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Anxieties Update

June - July 2009

 
An Award: ABCT Self-Help Book of Merit
  Self-Help Update: Talking to Anxiety
  Book & Media Update: Trichotillomania: An ACT-enhanced Behavior Therapy Approach

 

   
         



Stop Obsessing! Wins Award

In May, The Association for Behavioral and Cognitive Therapies (ABCT) presented the Book of Merit Award to our self-help book, Stop Obsessing! Taking Control of Your Obsessions and Compulsions.  The award is part of ABCT’s effort to educate the general public on the benefits of empirically supported treatment.

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Self-Help Update:
Talking to Anxiety*

Here is an interesting way to respond to the sensations and fears of any anxiety that does not require problem-solving—anxiety that shows up unneeded and unwanted. Consider this an advanced skill; it involves a leap of faith to create this transformation.  Not everyone will be willing to try this out, and it isn’t a required skill.  But I can tell you this: when it works, people report that it works in a powerful way. If you are up for the challenge, let’s get started.

The structure of this strategy appears to be on the level of changing what you are mentally saying, but that’s not it.  You are changing where you place your attention.  How? Here are the steps of “talking to anxiety” (and I’ll give you a formula for it in a moment):

1.  When you get anxious, literally speak to the anxiety as though it exists outside of you.

You are prying your attention away from its automatic focus on your worries.  Your worries feed your resistance. 
      ---   The less you attend to your worries, the less you will resist by giving yourself a competing task. 
      ---   The less you resist, the more powerful you become.
And what task are you investing in?  One that is weird and different for you.  That requires concentration. 
      ---   The more you concentrate on mastering this task, the less you attend to your worries.
Yet it simultaneously keeps your attention on your discomfort and doubt. We know from research that when you attend to your doubt and discomfort without resisting them, you contribute to your healing process.

2.  Give your anxiety instructions that are opposite of what it expects.
 

You force your attention over to the task of delivering a paradoxical message.  Your logic needs to be: I want to ask for more trouble as one way to combat my powerful, automatic message of “I hope I don’t have more trouble.”
      ---   Fighting and resisting has failed you.  Resisting a threat makes the threat feel worse.
      ---   The best way to stop resisting is to busy yourself with the task of inviting what you fear. 
You might be terribly clumsy at this task, and that won’t matter a bit.  You can win the booby prize as the least talented student of this skill on the entire Earth.  How good you are at these instructions is irrelevant.  What is relevant is where you place your attention. If you will attend to the task of developing the best skills of talking to anxiety, then, by default, your mind will have less attention available to float over to your worries.  In game theory they use a term called zero-sum.  It means you only have so much of certain resources available.  For instance, let’s say you have limited funding for a business project.  If you spend 80% of your money on research and development, you only have 20% left to produce and market the product. 

Your attention operates on a similar formula, and we can take advantage of that.  When anxiety is winning, it is because you are “spending” vast amounts of your limited conscious attention on reacting fearfully.
      ---   If you consciously and powerfully engage your mind in the project of figuring out how to ask anxiety to increase your sensations, then, by default, you will automatically, spontaneously withdraw mental attention from your fears.

So attend to this skill—as a student trying to master it—and you will discover that it serves your goal of not attending solely on how to resist. As you stop resisting, you start the healing process.

3.  Then return your attention to your current activity. Don’t look for any “benefit” from what you just said.  Turn away from your worries and back to your task.

You have been attending to your sensations or doubts in a negative fashion—fearing them and trying to resist them.  You will not be able to immediately wrestle your attention away from them.  Instead, change how you attend to them (by encouraging instead of resisting). Talk to your anxiety.  Talk to it as a customer asks for another serving, as a boss demands output from a lazy subordinate, as a blackjack player asks the dealer to “hit me again.”

Then turn your attention away from the transaction, gently and immediately.  You are done addressing your fearful thoughts.  Consider the transaction as complete from your vantage point.  Don’t expect anything back from anxiety and don’t check to see if it is responding.  Re-engage in your valued task. Turn your attention back to driving your car or talking to your friend or concentrating on your work.

When you turn your attention back to your task, your belief system and your body-&-mind will perceive it, at least in the beginning, as a risk, because you have been using your attention as a defensive system—to track your discomfort. Shifting your attention away from your worries is a form of dropping your guard. So assume you will feel anxious because of your intervention. Expect that. In the learning process we all feel insecure.

4. When anxiety grabs your attention again (which might occur within seconds), be O.K. with that and return to step 1.

Inevitably your distress will grab your attention again, usually within moments.  No matter how many times it grabs you, commit to responding to it each time in the same manner.  Yes, it distracts you from your task, but that is the sacrifice you must make.  If you want to get stronger, you have to practice. When you practice, you will not be able to devote all your attention to the task at hand, so others might notice you are nervous, or you might not be able to track the plot of the movie, or you may miss a turn while driving. But once you have invested the time in repeating this practice, and you have learned the skill, then you will discover the benefits of no longer fighting your fears.

The Formula

Here is a simple structure for any request you make of anxiety.  Express a desire, conveyed in a tone that you purposely choose. It can range from a soft tone (“would you please…?”) to an aggressive one (“Come on! Is this the best you can do? Give me your best shot, now!”).  This desire should be your direct request for anxiety or doubt to increase strength, length, intensity or frequency (“give me more, please”) of whatever currently threatens you, such as your bodily sensations or worries about the judgments of others.

How to Talk to Anxiety: The Formula
(choose one per column)

Request an increase in whatever
currently
threatens you

Want

Demand

Encourage

Plead

Invite

Urge

Beg

Stronger

More

More intense

Longer lasting

More frequent

More threatening

Scarier

Worries

Fearful thoughts

Physical sensations

Doubts

Confusion

Mistakes

Embarrassment

Please note that in order to convey these principles as simply as possible, I have labeled them as “talking to anxiety.” But you can give that entity any label that feels appropriate. Depending on what is threatening you, feel free to talk to “worry,” “panic,” “embarrassment” or “doubt.”

Now it’s time to try this strategy out.  Start off with low-grade threats and low anxiety sensations.  For instance, if you have a big event tomorrow and you are beginning to notice your nervousness today, even though you are prepared, then practice talking to anxiety. Ask it (or beg it or demand it) to increase your specific uncomfortable sensations at that very moment. “(Boy, am I anxious!) Oh, anxiety, would you please make my stomach tighter? Please?”  If your worries are more troubling to you: “(Geez, I’m all caught up in my worries about tomorrow.) Hey, anxiety, could you make those worries come more frequently, please?  And how about making them more catastrophic?  I mean, these are kind of wimpy. Really scare me, how about it!” 

Remember to give the instruction, and then turn your attention back to your current task.  Don’t sit there and ask, “Did that do anything?”  Just practice the mechanics of the skill, without attention to the results.  Stay with the practice, and look for opportunities to try again throughout the day. As you begin to master the structure of the communication and as you discover that nothing terrible happens as a result, then extend your practice into more threatening arenas.

* excerpted from Wilson, Don’t Panic: Taking Control of Anxiety Attacks (Collins Living, 2009)

 

 

 

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Book & Media Update:
Trichotillomania: An ACT-enhanced Behavior Therapy Approach

Trichotillomania: An ACT-enhanced Behavior Therapy Approach, Therapist Guide, Douglas Woods, Ph.D. & Michael Twohig, Ph.D. (119 pages, paperback), New York: Oxford, 2008.

Trichotillomania: An ACT-enhanced Behavior Therapy Approach, Workbook, Douglas Woods, Ph.D. & Michael Twohig, Ph.D. (81 pages, paperback), New York: Oxford, 2008.

Before treating someone with trichotillomania (TTM), I start with several questions:

  • How aware are they of the pulling?
  • Do they know what initiates the sequence?
  • Can we outline the steps through to the end of the pattern?
  • What’s helped already?

Depending on their answers, we’ll begin treatment, usually in this manner:

  • Raise their awareness of their thoughts, feelings and actions
  • Mess up the pattern

OK… that doesn’t sound quite evidence-based, does it?  But actually, it is.  It’s just missing some details.  That’s when this combination of patient workbook and corresponding therapist guide come in handy.  They consist of a well-structured, methodical 10-week treatment protocol. And they offer one great advantage over typical cognitive-behavioral therapy for TTM.  This disorder can be tenacious.  You give it your best effort as a therapist, and your patient appears motivated.  And then, somewhere along the way, the wheels fall off; you arrive at an impasse.  I believe that the ACT component adds a special insurance plan to the treatment.  While it is highly beneficial to introduce the skills associated with acceptance and defusion, it is the behavioral commitment assignments within ACT that inherently challenge a kind of unconscious urge to avoid.  You push beyond the TTM to the patient’s valued actions, and seeking out those activities becomes a primary task. So patients aren’t simply combating the urges, they are discovering any hesitations they have with joining their world again, and they are confronting obstacles to enjoying an active life each and every week.  This adds leverage to your treatment, lifting patients out of 100% focus on their symptom struggles.

I promise you, if you are treating trichotillomania, you and your patients will need all the support you can find.  This companion set will serve you well.

 

 

 

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