Drs. Narsimha Pinninti and Rajnish Mago offer a brief, easy-to-use intervention to teach patients to control their anxiety. (“In-session anxiety: 5 steps to help patients relax,” Current Psychiatry, August 2005).
In step 4, the authors recommend having a patient with cognitive symptoms “look around the room and describe in detail what he sees” over 3 minutes. They also suggest having a patient with physiologic/affective symptoms “close his eyes and (remember) when he felt safe and content,” also known as the “safe-place technique.”
Distraction—the central ingredient in both interventions—is often used in cognitive-behavioral therapy (CBT), an empirically supported treatment for anxiety disorders. In CBT, however, the therapist first conceptualizes what is generating and maintaining the anxiety and hypothesizes what the intervention will teach the patient. For example, a patient who fears flying might use distraction to decrease pre-flight anxiety.
In other instances, such as during panic attacks, distraction may be a “safety behavior” that allows patients to control or avoid anxiety out of fear that the physical sensations they experience during panic are dangerous. While these behaviors may provide temporary relief (via negative reinforcement), they condition patients to rely on them to feel safe, thus perpetuating the anxiety.1 These patients should be encouraged to gradually and systematically experience anxiety symptoms and learn to manage or tolerate them.
Likewise, interventions such as those found in step 4 may help most anxious patients feel better during the session (via avoidance/distraction) but might maintain the anxiety that patients (and doctors) want to reduce.
Rather than applying a universal or “Procrustean” approach, psychiatrists should tailor interventions such as those suggested in step 4 to each patient’s anxiety.2 This way, they can be applied when appropriate with more durable and meaningful results.
Simon A. Rego, PsyD
Katherine L. Muller, PsyD
Colleen Jacobson, PhD
Cognitive-Behavioral Therapy Program Montefiore Medical Center
Bronx, NY
- Lazarus AA. Behavior therapy and beyond. New York: McGraw-Hill; 1971.
- Mowrer OH. Learning theory and behavior. New York: Wiley; 1960.
The authors respond
Dr. Rego et al raise some excellent points.
We agree that techniques based on distraction are among several that a clinician should consider. We do not advocate use of these interventions for long-term anxiety control or as complete cognitive-behavioral therapy.
Techniques based on distraction, however, can have unique advantages when used appropriately. First, distraction techniques are obviously more likely to work when in-session anxiety is pronounced. Also, as Dr. Rego et al note, distraction techniques can be valuable in acute situations.
Second, associated dysfunctional beliefs often fuel anxiety. For example, patients commonly believe that they cannot control their anxiety. Some also believe that they need PRN medications such as benzodiazepines to control the symptoms (safety behavior), leading in some cases to abuse of prescribed medications. The steps we suggest would help show patients that they don’t need PRN medication. Learning not to rely on these agents can improve their sense of self-efficacy and reduce their overall anxiety.
Third, patients engage in a range of “safety behaviors”—from simple distraction to substance abuse. In some instances, helping the patient change his or her safety behavior from medication reliance to reliance on self-regulated activities is a reasonable short-term therapeutic goal. We have found that these techniques have helped some patients reduce PRN medication use.
Narsimha R. Pinninti, MD
School of Osteopathic Medicine
University of Medicine and Dentistry of New Jersey, Camden
Rajnish Mago, MD
Thomas Jefferson University,
Philadelphia, PA