Anxiety! Why We're Anxious and the Secret to Getting Better
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Barlow was moving exposure practice to the extreme. He wasn’t easing clients into their behavioral assignments: he directed them to drop their crutches, their sacred rituals, and their compulsive efforts to feel safe. His view was that clients needed to learn to tolerate feeling profoundly unsafe. He had an eagle eye for even the smallest ways people shield themselves from distress. If a client sat down in his office and began to take off his jacket, Barlow would ask him to leave it on, just in case he was trying to get cool and relaxed. From Barlow’s perspective, a comfortable client wasn’t working on getting better.
The Relationships of Anxiety
Following my exposure to David Barlow’s approach, I studied everything I could about how people use safety behaviors to protect themselves from what they fear. Then I made it a point to help my clients peel away their crutches, including the breathing skills that had been the cornerstone of my work.
Next, I began to attend to a bigger picture: clients’ struggle with uncertainty and the anxiety it produced. All anxious clients enter treatment fighting or avoiding their doubt and distress. For the first half of my career, I’d focused on skills to help clients accept symptoms of anxiety, permit themselves to feel uncomfortable, and tolerate not quite knowing how things would turn out. Now I sensed that the best maneuver for clients was to provoke the doubt and discomfort they feared, regardless of where it appeared.
Once again, I began to experiment. The model I shaped is built around two relationships—my relationship with clients and their relationship with their anxiety and doubts. In terms of the therapeutic relationship, I believe my clients and I need to create a special partnership of mutual curiosity and exploration as two people with complementary assets joining together to solve a problem. As I gain rapport with clients, I ask questions at every turn, not to probe, but to defer. If I explain a principle, I stop to verify, “Does this make sense to you?” If it doesn’t, I work until it does. When we’re about to do a behavioral practice, I ensure that the client not only understands the instruction, but agrees with the logic behind the action.
I defer to clients because my ultimate goal is to hand everything over to them. If they can participate in the construction of the protocol, they can “own it.” If they own it, they can continue to use it in the future. This is the piece that so often gets lost in exposure treatment. Evidence-based CBT relies on a formula. Therapists describe how clients can recover from the disorder through repeated, graduated exposure to their fears over a number of weeks. Then they present the treatment steps and give the instructions for each step. Such therapists figuratively, and sometimes literally, “follow the manual.” This can cause them to lose track of an essential task: helping clients metabolize the strategy.
The second relationship I’ve built my model around is the one between clients and their doubt and distress. They enter treatment seeking to remove their doubt, to know for certain that events will turn out in the best possible way, and when they can’t guarantee the outcome, they become more anxious and avoidant. My primary intent isn’t to give clients reassurance and comfort about the specific themes of their worries, but rather, to help them shape a new way to relate to their uncertainty and discomfort. We don’t simply focus on solving the presenting disorder, even though that’s what clients first expect. Anxiety disorders continue throughout life; therefore, clients must change their relationship with the disorder, which is what generates their distress.