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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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Talk to your primitive brain. Let it overreact, and then say, “I like your expression, but you don’t have to juice me up so much next time. I’m fine. Save that for real situations.”

In a one-year follow-up, Mary reported handling tunnels and parking garages well, and she’d only had one panic attack on a flight, which had been another source of extreme anxiety. When she’d become apprehensive driving through one long, unexpected tunnel, she said, “I remembered those horrible things you put me through, and that I came through those!”


As I was writing this piece, I could sometimes almost feel many readers in the therapeutic community recoiling, much as I did when I first heard David Barlow talk about a therapist “forcing” a claustrophobic client to stay on the elevator, no matter how terrified and quivering, all the way down to the ground floor. What shockingly brutal treatment! And how profoundly antipathetic to all the therapeutic values we were taught to hold dear! Aren’t therapists supposed to be patient and accepting, to make the client feel completely safe and secure, and to create in therapy a cozy haven from a cruel world? Surely, our psychodynamic forefathers and mothers would be appalled at the idea that a legitimate therapist—and not an outright sadist!—would design a treatment based on instructing clients to ramp up their fears past the point of bearing while telling themselves (through chattering teeth) how much they welcome the experience. Make no mistake: compared to the soothing ambience of the typical clinical encounter, this is therapy from the school of hard knocks and tough love.

Why does such a counterintuitive form of therapy work at all, much less exceptionally well, often when other approaches have failed? For one thing, it calls up qualities of strength and resilience in clients that therapists often miss. In this profession, we’ve perhaps become a little too used to thinking of our clients as fragile, wounded souls, who need more to be swaddled and protected and comforted than encouraged and challenged. I understand that perspective: as a therapist, the last thing I ever wanted to do was make my clients feel worse, particularly if I wasn’t sure there’d be an equivalent payoff for them at the end. But since I started down this path, I’ve been awed by my clients’ ability to summon up the personal courage, gritty determination, and willingness to try anything to surmount their fears, regardless of the costs in discomfort and unpleasantness. They’ve given me the strength to carry on, more than the other way around.

For another thing, everything I ask of my clients is done in the context of a deep, mutually trusting, and respectful therapeutic partnership. In that sense, this work looks more like “traditional” therapy than like some of the manualized, protocolized CBT approaches, in which the therapist gives instructions and assigns preset tasks aimed at eliminating discrete symptoms. In this method, clients and I together design a plan that’s intended to change their entire relationship with anxiety, which will prepare them to deal successfully with their anxieties—whatever form they take—throughout life. Before we actually begin doing anything, we determine together what they’ll need to do, how we’ll proceed, and what their long-term goals are. The focus isn’t on imposing a formula, but on helping them create a new personal philosophy and a more effective strategy for learning to live free of crippling terror. And, just as in any good, old-fashioned kind of therapy, my clients know that they’re not alone, that I understand fully what they’re going through, and that I’ll be there with them—supporting, encouraging, sharing their struggle—heart and mind, all the way through to the end.

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