WHEN GOOD IS NOT AN OPTION: CHOOSING BAD VERSUS WORSE

Part 2: Notes on Intervention

Basic technique is graded exposure with response prevention. Make sure it is not too graded and prolonged as it may minimize or negate effect.

Exposure involves independent, proactive, self-activation around targets of experiencing and tolerating emotion, as well as “risk”, or not knowing whether the outcome will make matters better, worse or will be neutral.

Therefore, any attempt on the therapist’s part to minimize negative emotions (for the client or others) is to be contained as it is counter-indicative to the exposure target.

Similarly, emphasizing positive outcomes is discouraged. The target is to take action where the client moves into or creates a situation where the outcome is “unknown” or with no guarantees.

Although the therapist can encourage and support the client in their exposure – the client should not be “pushed” or feel that they have to engage in action to appease/please the therapist in order to maintain the therapeutic relationship.

Effort is emphasized over mastery. Therapist self-disclosure can be useful - i.e. the therapist gives examples from their own life where they had to make a difficult decision/take action that involved uncomfortable/painful experiences and feelings.

Emphasize the link between taking action > negative emotions > taking risk versus what the outcome will be. The outcome will “be what it will be”, i.e. it is not the outcome that is important but exposure to independent self-activation that directly moves the client into discomfort and risk.

Exposure experiences can occur in the context of the therapeutic relationship, using imagery for past or current events, as well as outside the office in the client’s day-to-day life. Any given exposure experience should be repeated several times for it to be effective and gains maintained. Exposure experiences can be generalized to new situations, people, etc.

For exposure to be implemented and progress accordingly, the client’s defense mechanisms or “avoidant behaviors” need to be identified so the client can recognize and block them when they occur. Various cognitive restructuring techniques can be used here, as well as mindfulness (observe and describe without judgment), radical acceptance, or simply redirecting where one places their mind/attention. Remember avoidant behaviors come in many forms: They can be in the form of action (physical or verbal expression), affective in nature, or cognitive (both in content – particular thoughts, beliefs, expectations, or style – denial, under or over-estimating, excuse-making, procrastinating, selectively focusing on only one aspect or side, obsessing/ruminating, over thinking, analyzing or intellectualizing).

A good therapist manual that provides a theoretical framework and related assessment and intervention information is “Treating Affect Phobia: A Manual for Short-term Dynamic Therapy” by McCullough, Kuhn, Andrews, Kaplan, Wolf and Hurley. Guilford Press 2003

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