What Every Therapist Needs to Know About Anxiety Disorders

by Martin N Seif

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  8

  Exposure

  The Active Ingredient

  I believe that anyone can conquer fear by doing the things he fears to do, provided he keeps doing them until he gets a record of successful experiences behind him.

  Eleanor Roosevelt

  There is no failure. Only feedback.

  Robert Allen

  All exposure therapy is guided by the principle that anxiety is maintained by avoidance and intentional exposure is the active ingredient of recovery. If one moves towards the source of anxiety and willingly experiences the discomfort that arises, the anxiety will diminish. Patients begin to learn that they can cope with anxious feelings—that what is distressing is not dangerous—and so need not spend so much energy avoiding distress. When people pay less attention to avoiding anxiety—when they disengage themselves from anxiety’s false and frightening messages, anxiety becomes less intense, overall arousal reduces, and symptoms remit quite naturally.

  Equally therapeutic is a patient’s realization that they need not distance themselves from the source of their anxiety in order to feel better. They can experience anxiety and recover while still in contact with the anxiety triggers—an elevator for the claustrophobe, a crowded room for the social phobic, a dirty hand for the person with obsessive-compulsive disorder (OCD). This realization—that they can feel anxiety and then recover while still in the anxiety-producing situation—is a concrete step towards overcoming their anxiety disorder. It means that avoidance and escape are not the only means to feel less anxious.

  Exposure in the History of Psychotherapy

  It can be difficult to encourage patients to expose themselves to anxiety before they say they are ready. But anxiety will always tell patients they aren’t yet ready to face their fears, so imagine how this analyst felt when he wrote the about pushing limits to help severe agoraphobics.

  But the phobias have made it necessary for us to go beyond our former limits. One can hardly master a phobia if one waits till the patient lets the analysis influence him to give it up. [Certain agoraphobic patients] protect themselves from the anxiety by altogether ceasing to go about alone. … [With these patients], one succeeds only when one can induce them … to go into the street and to struggle with their anxiety while they make the attempt. One starts, therefore, by moderating the phobia so far; and it is only when that has been achieved at the physician’s demand that the associations and memories come into the patient’s mind which enable the phobia to be resolved. (Italics added)

  (Freud, 1955)

  Freud understood that avoidance can be the ultimate defense, and treatment for chronic avoiders must include inducements to approach anxiety triggers. He was willing to make modifications to his technique as needed to treat the patient. We differ on the purpose of exposure, but agree on its necessity.

  Exposure Therapy Is More Than “Just Do It”

  In order for exposure to work, it has to be done the right way. Otherwise, it is just repeating the miserable and demoralizing experience that brought the patient into treatment in the first place. “Just do it” is not exposure therapy. The right way includes six essential elements: first, exposure must address the underlying relevant fears; second, it should reframe anxiety as a positive learning experience; third, it should break exposure down to manageable steps; fourth, it must reduce or eliminate avoidances; fifth, each exposure session should be of sufficient duration for new learning about the feared stimulus to occur and, sixth, it must focus on the right side of the street. These elements, all derived from evidence-based research protocols, encompass a huge degree of subjectivity, and address the art of treatment.

  “Just do it” is not exposure therapy.

  1. Address the Relevant Fears

  Anxious people have differing sensitivities. Although there are variations among the diagnostic categories, and many patients have more than one anxiety disorder, here are some general rules. Because people with panic disorder are afraid of the sensations of arousal, exposure should be directly to those sensations by deliberately provoking them. This is called interoceptive exposure and includes such exercises as deliberately hyper-ventilating to provoke all its sensations, breathing through a straw to simulate shortness of breath, spinning to create dizziness, running in place or up and down stairs to raise the heart rate. People with panic disorder require exposure not only to the sensations but also to the thoughts associated with their experience of panic.

  People with social phobia are sensitive to, and therefore require exposure to, feelings of embarrassment. Their hypersensitivity to real or imagined criticism is based on this fear. Exercises in which people deliberately undertake situations which would make anyone feel embarrassed are part of exposure therapy for social anxiety. Examples would be deliberately mispronouncing a word, or knocking over a display in a store, or wearing one blue and one brown sock all day.

  People with OCD are exquisitely sensitive to obsessive thoughts and images—often with a combination of panicky and guilty feelings. The content of these thoughts and images are what define the underlying fears. These can be invoked by exposure to the particular triggers that provoke them, such as touching dirty things or walking through a hospital waiting room or whatever invokes the relevant thoughts and images.

  Traumatic anxieties require exposure to relevant memories and the associated emotions. Specific phobia exposures are to the external phobic objects as well as the internal sensations and thoughts that they trigger. People who worry too much (GAD) need exposure to worry thoughts, tolerating uncertainty, and their physiological arousal.

  Careful assessment becomes essential. Here is an example of someone who presented as typical panic disorder. She was afraid to drive over the Tappan Zee Bridge, and her stated concern was fear of losing control and driving off the bridge. This is a commonly expressed fear, and the typical sequence goes like this: someone starts to drive across the bridge, experiences a whoosh of anxious arousal, and fights the feelings, which makes them more intense. Then starts a series of “what if?” catastrophic thoughts, further escalating anxiety. Feeling out of control and enmeshed in anxious thinking, the thought arises, “what if I lose control and drive the car over the guardrail and into the water?” further adding to the terror. The altered state of anxious thinking makes the thought see
m like it could really happen.

  Since exposure is the active therapeutic ingredient, one would expect this patient to feel much less anxiety after repeatedly driving over the bridge in the presence of her therapist. However, there was no change after over 50 crossings! The problem here is that the therapist misdiagnosed the anxiety disorder, and therefore failed to expose the patient to the relevant underlying fears. In panic disorder, the initial fear is almost always the fear of sensations. This fear increases until the patient reaches panic, or near panic. The “what if?” thoughts come about as a result of the initial anxious arousal. They are part of the second fear.

  However, this woman suffered from OCD, not panic disorder. With OCD, the primary fear is often a fear of the thought, in this case, “What if I drive the car off the bridge?” This obsessive thought increased anxiety, and the resultant attempts to lower anxiety (the compulsions) are in the form of self-reassurances and avoidances. In panic disorder, the “what if?” thought follows the emergence of first fear. In OCD, the “what if?” thought triggers the first fear. The relevant fear is the obsessive thought, and that is what needs to be addressed. Exposure to the bridge is not sufficient: exposure must be to the thought while she is driving on the bridge. Because of the misdiagnosis, the anxiety management techniques she was using were working in reverse. She thought it kept her anchored in the present, but it functioned instead to avoid the anxious-making obsessive thought of driving off the bridge. The technique prolonged the anxiety, rather than reducing it. What was needed was to drive over the bridge while deliberately thinking— “I could yank the wheel and drive off the bridge.”

  Here is a similar case where addressing the relevant fear is shown to be essential. A patient afraid to leave the house was unproductively practicing tolerating rapid heart rate and gastrointestinal distress while standing in the door and on the front porch. It was then discovered that what he was actually avoiding was encountering the gaze of other people who made him instantly self-conscious and anxious. Tolerating eye contact and his embarrassment was the needed exposure task.

  2. Reframe Anxiety as a Positive Learning Experience

  Anxiety feels dangerous and there is a built-in desire to avoid its source. Encourage patients to seek out and embrace anxiety as part of the therapeutic process. This is a challenge to anxiety’s ability to trick people into thinking they are in danger. Remind patients that they are safe even while experiencing fearful distress. No amount of reasoning can think away an anxiety disorder.

  No amount of reasoning can think away an anxiety disorder.

  Experiencing anxiety is the only way for patients to learn how to better handle it. Despite its discomfort, an anxiety-laden day is a “good” day, and a non-anxiety day is a missed opportunity to practice and learn. Suggest that they welcome the anxious feelings with open arms. Patients need to believe that experiencing anxiety is not a failure. (Lots of patients see it that way.) In contrast, let them understand that feeling anxiety is a positive step in the therapeutic process, and there are great benefits to feeling manageable anxiety. Having symptoms and learning to experience them as less aversive changes patients’ relationship to anxiety, so that it no longer runs their lives.

  Experiencing anxiety is not a failure; it is an opportunity to learn. It is a necessary positive step in the therapeutic process.

  Overcoming an anxiety disorder is a learning process that requires practice. As an analogy, imagine learning a foreign language without speaking the new language. In both cases, the brain needs to create new circuitry. Speaking a new language is uncomfortable and frustrating at first, but the speed that one learns a language is directly related to one’s willingness to dive into awkward conversations.

  There is also the need for patients to accept and actively allow their anxious feelings. Any time a patient feels disappointed, angry, or let down because of their anxiety, the process of avoidance, resistance, and neutralization is triggered. This, in turn, will increase and prolong the anxious feelings.

  3. Manageable Steps

  Most highly anxious people will tell you that they have repeatedly tried—and repeatedly failed—to overcome their anxieties. Failure often comes from not understanding the importance of taking manageable steps. When patients try to expose themselves to overly anxiety-intensive situations, they run the risk of resensitizing themselves and learning only that it really is a good idea to stay away from the source.

  It is common to teach patients to subjectively quantify their levels of anxiety as they are going through the experience. Many use a 0–10 scale, where a higher number corresponds to greater anxiety. So one might say to a patient, “I’d like you to start quantifying your anxiety on a 0–10 scale, where a higher number means greater anxiety: 0 means no anxiety—you may have felt that for a brief time a few years back—and 10 is the highest level you can imagine, a no holds barred absolute panic. Now remember, this is very subjective. If you think about that, at what anxiety level would you rate yourself right now?” If the patient responds with “5,” one might continue: “Okay, great. Remember this is subjective, and there is no way to know whether your ‘5’ corresponds to mine. But we do want internal consistency, so that your 6 is more anxious than your 4, and your 5 is less anxious than your 7 or 8. Is that clear?” Most patients have no trouble with this concept.

  Working in manageable steps usually involves working with anxiety levels at a moderate 4–6 level. However, as patients learn about anxiety and gain confidence in their ability and willingness to manage those feelings, manageable steps can involve much higher levels. And eventually, when it is clear that anxiety is no longer feared but embraced, the steps themselves often become unnecessary.

  Here are examples of manageable steps. For the person with panic disorder who panics in a shopping mall, sometimes even parking in an indoor garage is too large a step. Patients can park their car outside the mall, and then slowly approach the mall. You can work out ways so that they can stay in control of their location, which helps to keep anxiety levels manageable. An elevator phobic might work on merely approaching an elevator, and get in and out before the door closes. For some, having the door actually close increases anxiety beyond a manageable step.

  Patients need help understanding manageable steps to avoid getting frustrated and trying for unrealistic goals. Encourage exposure while keeping anxiety levels low enough so that patients begin to feel confidence in their own abilities. On the other hand, the steps cannot be so small that no anxiety is experienced, as this will not result in any helpful learning. Often they keep their eye on the goal as opposed to the process. We will discuss this in much more detail later in this chapter under “The right way to practice exposure.”

  For a person with OCD who is a cleaner, manageable steps might include modifying or shortening the cleaning compulsion, but still keeping levels of anxiety in middle ranges. Specifically, if the patient washes the soap (or soap bottle) before washing himself, you might ask him to try to stop doing that one step in his ritual. The result is that he exposes himself to moderate levels of anxiety while continuing with a partial ritual. Similarly, ask cleaners to stop washing before all their anxiety goes down—they usually interpret that as before they feel clean—and ask them to then wait with their anxious feeling until the feeling goes away, or the exposure time has expired.

  But the patient needs to understand that the primary criterion for manageable steps is manageable levels of anxiety, not a predetermined set of tasks marching towards a goal. The identical exposure may bring on differing levels of anxiety on different days. Your patient might feel more or less willing to tolerate anxious feelings on certain days. This is all part of the process, which is anything but linear. Once a patient grasps that it is not the external situation but his own appraisal and tolerance of anxiety that he is addressing, formal “hierarchies” of triggers tend to collapse. The external situations are simply ways of invoking the anxious thoughts, feelings, sensations, and memories so th
at new learning can occur.

  4. Reduce Avoidances

  Since anxiety is maintained by avoidance, reducing avoidances during exposure is essential. Most highly anxious people put themselves in a difficult position. They expose themselves and—at the same time—they look for ways to avoid feeling the uncomfortable feelings. Unfortunately, they learn to become better avoiders, not how to better manage their anxious feelings.

  Here are some examples: the elevator phobic who only goes in certain elevators during certain times; the fearful flyer, who insists on certain seats, will not fly at night, over water, or on flights longer than a certain length; the bridge phobic, who avoids driving on certain lanes, levels, or times of the day; the cleanser who, under group pressure, will dirty his hands but then focus on how good he will feel once he is able to have a good, long, hand wash; the social phobic who must pitch a project and makes sure that most of the pitch is delivered by a subordinate. And there is the worrier who is engaged in a constant internal conversation in which he poses worry questions and then tries to reassure himself that his worry is irrational.

  Create an ongoing line of communication between you and your patient, especially when he is feeling high levels of anxiety. You are identifying triggers as well as focusing on the patient’s internal dialogue between the misleading messages of anxiety, and the ways your patient responds to them. Sometimes it is helpful to tell patients that they are both the patient and also the co-therapist. They go through the experience as the patient, but also observe and relate to you what is happening.