Anxiety! Why We're Anxious and the Secret to Getting Better
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Foa and Kozak’s theory was that people who develop an anxiety disorder hold on to distorted information about themselves or their environment, which causes them distress. The faulty information is contained within the strong threatening feelings that are associated with their specific fear—what the authors called the “fear structure.” They postulated that the only way for anxious clients to incorporate corrective information was for them to access the intense arousal associated with that specific fear and then linger in that state long enough, without blocking or muting their thoughts or feelings, to learn at a primal level that they’re safe.
Foa and Kozak’s theory helped me begin to see that, in order to improve, clients needed to experience close to the strongest level of anxiety they ever had in a feared situation, and stay in that situation much longer than I’d been suggesting. However, I had to confront my own timidity about assigning long, hard exposure practices. I was afraid that if I pushed clients, I’d chase them away. But when I went easy on my most troubled clients, letting them gradually work their way up their hierarchy of fears, they tended to drop out before making any gains. I decided to become more directive in my work, although I was still concerned about losing clients.
As I attempted to be a student of this prolonged, intense exposure, I struggled to teach my clients the behavioral model of repeated exposure, because it simply didn’t fit my personality to be pushing only behavioral change. To balance this exposure treatment with a more comfortable personal style, I returned to my roots as a cognitive therapist, with one big change: I no longer challenged cognitive distortions sentence-by-sentence.
In the past, I’d spent multiple sessions helping clients identify and correct the errors within their catastrophic, mind-reading, black-or-white thinking, and other cognitive distortions. That process now seemed tedious to me and far too labor-intensive for my clients to tolerate. I felt we could have greater leverage if we worked together to address clients’ beliefs instead of just their momentary thoughts. In addition, I wanted clients to know why they were practicing this new approach more than I cared about exactly what they practiced.
By that point, my referrals had broadened to the other anxiety disorders. Obsessive-compulsive disorder (OCD) became my new nemesis because those clients were so rigidly stuck in their obsessive beliefs. One OCD client was Camille, a 42-year-old mother of two, who feared “sickness” from rabies and from various objects that represented the death of her grandfather. An alcoholic, she drank a bottle of champagne every day, starting at about 5 p.m., when her major parenting chores were complete. Drinking was the only remedy she could find for her obsessions.
In typical exposure-based treatment, the therapist details every step of the procedure. With Camille, once I explained the principles behind OCD treatment, I reduced all of those procedural instructions to two. “To get better, first you must do just the opposite of what the disorder is compelling you to do: you need to generate doubt about getting sick from touching objects. Second, you must try to keep that feeling as long as possible.” Then I did my best to look and sound confident, despite being unsure about my ability to turn simple theory into helpful practice.
To my (well-concealed) shock, Camille got better. After five sessions over six weeks, she was well on her way to recovery. She even had eight consecutive days without a drop of alcohol. When I asked her how she’d accomplished this, her answer included, “I’d touch a contaminated object and have such a strong urge to wash! But I’d remember what you said, and I wouldn’t wash. Sometimes my arms went numb all the way up to my shoulders, but I wouldn’t wash. And I’d say to myself, ‘I hope that good doctor knows what he’s talking about!’” Camille was willing to trust me enough to go against the demands of her disorder.