Using CBT to challenge beliefs and promote curiosity during exposure therapy

By Michael A. Tompkins, PhD, author of Anxiety and Avoidance

Although cognitive behavioral therapy (CBT) works for most clients with anxiety disorders, the exposure tasks are not easy. Because exposure to anxiety-provoking situations is difficult, tending to your client’s willingness throughout treatment is essential to a good outcome. Here are two standard cognitive-behavioral strategies to enhance willingness:

Place question marks next to your client’s beliefs

Clients enter cognitive behavioral therapy believing what they believe. They seldom question their beliefs or assumptions, and the goal of cognitive behavioral therapy is to place a question mark next to a belief rather than trying to change it. Changing beliefs is very difficult and new research tells us that changing a belief may not even be possible. Instead, try to help your client question the value and accuracy of what he believes. Explore with your client his problematic beliefs. If he believes that he can’t handle the fear that he predicts he’ll feel, ask him if he’s handled other distressing feelings in the past and how he managed those. If a cat phobic believes that cats jump on people’s laps to scratch out their eyes, ask him why people would own cats if that were true. Watch for the question mark.

Invite your client to think in terms of experiments

Curiosity enhances willingness. If a child is curious about how a clock works, she may be willing to work persistently to take it apart. Avoid lecturing or instructing your client. Instead, when your client presents an interesting belief or prediction, ask her, “Any ideas about how to test that out?” Ask her what she means when she says “she can’t handle her fear.” Many clients believe that escaping their fear means that they can’t handle it. Help your client see that this is not a good test of whether she can handle her fear or not, then ask, “Can you think of a better way to test that out?” Curiosity initiates experiments. Help your clients become more curious.

Michael A. Tompkins, PhD, is founding partner of the San Francisco Bay Area Center for Cognitive Therapy, Diplomate of the Academy of Cognitive Therapy, and assistant clinical professor at the University of California, Berkeley. He is the author of five books, including Anxiety and Avoidance, OCD: A Guide for the Newly Diagnosed and Digging Out: Helping Your Loved One Manage Clutter, Hoarding, and Compulsive Acquiring (with Tamara L. Hartl, PhD).