Anxiety! Why We're Anxious and the Secret to Getting Better
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An example: Mary came in for two sessions last year to address her classic symptoms of claustrophobia, the fear of restriction and suffocation. Parking structures were tough. “With their low ceilings, I feel like I’m going to be crushed in there.” Elevators and traffic were a struggle, especially if they were crowded or slow.
In session one, as I learned about the extent of her difficulties with feeling closed in, I asked how she coped with the problem. I was looking for her safety crutches, something I wouldn’t have done in the past. However, I knew that she and I would need to create a plan to reduce her dependency on her distress-avoiding maneuvers.
“I avoid closed-in places—parking garages and tunnels,” she said. “If I have to go in a parking garage, I always try to go in the daytime and park where there’s the most light. I also try to get others to drive me.”
As we continued, I asked her about her expectations of the sessions.
“Well, I’m hopeful and a little nervous,” she replied. “Earlier you said, ‘You have to go through the eye of the needle.’ So, of course, I started thinking, ‘Is he going to lock me up in a small place and test me?’
I teased her about her response. “There’s an idea! Do you have others for me?” She was right that we’d soon be doing some provocative exposure practices, but I wanted us to conduct them within a trusting partnership. Being playful is one of the ways I develop rapport.
Early in the first session, I ask clients about their long-term goals. Tolerating doubt and discomfort is hard, and I want them to have ready access to an outcome picture that’s strong enough and important enough to help them do the work. Mary’s goal was to be able to move through her world with more ease and less hesitation.
My intention with clients is to gain rapport by reflecting back how they currently perceive their relationship with uncertainty and discomfort, and acknowledging that it makes perfect sense to me that they’ve decided to be so intimidated. I find out if they have any specific themes that need to be addressed—Mary’s were being trapped, having a heart attack, or suffocating in an enclosed space—and I offer them alternative views to challenge their catastrophic fears. This is standard CBT fare, but I’m not interested in lingering on this: I want to address such specific fears and put them behind us. I use those conflicts to introduce the higher-level theme of their relationship to doubt and distress.
When we get to the treatment plan, we build it together, piece by piece. I impose nothing on the client. For example, to Mary I said, “I’m going to suggest that you do some things that are uncomfortable. Short-term pain for long-term gain. You’ve heard that expression before?”
Yes, she was on board with that concept. Then she continued, “I’d like to get to the point where I might have just a mild dislike of something, but I don’t go into these panic attacks.”
Great! She’d just linked the strategy of going toward her discomfort in our practice with achieving her long-term goals. I took that opportunity to reinforce how this “pain” would help her reach those goals.
“We call that habituation,” I said. “It means you develop a habit of facing it enough so that in the future, when you face it, your distress level doesn’t go up here (I point above my head). It just goes to here (I gesture around my waist).”