Boice Counseling's Blog - Boice Counseling for Couples

Anxiety does not last forever

8/27/2021

“During the exposure sessions you might want to imagine me saying anyone of the following:
You are discovering that the anxiety indeed decreases when you stay long enough in the situation that you’re afraid of.

Note that you’re much less anxious than you were in the beginning of the session.

I can see that you’re more relaxed this time than during last session’s exposure.

As you can see, the more you confront the situation, the association of things that he becomes weaker and weaker.

As you’re finding out, anxiety does not last forever.

As predicted, none of the things that you feared would happen, did happen.

Touching doorknobs and problem places without washing hands does not cause you to get very sick or infect us or your children.

You will find that checking the entrance door lock only once does not cause robbery of your home.

Tell me your interpretation of the reduction in your distress levels.

Did the consequences happen?
Can you elaborate on that?
Did you refrain from ritualizing during the exposure?

August 26th, 2021

8/26/2021

Trouble Getting Started

8/25/2021

Research by Edna Foa PhD

“If you find yourself hesitating or balking, think of me saying to you:
“I’m sorry to see that you’re having trouble deciding to do this. I’ll support you as much as I can during the exposure if you become upset by doing it.”

“Remember that this is the next step we agreed on, and I will be doing you a disservice to reinforce your tendency to avoid. If you really don’t feel you can do it at this very moment, we will stop for now and resume a little later in the session when you feel ready.

Rarely people actively try to conceal from the therapist ritual activity. Think of me saying this to you:

“I understand that you’ve been having difficulty not checking the front door several times before leaving the house. For the treatment to work well for you, it’s important to adhere to the ritual prevention component. If you’re having a hard time not doing the ritual, please make sure to let me know or your designated support person though, so we can help you overcome the urge to do a ritual.”

We are a team and we know how to win. We can overcome this best by working together.

“If you’re struggling to follow the rules on a regular basis, imagine me saying this to you: “It seems that right now you are unable to stop ritualization as agreed-upon at the outset. For the treatment to be effective, it’s essential that you do so during treatment. Every time you relieve your discomfort by ritualizing -by washing, checking , repeating, you prevent yourself from learning that anxiety would have declined eventually on its own without rituals and that you are able to tolerate the anxiety until it declinesand you don’t fall apart. Doing exposures to feared situations -without stopping the rituals -is not helpful.”

How can we work together to help you follow the “no rituals “rule?

You Deserve the Full Benefit

8/24/2021

“Some patients are resistant early in treatment, EXRP is done gradually through the use of a hierarchy of feared situation.

When you reach the items at the top of the hierarchy, you’ll feel less anxious than you feel right now, because you have already tackled the items lower on the hierarchy.

Your anxiety decreases without doing rituals, your feared consequences do not incur in, during, or after exposure to the feared situations.

Please approach the items at the top of the hierarchy because your mistaken beliefs will be weakened by the time that you even get to the top.

Sometimes we use analogies to demonstrate why drawing lines in the sand puts you at risk for relapse.

Would happen if you weeded a garden but some weeds were left behind?

What would happen to your garden?

Leaving bits of OCD behind increases the likelihood of relapse. “

You want to stack the deck in your favor. OCD cannot win, when you do this. You will prove that you can do it and do it well.

“I don’t want you to cheat yourself out of being able to benefit fully from the treatment. You’ve done the hard work you deserve the full benefit.

Please consider all the things that you want to do but aren’t able to do now because of OCD. What is the cost of OCD?

I want to facilitate your ability and willingness to do different exposures and to adhere firmly to ritual prevention.”

Please Don't Draw Lines in the Sand

8/23/2021

Edna Foa takes on the concept of resistance to the therapy, “Finding resistance?

Consider this perspective: You and the therapist have a battle against OCD that we are waging together. OR

Treatment is not a battle between me and you. When I encourage you to do something, it’s because experience tells us that the exercises that I prescribed will help beat OCD.

If you find yourself procrastinating, I might say, “The time is better spent doing exposures, rather than discussing why you should or should not do them. I would not ask you to do anything that I would not do myself.

I ask you to be fully on board. Please don’t draw lines in the sand.”

You got this. You can be on the other side of OCD and not need my help as much. Go ahead and lean into discomfort. It is worth the short term pain.

Keep Facing Fears Rather than Avoiding

8/20/2021

Edna foa PhD, continues, “After treatment is done, continue to do exposures to the object or situation that used to disturb you. Do this at least weekly.

Do exposures more often if objects or situations are still disturbing.

Make a point to confront the situation deliberately, if you detect a tendency to avoid it.

Remember that the action you perform should not be ended by reducing anxiety or distress. If it does, delay the behavior until the anxiety has decreased.”

Work to face your fears and they lessen. Avoid your fears and they have this tendency to get bigger.

This is not about relaxing or reducing stress. This is about teaching your body and brain that when you have distress, you are competent. You are able to tolerate stress and distress without a ritual or a relaxation technique. You can do those later if you want, but right now, a relaxation technique would lower the distress. That is not the immediate goal.

The Rationale For Prolonged Exposure Treatment

8/19/2021

Edna Foa PhD, Explains, “The rationale for treatment

This treatment involves exposure and ritual prevention.

I’m going to explain to you how “in vivo exposure” together with “ritual prevention” helps overcome OCD symptoms.

When you confront a situation because you’re distressed and you stay in the situation for a long enough time without escaping -you’re not doing rituals, you learn several things first, you learn that the anxiety does not last forever.

In fact, it decreases even without escaping- avoid the ritualizing. Also, you’ll find out that at the same time your anxiety decreases, your urge to ritualize and escape also decreases.

If you have OCD that includes disastrous consequences, such as dying from an illness, causing a fire or flood, think about this but confronting Fear.

You will learn that if you are afraid it will happen if you don’t ritualize, it actually does not happen. You also learned that anxiety does not last forever but you don’t have a nervous break down.

On the contrary, you have to do the same exposure several times, so you’ll feel that you are in control and you’re gonna start feeling like you can overcome the OCD. Do you have any questions about that?

By confronting the things that trigger your fears about something bad happening in years to come, you’ll learn to live without certainty and to tolerate the uncertainty just like most people don’t really know what the future holds. Avoiding, escaping in response to the triggers only gives you the illusion of control.

The rituals strengthen your OCD symptoms in the present.

To help you with some of these objects, images, situations, or thoughts that trigger disastrous consequences, I will obviously not recommend the use of in vivo exposures to certain things. Instead, I will teach you how to do exposures in your imagination. The worst case scenario is that your OCD is presenting to you coupled with ritual prevention so that you can learn that although the thoughts that allowing the thoughts in, increases her stress level, you can tell her and find out That your anxiety will decrease just like with the in vivo exposure.

I now want to explain to you how images in imaginal exposure works to reduce your OCD symptoms. Imaginal exposure can help you in several ways. Imaginal exposure, you and I will write down in detail the things that you’re afraid will happen to you. I’ll ask you repeatedly to imagine these things actually happen. How will imagining these bad things actually happened, help you?

First you will learn that repeatedly imagining that the terrible things you’re afraid of when did happen while to get used to these things you gradually be able to think about them without experiencing high levels of anxiety and distress.

Second you’ll learn that even though your anxiety decreases when thinking about the things you’re afraid of happening, you’re not likely to start engaging the fear."

Extreme Measures for Extreme Disease Conditions

8/18/2021

Edna Foa writes, “Legitimate inquiry is often made by suffers of OCD “would normal people do those extreme things?”

The answer is that extreme measures are required for extreme disease conditions.

Normal people do not get radiation or chemotherapy unless they are fighting cancer.

You’re willingly participating in exposure and ritual prevention in order to best fight OCD.”

How successful do you want to be in life? How much do you want a life that works for you? Yes, you have to work hard sometimes. Yes, even before you are absolutely convinced it is worth it. You have to trust that others have done hard work and it paid off for them and it could for you, as well. Or you can be skeptical and not take necessary risks, just be willing to accept the consequences of your behavior.

Making Sense of "No Pain, No Gain"

8/17/2021

“Most people with OCD temporarily stop their avoidance and rituals, but they find doing so is very uncomfortable, and after a while they may find themselves wondering why anybody would willingly wanna go through that level of discomfort.

To increase the success of exposure and ritual prevention, you must do well-designed exercises, and do them correctly.

Your therapist will coach you.

What you get out of exposure and ritual prevention depends heavily on what you put into it. It also depends on you and your therapist collaboratively coming up with an exposure plan that fits your particular OCD symptoms.”

There is good pain and bad pain in the “No pain, no gain” world. We are walking you through legitimate, necessary pain. In life, there is pain that is unavoidable. If you try to avoid legit pain, that is considered “neurotic” and will warp your experiences here. Go through necessary pain and you will learn that you have more strength and bravery than you realized. You got this. You can do this. It is hard, but you are stronger than it.

“Sometimes exposure exercises may seem counterintuitive or extreme, it will be important for you to practice them anyway.” Edna Foa PhD

Emotional Engagement During Exposure Exercises

8/13/2021

“To be effective and to be helpful, you must become emotionally engaged during the exposure exercises. The exposure situation must evoke the same kind of distress, obsessional distress, that you experience in your daily life when you encounter these situations.

To promote emotional engagement, we will develop exposure exercises that are a good match to the real-life situations that provoke your obsessions and the urge to ritualize.

During the exposure exercises that are a good match to your obsessions, you should pay attention to the distressing aspect of the exposure situation, rather than try to ignore them or distract yourself.

You should think about the potential harm that concerns you.” Edna Foa PhD

We want you to practice it as realistically as possible. It is similar to a scrimmage in sports or dress rehearsal in plays/performances. Practice as close to real as possible and you will learn more and benefit more.

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