Our definition of avoidance is a very general one, and includes everything that patients do to fight anxiety. We have articulated this in some detail in Chapter 2 but the concept warrants further discussion. Avoidance includes both behavioral and cognitive avoidances. It includes physically avoiding experiences that cause anxiety, as well as all cognitive mechanisms to avoid the experience of anxiety while in the anxiety arousing situation. These include outright avoidance as well as mini-avoidances (shortening exposure, counting down the time until one can escape, taking a less-anxious path), covert avoidances (attempts to reduce or avoid the anxious feelings while staying in contact with triggers), rituals and superstitions (needing to wear the “right” shirt, stepping into the elevator with the right foot first), mental reassurances—even as subtle as telling oneself that it won’t be that bad (which are sometimes called neutralizations)—imagining who can help, who is available, where the closest medical facility is located, any escape or avoidance plans, or the thoughts “I can get help whenever I need it,” “this isn’t that dirty because they vacuum the room every night.” In short, anything other than allowing anxious thoughts and feelings to continue unabated while focusing on the task on hand is considered an avoidance and ultimately counter-therapeutic. Table 8.1 presents a listing of avoidances, grouping them in a manner that makes it easy to identify their variations.
Anxiety management techniques are helpful ways to allow time to pass while the anxious brain does its thing. When used in this manner, they are therapeutic. But if these same techniques are used to evade or block anxiety, then they will ultimately maintain and reinforce anxious feelings. This subtle distinction will be need to be revisited again and again—before, during, and after exposure tasks—whether they occur as intended practice or in the course of daily life.
Whenever a patient remains fearful of something they do frequently—flying is a good example—look for covert avoidances. Covert avoidances give patients the worst of both worlds. They experience anxiety that is potentially therapeutic, but the avoidances negate those benefits. What we note as covert avoidances are often called “coping skills” by the patient—and it will take considerable explanation and discussion for them to see how these so-called “anxiety reducing techniques” actually maintain the anxiety and undermine recovery, reducing, and sometimes eliminating, the therapeutic benefits of exposure. Coping skills of this sort are not only unhelpful, they are often the reason the patient is not making progress. Unfortunately, many people who are engaged in self-help or uninformed counseling will be encouraged to use these sorts of covert avoidances. It is important to explore what the patient is doing behaviorally and mentally to cope with anxiety: this is a key concept, something not at all obvious to most patients, and a huge breakthrough when it is grasped.
Table 8.1 Different kinds of avoidance
Look for and let go of covert avoidance (sometimes called “coping skills” by the patient).
5. Sufficient Duration
Ideally, each exposure session should last long enough for anxiety levels to start lowering. If the exposure is just long enough to feel a jolt of anxiety, and the patient then leaves the situation, nothing therapeutic has happened. On the contrary, fear-generating reactions have been reinforced and the patient may conclude that, in fact, he can’t handle the situation and ought to stay away.
There is controversy about the curative processes that occur during exposure. The more traditional view is that fear is extinguished through the process of habituation, where ongoing exposure reduces sensitized reactivity and the brain learns a new connection to anxiety triggers. Exposure continues until the fear is gone, or nearly gone, and the brain learns to substitute “I’m not afraid” circuitry for the old “I am afraid” circuits (Foa, Hembree, and Rothbaum, 2007; Foa and Kozak, 1991). Unlearning a fear response is something of a misnomer. Neurologists know that old circuitry is never really lost, but new “non-fearful” circuits are learned and these new neural pathways can inhibit and take the place of older, less used circuitry. So a more accurate way of describing successful desensitization is that default circuitry switches from “automatic terror” to “no fear.” The “automatic terror” circuits still exist in the brain, but are not accessed by the old triggers.
More recent findings by Craske, Liao, Brown, and Vervliet (2012) indicate that exposure need not progress to where the patient feels little or no anxiety. In this inhibitory model of exposure, the essential point is for patients to learn they can experience anxiety and develop a tolerance for the discomfort. The original fear circuitry remains, but is inhibited by what is learned during exposure. In this case, the default circuitry would switch from “I’m afraid and I can’t tolerate it” to “I’m afraid but I am able to cope with these feelings.” The goal is then to foster anxiety tolerance as opposed to anxiety elimination. Research suggests that this approach eventually leads to greater symptom remission.
The therapeutic benefits of exposure require that anxiety be triggered as part of the process, and learning new brain pathways is dependent upon anxious arousal. The term “exposure plus activation” describes exposure to underlying relevant fears, and the triggering of the anxious reaction. Ideally, each exposure session should continue long enough for new learning to take place. For people with panic disorder, this can be within 15 or 20 minutes. Patients with OCD often take considerably longer. In practical terms, one almost never has ongoing contact with anxiety triggers, and there is great subjectivity in the exposure process. Ask patients to try to remain in the situation until they feel their anxiety starting to decrease or experience some subjective change in the tolerability of their distress. Another technique is to ask someone to practice until they start to feel bored, since boredom is anathema to anxiety.
A key is to practice in many different situations and variations over time, in as many contexts as possible. The goal is to both create the new neural circuits, and also to make them as accessible as possible. A helpful metaphor might be to imagine that a new roadway is being built, the old one still remains, and the new roadway will only be used if many entrance and exit ramps are also constructed. It is impossible to overemphasize the importance of repeated practice under a variety of circumstances, so there are variations to practice sessions. We regularly supervise therapists who ask what is wrong—their patients are not progressing. Often the answer is that nothing is wrong, but that patients need to practice more often, more consistently, and under more varied situations.
Practice in many different situations and variations over time.
Choosing when to end an intentional exposure is also a critical part of the learning process. Exposure practice decisions are made by mutual agreement with the patient, based on willingness to experience anxiety during any particular task. If anticipation of the experience is too high (even though anticipatory anxiety is not an actual predictor of symptomatic response—see Chapter 12), then the exposure plan needs to be reduced until it is a challenge but not overwhelming to the patient. On the other hand, once a specific goal is set and the willing attitude is in place, then the end of the exposure task needs to be considered and planned as well. The most unhelpful way to do this is to keep going indefinitely—and to stop only when the symptoms have begun to escalate to the point where it feels like “too much.” This will reinforce escape as a solution to anxiety, and give the patient the impression that he might not have been able to make it a moment more. It also produces a constant anxious monitoring of symptoms for when to leave—with the notion of “Is it more than I can stand?”, “Should I stop now?”, or “Is this really worth doing?”—all of which are counterproductive in maintaining the attitude of acceptance.
A positive example would be to drive three exits on the highway and then exit, whether feeling relaxed or anxious or anywhere in between. Another would be to spend 15 minutes talking with a stranger, and then end the conversation, even if there is an unanticipated willing attitude to continue. Or to finish a showe
r at a specific time limit, whether or not the compulsive washing has reduced anxiety to its lowest level—and to continue the shower for its limit in the unlikely case that anxiety is reduced more quickly than anticipated. It is also the case that forcing oneself to remain in an exposure task by adopting a white knuckling, grim determination is almost never helpful. Should this be occurring, stopping exposure assignments temporarily and reviewing the purpose of exposure and the attitudes needed for new learning is advised.
6. “Stay on the Right Side of the Street”
The aim is to identify an internal process—that of adding fear to sensations, memories, and thoughts—and to have patients change that process. An aspect of this is focusing on what is relevant. The right side of the street is what goes on inside the patient. The wrong side of the street is the external triggers.
Here is a story that illustrates this point:
A man comes out of a bar one night to find a group of people huddled by the ground under a streetlight. He goes to one of the people and asks what is happening. “A woman lost a contact lens, and we are trying to find it,” is the response he gets. So the man joins in. But after a few minutes, he realizes that contact lenses are small, and the grass on the ground makes for good camouflage. So he decides to ask the person who dropped the contact lens if she could tell him—to the best of her ability—precisely where she believes it was dropped. That way, he thinks, everyone could start at that point and search more systematically, in concentric circles from where it was last seen. He asks the woman, “Please—to the best of your ability— point to where you think it was dropped.” The woman stretches out her hand and says, “Oh, I dropped it on the other side of the street,” while pointing in the distance. The man is astounded, and asks, “Why look here if you know that you dropped it across the street?” To which the woman responds, “Because the light is much better here.”
During exposure, it is easy to focus on the wrong side of the street, because it is easier to focus on external triggers, as opposed to internal processes. Patients forget that they will never find the source of their anxiety by looking at the externals—just like the woman looking for the contact lens will never find it under the streetlight. Here are some illustrations:
A patient with moderate agoraphobia manages to travel outside of his safety zone, feeling little or no anxiety, and might feel proud of this achievement, believing he has made real progress. While this might seems like a commendable achievement, it is an example of looking on the wrong side of the street. It is focusing on achieving external goals—in this case traveling outside of one’s safety zone. If no anxiety is generated, there is no opportunity to better understand and change his fears.
Looking at the right side of the street pays less attention to where the patient travels, or even how much anxiety is experienced. Instead, the primary focus is on how the person manages and relates to the anxious feelings that arise. The patient is encouraged to focus on the internal fear-generating processes, while learning the skills to feel less frightened by the emergence of these thoughts, sensation and images. In this instance— where the client has traveled outside of a safety zone with little or no anxiety—there has been little or no therapeutic exposure.
Alternatively, let’s suppose that this same person forges outside their safety zone and experiences considerable anxiety, but manages to stay by gritting their teeth, powering through, and counting down the minutes until getting back to comfortable surroundings. This is yet another example of focusing on the wrong side of the street. The important point is not where the person goes, or how much anxiety he endures. The right side of the street focuses on the internal anxiety-generating processes, and how the person inadvertently maintains anxiety by trying to avoid it, as well as observing what happens when he stops avoiding.
Similarly, let’s look at someone with OCD who is a cleaner who triumphantly reports that he managed to put his hands on the carpet at work and not wash for 20 minutes. But further questioning reveals he counted down the 20 minutes, refused to touch anything else during that wait, and checked out the carpet, deciding that it really wasn’t all that dirty. We can congratulate this person for the courage to face his fear, but the exposure was moderated by a number of avoidances and neutralizations, and this is another example of focusing on the wrong side of the street. It is the willingness to actually connect with the anxious experience that is the right side of the street.
Sometimes these differences are subtle, and we accidently join our patient on the wrong side of the street. A patient with OCD might ask, “What if I poison my child by inadvertently mixing cleaner in the lemonade?” or, “What if I left the gas on?” The person with panic disorder might fear panicking and screaming during a theater performance. The person with social anxiety disorder (SAD) might fear blushing during an introduction. Sometimes the fears are so absolutely preposterous that we start to reassure the patient. When one patient with OCD reported fears of stepping in chicken feces and starting an epidemic over the east coast of the United States, it was difficult not to challenge the probabilities. In the same manner, if one tells an aviophobe that flying is really very safe, that starts to cross onto the wrong side of the street. Avoid getting into a discussion about the chances of these things happening, or reassuring patients that they won’t. Talking about what goes on “out there” is looking on the wrong side of the street.
There are times, however, when it makes sense to restate facts that are also reassuring. This is part of psycho-education that encourages patients to know the facts about their fears. Correcting misinformation is not the same thing as attempting to provide reassurance. The distinction can be hard to make at times, but good general rules are (1) repeating the same facts again and again is not helpful and (2) trying to provide a sense of certainty about an unanswerable question will backfire. For example, teaching patients the fact that airplane accident rates during turbulence are the same as without turbulence can be helpful to patients who fear bumpy flights. The primary purpose is education, and it would be proper to provide the correct information even if turbulence increased accident rates. Repeating these facts over and over in an attempt to calm anxiety while on the plane will not be helpful. There is a need to face and accept that no one can guarantee that bad stuff won’t happen. Staying on the right side of the street is about tolerating uncertainty and allowing for a new way to respond to “what if?” thoughts.
Patients often say, “I could easily drive over the bridge if I knew that there wouldn’t be any traffic delays,” or, “I wouldn’t worry about my child taking the school bus if I could drive the bus,” or, “I wouldn’t fear stepping on red spots on the ground if someone would guarantee that the spots aren’t AIDS-infected blood.” But people usually have little control over external triggers. The realities of traffic, dirt, delays, crowds, speeches, and mistakes (to name just a few external factors) are impossible to control.
The realities of traffic, dirt, delays, and mistakes are impossible to control.
The most effective therapeutic exposures pay less attention to external triggers, hierarchies, and external goals realized, and focus more on the patient’s internal world. Patients react to sensations and feelings, frightening thoughts, and distressing memories. These fears are what need to be worked on. That is the right side of the street.
A work by Sisemore (2012) contains a comprehensive listing of ideas for exposure tasks arranged by diagnosis. They can help to generate ideas to be discussed while planning individualized exposure tasks with patients.
Role of the Therapist During Exposure: What to Say and Do
Dealing with a patient when experiencing high anxiety is akin to dealing with a terrified infant or a frightened pet. The part of the brain triggering anxious arousal is among the most primitive—the amygdala. Like an infant or a pet, the amygdala does not communicate with words, but responds to body language, quality of sounds, and general attitude. When an infant becomes frightened, it does no good t
o explain that his reaction is inappropriate, or to tell him to calm down or get over it. A frustrated tone only makes it worse. Similarly with an anxious patient, any sense of urgency, tension, or anxiety will be projected, transmitted, and amplified. If the therapist is anxious about the patient’s anxiety, the patient will feel that anxiety. If the therapist feels pressure or urgency to make patients feel better, the major message transmitted is pressure, which undermines the attitude of acceptance and models a fear of fear. When communicating to a patient to “accept and allow,” it does best to promote a general attitude towards anxiety itself— discomfort not danger—and not be just a verbal message. Soothing speech and a relaxed and patient attitude promote calm far more efficiently than any other methods. This can be shown in the accepting, empathic, and confident manner of supporting the patient during anxious times.
When patients experience anxiety in your presence, remind them that this is anxiety, that they are safe, that anxiety is painful and uncomfortable but not dangerous, and that the courage they show in exposing themselves to this distress will be rewarded by less suffering in the future. When to stop exposure is a clinical decision, looking for the optimum point between too long and not long enough. Patients often express initial hesitation about exposure, so we recommend encouragement when they desire to stop. But waiting until they insist and anxiety approaches panic is probably too late. Remind them that exposure is not a test but practice, an experiment with the purpose of gaining more information about the anxious experience.
Finally, go over rules and expectations for physical contact and closeness before exposure commences. Some patients prefer to be left entirely alone, and given a wide physical space. Others appreciate proximity. Some patients are comforted when the therapist taps their arm or makes some other physical contact. But these preferences must be discussed when the patient is feeling comfortable and able to communicate without pressure.
What Every Therapist Needs to Know About Anxiety Disorders Page 20