What Every Therapist Needs to Know About Anxiety Disorders

by Martin N Seif

  PATIENT: I am at a 4 right now.

  THERAPIST: OK, how about walking to the back of the store and locating the milk?

  PATIENT: I just shot up to a 7.

  THERAPIST: Well you are still in the same place. What happened that you went to a 7?

  PATIENT: I was imagining me getting lost and panicky when I could not see you. Can you come with me?

  THERAPIST: So your imagined scene of panic made your anxiety go up to a 7. What happens if you imagine me there with you?

  PATIENT: It went back down to 5.

  THERAPIST: And the whole time we haven’t moved.

  Here is another labeling technique: adding “I’m having the thought that …” to the beginning of a statement often helps to distinguish thoughts from facts.

  PATIENT: I don’t want to interact with my neighbors. They don’t like me.

  THERAPIST: Could you try “I am having the thought that my neighbors don’t like me”?

  PATIENT: I am having the thought that my neighbors don’t like me.

  THERAPIST: Any different?

  PATIENT: I guess I do not actually know this. But it could be true.

  THERAPIST: Well, yes, it could be true or not true. But I want you to see that you are treating this thought as if you already know it is a fact.

  The simple mindful technique of labeling and observing thoughts is also helpful. During this flight, notice the therapist makes no attempt to distract, refute or counter any of the patient’s “what if” thoughts.

  PATIENT: I’m afraid the plane will crash.

  THERAPIST: That is an anxious thought, go on.

  PATIENT: I worry that we will hit another plane in this fog.

  THERAPIST: Another anxious thought.

  PATIENT: The computer to see other planes could break down.

  THERAPIST: Another anxious thought, next?

  PATIENT: It will be windy and foggy when we land.

  THERAPIST: Anxious thought.

  PATIENT: Yes, I’ll go on. A gust of wind could topple us over.

  THERAPIST: Anxious thought.

  PATIENT: The computer could be wrong. Anxious thought (laughs).

  THERAPIST: I’m not sure I’m needed here.

  Increase Doubt about Anxious Messages

  The following person with OCD has an elaborate sleep time ritual to ensure that no germs contaminate her bed.

  PATIENT: I am exhausted by the time I get into bed. The last thing I do is turn off my light with a tissue.

  THERAPIST: And you do this because you believe the germs can hurt you?

  PATIENT: Yes. My bed is the only safe place in the house. And if stuff from outside got onto my floor, and then onto my bed, I would be dirty as well.

  THERAPIST: Is this an uncomfortable feeling or do you think you are really in danger? Or another way to put it, is this an OCD thought or a factual representation?

  PATIENT: I don’t know. If I knew it was OCD, I wouldn’t be driving myself crazy. It seems real. It feels real. I don’t know. I can’t know.

  THERAPIST: I agree you can’t know for sure. But let’s try to see your very best guess. Imagine this: “I have a gun. I will shoot you if you guess wrong. You only get one guess. I want you to tell me if this is an OCD thought or a real danger.”

  PATIENT: That way. If I must choose, and if I die if I’m wrong, then I’ll say it is OCD.

  THERAPIST: So you are at least 50.00001% sure it is OCD. So you need to treat it as an OCD thought.

  This is an example of the Gun Test proposed by Grayson (2003). The patient suspects OCD thoughts, but isn’t sure, and wants to be sure. The Gun Test allows for uncertainty even while labeling the thought as anxiety. Grayson says that “Thoughts are just guesses about reality.”

  Psycho-education plays a role in increasing doubt about anxious thoughts. One patient had a lightheaded feeling that triggered terror and the fear of a brain tumor. She was able to hold onto the information that lightheaded “faintiness” is a common symptom of anxiety. Sometimes these feelings were reduced during diaphragmatic breathing. Together, this enabled the labeling of feelings as anxiety rather than a dangerous neurological condition. It gave her courage to allow the feelings and dispense with her usual reassurance behaviors. It allowed the anxiety to reduce on its own.

  The following patient with SAD was able to use information modeled by his therapist. The patient feared leading weekly team meetings at work. He worried about losing his concentration; just standing in front of the room awkwardly paused, with everyone thinking of him as a weird, incompetent team leader.

  PATIENT: And the worst part is that I get so anxious that I actually lose my place. I stand there saying nothing while looking for my notes. Everyone sees how weird I look, and that makes it worse.

  THERAPIST: You think standing there without saying anything makes you look weird? How long do you stand there?

  PATIENT: Certainly. And even if it isn’t long in an objective sense, it still feels like eternity to me.

  THERAPIST: Well, let me tell you a story about one of the great orators. He would speak to thousands of people. And here … is … one … secret … to … what [the therapist’s speech slows significantly] … this person … knew…. Here it is … [a pause of 10 seconds]. It is that [resuming normal speaking speed] putting pauses in talks actually engrosses the audience. Now, what was your experience as I was pausing my speech?

  PATIENT: I was waiting for you to continue. I started to lean forward.

  THERAPIST: Did you think I looked weird?

  PATIENT: No, but I hoped you were okay.

  THERAPIST: There is a lesson here for you.

  PATIENT: I got it.

  Encourage the Paradoxical Approach

  Anxiety is a relentless bluffer, and following its directions will prolong anxious arousal. The general rule is to do the opposite of what anxiety is telling one to do, or, more often, to move in the direction that anxiety is telling the patient not to go. Carbonell (2004) calls this the rule of opposites.

  A patient with panic disorder must attend a benefit concert for work.

  PATIENT: I am having nightmares about the concert. What if I panic in the middle of the performance? I haven’t been able to buy my tickets, because I just don’t want to think about it.

  THERAPIST: Buy your ticket; it will actually lower your anxiety. You are currently going through an internal “should I or shouldn’t I?” debate that is keeping your anxiety level higher. There is nothing more anxiety-producing than staying on the fence. Make a commitment, and see what happens.

  This next patient suffers from SAD and fears dining with others in restaurants. He fears the embarrassment of having to leave the table to use the bathroom. More specifically (and this is an example of why details make a difference), he fears having to use the men’s room a second time, since he imagines that will put him under great scrutiny. For that reason, he tells himself, he must “save” his first bathroom visit, because once he uses it he is vulnerable to the humiliation of going a second time.

  PATIENT: I was in the restaurant and my stomach was hurting and I knew I had to hold on. But then I wondered if people are noticing that something is wrong, and maybe they are thinking I’m looking odd. And all of a sudden I had this urge to pee. But I wanted to wait. It was too close to the beginning of the meal.

  THERAPIST: I’d like you to do the opposite. Walk into the restaurant and use the men’s room. Sit down at the table and use it again, whether you feel the urge to pee or not.

  PATIENT: But I’ll worry they’ll think I’m weird.

  THERAPIST: Perhaps, but your worry will be less than if you follow what your anxiety is telling you to do.

  Here is another example:

  PATIENT: When the plane takes off I put my head between my legs, close my eyes, and pray that everything will work out okay.

  THERAPIST: Why do you put your head down that way and close your eyes?

  PATIENT: I hate the feelings of acceleration and turni
ng, and I hope that with my head down, I won’t feel them.

  THERAPIST: Those actions are making you more sensitive to the sensations. The next time you take off, do your best to sit up, look around with your eyes open, and focus on what is happening in the present. There is a good chance you will feel much less anxious.

  Here is another example:

  PATIENT: Whenever I go to a party, I am dreading that no one will talk to me. I feel like a loser.

  THERAPIST: Here is a suggestion: Spot the person who looks the most lonely and miserable and make it your goal that that person has a great night.

  And another:

  PATIENT: I text my kids several times a day. I just want to make sure they are OK.

  THERAPIST: You are obeying your OCD thoughts. I wonder what would happen if you turned off your phone and dealt with your “what ifs” as thoughts instead of messages.

  Anything Worth Doing Is Worth Doing Badly (WordPoints, 2011)

  The pursuit of perfection raises anxious arousal, increases anticipatory anxiety, and indicates an unwillingness to allow feelings of awkwardness that accompany new activities. The need for immediate excellence initiates a self-evaluative process that takes patients away from present experience into a world of “what ifs?” Patients can generally function well with high levels of anxiety, although not so efficiently. They are certainly unlikely to scream, faint, or do the embarrassing, outrageous, or dangerous things they sometimes picture in their mind. The need to be “the best” makes necessary uncertainties intolerable, and that is why perfectionism often paralyzes.

  Suggest to patients that their task is to do “well enough,” without precisely defining what “enough” means. Remind them that the only way to surely avoid making mistakes is to do nothing, and that is why the pursuit of perfection often leads to immobility and paralysis. The need for perfection is a bit like hot-wiring the amygdala, and so it leads to increased anxiety, writer’s block, and a more generalized freeze response.

  People cling to perfectionism for many reasons involving critical judgments about themselves as well as expected (and often projected) judgments by others. But most frequently they fear that if they give up the effort to be absolutely perfect, they will slide into mediocrity, apathy, and failure. In fact, releasing oneself from perfectionism allows for the achievement of excellence, in part because one learns best from mistakes, and resilience following mistakes is a genuine mark of excellence required in all performance.

  Perfectionism can also be conceptualized as a form of OCD—with the constant checking for mistakes and inadequacies as a compulsive way of avoiding the uncertainty of possibly not measuring up or being good enough. There is also the attempt to make certain that success will occur now and in all future endeavors. Thus, deliberately making mistakes—or even better—allowing the possibility of having made a mistake, and deliberately not checking—can be an excellent technique for dealing with perfectionism.

  Slow Down and Let Time Pass

  Patients frequently rush through anxious experiences in an effort to minimize their misery. They attempt to get home before the panic hits, get over the dreaded speech, or gobble down food to shorten a socially anxious inter action. Patients often believe that they were about to panic and would have surely lost control if they had stayed a moment longer, thereby feeding the illusion that danger was indeed averted. Some patients fight with time. Many believe that rushing makes them more productive, but rushing has little effect on productivity. Rushing is arousing to the autonomic nervous system, and adds to fear feedback loops. Additionally, rushing through experiences validates the belief that there is something wrong with slowing down, and makes it more difficult for patients to practice the valuable skills of mindful awareness and allowing time to pass. Some patients acknowledge this with the promise that they will slow down “as soon as I have finished what I need to do.” However, experience shows that most of these patients never finish what they need to do. If patients wait until their work is done to slow down, most never will.

  Slow down and let time pass.

  A better way of managing anxiety-producing situations is to slow down, pay attention, and consciously allow the unfolding of what is happening. A helpful metaphor is to imagine walking in a swimming pool where the water is chest high. The eventual goal is to get to the other side. It is impossible to go fast, each step must be deliberate, and the goal will be reached, one step at a time. Slowing down is a prerequisite to mindful awareness.

  Reminders to Take Care of Oneself and Not Everything Else

  Patients need reminders to define and limit their job and to try not to manage the whole world. That tendency increases “what if” thoughts, leading to feelings of being overwhelmed and increased anxiety. Ask your patients if they can let the pilot take care of the plane, let the driver take care of the bus, and let the others do their own job. Carbonell, describing the most therapeutic attitude to cope with fear of flying, tells patient that they are only “Baggage that breathes” (2004, p. 136). The patient’s job is to take care of himself, monitor his own anxiety level, and do manageable things in the present.

  Let the pilot take care of the plane.

  Similarly, it is common for anxious parents to feel as if they are the only ones making decisions about their children: actual shared responsibility for both decisions and outcomes is often a vague concept. People with OCD frequently have an inflated sense of responsibility. Here is an example:

  PATIENT: I am compelled to pick up every bit of trash I see.

  THERAPIST: What is the thought that drives that?

  PATIENT: Well, if I see something on the street and I don’t do anything about it, then if someone trips over it and breaks a hip, it is my fault. I can’t stand that idea.

  THERAPIST: Do you think I would be a bad person if I walked past a piece of trash?

  PATIENT: No, I wish I were like you.

  THERAPIST: Well if it is not my job, why is it yours?

  I Am Bigger Than my Thoughts

  Anything that encourages a different figure/ground relationship between anxious thoughts and sensations, and ordinary present experience can be helpful. This would include creating metaphors to understand how to passively observe thoughts, images, and sensations while pursuing behavioral goals. Watching dispassionately what is happening in the mind and body allows one to move anxious arousal from the overwhelming foreground to the less consuming back ground, thereby creating a larger perspective. Many psychological paradigms describe this phenomenon of becoming aware of and operating from an internal stance of “I am bigger than my thoughts.” A simple illustration of this perspective is to add the words “I am having the thought that …” in front of an anxiety-producing thought. Thus, “I am losing control” becomes “I am having the thought that I am losing control.” This immediately draws attention to the larger “I” which is observing the “I” having the thought. Another simple application is the question “What is my mind telling me now?”

  I am bigger than my thoughts.

  This same change of perspective is akin to Gestalt principles of figure/ground (Rock and Palmer, 1990), the concepts of defusion and expansion derived from acceptance and commitment therapy (ACT) (Hayes, 2004; Harris, 2008), the mindful stance central to dialectical behavior therapy (DBT) (Robins, Ivanoff, and Linehan, 2001), and mindfulness based stress reduction (MBSR) (Miller, Fletcher, and Kabat-Zinn, 1995).

  Reid Wilson’s (2009) concept of “the observer” was an early description of consciously promoting this kind of disengaged awareness during anxious arousal. Wilson also describes shifting anxiety symptoms from “signal” (meaningful or important intrusions) to “noise” (background annoying but unimportant static).

  Increase Willingness to Experience Discomfort

  This is a variant of motivational interviewing, but in this case the patient is taught to interview himself. The approach addresses an oft-observed phenomenon: in the throes of anxious arousal, the patient might not be able to r
emember why—or believe that—therapeutic goals are worth the discomfort. Anxiety has the capacity to wash out other emotions: an intense desire to face fears and expand one’s life can be lost to anxious arousal. The therapist can query the patient and remind him about his reasons for persevering through the anxious storm to the other side. Questions include:

  Ask: Why are you willing to experience discomfort?

  What have you paid in terms of quality of life and restrictions on freedom to keep your avoidances intact? Are these payments costing you more than you can afford?

  Who else are you hurting (family? friends? employer?) by giving in to the false messages of your anxiety?

  What values important to you personally do you betray by being unwilling to undergo this discomfort? Will you ultimately feel worse or better if you undergo this discomfort?

  There is an art to these motivational pep talks, and they can be counter-productive if turned into non-compassionate self-bullying. But if compassionately delivered, these reminders can increase motivation to stay with discomfort. They spell out concrete reasons to experience short term discomfort for a future with less suffering.

  Competence-enhancing Skills

  Sometimes anxious anticipation is a reasonable response to poor skills or competencies, as opposed to a fear of arousal. In these cases, it is helpful to practice new techniques, learn new competencies, and generally increase skills for coping with practical requirements. One example of this would involve social skills training and role-playing practice for exceedingly shy people who lack social interactions skills. Another would be that of a musician practicing to the point of trusting one’s “automatic pilot” to form the backdrop for treating performance anxiety. Similarly, if someone’s anxiety over driving is fuelled by a poor sense of direction, then learning to read a map or consulting a GPS would be helpful.