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Notes from a Therapy Session with Dr. Aaron Beck

Dr. Aaron Beck recently did a roleplay with a therapist who was attending one of our on-site workshops. (He does a question and answer and roleplay session at each of our workshops.) The therapist played a patient from his own practice, John. John is in his mid-twenties and has a longstanding anxiety disorder.

Here is Dr. Beck’s conceptualization and treatment of John’s problem:

My initial formulation was that the individual had anxiety, which led to his avoiding almost all social contact. He interpreted his severe anxiety and avoidance as a sign of weakness, incompetence, and sickness. After establishing that his goal was to join the military and become a firefighter, I initially thought that I would go step-by-step in desensitizing him to his anxiety. As we talked, though, it struck me that his self-esteem was so low that working on the anxiety would be problematic. He hadn’t been willing to do any exposures. I conceptualized that at the moment, he did not have enough inner strength to confront his anxiety. Focusing on it only intensified his sense of being sick.

My additional formulation thus led me to the idea of building him up, drawing on his strengths, restoring his morale, and so on. I therefore went back to talking about firefighting. I asked him to imagine a specific scene in which he was rescuing people. I also asked him what feelings he got when he imagined this scene. He said he felt very good. When I asked him what he felt good about, he replied that in the image, he was helping people, which made him feel brave and competent. I then asked him what specific activity he could engage in now that could recreate this powerful feeling. It was important to elicit a specific activity, not just any non-specific action. He came up with the idea of helping out his disabled uncle, which I believed would be a great start. Building up a greater sense of a competent self through this specific activity, and others, could later lead him to take the necessary steps toward joining the military or applying to a firefighting academy.

Looking back, I realized that he had been in the sickness or “patient” mode. He had been recusing himself from any activity that would involve the experience of anxiety. He interpreted even therapeutic suggestions (learning strategies) as a sign of sickness. It became important to switch him to the “adaptive” mode before any constructive work could be done. Thus, the focus on his aspiration, namely joining the military or becoming a firefighter, became paramount. I helped him see that helping his uncle could recreate the feeling and the meaning of firefighting.

It is not crucial that John actually achieves his aspiration in order to get better. He was turned down by the military and the firefighting academy because of his history of anxiety. The important objective is to get him involved in activities that have similar meanings to him, such as helping people, being reliable, and so on. Once he’s in the adaptive mode, he is going to be in a much better position to respond to the usual CBT strategies to relieve his anxiety, for example, cognitive restructuring, exposure, and mindfulness and acceptance strategies.