Issue # 2

Self-Help & Professional Update:
Dismantling the Comfort Zone: 
Common Themes in Anxiety Treatment
PART 2

(I am offering this longer, original article in two parts: in the last issue and in this issue. A briefer version of this article appeared in the Psychotherapy Networker)

Treatment rarely unfolds according to a master plan, no matter how well researched. Behaviors that we euphemistically attribute to "resistance" can be generated by numerous sources. For instance, the plurality of anxious clients has more than one mental disorder, most commonly depression, a second anxiety disorder, dependent personality or avoidant personality. Proper assessment of these comorbid disorders is essential to treatment planning. Any troubled part of the personality that goes unrecognized gets to play jungle warfare, sabotaging the client's best intentions while remaining hidden. 

Some are demoralized by previously failed treatments. Others are riddled with shame, and doubt they have what it takes to get better. Clients might be influenced by an unconscious fear that getting better will threaten their fragile role in the world. And many are simply too afraid of symptoms to engage in the therapeutic alliance. 

I do the best I can to uncover these themes as early in treatment as possible and keep them in the front of my mind during the session, even if I don't overtly address them. I also use certain client behaviors as cues that one of these issues may be in active play. Is the client missing appointments, forgetting to do homework, or continuing to seem confused about the approach? At these times I consider backing away from my common routine and look for the intruding theme.

Staying Focused on The Tasks

One of the most common themes in anxiety treatment is avoidance. I bring great attention to finding ways to support them being active in the world. For example, the more threatening the work is, the more contact I have with the client. I augment 45-minute sessions once a week with emails or phone calls from clients, letting me know when they have completed a homework assignment, or when they failed to do the homework by a designated time. (Most would rather do their homework assignment than have to phone me to say they didn't!) We design charts to record their threatening events or their planned experiments. If they continue to have trouble, I won't purposely provoke guilt, but I might spend ten minutes at the opening of the next session posing questions to "analyze" together about why they are having trouble. I am usually less interested in their answers than I am in making them uncomfortable enough with the questioning. The next visit, they come in with their homework done.

Divide and Conquer

Another troublesome area is secondary gain: some clients tend to link together the idea of getting well with the fear that they will lose something or someone of value, leading to their need to stay stuck. This was blatantly evident two months ago when one 35-year-old OCD client, living with her parents, starts the session by saying, "I am doing a lot better controlling my morning routines." I respond, "How are you feeling about that?" "Sad and scared," she says. "Really? Why?" "Because that means I'll have to lose my dependency on my mother." Later in the session I ask again how she feels about progressing. “Excited.” "But you just said 'sad and scared' 10 min ago!?” “Well, I am.”

In these situations, my approach appears contrary to what would be expected from the therapist. I do not necessarily give optimistic predictions of successful outcomes on all fronts. I may do just the opposite. I will separate the gain over the anxiety disorder from the other therapeutic goal (that the client currently perceives as a threatening loss.) With this woman, I devise a plan with her on how to keep her gains secret from her mom. I also instructed her that she was not allowed to consider moving out of her parents' home as a result of getting over OCD; that we would either tackle that issue later or never address it at all. 

Similarly, some with panic disorder consciously want to get well in order to leave a bad marriage, but unconsciously believe that they are neither lovable or capable on their own. I might suggest that they don't even think about separation until six months after they are completely well. I make that request firmly and dogmatically, because I am attempting to push the symptom cluster aside while upholding the secondary gain with my command.

With hesitant clients, I also want to separate early therapeutic steps from any later threatening events. I help clients break down their change process into small independent pieces, not steps that flow toward the goal. Many OCD clients who fear contamination really do believe, at the moment of exposure, that they must repeatedly wash to save their life or that of someone they love. They often enter treatment without trusting that it will be successful. Based on my experience, I consider that any small little change in the pattern can be therapeutic. So I might offer an assignment such as this: "Would you be willing to simply count the seconds each time you wash, and write them down for me?" It might take three 45-minute sessions to convince someone to attempt this one undemanding practice. I've gotten very good at persuading over the years. I am quite patient when need be, because I know that this first seemingly small effort is often the first crack in the walls of the symptom fortress. The more "resistant" the client, the more I nurture this initial effort along. 

Mary’s Panic

These last two case examples will illustrate similar outcomes with significantly different treatment strategies. Mary's story comes first, and supports one alternative approach for the therapist: work methodically through the basic skills while respecting clients' early resistance to exposure; decisively give them the principles to recovery; build experiments that are within their reach; and expect that they will discover their lessons at their own pace. 

Mary began to have a few panic attacks in high school, more in college, and now she asked for my help as a graduate student. Her most frightening thought is similar in most situations: that she might faint (although she has never had a fainting experience). Her body always responds quickly and broadly to the prediction. She feels pressure in her chest; and her heart races, stomach aches, and vision blurs. Soon, her hands are shaking, her chest gets splotchy, and she feels like her “insides go numb." Her breathing is especially threatened, as though she is choking and, at the same moment, "like I'm breathing through a sponge.” It is no surprise that the symptoms overwhelm her so that she can barely think of any response but "run!"

By the time she sees me, the symptoms are encroaching on far too many settings: walking across campus, sitting in classrooms, standing around in a small group of friends, walking through the mall or waiting in the cafeteria line. She can no longer control them through distraction and escape. On occasion she avoids leaving the house for fear that she might experience fainting as she crosses campus or while sitting in the classroom.

We begin working together in October. In that first session I listen to her words, her tone; I watch her facial expressions and body language. She clearly has the character of a spunky, vibrant young woman. But at the same moment, she appears beaten down by the distress. Her youthful look can hide a lot, but I see the light bags under her eyes, the pale face, leaning toward jaundice. She feels trapped, and she is clearly beaten down. If I ask certain questions I know that those fragile eyes will spill tears of depression and despair. I steer clear of that for today and align myself with her underlying character, encouraging her to enter treatment with high expectations.

She is so frightened about the possibility of losing control of her body. When out in the world, she thinks that will occur imminently and cost her at least humiliation, at most death. Like many clients, she will need time to rebuild her strength while keeping her relied upon defenses of worry, self-monitoring and avoidance. If I to push her into confronting her feared situations too quickly, I predict that she will run from treatment. I decide to focus only on the basic self-help skills for anxiety. 

Mary becomes a diligent student. Within a month, she quickly masters special breathing skills, she practices relaxation training daily, and she even has a set of soothing self-statements.

She is, however, still stuck and frightened, since we have challenged none of her beliefs. The fifth meeting changes all that. This is a fast-moving session in which I introduce assignments on two fronts: the mall and the classroom. 

Changing Strategies

Any time she walks through a mall she has three strategies. She begins a plan of escape, noting how she will get away from a clerk and out the door in the briefest amount of time. Throughout the event she monitors her body for cues of panic. Every few minutes she takes her pulse to verify she is still in control. I ask her to conduct the following experiment: go to the mall twice this week. When she notices herself planning her escape, practice dropping it. Don't check her pulse. Don't check in with her body. And look for friendly faces while she is shopping. I add this caveat: she doesn't need to practice if she doesn't want to; she should only do it if she feels ready to learn.

In any classroom, if she can get herself to attend, she sits in the back corner, closest to the door, monitoring the time with her watch. She worries throughout that she might pass out. When I ask her what would cause the fainting spell, she doesn't really know, but thinks it would be because of a heart disorder or a brain disease. Does she really think she has one of those illnesses? No. I give her two assignments. For any classes she decides to attend, she is to take her watch off and ignore the time. She is to monitor all worries that pop up in classes and jot down what the topic is. If it is fear of passing out, she is to note whether it would be from a heart problem or a brain problem. Again, she only needs to practice if she feels ready to learn.

A week later she tells of going once to the mall without planning her escape route, but still scaring herself with thoughts of, "I could pass out." She only monitored one class all week. Seven times in that hour she had worries of passing out: five because of heart related problems and two because of a brain disorder. 

Forget the Content—Go for Discomfort

By following these assignments she works on all three of my principles: challenge worry as productive, act while uncertain, and seek uncertainty. I didn't care how many times she practiced. I wanted her to make up her own mind to start challenging her beliefs, even if she stumbles through a half-hearted attempt. After all, she is confronting not just the fear of fainting (which is threatening enough) but that she might drop over dead. 

This session turned out to be her first of two breakthroughs, even though we didn't recognize it at the time. Later she would say that it was the classroom data that did it. She had the insight that the content of her worry was not relevant, that she didn't need to address the actual possibility that she was ill. It was more helpful to believe that this was about simply being anxious. Anxiety is uncomfortable, but it is not fainting and it is not dropping dead.

From then on, she took control of her practice. With my help, she took provocative action in three of her classes the next week, sitting by the front door instead of the back door in her Spanish class, sitting on the front row in History, and sitting in the middle of the right side in Art History. I explained again the principles of habituation: purposely to stay uncomfortable in a feared situation for a prolonged time, helping the body tolerate it. Her new assignment in those classes: be uncomfortable. She was to greet her anxiety ("hello, my old friend"), then stay with her distress, even if she didn't concentrate on the lectures very well.

Within two weeks, Mary stopped missing classes. She began addressing her fears of social activities ("people are looking at me, watching my every move, noticing if my hands shake"). She practiced by attending mixers at her sorority and traveling to the beach with friends. We added several skills to manage her anticipatory anxiety, such as thought-stopping, singing her worries, postponing her worries to a later time, and setting aside ten minutes to do nothing but worry.

“Give Me Your Best Shot!”

The insights from these courageous practices lead Mary to her second breakthrough: applying the paradoxical run-toward-the-roar approach to her symptoms. One particular evening in January she was following the course of so many graduate students before her: Taking the elevator to the upper floors of UNC’s Davis Library to continue researching her masters’ thesis. 

After about 20 minutes pouring through the 17th Century British Literature section of the stacks, her heart took center stage. Sudden, strong pounding. Then came that suffocating feeling that you can only relate to by imagining that you’re trapped inside a car on a 100-degree day. “I really wanted to run out of there. My body started shaking, I felt lightheaded and I lost all concentration on my work.” 

She describes her next moves. “Then – I don't know how it came to me – but I decided to take the bull by the horns. I walked to the end of the row of shelves and sat down cross-legged on the floor. (I didn't want to crack my head open if I fainted!) Then I said, ‘Come on, panic, give me your best shot.’ I really meant it. And I just sat there. I sat there and took it. Within two or three minutes all the symptoms stopped. I got up and finished my work, which required about three more hours in the library.”

This was a turnaround experience for Mary. Up until that night she was using a permissive stance to cope: she applied breathing skills and supportive self-talk to keep her from escaping the scene. Her message was, "It's OK, I can handle these symptoms." In the library, Mary moved to the next level of her work by practicing the paradoxical stance. She consciously attempted to increase her symptoms, not just put up with them. 

Panic requires resistance to persist. Without something pushing back at it, panic loses its strength. Before that night she would have left the building immediately upon noticing her symptoms, because they came on so suddenly and caught her off guard. She would have gone straight home, interpreted this as a major setback, avoided library-like environments and mentally kicked herself over the next two or three weeks for having failed at her task.

After that one night in the library, Mary started an accelerated climb out of her suffering and into recovery.

Yolanda’s OCD

Yolanda is an attractive and composed 42-year-old mother of two. In our first session I quickly learn that her physical appearance and demeanor hide 21 years of suffering from severe OCD. It has caused her to hide away in a private life of "pure hell," losing her first marriage, not being able to work outside the home, finally succumbing to alcohol as a tonic to her disability. 

Then she reveals the painful routine of her daily life. Her checking and washing rituals take two hours a day, but her obsessions last throughout her waking hours. Above all, she dreads anything entering her house that has come in contact with the ground outside, fearing it might transmit the rabies virus. Alcohol brings the only quiet from her inner terrors. At 4 o’clock each afternoon she begins drinking a full bottle of champagne – every afternoon of every day for the last eight years. Most mornings she arises feeling ashamed and disgusted with herself.

I do my best to offer her hope about the future, the possibility of recovery, that other people like her have gotten well. I conclude that session with a single concept: I will help her focus on having obsessive urges and then not responding to them with compulsive behaviors.

On the following Wednesday she tells me that she felt angry the day after our first session, angry that the OCD has run her life for so long. She also experimented with that concept of having the urge but not responding to it with a ritual. On Sunday she dusted the TV and another table and didn't immediately wash her hands.

“I Must Get Distressed!”

My plan this session is to avoid threatening her with specific assignments, but to keep fostering her understanding of what it will take to get well. I build on her success with the cleaning by introducing three guidelines for her treatment. On my 3-by-5-foot whiteboard I list: "1. I'm willing to be uncertain, 2. I'm now going to generate uncertainty, 3. I must be distressed for prolonged periods in order to get better." I embellish each of the points and instruct her that any experiments she wants to conduct should be based on these principles. That’s it. No techniques. No skills. No homework tasks. She walks out of that session and gets to work, making up her own practices.

Two weeks later she returns for session 3. The three guidelines are back up on the board when she enters the room. She tells how she has been keeping a journal of all her OCD-related activities. She's been doing well by touching things that she usually avoids during her daily routine. Guideline number 2 is harder for her; she is not purposely provoking her uncertainty. A variety of feared consequences are running her avoidance, but the main one is, "my children will get sick and die." Much as she wants to get well, nothing is worth that terrifying outcome. This is the issue that controls most people with OCD, and it requires the strongest therapeutic effort. Fortunately, Yolanda trusts my knowledge and experience enough to challenge her position. 

Personifying OCD, I emphasize how it needs her to believe the specifics of her fears. The person who wins over OCD will hold fast to the belief that this is an anxiety disorder. With an anxiety disorder, your battle should be with the physical symptoms of anxiety, never with the content of the obsessions. It is never about germs or rabies or salmonella. It is always about the threat of feeling distressed. 

The most consistent thing I do with anxiety clients is to keep a simple message at the heart of our discussions. The clearer I am about a few points, and the more emphatic I am about using them as guiding principles, the more successful I am at influencing the client's point of view. Yolanda left with this specific instruction: "Focus on anxiety, not content."

She starts session 4 smiling broadly. She has had no alcohol for 8 days, and she is feeling wonderful. She accomplished a number of "firsts" in these two weeks. She pumped her own gas for first time in years. She is not washing her hands after touching money or many of the previously taboo items in her house.

She doesn't confront everything yet. She avoided the field trip with her daughter's class. She is still quite anxious about the possible rabies contamination of driveways and parking lots. (For 4 nights after session 3, she had nightmares about animals.) She squeezes her car keys to prevent them from dropping on the ground while she is walking. Despite the fact that she is happy with her progress, she feels a "cloud of doom" that either she will have a setback or that her worst fear will come true: someone will die because of her negligence.

A Chance with The Tires

I keep my job simple in this session. Yolanda is quite animated and garrulous now, so I listen. I support her excitement. I acknowledge how frightening her fears are and see no need to reassure her that nothing terrible will happen. The possible death of a daughter is horrifying, and she has been run by that thought for ten years. I will not attempt prematurely to demand that she ignore the content of her fear. More importantly, she must continue to consider the source of the thought to be OCD, not a premonition of involuntary manslaughter. I trust that Yolanda is taking responsibility for her work and that she will wrestle with the OCD at her own pace. Then, in session 4, something quite interesting happens. 

When working with anyone with anxiety, I want my intuition to remain active. I want it to compete, if needed, with the common protocols of cognitive-behavioral assignments that suggest that we use a step-by-step sequence of exposures to feared situations. If anxiety disorders are frequently run by irrational beliefs, then it should be possible to respond occasionally to such beliefs outside of the rational, logical, gradual approach. 

When session 4 ends, I decide to walk Yolanda to her parking space. This is unusual for me, and I don't really know why I'm doing it. As we stand by her car, I then ask, "Will you let me touch my own hands to your tires?" (She believes her tires are constantly contaminated with rabies.) She appears visibly shaken and her face pales. I can imagine her internal struggle between wanting to trust me and being petrified of some catastrophic outcome. Finally she nods her head. I walk around to each individual tire and dirty my hands. As I stand up and turn around from touching the fourth tire, she is directly in front of me. With tears rolling down her cheeks, she grabs both my hands in hers and squeezes. Without speaking, she gets in her car and drives away. I'm standing in the parking lot, shocked by her escalating my threat. My impulse is to immediately leave a message on her answering machine for her to call me when she arrives home. But I resist this unsolicited rescue and wait the two weeks.

Her fifth session marks the turning point. Yolanda is 3 weeks sober. She reports getting into bed each night terrified of her feelings. She struggles to fall asleep for 20 minutes, then wakes up in a panic, as though she can't swallow and can't breathe. But every hour during the day, she has been trying to practice another exposure. It all started when she came home from the previous session, feeling contaminated with rabies, and didn't wash her hands until suppertime. 

This is the first session that I offer her explicit homework assignments to further her gains. They all involve her checking behaviors. Locking up at night, she can look at the sliding door once but not check it, she can push on the front door once after locking it, and she can look at the window locks once but not touch them. At night, she is to leave the lids to the toilet seats up, not check for water dripping in her sinks and showers, not check the stove or nightlights. She can ask if the house alarm is set, but she can't visually confirm it.

“What You Put on the Board!”

Yolanda progressed steadily forward. We had two more bi-weekly sessions, then moved to monthly consultations for several months. By the time she completed treatment, Yolanda had started working again as a nurse’s assistant. Within a year, she returned to school, earned her nursing degree in two years and is now working full-time, symptom-free. 

During session six she tried to explain her newfound success. Gazing down, pensive, she says, “I don’t know exactly what I accomplished in the first two weeks. I know that after the second week I felt much better about it. I said, ‘I am able to talk about it.’ And, um….” Pregnant pause. Then she looks up, past me, and stretches out her arms in a dramatic gesture to frame in the whiteboard on my wall. Her eyes sparkle, and a wide smile grows on her face. She leans forward, excitedly declaring, “What you put on the board! That’s what you did; that’s what you did! You put on the board how I need to feel anxious and feel distress ‘for prolonged time.’” She pulls her hands in and motions the idea of feelings progressing down her torso. Laughing now, she says, “I had that memorized and I still say that to myself!”

“The Happiest Day of My Life”

Yolanda got well because she used her commitment to change and her trust in me as leverage to tolerate her fear of exposure to rabies. This is how she describes it. “So, little by little, I started touching things that distressed me. Then I’d say to myself, ‘you’re going to have to feel anxious,’ and I would resist the washing. I kept telling myself, ‘I hope that good doctor knows what he’s talking about!’”

She actually stopped her mind's worried monologues about getting rabies and started directing her attention to purposefully feeling doubtful and uncomfortable. She recovered because she narrowed her concentration to a few very simple (but difficult) tasks.

“After touching some things I would move on within fifteen minutes to other activities and never think about it again. There are other things I held and my whole arm felt freezing cold and numb because it felt so contaminated. But I kept saying, ‘I will not wash it, I will not wash it.’ I didn’t wash, and I didn’t like how it felt. But then sometimes an hour later it felt fine. It felt clean. And I hadn’t washed! It might have been something I hadn’t touched for years, and I did it. Maybe the second time it only felt numb up to my elbow, then the next time up to my wrist.” 

“After awhile it just got easier to do. Now, I’m just moving some of these things out of my way. I don’t have the worried thought anymore. I’m just touching them, and it’s as easy as brushing my teeth. And actually I’ve only been practicing for two weeks.”

“Each day is just getting better and better. And I haven’t had a drink in a five weeks! Every day I can feel myself getting stronger and happier. My old healthy self is starting to come back.”