encouraged S. C. to look over the list and her ratings and to choose two or three things to work on during the coming week. He explained that she was free to choose whatever she liked but noted that things rated closer to 1 would be less likely to be overwhelming and thus might be a good starting point. She responded, “This thing with driving is really getting to me, and it's a major inconvenience, so I think I'd better focus there—how about ‘taking the car keys from my purse,’ ‘getting in the car and putting on the seatbelt,’ and ‘backing out of the driveway.’” Here, the patient, not the therapist, was choosing the parameters of her therapeutic activity.
Also in keeping with providing choice, P. W. agreed that these were reasonable to try and asked how often per day C. S. felt that she could do each task. She replied, “I don't understand—you mean how many times per day can I, for example, take my keys from my purse? Or back out of my driveway?” He affirmed that the latter was what he meant.
“Well,” she said, “I think I could do that multiple times per day, but I just want to make sure I understand—you want me to get in the car and buckle the seat belt and sit there for a while, and then get back out and do the same thing again later? And you want me to back out of my driveway and then pull right back in, and then do it all again later? The neighbors will think I've really lost it now.”
He replied, “It's ultimately up to you whether you do these things, but yes, I do think these small steps toward conquering fear of driving and of the accident will be good starting points, and although they may make you a little self-conscious with the neighbors to begin with, my sense is that it will be worth it, and plus, your feelings of self-consciousness will probably fade quickly.”
The patient decided that she would try this, and specifically, that she would handle her car keys and get in the car and buckle the seatbelt at least four times a day and, after doing this for two or three days, that she would start backing her car out of the driveway at least twice a day (in addition to the times she drove for essential purposes).
At the next session, C. S. reported substantial success. She had done the keys (p.151) and seatbelt exercises and now would rate those as a 1 on the rating scale—they were no longer problems. She had also performed the driveway exercise as planned, and her anxiety about that had gone down to a 2 or 3 on the rating scale (down from 5). She had even decided to “get ahead” a little and drove around the block a few times during the week for no reason except just to do it. This helped with her anxiety about driving in ordinary conditions away from the accident site (rating of around 4, down from 6). Incidentally, C. S. stated that she initially felt silly doing the exercises—and wondered what the neighbors thought—but she quickly forgot these feelings and came to view the exercises as challenges she enjoyed meeting, much as if she were trying to run a certain distance or lift a certain amount of weight.
The therapist's mam response was simply to admire the week's accomplishments, using such phrases as “I'm really impressed by how you took the bull by the horns here.” In making such statements, he was affirming that the impetus for action and change resided with her, the patient. He was also curious about the status of such symptoms as nightmares, flashbacks, and preoccupations with the accident. Here, too, C. S. reported progress—in previous weeks, she estimated that she experienced five or so nightmares per week; during the last week, she recalled only two. Flashbacks about the accident's aftermath, as well as brooding about the accident and associated issues, though still present, had also decreased noticeably.
And, in keeping with choice provision, P. W. then posed the question, “Well, where to now?” Encouraged by the week's success, C. S. responded, “I think I'd just like to work my way up the list we made. I can tell that I'm going to make the most progress with things related to actually driving, so I'd like to focus there. Maybe this week I'll step up the drives around the block, and then also do more driving in busy areas.”
These goals were also met, with further decreases in C. S.'s PTSD symptoms. In subsequent weeks, she rented and watched a movie that she knew contained a serious car accident, began driving in traffic daily, had several conversations with her daughter about the accident, drove her car to within a half-block of the accident intersection, visited the intersection on foot, and, near the end of her treatment, drove through the intersection, first alone and later with her child. By the end of twelve weeks of combined drug plus cognitive-behavioral therapy, C. S.'s PTSD symptoms were completely remitted.
Throughout this process, the therapist monitored the patient's cognitions related to the accident, driving, and so forth. She did have some cognitions that might have been a therapeutic target (such as “Driving, no matter what the conditions, is inherently extremely dangerous and life-threatening”). However, as C. S. made progress with the exposure exercises (keys, seatbelt, (p.152) driveway, movies, driving in traffic, and so on), these cognitions receded naturally, without need for special therapeutic attention. There are patients, it should be noted, for whom a cognitive focus is necessary and beneficial. For the woman who experienced the motor vehicle accident, however, exposure exercises sufficed.
Together with her therapist, the woman had participated in what is variously known as a “manualized” treatment, an “empirically validated” therapy, or a “scientifically supported” treatment. Apparently, the terms “manualized” and “scientific” confuse some nonscientifically oriented practitioners, who sometimes caricature manualized treatments as robotic, scripted, or confining and as ignoring patients' individuality. This misperception overlooks two basic facts: (1) “robotic and scripted” procedures are often helpful to people with mental disorders, as the literature on bibliotherapy and computerized treatments clearly show; and (2) in any case, cognitive-behavioral therapy, as illustrated in this example, is far from “robotic and scripted”—the patient's individual experience was always front and center, and a warm, trusting relationship developed between patient and therapist. Thus, SDT prescriptions were implemented throughout the treatment. The worst aspect of the common misperception that exposure therapies are dehumanizing is that it prolongs real suffering—as we write there are people with PTSD who could be remitted two to three months from now but whose symptoms will persist for many months because their therapists do not want to be “robotic and scripted.”
More on the Interface Between Clinical-Technical Skill and Motivational Principles: An Ersatz PTSD Diagnosis
The refrain should be familiar by now—attention to self-determination principles in the absence of clinical-technical skill is unlikely to help (and may harm); ignoring self-determination principles undermines clinical-technical skill. In this context, consider this remarkable account. A woman and her husband are fast asleep in their bed on a mundane weekday night, like many hundreds they had experienced before. They awake suddenly to find themselves flying through the air at great speed as debris pummels them from all directions. A tornado has hit their home, and the woman vividly remembers waking up in the air. She can recall the details of the stings and bruises of debris flying into her, of the roar of the wind, and of her impact on the ground in a grassy field about two hundred yards from her home.
Miraculously, she was not seriously hurt—according to her, her “whole body was black and blue and scraped and cut”—but she broke no bones, damaged no organs. Her husband landed in the same grassy field; he, too, was very fortunate, but less so than his wife: he sustained a severe concussion (and (p.153) remembered nothing of the event) and a broken pelvis. That either of them survived was really incredible. Others were not as fortunate; a friend from their neighborhood was killed.
She approached one of us (Joiner) at a break during a meeting, told this incredible story, and mentioned that she was undergoing “eye movement treatment for PTSD.” Joiner responded, “Well, I'm not sure I've ever heard a more interesting story; I'm so glad you were not badly hurt; I hope your husband's well; and I'm very sorry to hear about your neighbor.” She expressed gratitude, and Joiner continued, “With something as traumatic as that, PTSD would not be unusual at all. If I may ask, what kinds of PTSD experiences are you having?”
Mildly, freely, she said, “PTSD experiences? I'm not sure what you mean.”
Joiner: “Well, for example, I imagine you might be having nightmares about the tornado.”
“Oh. Well then, flashbacks about it?”
Joiner, with slightly increasing concern: “Then you must think about it a lot.”
“Well, as you might imagine, people ask me about it all the time—it gives you a kind of celebrity, you know—and I've enjoyed telling people about it. So, yes, in that sense, I think about it a lot.”
“Do you dwell on it in a sort of negative way when you're alone?”
“Are you more jumpy now than you were before the incident? In other words, do you startle or scare easily?”
“I don't think so.”
“Just after the tornado, before you started treatment, did you have jumpiness, or nightmares, or flashbacks?”
“Well, I have two reactions to all this. The first one is admiration for the way you've handled all this—you flew through the air in a tornado and now you enjoy telling about it! The other reaction is to wonder if you really do have PTSD. What has your therapist told you about this? In fact, why did you start therapy in the first place?”
“Relatives and friends who knew what happened said therapy would be a good idea. The therapist I see said that I'd clearly been through a trauma and so I probably had PTSD at some level, even if I wasn't really aware of it. He said that the only real choice for PTSD was ‘eye movement therapy’ and that through the therapy, I could become more aware—and get beyond—my reactions to the whole thing.”
“Often I'll just tell the details of what happened, and while I do this, I'll follow this kind of light-stick with my eyes as he waves it back and forth. We've also talked about the aftermath of it all—my husband's injuries and recoveries, the death of our neighbor, plus of course the house was destroyed.”
Joiner, thinking he had missed something: “Yes, of course, the house; and I'm sorry, I should have asked, was anyone else in the house with you? Do you have any children?”
“Our two girls were off at college, luckily. And, yeah, I guess the house was a kind of trauma, but we had good insurance luckily, and that all turned out pretty well, fortunately.”
“Yes, well, good. Then I'm back to the same place—trying to understand why you're being treated for symptoms you appear not to have.”
“Well, you tell me.”
Joiner, with a short laugh: “I'm not sure that I know. Why do you keep going in for treatment?”
“Oh, my therapist is great. He is really understanding, warm, and a great listener. It's comforting to have someone to really listen to you every week. Why, do you think something's wrong?”
Joiner, conflicted: “Not necessarily. It's just that, if you do not experience PTSD symptoms, it's hard to understand why you'd be treated for the condition! On the question of PTSD, I wonder if a second opinion might be in order. On the other hand, apart from the question of PTSD, you're certainly right that an attentive and warm therapist can be a comfort.”
The meeting was starting back up, and the woman and Joiner said goodbye. During the rest of the meeting, Joiner pondered the resilience of this woman, as well as the irony of an ersatz therapy being recommended for an ersatz diagnosis. From the description, the woman's therapist had excellent motivational skill; he had motivated the woman to keep attending therapy sessions even though they were unnecessary! Unfortunately, his lack of clinical-technical skill—on both diagnostic and therapeutic fronts—was obvious. Again, clinical-technical skill (based on science) and motivational skills (based on SDT and science) are each necessary—and neither is sufficient—for good therapeutic outcomes.
Case 2: Severe Obsessive Compulsive Disorder
When M. A. is about thirty, her OCD begins to dominate her life. It becomes debilitating. Keeping a job, relating to her husband, caring for her adolescent son—all these become difficult, even secondary, to her consuming (p.155) concerns over contamination with dirt and germs and her intricate washing and cleaning rituals. She spends at least an hour in the shower every day, sometimes more if she does not follow a specified sequence of washing and has to start over. Cleaning the house is similar—it absorbs hours per day and again involves a sequence of activities that, if violated, must be repeated from the beginning. At her husband's insistence, M. A. tells her family physician of the problem, and he refers her to a psychiatrist. The psychiatrist prescribes chlomipramine, a leading treatment for OCD.
Several weeks later, M. A. meets with her psychiatrist again, and both are encouraged by the progress. The disorder has not remitted, but the amount of time spent in washing and cleaning has been cut approximately in half, and M. A. can point to ways in which her quality of life has improved (for example, better family relations). The psychiatrist recommends continuation of the medicine, with hopes that progress will continue; a follow-up appointment is scheduled for two months later.
At the follow-up appointment, the hoped-for improvement has not occurred. Things are still better than they were initially, but some of the original gains from the medicine appear to have eroded. The psychiatrist recommends an increased dosage of chlomipramine, with a follow-up appointment in six weeks.
By the next meeting, the situation has deteriorated somewhat. M. A.'s adolescent son invited a girl over to their house when she was not there. Later, she saw that they had rented a movie (the movie and its container from the rental store were still there) and that they had eaten microwaved popcorn. She imagined that they had watched the movie while eating the popcorn on the couch. Furthermore, she wondered whether they might have had sex on the couch. This thought was very disturbing to her, and her worries “mushroomed” from there: What if the sex was unprotected? What if fluids had gotten on the couch? Was her son now “contaminated”? If they had sex before they prepared the popcorn, might the microwave have been contaminated? Her reaction was to throw the microwave away and to arrange for a charity to pick up her couch (she felt guilty about donating a “contaminated” couch, but her trash service would not haul it away). She understood that her reaction was out of proportion but felt that she could not control it. This state of affairs was very distressing to her and her family alike.
When the psychiatrist learned of the situation, he concluded that a different approach was needed. He recommended continuation of chlomipramine but also recommended the addition of cognitive-behavioral therapy, specifically, exposure with response prevention. This technique involves confrontation of the feared stimulus—in the woman's case, germs, dirt, and other (p.156) contaminants—as well as short-circuiting the typical response—here, engaging in washing and cleaning rituals. A meeting with a cognitive-behavioral therapist was arranged.
With M. A.'s consent, the psychiatrist and therapist had already discussed her symptoms, and so the therapist had little doubt about the diagnosis and started immediately with the therapy. In a general sense, the process of the therapy was similar to that we described above for the woman with PTSD associated with a car accident.
First, a detailed rationale was provided for the “exposure with response prevention” technique. Again, although rationale provision is important in any motivational situation, it is particularly important with anxiety disorders, because patients are asked to do things that they really fear and do not want to do. Patients with OCD may struggle with this even more than those with other anxiety disorders—the intense quality of their fear and disgust can make exposure and response prevention an excruciating experience, for the therapist as well as the patient! Successfully enacting the therapy requires “self-applying” motivation, as we discussed at the beginning of Chapter 6.
Notice that rationale provision, but not choice provision, had been highlighted up to this point. For OCD, the research base clearly shows that the range of treatment choices is limited: chlomipramine or a selective serotonin reuptake inhibitor and exposure paired with response prevention comprise the entire range of choice. Thus, it is crucial to make the procedure understandable to the patient! However, choice provision became more important in the next phase of the treatment.
The next step was to form a list of specific objects or situations that M. A. obsessed over and were tied to her compulsions to wash and clean. In fact, three lists were formed—one regarding her house, one regarding the therapist's office and surrounding area, and one regarding a public place of her choice (she chose a local mall). The list for her house was of central importance, because this was the location of most of her compulsive behavior and would be the primary place where she practiced exposure with response prevention on her own between therapy sessions. The list for the mall was important, too, because it offered an opportunity to generalize progress from her home to other places. For the therapy sessions themselves, the list for the therapist's office was important, because this would form the basis for in-session exposure with response prevention exercises.
Again, in keeping with the autonomy-supportive and collaborative emphases of SDT, the patient generated these lists while the therapist threw in some “brainstorming” tips, particularly regarding his office and surrounding areas. For example, after the “office list” was completed (it included things like the trash cans, bathroom area, doorknobs, welcome mats, and dumpsters (p.157) outside the office), the therapist stated, “Many people with contamination fears are very worried about medical settings, because of fears that disease may be around, or that blood or other body fluids may be around. Is that a concern of yours?”
With a grimace, M. A. said, “Most definitely.”
“There is a medical practice here in the building on the third floor,” the therapist said (his office was on the first floor). “What about adding that to our ‘office list’ of feared things?”
She agreed that this was a good idea.
For the rest of the session they went over the lists, rating each object or situation on a scale of 1 to 10 in terms how anxiety-provoking it was. For the office list, the most anxiety-provoking objects were the medical practice, the bathrooms, and the outdoor dumpsters; lower on the list were doorknobs and welcome mats. The therapist said, “We're about out of time, so I'd like to suggest this: I'll photocopy these lists in a minute, so that you can take one with you and I can keep one here. During the week, you might try to experiment with the things on your home list that are not too tough; things that you rated around a 3 or so. The idea is to expose yourself intentionally to the things and to persist until you notice your anxiety level subsiding. Once you notice that your anxiety has clearly lessened, you can stop, but then here's the crucial part. You have to resist the urge to go through washing rituals. Don't overdo it; just experiment some so you can get a sense of the procedure, and feel free to check in with me by phone if you feel that your experimenting is too troubling.”
At the next session, the therapist inquired how things had gone during the week. The patient reported that she'd done some minor experimenting; for example, her son had cut an apple in two, eaten one half, and left the other half on the kitchen counter. The half on the counter was still relatively fresh, but she could notice some discoloration on it. Her usual approach would be to place several paper towels over the apple, quickly pick it up and throw it into the trash, and then engage in a hand-washing routine lasting about three minutes and a counter-cleaning routine lasting about five minutes. She stated, “As I put the paper towels on it, I thought, ‘Well, here's a good chance to try this stuff out.’ So, I picked it up with my bare hand, and just stood there for a while. Like you said, I paid really close attention to how anxious I was. At first, I was definitely anxious—I wanted pretty badly to just get rid of it and start cleaning up. But I stayed with it, and after a couple of minutes, I still was uncomfortable, but I could see I wasn't quite as anxious as before. So I threw it away, and then was able to wait several minutes before I washed up. I still went through some routines, but I was able to cut them a little short.”
The therapist expressed his congratulations and admiration at this, noting (p.158) that M. A. had been particularly successful at self-monitoring her anxiety levels on an ongoing basis, at least over the few minutes of the “apple experiment.” This self-monitoring is a straightforward matter but often something that OCD patients have simply lost the habit of doing. Self-monitoring is also quite consistent with SDT's emphasis on the self's quest to master events at the “internal boundary”—here, M. A.'s self was actively monitoring internal information and making decisions and executing behaviors on this basis.
The therapist suggested that they build on this excellent start by turning to the office list. “Where should we begin?” he asked. “Starting off gradually seems to work well, so we probably should not start with things you rated as 10.” M. A. chose doorknobs and welcome mats as good starting places.
The therapist continued, “As we go through these exercises, and as you do them on your own, it can be helpful to use a scale to monitor your anxiety level; in fact we can just use the same 1-to-10 scale we used to rate how anxiety-provoking things are for you. Only here, you'd be rating how anxious you currently are as you go through the exercises. For these exercises, it's important that they last long enough for anxiety to noticeably decrease; let's say at least by a point or two on the scale. In other words, if you start out at a 9, you'd want to persist at least until your anxiety decreases to around a 7, preferably even longer. For all of these office exercises, I want to show you that we are in this together, so I will never ask you to do anything that I don't do first. You may notice that it makes you nervous even for me to do the exercises, and so that will be another opportunity for you to monitor your anxiety levels. As I do the exercises, I'll periodically ask you to rate your anxiety from 1 to 10; then, as you do them, you'll again rate your anxiety, and try very hard to persist until anxiety clearly subsides.”
Only half-jokingly, M. A. said, “What's to keep me from cheating? I could say I went from a 9 down to a 6, when really I'm still at a 9, and then I could stop.”
The therapist replied, “Good point! Of course, we're on the honor system here—it's up to you how honest you are with your ratings, and I have no real way of knowing if you're only saying your anxiety has decreased when really it hasn't, just so you can stop doing the exercise. What we do is up to you, but I should point out that cheating at these exercises will keep all these problems in place. The other thing we could do is agree on a minimum amount of time for an exercise. For example, we could say that even if your ratings drop 2 or more points, the minimum amount of time you'll engage in the exercise is x number of minutes?”
M. A. said, “Okay, I could do that. How many minutes?”
“What are your thoughts on that?” he asked.
He replied, “It's agreed then. So let's get right into this. I'll put my hand on the doorknob now, we can time me on the clock over there, and periodically, I'll ask you for your anxiety rating. You'll get the most out of this if you don't distract yourself; try to focus on the doorknob and my hand.”
The therapist grasped the doorknob for two minutes and asked M. A. for her anxiety rating every fifteen seconds. The ratings were 7, 6, 6, 6, 5, 5, 5, and 4. The therapist then said, “Good. Just in the course of two minutes it seems that your anxiety decreased noticeably, to a fairly tolerable level. What's on your mind right now?”
M. A. answered, “I'm anxious about doing it myself, and I'm having the urge to go wash my hands.”
The therapist said, “Of course, that's the other key part of this—the urges about the rituals. Let's monitor those, too, using the same 1-to-10 scale; 1 for no urges, and 10 for an overpowering urge. Where would you rate your urge to wash right now?” The patient assigned her urge to wash a score of about 6.
The therapist then encouraged M. A. to do the doorknob exercise. She approached the door somewhat reluctantly, closed her eyes, and quickly grabbed the doorknob. Her facial expression and body posture indicated substantial but not overwhelming anxiety. At the fifteen-second point, the therapist said, “You're doing great. What is your anxiety rating now?”
“About an 8, I'd say.”
“Okay, hang in there; you're doing fine. If you can, you might get more out of this if you opened your eyes and focused on the doorknob.” She did this, and at the thirty-second mark she reported a rating of 8. Subsequent ratings were 8, 8, 8, 7, 7, and 7. After the last rating, the therapist said that she could let go of the doorknob if she liked and asked her to rate the strength of the urge to engage in washing rituals. The patient assigned a score of 9.
The therapist said, “Okay, let's just track the strength of that urge for a while. We can just relax for a while here, and every so often, I'll ask you to rate the urge.” Over the next five minutes, the therapist asked for ratings at thirty-second intervals, and the last rating was a 5. The therapist remarked, “Interesting. Over the course of only five minutes, the power of your urge really lessened, just by waiting it out.”
The rest of the session was devoted to a repetition of the doorknob exercise, similar work with the doormats, and planning between-session exercises at home and at the mall. The therapist reiterated M. A.'s in-session success at waiting out the cleaning urges and encouraged continued practice of this, especially just after arriving home from the session (the therapist sought to prevent the possibility that M. A. would immerse herself in rituals at home in (p.160) response to the in-session exposures). The two also discussed pleasant activities to replace ritualistic activity. The patient identified walks with her husband, playing board games and watching movies with her son and husband, and helping her son with homework as activities she would feel good about increasing.
Subsequent sessions followed in this same vein, with escalating intensity and length of exposure. Over fifteen or so weeks, M. A. mastered a series of previously feared things, ranging from handling paper trash in the therapist's office to touching the dumpsters outside his office to touching things associated with the medical practice (for example, a special overnight delivery bin where blood and urine samples were kept; permission was obtained from the practice's medical director, who also affirmed that touching the bins was medically safe). She ended the therapy with no OCD symptoms; regular follow-up visits with her psychiatrist were scheduled, however, as was a “check-in” session with her therapist six months after therapy ended.
An interesting footnote to this woman's experience was that the hardest obsessions and rituals for her to overcome involved her bedroom. When asked why, she replied, “It's my special territory. Everything in there is mine and just the way I like it. I feel safe there, and I want to make sure no one violates my special territory.” Desires for safe and special territory are universal in people and animals, and indeed, there is conceptual overlap between desires for territory and needs for autonomy and self-determination. Interestingly, though, people with OCD may suffer from excessive “territoriality.”
It is instructive to consider the nature of territoriality in greater detail. First, human territoriality has been described as an ordering of the environment (Malmberg 1980), and thus there is an obvious phenomenological similarity between territoriality and OC symptoms (such as counting, partitioning, stacking, and so on). Further, territory restrictions are clearly associated with a range of OCD-like behaviors in animals, including fish, reptiles, birds, and mammals (for example, Draper and Bernstein 1963). One such behavior is canine acral lick dermatitis (compulsive self-licking, to the point of causing skin damage), which can be induced by territory restrictions (Stein et al. 1992) and which, interestingly, can be treated with the anti-OCD medicine chlomipramine. Joiner and Sachs-Ericsson 2001) have empirically documented the connection between territoriality and obsessive compulsive symptoms and disorder, showing, among other things, that extreme territoriality serves as a risk for the future increase of OC symptoms and that OCD patients manifest territoriality needs by choosing to sit farther from their therapists than non-OCD patients.
The clinical implications of this are interesting to consider in light of self-determination (p.161) principles. Is the patient being “controlled” by territorial obsessions? One potential prescription is that therapists should be encouraged to intrude into the territory of OCD patients! However, such intrusiveness is hard to reconcile with the idea of supporting a patient's autonomy. A contrasting implication is that, because severe territorial restrictions appear to produce OC-like phenomena in people and animals, “most-prized” territories should probably remain intact and available so that they can buffer against symptom relapse. This supports patients' wishes, but it may permit patients to hide in a cocoon of their own devising. We support a middle position: we advocate approximately normal territory use, such that territories serve as places for autonomy, self-determination, privacy, security, and rest but not as havens for OC symptoms. Indeed, for the woman described earlier, M. A., some of her most challenging—and ultimately most beneficial—homework assignments involved bringing “contaminants” into her bedroom. As M. A. and the therapist gradually reduced M. A.'s distressing obsessions regarding her bedroom, she was enabled both to extract full benefit from her “home space” and to free herself from her disorder at a level closest to her sense of self.
The description of M. A.'s experiences with treatment illustrate the best empirically supported treatment of OCD—namely, “exposure with response prevention.” What has also been demonstrated is the compatibility of this very technical behavioral therapy with the self-determination principle of autonomy support. In particular, rationale provision was highlighted, especially in the beginning stages of treatment. Later, choice provision, too, was emphasized (for example, in generating lists of feared situations and in choosing which to prioritize). Throughout the process the patient's perspective on matters was continually elicited, reflected, and supported. An additional aspect of the therapy was the therapist's willingness to first do everything he asked the patient to do; this showed solidarity and enhanced the sense of partnership and relationship between the two of them. To summarize again: the therapist's attention to clinical-technical elements was crucial for successful treatment, but attention to self-determination principles was also crucial, because motivation failure is the main obstacle to treatment success. Clinical-technical skill and self-determination principles facilitate each other and maximize benefits for people who are suffering.
Other Anxiety Disorders
The examples of the women with PTSD and with OCD illustrate the general cognitive-behavioral approach to the anxiety disorders. The approach is straightforward and involves the behavioral confrontation of and habituation (p.162) to feared things, as well as correction of any exaggerated anxiety-related thoughts. The research support behind the approach is compelling.
In general, the same approach applies to other anxiety disorders, such as panic disorder, social phobia, and generalized anxiety disorder. For generalized anxiety disorder, however, the focus is often more cognitive than behavioral. This syndrome involves worry and tension centered on major life themes, such as finances (“Can I support myself and my family?”), relationships (“What if she leaves me?”), or work success (“Am I doing well enough to keep my job?”). For someone worried about the stability of relationships, for example, the clinical task would be to identify cognitions underlying the worry (for example, “My partner is not satisfied with me and there's nothing I can do about it,” or “If my partner is not with me, I will not survive”) and to evaluate and counter these cognitions with objective information. For example, to evaluate the thought “My partner is not satisfied with me and there's nothing I can do about it,” the patient might be encouraged to actually ask the partner about satisfaction. If dissatisfaction actually does exist (and it may not—“you can't know for sure until you ask”), the patient might be encouraged to determine the specific areas of dissatisfaction, as well as list areas where things are going well in the relationship. Regarding areas of dissatisfaction, the patient might be encouraged to negotiate ways of decreasing dissatisfaction. As soon becomes apparent, something can be done about it!
Throughout all this, the capable cognitive therapist will emphasize and prioritize the patient's perspective, but, it is key to point out, this does not include the therapist's validation of anxiety-producing cognitions. For example, a patient with generalized anxiety disorder might state, “I'm so worried that my wife will leave me that I'm not concentrating at work, and so that makes me worried about work performance, and I know that if I screw up my job, my wife will have even less reason to be with me, so it is all just snowballing inside of me.” A clinician who is only attending to perspective-taking might reply, “You're concerned about the future of your relationship and of your work; you're worried that both might end badly and that things could spiral downward.” This is a good example of “listening with empathy,” mentioned in the chapter on motivational interviewing, but by itself, it would probably not be helpful to a patient with generalized anxiety disorder (and given the propensity of people with this disorder to catastrophize, the statement, if left hanging, could provoke and consolidate anxiety).
By contrast, the following statement incorporates perspective-taking and listening with empathy but uses those techniques as a foundation on which to base effective clinical-technical interventions: “You're concerned that your marriage and work life aren't going well and that the problems feed off of each (p.163) other, so that it all seems very overwhelming to you. I see that you're in a lot of distress about this. I have a suggestion for something that you and I can do together that may help. Let's first focus on the thoughts underneath your conclusions that things aren't well. Once we've identified the thoughts, I want to play a game of ‘prove it’ with you. In other words, your thoughts on all this may well be on target, but how can we know for sure? For each thought, try to convince me of its accuracy, using only objective information. Through this process, we may discover that you're right about your marriage and work, in which case we'll discuss how to cope with that. But we may discover some misperceptions, and if so, then uncovering these and correcting them could be quite a relief.”
Here attention to the self-determination principle of perspective-taking is not therapeutic by itself; rather, it lays the groundwork for cognitive interventions that are therapeutic. It is also worth pointing out how readily one can acknowledge another's perspective without necessarily agreeing that it is true. Clear insistence on evidence is just as important for evaluating individual patients' maladaptive beliefs as it is for evaluating advertised claims regarding such “alternative” therapies as eye-blink desensitization!
Bulimia nervosa is the binge-purge syndrome. It commonly affects women, but as many as 15 percent of people with bulimia are male. People with the disorder regularly binge on large amounts of food (often feeling unable to control the binge) and then regularly engage in compensatory purging behaviors, such as self-induced vomiting, abuse of laxatives, and the like. The disorder is serious. Without treatment it can persist and recur throughout most of adult life. It is associated with numerous physical health problems (such as damage to the digestive system), and it is occasionally fatal (usually through electrolyte imbalance, which leads to cardiac problems).
Cognitive-behavioral therapy is a leading treatment for bulimia (Fairburn et al. 1995). As with generalized anxiety disorder, the cognitive component of the therapy is key, and the use of perspective-taking as a platform from which to engage in cognitive interventions is an approach that combines effective therapeutics and self-determination principles.
Bulimia is sometimes compared to obsessive-compulsive disorder because the two syndromes share some similarities. Both involve obsessions—for the bulimic patient, food, diet, weight, appearance, and attractiveness are common obsessions. Both syndromes involve compulsions tied to the obsessions—for the bulimic patient, binging and purging behaviors both have compulsive qualities. It has been found also that eating-disordered patients, when (p.164) compared to general psychiatric patients, display higher levels of rumination and rituals as well as excessive cleanliness and orderliness (Rothenberg 1990). Also relevant to the overlap of the two syndromes, selective serotonin reuptake inhibitor medicines have been demonstrated to be helpful for both, and perfectionism—which is clearly related to OCD—is a reliable predictor of future bulimic symptoms (Joiner et al. 1997).
Given the overlap of bulimia and OCD, exposure with response prevention for bulimia (as an adjunct to empirically supported cognitive therapy, perhaps in combination with SSRI medicines) may be worthwhile. The approach would be similar to that described earlier for the woman with severe OCD, but the list of feared stimuli would include foods and associated experiences (such as grocery shopping) as well as appearance-related issues, and the responses to prevent would involve binging and purging. In-session exercises might involve the eating of particular foods and countering the impulse to purge the food. In this approach, rationale provision is crucial; a bulimic woman is likely to be extremely reluctant to bring food to eat during therapy sessions. The therapist can emphasize choice by asking patients to take the lead in planning and structuring the contours of the exercises. Modeling—the therapist engaging in the same exercises as the patient—may lead to shared perspective and experiences as well as an enhanced connection between therapist and patient.
In caricature, scientifically supported treatments ignore self-determination principles and construe therapists as robots reading from a script. Of all the scientifically supported treatments for mental disorders, it is easiest to apply the caricature to anxiety disorder treatments, because they are among the most structured of all such treatments. But in reality, the treatments require clinical-technical skill, sensitivity, warmth, and attention to motivational issues. There are clear areas of complementarity regarding these treatments and self-determination principles, and we have illustrated these areas in this chapter through several clinical examples. We believe that clinicians who ignore scientifically supported treatments for anxiety disorders cause harm by needlessly prolonging real suffering in patients. However, clinicians who ignore self-determination principles may also cause harm by failing to motivate their clients to take full advantage of these clinical and technical procedures. In our final chapter, we demonstrate this once again in considering mood and personality disorders.