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Anxiety! Why We're Anxious and the Secret to Getting Better

Here is what I discovered about how to treat anxiety.

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In 1988, I wanted to take another step in turning over more control to clients. I’d recently developed a brief-treatment protocol for individuals who feared flying. To find out what would happen if I reduced my attention to the details of each client’s problems, focused on the broader principles of recovery, and encouraged clients to take greater ownership of their recovery plan, I designed a two-day group treatment for fearful fliers. A staff member from the corporate offices of American Airlines participated in the third group I held, and benefited from the treatment. Six months later, American contracted me to create a national program. Soon my weekend treatment group grew to 25 participants at a time. The weekend culminated in two round-trip “graduation flights” on Sunday afternoon.

I treated this crowd of clients using three central principles of cognitive-behavioral therapy (CBT) for anxiety disorders. The first principle is to convince clients that their anxiety stems from an exaggerated appraisal of the threat. One of the biggest obstacles to treatment is clients’ catastrophic belief that something terrible is going to happen, and they won’t be able to handle it. CBT strategies help clients reframe the severity of the problem they’re facing so it becomes something they can handle. The socially anxious client might be embarrassed to stumble over his words, but he doesn’t need to perceive himself as humiliated. The agoraphobic who’s in good health might have a panic attack, but not a heart attack.

The first task of the team leaders—a senior pilot with American, a recovered fearful flier, and me—was to address the participants whose fears related to safety. We helped them become more familiar with pilot training, maintenance schedules, and airline safety records. Then we addressed the issues of those who were more concerned with their own anxiety by reframing their symptoms as normal and harmless features of the fight-or-flight response.

A second principle of CBT for anxiety is to dissuade clients from struggling against their anxious sensations. Since we’re asking them to enter situations that they perceive as threatening, they need to expect that anxiety will come with the territory. If they fight and resist feeling anxious, paradoxically, they’ll feel more anxiety. We encourage them to replace this demand with an accepting attitude like, “I can allow myself to feel anxious here.”

In the flying program, after we challenged their catastrophic beliefs, we worked specifically on shifting their attitude about their anxiety to, “I can handle my anxiety, because I know my fears are exaggerated.” We also taught them several skills to help them control panic, instead of trying to eliminate all anxiety.

A third principle of CBT for anxiety disorders is to counsel clients that the best way to turn off their “fear program” is to confront the feared event. In this case, the confrontation was in the form of taking a commercial flight. Their job was to enter and remain in the feared environment—to take the flight—while holding on to that attitude of acceptance: “It’s OK for me to be anxious. I can handle it.”

In many ways then, our flying program looked like the traditional cognitive-behavioral protocol, but I challenged the traditional CBT approach in three ways. First, because we worked with 25 participants, I couldn’t target the specific thoughts and feelings of each one, as standard CBT treatment dictated. Second, because of our time constraints, we couldn’t help the participants test out the validity of the principles through a series of behavioral assignments. Third, participants didn’t gradually work their way up the hierarchy of fears: they moved directly from sitting in the classroom to engaging in the activity that was at the highest level of their fear hierarchy.

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