September 2008
Shyness: A Bold New Approach, Bernardo
Carducci, Ph.D. (384 pages, paperback), New York:
Quill, 2002.
Shyness is a common human experience, not a disorder,
frailty or character flaw. In fact, 20 percent of Rhesus
monkeys (whose brain structures are closest to human) are
behaviorally inhibited (shy), both in captivity and in
the wild. The trait is so genetically predetermined that
we can breed shy monkeys. And if we give those
infants to a dominant mother, she will nurture them right
out of their inhibitions so that a few years later they
act just like the average adolescent. Conclusion: you can
be shy and still perform successfully out there in the
world. Dr. Carducci honors and respects those with shy
traits and simultaneously shares the key moves to strengthen
self-acceptance and build social skills. He exquisitely
recognizes the narcissistic paradox: when you become preoccupied
with critically observing your own behavior, you become more anxious,
and then tend to botch the social encounter. He teaches
the reader, among other things, how to transfer attention
off the self and toward the other, thus giving a more realistic
sense of the social encounter.
This is a wonderful guide that tracks and assists through
all stages of the lifecycle, from pre-school through
adulthood, and steers among the major settings of life,
from intimacy to the workplace.
In the November-December issue I’ll outline how he distinguishes the small talk skills of confident people and his recommendations for strengthening those skills in shy people. |
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The Mindfulness & Acceptance Workbook
for Anxiety, John Forsyth, Ph.D. & Georg
Eifert, Ph.D. (267 pages, paperback plus CD), Oakland:
New Harbinger, 2007.
The brain is built to respond to all threat as a signal, instructing the body-&-mind to “take action now.” After a bit, the body-&-mind memorizes the signal-response pattern, and many of our responses become automatic. The brain is programmed to err on the side of assuming threat instead of assuming safety. This is a good thing for survival. But we end up responding to a lot of false positives. This is unfortunate when our automatic reaction to lots of situations becomes a sense of threat, anxiety, and avoidance. How to change this is very simple; we could send the instructions on a postcard. And when you follow the guidance of this wonderful workbook, by the end you’ll be able to fit the principles that guide you onto the back of a postcard, too.
The challenge, as they say, is in the details: how to
change your mind so it lines up with those instructions.
Herein lays the gift of The Mindfulness & Acceptance Workbook for Anxiety. Forsyth and Eifert intend to accomplish this task in a holistic manner. They know it will take persuasion, time, and patience. Influencing your point of view is what they are great at: metaphors, analogies, diagrams, cartoon illustrations, examples, written exercises and homeworks, within 270 workbook-sized pages. The accompanying CD contains 8 audio-guided meditations and the book’s 13 printable exercise forms.
Here’s what this workbook isn’t: a set of skills to practice in order to control anxiety. Instead, this is a framework to orient you toward the rest of your value-filled life. You will be taken on a journey. Go. Because if you win at this task of uncoupling from your anxious reactions to life, it will be because you have altered your consciousness. No small task! It takes a student’s mind and a willingness to be coached. Fortunately, you will find these authors to be trustworthy and competent guides. |
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Self-Help
& Professional Update:
How to Keep Fear from Returning: A Challenge to the Basic Principles
There are two cornerstones to the standard
protocol for exposure practice:
- Remain in the feared context until your anxiety begins to diminish,
and
- Create a hierarchy of threats and work your way up from low to high
threat.
This set of beliefs is so widespread that most cognitive-behavioral therapists
will recite them as principles. I question these assumptions,
and I think you should, too. If you want to look at the data, I’ve
attached the research articles at the end. Here is how I interpret
them.
I. You don’t have
to calm down to get better
Within session habituation—that is, staying in the feared situation
until you begin to become less anxious—may not be necessary. It
might not even be the best strategy to lower the chance of fear returning. The
mind is built to not extinguish a fear response. (Extinction
is defined here as the progressive weakening of the fear response.) Survival
required that we remember where the threats are, so modifying that guidance
system can take some work. Maybe we need to stay anxious
longer and focus on changing our belief instead.
There have already been studies indicating that when you increase the
arousal of mice (through a stimulating drug) during exposure, and maintain
that arousal, they tend to override this natural tendency to slow the
extinction process. I’m not saying mice operate out of a belief
system. But I think we do!
Several clinical studies with panic disorder, OCD and several phobias
showed that the requirement for within-session or between-session reductions
of arousal may be overstated. It is possible, for instance,
for someone to improve just as well (sometimes even better) when they
keep their heart rate elevated throughout their exposure practice session
instead of having their heart rate slow as time passes. And they
may improve just as well, or better, if their heart rate is as high during
the exposure in later sessions as it was in their first session. These
results challenge our view of what “improvement” looks like.
II. Disorganize your
practice
We typically do blocked practices: we work our way up the hierarchy of
one context until fear declines, then take on the next. And we are
more likely to conduct consistent practice: approaching each feared situation
in the same manner. How can you mess with that design? You can practice facing
your feared situations randomly, mixing them in together. And
you can change up all the different ways that you approach each
item (in the afternoon, then at night; approaching it slowly, then rapidly;
plan a practice, then later do it spontaneously; modify the temperature;
change the number of people involved.)
We are starting to gather evidence on some interesting hunches. For instance,
we are looking for non-emotional learning (not based on the alarm response)
which leads to self-efficacy, such as a message of “I can
handle this.” Ideally, I want the client to have a simple
supportive self-instruction that remains stable over time and can be applied
across a variety of situations. That’s what random and variable
practice do: They help the person hold onto that point
of view over time. And the variable practice adds into memory
a larger number of cues that will remind the person of their learning.
On top of all that, random and variable practices help the person remain
aroused throughout the treatment. That may embrace the extinction
process, as I talked about in the previous point.
The punchline? If you focus on being more anxious
during the practice, perhaps you’ll be less anxious over time.
III. Mentally review
your past successful practice
Just before you complete an exposure practice, do a complex imagery review
of your previous practice, attempting to re-experience what you saw, felt,
heard and learned. Then go try to get anxious again. Repeating that process
will solidify your learnings and support the extinction process.
Conclusion
Let’s generate more flexibility in our model of the way to overcome
a fear. How well one “manages” anxiety during an exposure,
and whether one “cools out” by the end of the practice—these
measures deserve to be challenged. If the goal is a stable belief
of “I can handle this,” then we should take some practical
steps. Purposely
seek out arousal during practice. Mix up the format of
your practice sessions. Visualize your successful practices to
encourage the protocol. Here’s some additional advice: Those
of us who are therapists can help people stay in a fearful situation beyond when
they think they’ll fall apart, or repeat a behavior beyond the
number of times that they predict will cause catastrophe. Life
is more chaotic than we generate in organized exposure practice. Mess
things up and challenge beliefs, especially your own.
Resources
Cain, C. K., Blouin, A.M., & Barad, M. (2004). Adrenergic transmission
facilitates extinction of conditional fear in mice. Learning & Memory,
11, 179-187.
Craske, M., & Mystkowski, J. L. (2006). In Craske, M., Hermans, D. & Vansteenwegen,
D. (Eds.), Fear & Learning: From Basic Processes to Clinical Applications,
p 217-233.
Kozac, M. J., Foa, E. B., & Steketee, G. (1988). Process and
outcome of exposure treatment with obsessive-compulsives: Psychophysiological
indicators of emotional processing. Behavior Therapy, 19,
157-169.
Lang, A. J., & Craske, M. G. (2000). Manipulations of exposure-based
therapy to reduce return of fear: A replication. Behavior
Research and Therapy, 38, 1-12.
Magill, R.A., & Hall, K. G. (1990). A review of the contextual interference
effect in motor skill acquisition. Human Movement Science,
9, 241-289.
Mystkowski, J. L., Echiverri, A. M., Labus, J. S., & Craske, M. G.
(2006). Mental reinstatement of context and return of fear in spider
phobia. Behavior Therapy, 37, 49-60.
Riley, W. T., McCormick, M. G. F., Simon, E. M., Stack, K., Pushkin, Y.,
Overstreet, M. M., et al. (1995). Effects of alprazolam dose on the
induction and habituation processes during behavioral panic induction treatment. Journal
of Anxiety Disorders, 9, 217-227.
Rowe, M. K., & Crasek, M. G. (1998). Effects of varied-stimulus
exposure training on fear reduction and return of fear. Behavior
Research and Therapy, 36, 719-734.
Schmidt, R. A., & Bjork, R. A. (1992). New conceptualizations
of practice: Common principles in three paradigms suggest new concepts
for training. Psychological Science, 3, 207-217.
Smith, S. M. (1979). Remembering in and out of context. Journal
of Experimental Psychology: Human Learning and Memory, 5, 460-471.
Tso, J. C. I., & Craske, M. G. (2000). Timing of treatment and
return or fear: Effects of massed, uniform-, and expanding-spaced
exposure schedules. Behavior Therapy, 31, 479-497.
Vansteenwegen, D., Dirikx, T., Hermans, D., Vervliet, B. & Eelen,
P. (2006). In Craske, M., Hermans, D. & Vansteenwegen, D. (Eds.), Fear & Learning:
From Basic Processes to Clinical Applications, p 197-216.
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