Intensive Anxiety Treatment: A Case Study in More Rapid Recovery

By Ferdinando Palumbo, MSW, LCSW, Founder of Northern NJ CBT

Background

It’s 10:00 AM. I am meeting a client at a mall. He has not tried on clothes in at least 5 years, but thinks it could be substantially longer. This client suffers from OCD and his OCD has regaled him with all sorts of horror stories that it claims could happen if he tries on clothes at the mall. Mostly, the OCD nagged him with the terrifying notion that he could spread germs inadvertently to innocent or frail people if he wasn’t extremely careful with getting dressed.

 We had been working for some time together, making some significant gains, but there remained obstructive compulsions related to carefully putting on clothes to avoid spreading germs in public. After stalling a bit in treatment, trying to get him to dress at home on his own without compulsions, I proposed something more drastic—intensive 2-hour sessions, repeatedly putting on clothes in public without any compulsions or safety behaviors.

Although the 45-minute session is largely standard across the United States, and can be very effective in many circumstances, there are times when prolonged sessions and meeting more frequently—sometimes referred to as a therapy intensive—can be more effective in achieving therapeutic goals than a standard 45-minute session. Although we will be discussing this concept in relation to my specialty, Exposure Therapy, the concept of therapy intensives is growing in popularity for many mental health challenges. Some mental health experts, including Dr. David D. Burns of the incredible Feeling Good Podcast, advocate for longer, multiple-hour sessions to assist particularly stuck clients. With this client, he agreed that it was time for a more intense approach to therapy to break through this particular OCD plateau.  A look at the graph below might show us some of the advantages of an intensive approach to anxiety treatment.

Data

These lines reflect data collected from the two intensive sessions. Every 30 minutes of the session, we recorded the reported anxiety on a 0-10 scale. We’ll see when the exposure started his reported anxiety was 10/10. Technically, he said it was 12/10, but for logical consistency, we’ll call that 10/10. This is often where clients are most vulnerable to engaging in avoidant coping, which will reduce their distress in the short-term, but raise it significantly in the long run. However, with me there, I urge him to continue in the exposure and slowly we see the level of distress shrink downward. This is sometimes called a decay slope or habituation curve in clinical literature. Slowly, the distress went from being difficult to manage to being much more tolerable. Then, when we look at the second intensive session, we see this client starts with his distress at an 8/10, but the decay slope/habituation curve drops much more quickly, and then remains at a much lower level of distress. The client was almost shocked that what had been avoided for over 5 years was now causing only near-imperceptible discomfort. The following few paragraphs will explain what this looked like in the intensive sessions.

Intensive Session One Summary

We met at the mall, and he was understandably nervous. He was preparing to stand up to his OCD in a very big way, and he knew he would be flooded with feelings of panic and thoughts of calamities that could, at least hypothetically, occur. We went into the first store, I told him to grab a number of shirts and pants. He asked a store clerk for access to a fitting room, and he put on the clothes.  I asked him on a 0-10 scale how high his anxiety was, he indicated with a slight joke it was 12/10 anxiety. As we reasonably predicted, the OCD was roaring back, trying to convince him that all sorts of catastrophic outcomes could happen. We went to the next store where he tried on more clothes, his anxiety was still at 10/10. Eventually, we moved onto the third store, where, after trying on clothes, the anxiety came down to 9/10. By the time he tried on clothes at the fourth store his anxiety was a 7/10 and we were an hour into the exposure. By the 90-minute mark, we were on our sixth store, and his distress had dropped to a 6/10. We spent the remaining 30 minutes having him try on clothes at the last store of the day, and by the end of our intensive session, he was reporting 4/10 distress. There were some times in there that he felt tempted to wash his hands or engage in other avoidant coping, but after 2 hours, he was glad that he just faced his fears without ceding ground to the OCD.  We talked about the importance of remembering that even intense distress is only temporary as long as one doesn’t give in to avoidant coping.

Intensive Session Two Summary

We meet at the mall. He has some initial apprehension but we get started. We go to the first store and he puts on clothes, but I notice he’s wearing an undershirt as a form of avoidant coping. I remind him that the avoidance will only feed the OCD, he reluctantly agrees and changes again without the undershirt. He reports his initial anxiety at an 8/10. Already a big improvement from the last session where he needed to face his fears for over an hour to get to that level of distress. By 30 minutes, his anxiety had already reduced to a 5/10 and we kept going to additional stores to continue the exposures while ignoring the OCD telling him he needed to wash his hands. By 60 minutes, his anxiety was a 2/10, which remained for the rest of the intensive session. In the second intensive, we had a much more rapid habituation curve/decay slope, where the intensity of the anxiety decayed substantially faster than in the first intensive session.

Conclusion

It would have been very difficult, if not impossible, to achieve these same results in a 45-minute or even 60-minute session, but with additional time in an intensive session, this client could experience the decay in his distress to a much more manageable level and build his confidence in facing these fears. Unfortunately, insurance companies limit therapists to 53-minute or 45-minute sessions, despite substantial evidence for the effectiveness of longer, intensive sessions. If you are stuck with particularly hard-to-face fears, though, it may be a wise investment in your recovery to schedule an intensive session for your anxiety. This is a service we are glad to provide here at Northern NJ CBT. If you are interested in scheduling an intensive therapy session, please contact us here.