It’s that specific intention—to find a way to practice taking the hit—that distinguishes this work. In typical exposure treatment, the client is assigned tasks that generate discomfort. Instead, I’m intent on helping clients to change their point of view from “I know I’m supposed to face my fears to get better, so I guess I’d better go do it” to “Where can I find some more opportunities to face my symptoms?” It’s the difference between saying, “I hope I don’t get too anxious doing this” and “I hope I get anxious enough to make this a good practice; I really want to get stronger, and I believe this is a good way to reach that goal.”
“How did you feel when you drove out of the garage?” I asked.
“Well, I felt more empowered. I felt really happy about that,” she said.
Then I queried, “So, what do you think would happen if you don’t practice another garage for three months?”
She answered, “I’m not going to habituate.”
With Mary, I immediately reinforced her spontaneous-imagery rehearsal by keeping our conversation focused on the future. In traditional exposure treatment, the therapist’s attention is on implementing the proper procedures for the current practice. That task is critically important, but insufficient. By contrast, I continually elevate the discussion to principles that clients can adopt as a standard of living.
Later, I asked Mary, “If you had to put together a little set of guidelines for 10 people who are coming in tomorrow, facing these kinds of fears, what would you say are the most important principles of recovery?” She said:
Face your fears in small ways that you have control over, gradually do these things longer, and then do the harder things.
Talk yourself through it in a really strong, commanding voice.
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.
Reid Wilson, Ph.D., is associate clinical professor of psychiatry at the UNC School of Medicine. He runs www.anxieties.com, the largest free anxiety self-help site on the Internet. He’s the author of Don’t Panic: Taking Control of Anxiety Attacks and Facing Panic: Self-Help for People with Panic Attacks.
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