Review by Jennifer Myers, MFTI

This month’s workshop entitled “Anxiety Disorders: Effective Strategies That Work” featured Dr. Robin Zazio, Psy.D., LCSW, Owner and Director of The Anxiety Treatment CenterThe Cognitive Behavior Therapy Centerand The Compulsive Hoarding Center in Sacramento.

Dr. Zazio is a highly informative and engaging speaker who, in her work at The Anxiety Treatment Center, “helps people overcome things that don’t exist” primarily through the use of Exposure and Response Prevention Therapy. Her own definition of the work she does underscores two crucial points regarding the treatment of anxiety disorders: they are often not trauma-based, and the use of logic cannot overcome them, as the fears are irrational and are not believed by the client. She also pointed out that many of the clients she treats have previously sought treatment from an average of 7-9 therapists who have unwittingly given them false promises as a result of a misguided understanding about effective treatment for anxiety disorders and lack of specialized training -- two conditions Dr. Zazio was well-prepared to eradicate within the group of those of us fortunate enough to attend this workshop!

The emphases of the day were obsessive-compulsive disorder, social anxiety and panic disorder, which (in that order) are the most commonly encountered anxiety disorders with approximately 5-7 million Americans suffering from OCD, 13% of Americans experiencing social anxiety disorder, and 1 in 113 suffering from panic disorder. Despite their increasing prevalence, many people remain unaware that their condition is clinically significant and can be treated.

One of the common misconceptions that Dr. Zazio dispelled regarding OCD is that “obsessions” and “compulsions” exist independent of each other -- a misconception that is reinforced by the DSM diagnostic criteria which presents the symptoms in an either/or format. In actuality, the obsessions fuel the compulsions as the client attempts to quell the discomfort of the unwanted thoughts, images or impulses with various repetitive behaviors that provide negative reinforcement in the form of immediate relief from the anxiety symptoms -- which in turn serve to further entrench the client in the cycle of unwanted, irrational fears and behaviors. Educating the client about their condition is also a key component of treatment, as clients are often unaware of the full extent of their condition.

Another area in which Dr. Zazio pointed out that well-meaning therapists can lose effectiveness in treating OCD is in their reaction to a client’s obsession about self-harm; at this point, many therapists lose sight of the ego-dystonic nature of the condition, and may believe that the client is actually at risk for harming themselves -- when if the therapist had asked more questions relevant to the condition, it would become clear to them that the thought of self-harm terrifies the client, and doesn’t create a feeling of excitement or relief as one would expect to see in a true self-harming client who might be considered for an Axis II diagnosis. The preemptive reporting of the client’s unlikely behavior (which if viewed through black-and-white lenses may seem a part of our obligatory duty as therapists) can unintentionally fuel the client’s irrational fears, discourage them from seeking treatment, and perhaps do more harm than good.

Therapists should also be aware that seeking reassurance is the most common compulsion in obsessive-compulsive disorder, making it an inherent pitfall of treatment if not monitored closely. We may naturally want to provide comfort and reassurance to our clients, but in this instance, it actually contributes to their condition. Seeking reassurance may take on various forms throughout the course of treatment, and once its insidious nature is identified and discussed with the client, requests for reassurance (“This doesn’t mean I’m crazy, right?” etc.) should be ignored as they provide the same negative reinforcement as other, perhaps more tangible behavioral compulsions.

Dr. Zazio pointed out the importance of discussing with clients the fact that they will feel worse during treatment before they begin to feel better; in fact, that provides the basis for the very nature of Exposure and Response Prevention Therapy, and contributes to its long-term effectiveness. In ERP, the client will be asked to create a fear hierarchy, select certain fears to work on, enact specific behaviors related to the fear which incrementally increases their anxiety, to then rate that anxiety on a scale of 1-10, to sit with the anxiety until it begins to reduce (desensitization), and to gradually stretch themselves to a point where the situation no longer produces an anxious response. Through this guided process, the client learns that they can remain safe in the experience and that their irrational behavior is no longer necessary, creating a sense that, “Yes, it was uncomfortable, but I felt better when it was done.” Through these experiences, it is Dr. Zazio’s goal to teach the client how to function in the real world, and in the long-term, how to become their own therapist.

As such, Dr. Zazio pointed out that homework is essential to the effective treatment of anxiety disorders -- perhaps even as much as 1-2 hours per day during intensive outpatient treatment. One of the ongoing homework assignments that she commonly assigns is for clients to create a journal with four sections: Education, Homework, Accomplishments and Exposures in which the client learns to become their own therapist by acquiring knowledge about their condition, a list of tasks that can be done to help reinforce the gains made during therapy, what they’ve accomplished along the way, and what situations qualify as an exposure. For example, if a client with social phobia had the homework assignment to order a cup of coffee at a coffee shop, this would be “homework” and an “exposure” which would be rated on the scale of 1-10 in terms of feelings of anxiety, and noted at 5 minute intervals so as to allow the client an opportunity to watch the anxiety decrease over time. If the client successfully completed it, that would be listed as an “accomplishment.” If, while completing the original assignment, a stranger struck up a conversation with the client, this would be listed in the client’s journal as an additional “exposure” and “accomplishment.” Thus the client becomes primed to identify opportunities and successes achieved in the real world, and gain first-hand experience in overcoming their irrational fears.

Even with all of the invaluable information provided to us during this workshop, it is important to know the threshold for referral to a specialist or treatment center should we encounter clients suffering from these conditions. To that end, Dr. Zazio suggests that if our  client isn’t improving despite completing their homework assignments, if they aren’t improving or are getting worse, we should consider consultation or referral.

As can be surmised by the length of this review (!) there was much to be learned from Dr. Zazio’s wonderfully information-dense presentation, and for members such as myself, 2.5 hours was simply not enough!

Jennifer Myers, MFTI

 Thank you Jennifer for this wonderful review!

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