Early in the first session, I ask clients about their long-term goals. Tolerating doubt and discomfort is hard, and I want them to have ready access to an outcome picture that’s strong enough and important enough to help them do the work. Mary’s goal was to be able to move through her world with more ease and less hesitation.
My intention with clients is to gain rapport by reflecting back how they currently perceive their relationship with uncertainty and discomfort, and acknowledging that it makes perfect sense to me that they’ve decided to be so intimidated. I find out if they have any specific themes that need to be addressed—Mary’s were being trapped, having a heart attack, or suffocating in an enclosed space—and I offer them alternative views to challenge their catastrophic fears. This is standard CBT fare, but I’m not interested in lingering on this: I want to address such specific fears and put them behind us. I use those conflicts to introduce the higher-level theme of their relationship to doubt and distress.
When we get to the treatment plan, we build it together, piece by piece. I impose nothing on the client. For example, to Mary I said, “I’m going to suggest that you do some things that are uncomfortable. Short-term pain for long-term gain. You’ve heard that expression before?”
Yes, she was on board with that concept. Then she continued, “I’d like to get to the point where I might have just a mild dislike of something, but I don’t go into these panic attacks.”
Great! She’d just linked the strategy of going toward her discomfort in our practice with achieving her long-term goals. I took that opportunity to reinforce how this “pain” would help her reach those goals.
“We call that habituation,” I said. “It means you develop a habit of facing it enough so that in the future, when you face it, your distress level doesn’t go up here (I point above my head). It just goes to here (I gesture around my waist).”
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.”
This is exactly the response I’m looking for. I want clients to absorb the principles well enough to invent their own practice. Mary knows that seeing more light is a crutch that makes her practice easier. She’s now looking for helpful practice, not easy practice. When she noticed she wasn’t feeling panicky enough, she drove to the darkest place she could find. She’s incorporated the essence of the treatment in a single message: “I’m going to go toward whatever is frightening me.” Excellent! That’s a dramatic change in her relationship with her fears.
I said, “When you left yesterday I was feeling that I didn’t orient you enough. I thought, ‘Oh, she’s going to distract herself.’”
“No,” she answered. “Actually I turned the radio off and I left the windows up, which I never do. And then there was quite a bit of light coming through, so I went like this (she shades her eyes with her hands) and just concentrated on that really low, concrete ceiling. I tried to make it as unpleasant as I could, and sit with that for a bit. And I waited.
“You were saying what to yourself?”
“It was something like, ‘Stick it out; this is fine,’” she said.
Because she absorbed our general plan from session one, she instructed herself to refrain from the typical crutches she used to keep her feelings at bay—finding more light, rolling the window down, turning on the radio—and then she provoked further threat by directing her attention to her highest fears: darkness and low ceilings. She trusted that the treatment theory was valid, she committed herself to change her relationship with her threats, and then she found every opportunity to take the hit.