1 Specific Phobias & GAD JONATHAN GASTON DIRECTOR – EMOTIONAL HEALTH CLINIC CENTRE FOR EMOTIONAL HEALTH

2 Defining Fear/Anxiety ‘Fight-Flight Response’ A necessary inbuilt protective response mechanism to protect us from danger and help us survive Only a problem when: Mechanism is switched on when we don’t want it to be OR The intensity of the response seems ‘out of proportion’ to the actual danger

3 Physiological Anxiety Response Rapid heart, heart palpitations, pounding heart Sweating Trembling or shaking Shortness of breath or smothering sensations Dry mouth or feeling of choking Chest pain or discomfort Nausea, stomach distress or gastrointestinal upset Cold chills or hot flushes Dizziness, unsteady feelings, lightheadedness, or faintness Feelings of unreality or feeling detached from oneself Numbing or tingling sensations Visual changes (e.g., light seems too bright, spots, etc.) Blushing or red blotchy skin (especially around face) Muscle tension, twitching, weakness or heaviness

4 Neurobiology of Anxiety (Stein et al., 2007; Etkin & Wager, 2007) 1.Amygdala Hyperactivity – central to fear conditioning 2.Insula Hyperactivity– regulates autonomic nervous system and associated with interoceptive awareness

5 CBT MODELS & ANXIETY

6 ‘Traditional’ A-B-C Model of CBT Linear Unidirectional ‘Thoughts cause feelings’ ABCD SituationsThoughts Feelings Behaviour Focus is on challenging irrational thoughts (cognitive restructuring)

7 More Current CBT Model Thoughts Physiology Mood/Emotion Behaviour Non-linear Integrative All components of equal importance

8 COGNITION Physiology (Physical Symptoms) Mood/Emotion BehaviourPerception/Attention ‘More Conscious’ ‘More Automatic’ Final Cognitive Pathway Model ‘Environment’

9 Cognitive Pathway Model Cognitive, behavioural, emotional, physiological and attentional approaches are potentially ‘synergistic’ not ‘antagonistic’ Humans always employing cognitive processes in solving any problem- whether these processes be more automatic or more conscious in nature Different common pathways (eg., conditioning, observational learning, cognitive challenging, emotional processing, mindfulness) lead to same final common pathway: “Action on an underlying cognitive belief structure”

10 DANGER/THREAT APPRAISALS Anxiety Symptoms ‘Fight or Flight’ Response Anxiety/Fear & Apprehension Safety Behaviours Avoidance Escape Neutralising Hypervigilance for Danger ‘Scanning for threat’ Look for ‘confirming evidence’ ‘Probability’ & ‘Cost’ Final Cognitive Pathway Model for Anxiety ‘Environment’

11 Aim of Treatment for Anxiety “To modify danger/threat appraisals to become more realistic and adaptive”

12 In Designing Treatment for Anxiety Key in Assessment: What are the specific danger/threat expectancies? Key in Treatment: What factors are currently maintaining the specific danger/threat expectancies? Order of Effectiveness in Learning: (Reiss, 1980) 1.Experience 2.Observation 3.Symbolic (e.g., language)

13 CBT for Anxiety - Cognition Key: need to address both probability and cost with some fears Also need to consider ‘Metacognition' - beliefs about the problem itself: –problem (causes, maintenance, costs, benefits) –utility of current coping strategies (general) –specific safety strategies –change –self-efficacy –coping with actual physiological sx. (are sx. harmful?)

14 CBT for Anxiety - Behaviour Key: How is the client's behaviour maintaining their threat appraisals? Safety Behaviours –avoidance & escape behaviours –proactive (‘neutralising’) behaviours –'subtle' in-sitn. safety behaviours –cognitive safety behaviours

15 CBT for Anxiety – Physiology & Emotion traditionally a ‘control-based’ approach now less emphasis than previously relaxation can useful as general stress/anxiety reduction tool be careful intervention strategies do not become safety behaviours often treatment (exposure) will involve increasing Sx. ‘symptom surfing’ - increase coping ‘symptom exposure’ – increase tolerance ‘short term gain vs. long-term change’

16 CBT for Anxiety - Attention attentional focus can interfere with the processing of information from feared situations (‘selective filter’) client needs to process 'range' of perceptual evidence 'task-focussed attention' 'mindfulness' (being in the moment) how best to train???

17 Do Psychotherapies produce Neurobiological effects? (Kumari, 2008) Emerging empirical evidence to demonstrate that psychological therapies produce changes at the neural level Paquette et al., (2003) –Successful CBT modified neural activity in the dorsolateral prefrontal cortex and the para-hippocampal gyrus in a group of spider phobics –“CBT reduces phobic avoidance by de-conditioning contextual fear learned at the hippocampal/parahippocampal region, and by decreasing cognitive misattributions and catastrophic thinking at the level of the prefrontal cortex”

18 SPECIFIC PHOBIAS

19 Lohr, Oluntunji & Sawchuk (2007) The more explicitly danger is signalled in terms of location, duration, intensity & onset, the more specifiable safety signals can be Specific phobias provide the best example of a danger signal with clearly defined boundaries & properties The safety behaviour of avoidance is often so effective that daily life is only minimally disrupted This may account partially for the significant discrepancy between the high diagnostic prevalence vs. the low proportion seeking treatment (1%)

20 SPECIFIC PHOBIA - DSM IV A. MARKED AND PERSISTENT FEAR THAT IS EXCESSIVE OR UNREASONABLE AND CUED BY PRESENCE OR ANTICIPATION OF A SPECIFIC OBJECT OR SITUATION. B. EXPOSURE TO STIMULUS ALMOST INVARIABLE PROVOKES IMMEDIATE ANXIETY. C. PERSON RECOGNISES EXCESSIVENESS OF FEAR. D. STIMULUS AVOIDED OR ENDURED WITH DREAD. E.AVOIDANCE INTERFERES SIGNIFICANTLY WITH NORMAL ROUTINE OR FUNCTIONING

21 Specific Phobia - Subtypes ANIMAL – spiders, snakes, other insects, dogs, birds, sharks, etc NATURAL ENVIRONMENT – storms, heights, water BLOOD, INJECTION, INJURY – seeing blood or an injury, receiving an injection or invasive medical procedure (common fainting response) SITUATIONAL – tunnels, bridges, elevators, flying driving, enclosed spaces, driving OTHER – choking, vomiting, contracting an illness, loud noises, costumed characters

22 DANGER/THREAT APPRAISALS IN SPECIFIC PHOBIAS? Pain Physical/bodily harm Illness/Disease Death

23 Demographics of Specific Phobia LIFETIME PREVALENCE12.5% (Kessler et al., 2005) AGE OF ONSETYOUNG (ÖST) –ANIMAL FEARS - <7 –BLOOD - <9 –DENTAL - <12 –SITUATIONAL (CLAUSTRO)- 20 AGE OF PRESENTATION?? SEX DISTRIBUTION FEMALE 2:1 ratio COURSE OF DISORDER UNKNOWN DEGREE OF INTERFERENCE LOW COMORBIDITY HIGH WITH OTHER ANXIETY DIS (Magee et al., 1996)

24 HERITABILITY OF SPECIFIC PHOBIAS – KENDLER ET AL (1999) TYPEHERITABILITY ANIMAL47% BLOOD / INJURY59% SITUATIONAL46%

25 CONDITIONING THEORY OF PHOBIAS CS UCS (DOG)(BITE) CR UCR (FEAR) (PAIN/FEAR) AVOID

26 PROBLEMS WITH THE CONDITIONING THEORY OF PHOBIAS - RACHMAN (1970), SELIGMAN (1971) MANY AVERSIVE EXPERIENCES DO NOT RESULT IN PHOBIAS (E.G. AIR-RAIDS) PHOBICS DO NOT OFTEN RECALL “CONDITIONING” PHOBIAS DO NOT EXTINGUISH EASILY PHOBIAS OCCUR TO A LIMITED SET OF STIMULI (NO EQUIPOTENTIALITY)

27 PREPAREDNESS THEORY OF PHOBIAS - SELIGMAN (1971) A PREPARED STIMULUS IS ONE WHERE: FEAR IS ACQUIRED IN A SINGLE LEARNING TRIAL THE FEAR IS NON-COGNITIVE THE FEAR IS RESISTANT TO EXTINCTION

28 SUPPORT FOR PREDICTIONS MADE BY THE PREPAREDNESS THEORY OF PHOBIAS (McNALLY, 1987) PREDICTIONSUPPORTED 1. FEAR ACQUIRED MORE QUICKLY TO PREPARED CUE X 2. FEAR OF PREPARED CUE MORE IRRATIONAL X 3. PREPARED STIMULI WILL SELECTIVELY ASSOCIATE BETTER WITH PARTICULAR OUTCOMES X 4. PREPARED ASSOCIATIONS WILL BE HARDER TO EXTINGUISH ✓

29 Rachman (1976, 1977, 1991) Three (learning-based) Pathways to Fear: 1)Classical conditioning 2)Vicarious acquisition through direct or indirect observations 3)Informational acquisition

30 SPECIFIC THREAT EXPERIENCES IN HEIGHT PHOBIA (MENZIES & CLARK, 1993) A NON-ASSOCIATIVE ACCOUNT OF FEAR ACQUISITION ?

31 RELATIONSHIP BETWEEN FALLS AND FEAR OF HEIGHTS (POULTON ET AL, 1998) SERIOUS FALLS BEFORE AGE 5 FEAR OF HEIGHTS AGE 11 YESNO YES4%7% FEAR OF HEIGHTS AGE 18 YESNO YES7%12%

32 RELATIONSHIP BETWEEN FALLS AND FEAR OF HEIGHTS (POULTON ET AL, 1998) SERIOUS FALLS AGES 5 TO 9 FEAR OF HEIGHTS AGE 11 YESNO YES7% FEAR OF HEIGHTS AGE 18* YESNO YES * p <.05 2%13%

Cognitive Vulnerability Model of Phobias

Specific Phobia – Treatment Issues The development of good, well-designed and specific exposure hierarchies Being innovative in planning exposure (e.g., time vs. task) Potential benefits of massed exposure/quick gains ??? The client doing enough exposure (dose-response issue) Dealing with the physical sx. of anxiety while doing exposure ‘Subtle avoidance’ which may reduce exposure effect (the case for early ‘guided’ exposure) The case for ‘overlearning’ ??? Applied tension for fainting in blood-injury phobia ‘Fear vs. disgust’

35 Optimising Exposure (Craske et al., 2008) 1. Variability throughout Exposure –Retention of learned material is enhanced by random and variable practice –While variation increases learning difficulty, it enhances long-term outcome –Variation increases the storage strength of information –Variation results in pairing the information to be learned with more retrieval cues, this enhancing retrievability –Variation leads to superior generalization

36 Optimising Exposure (Craske et al., 2008) 2. Spacing of Exposure Tasks –Temporally spaced learning trials may result in stronger learning acquisition than massed –Evidence suggests though that each trial must sufficiently violate fear expectancies –? Massed X Spaced interaction –Some evidence for ‘tapering’ (progressively longer intervals between exposure occasions 3. Context Effects –Should conduct exposure therapy in multiple contexts, especially those in which the previously feared stimulus is likely to be encountered once treatment is over

37 Optimising Exposure (Craske et al., 2008) 4. Fear Toleration vs. Fear Reduction –Emotional regulation is potentially dysfunctional when applied rigidly to down regulate emotions through suppression, control, avoidance or escape –Persistent attempts to down regulate aversive states are often critical to the onset of phobias and other anxiety disorders – Some evidence that sustaining fear responding throughout extinction may actually enhance extinction learning

38 GENERALISED ANXIETY DISORDER

39 Lohr, Oluntunji & Sawchuk (2007) The more explicitly danger is signalled in terms of location, duration, intensity & onset, the more specifiable safety signals can be Danger signals that transcend time and place (unpredictability of onset) make for poorly defined safety signal development Danger signals in the form of intrusive thoughts and worries that are future-oriented and involve catastrophic outcomes with objectively low probability do not allow for the establishment of safety relative to current time and place The broad nature of threat will render safety seeking behaviour as ill defined and generalised Is GAD largely a chronic but unsuccessful search for safety ? (Woody & Rachman, 1994)

40 GAD: DSM-IV Criteria A.EXCESSIVE ANXIETY AND WORRY OCCURRING MORE DAYS THAN NOT FOR AT LEAST SIX MONTHS ABOUT A NUMBER OF EVENTS. B.DIFFICULTY CONTROLLING THE WORRY C.AT LEAST THREE OF THE FOLLOWING: –1) RESTLESSNESS OR FEELING KEYED UP –2) EASILY FATIGUED –3) DIFFICULTY CONCENTRATING –4) IRRITABILITY –5) MUSCLE TENSION –6) SLEEP DISTURBANCE D. FOCUS OF WORRY NOT ANOTHER AXIS 1

41 DANGER/THREAT APPRAISALS IN GAD? Many and varied Two key underlying issues: 1.The world is an unpredictable and unsafe place 2.I am ill-equipped to deal and cope with this danger and general uncertainty (‘ a poor coper’) People with GAD like control and predictability

42 DEFINITION OF WORRY BORKOVEC ET AL. (1983) AN ATTEMPT TO ENGAGE IN MENTAL PROBLEM-SOLVING ON AN UNCERTAIN ISSUE WITH A POTENTIAL THREAT OUTCOME

43 CONTENT OF WORRIES IN GAD - ROEMER ET AL (1997) GAD % OF TOTAL WORRIES NON- CLINICAL FAMILY / HOME / RELATIONSHIPS FINANCES WORK / SCHOOL ILLNESS / HEALTH MISCELLANEOUS

44 CONTENT OF MISCELLANEOUS WORRIES IN GAD - ROEMER ET AL (1997) GAD % OF TOTAL WORRIES NON- CLINICAL PSYCHOLOGICAL/ EMOTIONAL MINOR/ ROUTINE FUTURE SUCCESS/FAILURE TRAVEL

45 FEATURES OF WORRY IN GAD CRASKE ET AL. (1989) GADNON-CLINICAL DURATION ANXIETY CONTROL * REALISM * SUCCESS OF STOPPING *

46 GAD - DEMOGRAPHICS GAD has a lifetime prevalence of 5% GAD affects approximately adult Australians each year Gender ratio: Females 60% GAD makes the top 12 diseases for disability adjusted life years lost GAD presents a substantial financial cost to the community, e.g., high health care costs and lost work productivity GAD is associated with substantial co-morbidity - primarily other anxiety disorders & depression

47 DSM-IV DISORDERS AND AFFECTIVE STRUCTURE – BROWN ET AL (1998)

48 Life Interference GAD interferes with: –Work and academic functioning/aspirations (over & under achievement) –Enjoyment and quality of life (chronic cognitive & physical arousal, avoidance) –Emotional experience (can be aloof or overly-emotional) – Engagement in interpersonal relationships (stress, intimacy, genuineness, avoidance, isolation) Pure GAD is equally as disabling as pure MDD

49 Course GAD has an early onset and a chronic course Most people with GAD have always been worriers Mean onset is between the teens and late twenties BUT, onset may be earlier (children were previously diagnosed with “overanxious” disorder) GAD symptoms are chronic and persist for 10 yrs or more GAD is unlikely to remit spontaneously

50 PROBABILITY OF REMISSION OF GAD (YONKERS ET AL, 1996) WEEKREMISSION FROM GAD ONLY REMISSION FROM GAD PLUS ALL OTHER ANXIETY

51 Contributing Factors? Genetics, temperament factors, parenting styles Some evidence that people with GAD have more insecure attachment styles– primarily ambivalent Childhood relationships characterized by enmeshment with caregivers – children had inappropriate levels of responsibility (parenting their parents) Some evidence of heightened levels of early trauma These factors impact on: –Coping styles and Self-efficacy –Enhance vigilance and planning for threat, but feel poorly resourced to deal with actual threat; feeling overwhelmed –Enhance fears of uncontrollability and unpredictability –Children may internalize beliefs about vulnerability, weakness, inadequacy

52 FREQUENCY OF DISORDERS IN 1ST DEGREE RELATIVES - NOYES ET AL. (1987)

53 MODELS OF GAD

54 WORRY AS EMOTIONAL SUPPRESSION - BORKOVEC WORRY COMPLETELY SEMANTIC FULL EMOTIONAL PROCESSING REQUIRES BOTH SEMANTIC AND VISUAL PROCESSING HENCE WHEN WORRY - EMOTIONS PROCESSED AT A “LOWER” LEVEL THUS WORRY USED TO AVOID COMPLETE EMOTIONAL EXPERIENCE IN TURN, EMOTIONAL ISSUES ARE MAINTAINED

55 Emotional Avoidance and Regulation 1 Borkovec’s cognitive avoidance model essentially says that people with GAD fear intense negative emotions But he doesn’t conceptualise this as another threat appraisal that is fuelling worry Instead he argues that worry has a function, that is, it acts as a form of cognitive avoidance that inhibits negative affect through the automatic/unconscious inhibition of imaginal processing This in turn negatively reinforces the use of worry as an emotion regulation strategy, which dampens anxiety in the short term

56 Emotional Avoidance and Regulation 2 Mennin et al. (2002, 2004), following from Borkovec, have suggested that GAD is a disorder of emotion dysregulation involving: –Heightened emotional intensity –Heightened emotional reactivity –Maladaptive emotional management –Poor understanding of emotions Leading to emotional avoidance Poor tolerance of emotions

57 RELATIONSHIP BETWEEN WORRY, COPING & ANXIETY - DAVEY (1992) PARTIAL CORRELATIONS BETWEEN WORRY AND COPING, CONTROLLING FOR TRAIT ANXIETY ACTIVE COGNITIVE COPING.26* ACTIVE BEHAVIOURAL COPING.11 AVOIDANT COPING.30*

58 COGNITIVE MODEL OF GAD (WELLS, 1995) TRIGGER POSITIVE META-BELIEFS ACTIVATED (STRATEGY SELECTION) TYPE 1 WORRY NEGATIVE META-BELIEFS ACTIVATED TYPE 2 WORRY BEHAVIOUR THOUGHT CONTROL EMOTION

59 TYPE 1 Worries (Wells,1995) 1.Concern external daily events –(e.g., health of a partner) 2.Concern non-cognitive internal events –(e.g., bodily sensations)

TYPE 2 Worries – Meta-worry (Wells, 1995) How people appraise (both positive & negative) the activity and function of worry ‘worry about worry’ This meta-worry leads to the client further engaging in Type 1 worry Can broaden concept to use with other anxiety and non-anxiety problems - ‘beliefs clients may hold about their problems’ (origin, nature, maintenance, costs & benefits) Fit/misfit between your treatment model and their implicit model will effect engagement and progress

61 A THREAT EXPECTANCY (INTEGRATIVE) MODEL OF GAD (Abbott & Gaston, 2003)

63 Threat Expectancy in GAD The potential for danger is everywhere! Our model suggests that there are five core categories of threat expectancy that can be activated in GAD 1.Situations themselves are potentially threatening 2.Potential confirmation of negative core beliefs is threatening 3.Affect itself is perceived as threatening 4.The consequences of not coping are seen as threatening 5.Worry process itself is perceived as threatening

64 Threat, Affect and Neutralizing These ways of perceiving threat may be activated in isolation or in combination, and they all feed the perceived intensity of worry and anxiety Biological/tolerance factors may moderate the actual amount of affect experienced The cognitive and affective experience of anxiety triggers the use of avoidance and safety strategies to control potential threat and aversive experience

65 Predisposing Factors Predisposing factors for GAD include: –A genetic predisposition to negative affect –Ruminative perseverative cognitive style –Intolerance of strong negative affect –Early life experiences –Parenting styles

66 Negative Core Schemas in GAD Predisposing factors lead to the development of underlying schema. Themes of negative schema in GAD seem to include beliefs like: –I am defective –I am vulnerable –I am weak –I am inadequate/incompetent –I am worthless According to the model, these underlying negative schema drive threat expectancies in GAD

67 TE1. Inflated Perceptions of Situational Threat Overestimate the probability of negative events occurring AND Overestimate the cost of negative events, should they occur AND Underestimate their ability to cope, should a negative outcome occur

68 Intolerance of Uncertainty (Dugas et al., 2004) People with GAD find uncertainty threatening –fearing and avoiding situations with ambiguous outcomes –preferring the occurrence of a negative outcome to it’s possibility –Only situations that are perfectly controlled are safe But, uncertainty is certainly inevitable! Anxiety about uncertainty is closely linked to fears about unpredictability & uncontrollability and positive beliefs about worry “If I am in control and know what will happen, then I can prevent negative outcomes” “worry helps me do this”

69 INTOLERANCE OF UNCERTAINTY AND WORRY - DUGAS ET AL. (1997) CORRELATION WITH PSWQ UNIQUE VARIANCE EXPLAINED BAI % BDI.538.0% PROB SOLV SKILLS.160.6% INTOL. OF UNCERT %

70 TE2. Confirmation of Beliefs about the Self Anxiety is also experienced when there is the potential for negative core beliefs to be confirmed –e.g., Doing an exam will be anxiety-provoking if you believe it may confirm beliefs about inadequacy In response to the anxiety, clients use safety strategies, like perfectionism –e.g., Engaging in non-stop studying to prevent potential failure –e.g., Last minute studying allows a more palatable “excuse” should failure occur Potential confirmation of beliefs triggers anxiety Perceived confirmation of beliefs triggers low mood

71 TE3. Meta-beliefs about Affect Negative affect is perceived as threatening in GAD because it is experienced as overwhelming and distressing The experience of intense affect triggers attempts at avoidance or neutralizing Emotions that may be perceived as threatening: –Fear and Anxiety –Anger –Depression –Positive affect?

72 TE4. Meta-beliefs about Coping The perceived consequences of not coping with negative outcomes is also seen as threatening For example, If I can’t cope with the feared event, does that mean: –I am a failure? –I am irresponsible? –It’s my fault? –I am a bad person? –I can’t tolerate these feelings of guilt … People with GAD hold rigid standards about coping – they should cope perfectly, without any distress

73 TE5. Meta-beliefs About Cognition - Worry is Threatening People with GAD hold strong beliefs that the process of worrying is dangerous to them (e.g., Wells, 1997) If you believe that worry is harmful then you will probably spend a lot of time monitoring your thoughts, trying not to worry, and engaging in a range of associated safety strategies (e.g., checking physical symptoms; thought suppression)

74 Examples of Negative Meta-worries My worrying is uncontrollable Worrying is harmful to me I could “go crazy” from worrying My worries will take over and control me I could get into a state of worrying and then never be able to stop If I worry too much I could lose control Worrying makes me physically sick and puts stress on my body If I don’t control my worry then it will control me If I worry it means I am a weak person People will respect me less if they find out about my worry My worry is harmful to others (eg family members)

75 Avoidance & Proactive Safety Strategies – ‘Trying to Feel Safe and In Control’ The experience of intense negative affect triggers the use of behavioural, cognitive and emotional safety strategies –Perfectionistic behaviour may be triggered if not doing well on a task confirms beliefs about inadequacy –Engaging in frequent attempts to suppress worries may be triggered by beliefs that worry is harmful People with GAD use a large array of safety strategies to try and control potential negative outcomes and so they can feel safe

76 Some Safety Strategies Behavioural Reassurance seeking Controlling others, situations, feelings Perfectionism Over-responsibility Busyness Procrastination Avoiding uncertainty Avoiding triggers Cognitive Thought suppression Shifting, narrowing attention Distraction Checking symptoms Positive meta-beliefs about worry?? Rumination?? Emotional Repression Dissociation Numbing Emotional blunting

77 Effects of Using Safety Strategies Safety strategies provide some relief from anxiety in the short-term by exerting a dampening effect on anxiety But, safety strategies reinforce negative underlying schema and threat expectancies in the long term by: –Preventing disconfirmation of beliefs about threat –Providing some confirmation for beliefs about threat

78 TREATING GAD

79 Standard CBT Components Psychoeducation about anxiety Detecting triggers and early warning signs Implementing alternative coping strategies Teaching realistic thinking skills Teaching relaxation skills Teaching problem solving/stress-reduction skills Graded exposure (e.g., to worry triggers) Exposure to worry Worry time

80 Treatment Reality Research has shown that CBT is effective at reducing anxiety for sufferers. But the outcome data is not so impressive and we can still do a lot better “After 16 years of concerted effort, applications of behavioral and cognitive therapy techniques for treating this anxiety disorder continue to fail to bring about 50% of our clients back to within normal degrees of anxiety” (Borkovec, 2002, p.76)

81 What Should We Address in Therapy? Myriad of threat expectancies Underlying negative schemas The multitude of safety strategies that are in place to neutralize or avoid potential threat Particularly important to address the avoidance of intense affect and to facilitate the completion of emotional processing

82 Acceptance & Mindfulness-based Approaches Premise: ‘We compound our suffering by trying to avoid it’ Mindfulness is a strategy for gradually turning the client’s attention toward the fear (external and/or internal) as it is happening and exploring it in detail with increasing degrees of acceptance Gradual shift in client’s relationship to anxiety from avoidance to tolerance to acceptance Mindfulness is an awareness of, rather than thinking about, mental events - implying acceptance

83 Acceptance & Mindfulness-based Approaches The overarching goal is to reorient clients away from maladaptive attempts to alter their thoughts and feelings, and toward making positive, sustained behavioural change that is consistent with one’s values & goals - essentially to live better rather than to think and feel better

84 Current Questions ??? Control approach vs. acceptance approach ? Can we integrate mindfulness/acceptance with CBT ???

85

86 My Contact Details Jonathan Gaston Director – Emotional Health Clinic Centre for Emotional Helath Phone: (02) Fax: (02) Mobile: Office:Room 605, Building C3B