I began to notice some other limitations with the CBT model. Although the treatment techniques were powerful, the approach didn’t explain the when or why of anxiety or depression—something that many in the CBT community seemed to feel was irrelevant to successful treatment. It seemed obvious that negative thoughts triggered anxiety, but what caused the negative thoughts? What was it inside a person that made him or her so vulnerable to intense anxiety and insecurity?
Then one day, one of my patients got me to thinking about anxiety in an entirely new way. Margaret was a 25-year-old married woman who came to me because she was struggling with panic attacks at work. She was working as an administrative assistant for a man with a wholesale soda pop distributing company. She’d married and taken the job right after graduating from high school, foregoing her plans to attend college so she and her husband could afford to buy a house. Her father had helped get her the job through a family friend. Although she was doing good work and got along well with her boss, every time he walked past her desk, she developed feelings of intense nausea and had the urge to vomit. Then she’d have to go to the ladies room and lie down, waiting for the nausea to pass. Sometimes, she had to go home because she was so sick. Her doctor had run some tests and reassured her there was nothing wrong physically.
I used a battery of CBT techniques and Margaret faithfully did all her psychotherapy homework between sessions, but her symptoms only improved about 50 percent. Although she no longer had to seek refuge in the ladies room and was able to stay at work, she still struggled with strong feelings of anxiety and nausea. This wasn’t a satisfactory outcome by a long shot, but it was the same pattern I’d observed in so many of my anxious patients: they’d improve to a point, but then plateau, no matter how many techniques I tried.
I felt there must be something else going on, but had no idea what. I asked if she was angry or unhappy with her boss, but Margaret insisted, quite believably, that she admired him greatly. He treated her well, constantly sang her praises, and paid her well. She was happily married and had no conflicts with anybody.
Margaret had been working with the list of cognitive distortions from my book Feeling Good. One day, she asked whether All-or-Nothing Thinking, one of the distortions listed, could apply to family dynamics. When I asked what she was thinking about, she said that when she’d been growing up, her sister, Ann, had been labeled the “bad daughter” and she, Margaret, the “good daughter.” She explained that she’d always been expected to be a model citizen and perfect lady. She became studious, bookish, and hard working, getting straight A’s in school. She was responsible and ready to be helpful, did chores around the house, never tried smoking or drinking, and never disobeyed her parents. Likeable and popular, she was usually elected class president. As her parents said repeatedly, she was a “very good girl.”
Margaret went on to explain, however, that the “good girl/bad girl” labels weren’t really accurate, but a kind of caricature of a much more complex reality. In the first, place, she said that her sister, Ann, had always been a kind, conscientious person, who’d also gotten good grades and was now happily married with two children—not at all a wild, heedless party girl who never grew up. “And I,” Margaret told me cautiously, “am not as much a Goody Two Shoes as everyone seems to think.”
I asked what she meant, wondering whether I was about to hear revelations about a hidden life of secret vices. Nothing like that: what she meant was that she didn’t always want to be such a nice, compliant girl. Then she confessed that she secretly hated her job. Although working conditions were pleasant and her boss was terrific, she just didn’t want to spend her life selling soda pop. I asked what she’d be doing if she found her ideal job. She said that ever since she was a little girl, she’d always dreamed about being a dress designer, adding that she was good at art and had a talent for fabrics, color, and fashion. But how could she tell her boss, since he was so nice and she couldn’t stand seeming disloyal or hurting his feelings! It might show she didn’t appreciate what her father had done for her, and she was afraid she’d be letting down her husband as well.
A possible meaning of Margaret’s symptoms jumped to mind. Could her panic attacks be her way of saying, “This job makes me sick,” or “I can’t stand working here,” but instead of verbalizing her feelings, her symptoms allowed her to play the sick role and say, “I just can’t do this any more.” This idea resonated with Margaret, and she brightened up immediately. She left determined to talk things over with her boss and her husband.
At the start of the next session, much to my shock, a beaming Margaret announced that she’d talked things over with her husband and boss, who both supported her desire to change careers. She assuaged her feelings of disloyalty to her boss by giving him eight weeks’ notice and promising not to leave until she’d trained a suitable replacement. “And,” she said triumphantly, “I haven’t felt panicky or sick to my stomach even once since telling my boss.” Her symptoms had disappeared and her scores on the depression and anxiety tests were zero, indicating she was ready to terminate treatment. It was our last session. Six months later, Margaret sent me a thank-you note explaining that she’d found a job as an apprentice to a woman who manufactured women’s clothing, had never had another panic attack, and was still doing great.
Exploring the Hidden Cause
At first, I thought that Margaret’s case was just an isolated example, but over time, I began to notice the same pattern with more and more anxious patients who seemed stuck. I started asking them if there was something going on in their lives that they hadn’t told me about—something that was bothering them. At first, they’d all deny it, but after a few sessions, a hidden emotion or problem would emerge. When the patient expressed the hidden feeling or took steps to solve the problem he or she had been avoiding, the anxiety improved significantly or, more often, disappeared completely, just as in Margaret’s case. It seemed that these patients were trying to teach me something important about the deeper causes of anxiety, something that wasn’t a part of my CBT training. They were giving me a new tool I decided to call the Hidden Emotion Technique.
The vast majority of these patients were exceptionally nice individuals who felt a strong urge to please others. In fact, most of them seemed to exhibit—beneath their panic attacks, anxieties, and fears—phobias about conflict, anger, or negative emotions of any kind. They seemed to experience a kind of emotional perfectionism, the belief that they should always be happy, pleasant, calm, and totally in control of their feelings, even at the expense of their own desires and emotional needs.
In other words, when anxiety-prone individuals get feelings or urges that don’t seem “proper” or “acceptable,” they sweep them under the rug without realizing they’re doing this. Then they suddenly develop a phobia, a panic attack, or OCD symptoms and completely lose sight of the hidden problem or feeling that triggered the anxiety in the first place. This dynamic isn’t always happening—sometimes a phobia is just a phobia—but through the years, I’ve observed it in roughly 75 percent of my anxious patients, and when I help them uncover the hidden emotion, the anxiety disappears with astonishing regularity.
As I thought back to my own childhood and life, I noticed this pattern as well. When I was growing up, I struggled with all kinds of fears and phobias. I feared bees, dogs, horses, blood, heights, vomiting, cameras, public speaking, social occasions, and more. Why had I been so afraid of so many things?
Like so many of my anxious patients, I’ve felt a strong urge to be nice. I’m not entirely sure where it came from, but I was what’s known as a PK, or “preacher’s kid.” My father was a Lutheran minister and a basically kind man, but strict, demanding that his children adhere to a fairly rigid formula of “goodness.” We were expected not just to follow rules, but to follow them in a humble spirit, always to be polite and considerate, to please others, and to be models of good behavior. To this day, when I’m beginning to feel a sense of dread or generalized anxiety about my life, it’s usually because I’m feeling annoyed with someone, or upset about something, that I’m sweeping under the carpet—because I think I’m not “allowed” to have those kinds of negative feelings. When I bring the problem to conscious awareness and deal with it, in most cases, the anxiety immediately disappears.
You might call this the Excessive Niceness Syndrome, and it’s made me think about anxiety and phobias in ways much different from those I was taught during my psychiatric training. We commonly refer to phobias, panic attacks, and obsessive worrying as symptoms of anxiety disorders, as if they were mysterious pathological conditions without any meaningful connection to the emotional life of the person who’s experiencing them. In fact, we’re sometimes taught that depression and anxiety result from some type of chemical imbalance in the brain, although that theory has never been validated. Now I’m inclined to view anxiety as part and parcel of the human condition. Specifically, I wonder whether anxiety might ultimately result from a kind of existential fear of the self—fear of who we are and how we really feel as human beings. Perhaps these phobias and fears serve the purpose of safely isolating us from uncontrollable urges, feelings, desires, and impulses that we dislike and that contradict our idealized notions of who we think we are or should be.
From my work with large numbers of clients with every conceivable type of anxiety, I’ve learned more about the nature of the hidden problems that trigger the symptoms. First, the problem is almost never buried in the past. It’s something that’s bothering the client in the here and now. Second, it’s something obvious and simple, like hating law school, but feeling you have to stay in law school because your father always wanted you to be a lawyer. Third, it’s usually a symbolic expression of the hidden conflict. For example, the law student with panic attacks doesn’t have to say, “Dad, I’ve decided to drop out of law school because I don’t want to be a lawyer. I want to become a journalist.” Instead, by assuming the sick role, the student can say, in essence, “I just can’t continue with law school because I’m going crazy: I’m on the verge of a nervous breakdown.” This symbolism isn’t created at the conscious level, of course. Anxiety is a kind of creative poetry that the brain automatically generates, much like dreaming. As a therapist, you have to “listen” to the poem to detect the symbolic meaning.
Although the Hidden Emotion Technique appears to me to be a significant advance in the treatment of anxiety, I don’t mean to minimize the enormous contributions of the many brilliant therapists who’ve developed CBT and other new forms of psychotherapy. I’m proud of my own contributions to CBT and still enthusiastically use its techniques with every depressed and anxious individual I treat. But I now have a new model, which seems to illuminate some of the whys and whens of anxiety, along with a powerful new treatment tool to help dislodge anxious clients who’ve gotten stuck with only partial improvement when I’ve used more traditional forms of CBT.