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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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I take time to persuade all clients about the merits of habituation: frequent, intense, long exposures to the fear will reduce the threat. But my goal isn’t habituation. I take advantage of the logic of habituation—the necessity to go toward what they’re afraid of—to introduce the possibility of a new response to their feelings of intense distress and uncertainty. I often represent it by one of two messages: “This is hard, and I want it” and “I can take the hit.” Here’s how I introduced the first message to Mary:

“When you’re feeling like you’re suffocating or trapped,” I said, “I’m going to suggest that you say to yourself, ‘I want this feeling.’ What do you think about that?”

Mary replied, “I was waiting for you to say ‘I want this feeling to stop.’”

“So how do you think your body reacts to the message: “This is a bad experience. I want it to stop?”

Mary said, “Well, I think it probably heightens all the anxieties.”

“Then what if I had the opposite response and said ‘I want this’? I wouldn’t secrete so much adrenaline, would I?

“Yeah, I guess that seems right,” she said.

The second message I promote in response to the threat is “I can take the hit,” which is a different angle of the same theme. The “hit” is defined as whatever the client fears might happen. The socially anxious client may start visibly shaking while she gives her speech. The OCD client may not know whether he inappropriately touched a child. Those with generalized anxiety disorder will have to make decisions without being sure that they’ll turn out. To recover from these disorders, they all must be willing to embrace the sense of doubt about whether they’ll experience those outcomes, rather than trying to get rid of it. They’re going to get hit by distressing thoughts and feelings. Healing begins as they do more than just stop fighting: it begins when they start allowing themselves to take the blow instead.

It’s at this juncture that creating a partnership becomes essential. As we shape the approach, I frequently check if clients can recognize how this shift in their orientation might lead to their desired outcome. It takes the form of, “Do you see where we’re going?” When we begin the behavioral practices, I’ll once again defer to them. “Should we try this now?” “Does this experiment make sense to you?”

To Mary, I said, “If this doesn’t sound like a good idea to you, and you don’t trust me, then you shouldn’t do anything I suggest. I’ve got to depend on you—we have to collaborate—or nothing’s going to work. I’m wholly dependent on you, and I want you to understand you’re in control. I’m going to create a protocol to help you get better, but if I don’t sell it to you, we’re lost.” You might think I’m being overly solicitous and deferential by such talk, but I think I’m keeping clients in the room, engaged in the construction of a paradigm that they’ll carry with them for years to come.

We finish the session by designing an exposure practice that Mary suggested for that evening: to drive into one of her most distressing parking garages and linger there for 15 minutes. In our second session the next morning, she described her 15-minute practice in the parking garage.

“It’s three stories,” she said. “Unfortunately, it was sunset and there was a fair amount of light coming through, but still the ceiling was quite low. I really didn’t feel quite as panicky as I usually do, so I went into the middle. I went to the darkest place I could find, because I was trying to get that panicky part going so that I could just stay with it for a few minutes.”

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