The Anxiety Game

Anxiety and its next of kin, fear, are arguably the oldest, most basic human emotions, bequeathed to us by a vast history of prehominid ancestors. We owe our survival as Homo sapiens to these emotions, which were literally built into our nervous systems as an evolutionary hedge against extinction. Yet today, while still protecting us from genuine danger, they’ve morphed into a multitude of extraneous and dysfunctional afflictions—panic disorder, obsessive-compulsive disorder, phobias, and all-purpose generalized anxiety disorder (summoning up anxieties on any and all occasions)—the only effect of which seems to be to torment us pointlessly.

When I began my practice, psychotherapists still knew precious little about anxiety, even though it was probably the commonest form of suffering among the clients we saw. By and large, it was considered a symptom of some deeper psychodynamic process, and analysts helped clients find the deep-seated meaning behind their fears. The working Freudian hypothesis of agoraphobia in women, for instance, was that they withdrew to their homes out of an unconscious fear that they’d become prostitutes.

It wasn’t until the 1960s, when behavioral psychologist Joseph Wolpe’s experimental research perfected relaxation techniques and systematic desensitization, that anxiety began to be treated as a separate problem. To treat a fear of dogs, for instance, Wolpe taught the patient how to become deeply relaxed. He then introduced imagery that evoked a weak anxiety response, such as seeing a dog from a great distance and chained behind a fence. Relaxation procedures counteracted the anxiety produced by that image until it no longer distressed the patient. Wolpe would then introduce a slightly stronger anxiety-provoking image, such as being 20 feet away from a fenced-in dog, until it, too, ceased to arouse anxiety. Progressing up the hierarchy of fears about dogs led to recovery.

When it came to working with anxious clients, my own biggest asset was my experience, early in my career, of treating chronic pain patients in a hospital setting. I discovered that there were a number of similarities between the way people handle chronic pain and the way they handle anxiety symptoms. Those in chronic pain will anticipate their next pain episode with dread, so even though an episode might last only 10 minutes twice a day, it can dominate a pain patient’s waking hours.

Once I realized that I could substitute “panic attack” for “pain episode,” I began to get my bearings on treating the panic in agoraphobics, who’d started getting referred to me after a series of stories in the national media gave the condition a label for the first time. At first, I’d been hesitant to accept these referrals, but soon changed my mind. “Wait a minute,” I thought, “I know something about this.” Soon I’d cobbled together a treatment procedure.

I started by teaching agoraphobic clients formal relaxation, although I knew from my struggles with pain patients that, while relaxation could help some, it would never be enough. Additionally, I expected to use systematic desensitization, because it had worked well for the few clients I’d seen who’d had specific phobias. But with clients who feared panic, the method failed me. Since a panic attack arrives so unexpectedly, the client instantly becomes aroused to the highest degree and feels out of control. I couldn’t seem to undo that reflexive response by pairing relaxation with anxiety-provoking imagery of the event. Clients felt too scared to trust that these relaxation and desensitization skills would protect them.

I had to shift my thinking. I couldn’t help my clients undercut the intensity of their fear through some formal procedure in my office. Instead of progressing up a list of anxiety-provoking situations, I needed to focus on the on-off switch of panic. These clients either avoided their anxiety and felt comfortable or faced the threat and zoomed up to peak anxiety. I had to address the moment of panic. When you anticipate an anxiety attack, you desperately want something you can do that will bring immediate relief. I figured my primary strategy needed to focus on skills for responding to the actual feeling of panic.

I continued to teach formal relaxation, encouraging my agoraphobic clients to practice daily for a number of weeks. Then, instead of working only with imagery, we created and rehearsed a simple, structured, three-step response for panicky situations. As they approached a fearful situation, their first job was to counter their racing thoughts by mentally stepping back, accessing what I called “The Observer,” and objectively commenting on what they were noticing—what today we call “becoming mindful in the moment.” For instance, they might tell themselves, “We’re pulling into the parking lot, and I can feel my heart starting to race. I’m scared.”

Second, they were to shift their attention immediately to their well-rehearsed breathing skills. Focusing on the breathing had two functions: it reduced the chance that clients would start hyperventilating, which increased the symptoms they were trying to reduce, and it required conscious awareness. That helped draw their attention away from their fearful thoughts.

The third step was to subvocalize specific motivating messages that supported their goal of approaching the threatening situation. The most prominent were those that conveyed their intention to manage their distress instead of remove it. The common themes were “It’s OK to be anxious here” and “I can handle these feelings.” This step was no magic bullet, but it reversed the not-so-helpful tendency of desperately seeking comfort, which increases the distress because it’s an impossible goal in threatening moments. If clients could permit themselves to be somewhat anxious, they could learn to cope with their distress.

Once I’d developed this treatment approach, clients started getting better. After a while, I became a bit cocky about my clinical effectiveness. “No one else around here is doing this,” I thought to myself. “I’ve figured out something new!” So I decided to write a self-help book based on what I’d learned.

Then on one weekend in 1985, just as I completed the book, I got the proverbial wakeup call. I’d been looking through all my files to revel a little more in my successes and discovered that fully 40 percent of my clients had dropped out of therapy prematurely! None of them had said, “Dr. Wilson, this isn’t really working for me. I think I’m going to quit therapy with you.” They just didn’t make another appointment. Needless to say, none of this treatment failure had been showing up on my radar.

Widening My Perspective

After that rude awakening, I started searching for clinical studies on anxiety. I didn’t have to look long, because the research field was beginning to explode. Studies on systematic desensitization confirmed what I’d noticed: it yielded a small improvement, but, overall, it wasn’t any better than standard psychotherapy for treating agoraphobia. Replacing systematic desensitization was the new field of exposure-based therapy. Instead of training subjects to relax as they faced an image of the feared situation, researchers of this cutting-edge treatment asked subjects to expose themselves systematically to the situations they were avoiding, let themselves become anxious, and remain in the threatening situation. With each practice, researchers encouraged subjects to linger longer in the feared environment or move farther away from their safe zones. With time and repetition, their panic attacks subsided, and they could return to many of their previously avoided locations.

By the mid-1980s, exposure had become the first proven treatment of agoraphobia. However, it wasn’t clear how long clients needed to practice each exposure and what degree of anxiety they needed to experience during each exposure session. These features of the treatment engendered numerous studies, with conflicting results.

Then came a paper by Temple University therapists Edna Foa and Michael Kozak that suggested that exposure therapy might extend to all anxiety disorders. In 1986, they published what has become one of the most frequently cited psychology articles of all time, “Emotional Processing of Fear: Exposure to Corrective Information.” This paper looked past the study of panic to the nature of fear itself.

Foa and Kozak’s theory was that people who develop an anxiety disorder hold on to distorted information about themselves or their environment, which causes them distress. The faulty information is contained within the strong threatening feelings that are associated with their specific fear—what the authors called the “fear structure.” They postulated that the only way for anxious clients to incorporate corrective information was for them to access the intense arousal associated with that specific fear and then linger in that state long enough, without blocking or muting their thoughts or feelings, to learn at a primal level that they’re safe.

Foa and Kozak’s theory helped me begin to see that, in order to improve, clients needed to experience close to the strongest level of anxiety they ever had in a feared situation, and stay in that situation much longer than I’d been suggesting. However, I had to confront my own timidity about assigning long, hard exposure practices. I was afraid that if I pushed clients, I’d chase them away. But when I went easy on my most troubled clients, letting them gradually work their way up their hierarchy of fears, they tended to drop out before making any gains. I decided to become more directive in my work, although I was still concerned about losing clients.

As I attempted to be a student of this prolonged, intense exposure, I struggled to teach my clients the behavioral model of repeated exposure, because it simply didn’t fit my personality to be pushing only behavioral change. To balance this exposure treatment with a more comfortable personal style, I returned to my roots as a cognitive therapist, with one big change: I no longer challenged cognitive distortions sentence-by-sentence.

In the past, I’d spent multiple sessions helping clients identify and correct the errors within their catastrophic, mind-reading, black-or-white thinking, and other cognitive distortions. That process now seemed tedious to me and far too labor-intensive for my clients to tolerate. I felt we could have greater leverage if we worked together to address clients’ beliefs instead of just their momentary thoughts. In addition, I wanted clients to know why they were practicing this new approach more than I cared about exactly what they practiced.

By that point, my referrals had broadened to the other anxiety disorders. Obsessive-compulsive disorder (OCD) became my new nemesis because those clients were so rigidly stuck in their obsessive beliefs. One OCD client was Camille, a 42-year-old mother of two, who feared “sickness” from rabies and from various objects that represented the death of her grandfather. An alcoholic, she drank a bottle of champagne every day, starting at about 5 p.m., when her major parenting chores were complete. Drinking was the only remedy she could find for her obsessions.

In typical exposure-based treatment, the therapist details every step of the procedure. With Camille, once I explained the principles behind OCD treatment, I reduced all of those procedural instructions to two. “To get better, first you must do just the opposite of what the disorder is compelling you to do: you need to generate doubt about getting sick from touching objects. Second, you must try to keep that feeling as long as possible.” Then I did my best to look and sound confident, despite being unsure about my ability to turn simple theory into helpful practice.

To my (well-concealed) shock, Camille got better. After five sessions over six weeks, she was well on her way to recovery. She even had eight consecutive days without a drop of alcohol. When I asked her how she’d accomplished this, her answer included, “I’d touch a contaminated object and have such a strong urge to wash! But I’d remember what you said, and I wouldn’t wash. Sometimes my arms went numb all the way up to my shoulders, but I wouldn’t wash. And I’d say to myself, ‘I hope that good doctor knows what he’s talking about!’” Camille was willing to trust me enough to go against the demands of her disorder.

In 1988, I wanted to take another step in turning over more control to clients. I’d recently developed a brief-treatment protocol for individuals who feared flying. To find out what would happen if I reduced my attention to the details of each client’s problems, focused on the broader principles of recovery, and encouraged clients to take greater ownership of their recovery plan, I designed a two-day group treatment for fearful fliers. A staff member from the corporate offices of American Airlines participated in the third group I held, and benefited from the treatment. Six months later, American contracted me to create a national program. Soon my weekend treatment group grew to 25 participants at a time. The weekend culminated in two round-trip “graduation flights” on Sunday afternoon.

I treated this crowd of clients using three central principles of cognitive-behavioral therapy (CBT) for anxiety disorders. The first principle is to convince clients that their anxiety stems from an exaggerated appraisal of the threat. One of the biggest obstacles to treatment is clients’ catastrophic belief that something terrible is going to happen, and they won’t be able to handle it. CBT strategies help clients reframe the severity of the problem they’re facing so it becomes something they can handle. The socially anxious client might be embarrassed to stumble over his words, but he doesn’t need to perceive himself as humiliated. The agoraphobic who’s in good health might have a panic attack, but not a heart attack.

The first task of the team leaders—a senior pilot with American, a recovered fearful flier, and me—was to address the participants whose fears related to safety. We helped them become more familiar with pilot training, maintenance schedules, and airline safety records. Then we addressed the issues of those who were more concerned with their own anxiety by reframing their symptoms as normal and harmless features of the fight-or-flight response.

A second principle of CBT for anxiety is to dissuade clients from struggling against their anxious sensations. Since we’re asking them to enter situations that they perceive as threatening, they need to expect that anxiety will come with the territory. If they fight and resist feeling anxious, paradoxically, they’ll feel more anxiety. We encourage them to replace this demand with an accepting attitude like, “I can allow myself to feel anxious here.”

In the flying program, after we challenged their catastrophic beliefs, we worked specifically on shifting their attitude about their anxiety to, “I can handle my anxiety, because I know my fears are exaggerated.” We also taught them several skills to help them control panic, instead of trying to eliminate all anxiety.

A third principle of CBT for anxiety disorders is to counsel clients that the best way to turn off their “fear program” is to confront the feared event. In this case, the confrontation was in the form of taking a commercial flight. Their job was to enter and remain in the feared environment—to take the flight—while holding on to that attitude of acceptance: “It’s OK for me to be anxious. I can handle it.”

In many ways then, our flying program looked like the traditional cognitive-behavioral protocol, but I challenged the traditional CBT approach in three ways. First, because we worked with 25 participants, I couldn’t target the specific thoughts and feelings of each one, as standard CBT treatment dictated. Second, because of our time constraints, we couldn’t help the participants test out the validity of the principles through a series of behavioral assignments. Third, participants didn’t gradually work their way up the hierarchy of fears: they moved directly from sitting in the classroom to engaging in the activity that was at the highest level of their fear hierarchy.

This project pushed my persuasive skills to the limit, but that was my objective. I wanted to find out how efficiently and quickly I could hand over a therapeutic protocol to clients so they could change their actions. About 80 percent of those who took the course completed the two graduation flights on Sunday afternoon. Some had refused to fly for more than a decade, so it was a huge accomplishment for them. It showed me that anxious clients can absorb some basic principles, learn to trust their validity, and then take major steps toward confronting their anxiety without a lot of handholding from a therapist.

From Foa to Barlow

Then, from an eye-opening event in 1999, I committed myself to moving even more quickly and assertively in treatment. This required that I modify my procedures yet again, because I was spending too much time trying to help clients manage symptoms and the events that triggered those symptoms. I realized that the battle with anxiety is an internal one, and that I needed to start focusing on clients’ avoidance or denial of their own feelings.

The catalyst for my change came when I was co-teaching a daylong workshop with psychologist David Barlow of Boston University, who’s long been at the forefront of the research on anxiety treatment. During the workshop, he presented an eight-day intensive treatment model that he’d pioneered for individuals with agoraphobia. On day one, clients were asked to drink a half-liter of caffeinated water to ensure that they’d have a good anxious buzz during their exposure practices. The treatment goal by the end of the first day was to have clients face the highest fear on their hierarchy.

The idea of moving quickly didn’t shock me, since I’d taken a similar tactic with the fear-of-flying program, but requesting that clients begin treatment by drinking caffeine to accelerate their symptoms—that was surprising! Then Barlow showed clips from an episode of 20/20 featuring his program, and it caught me off guard.

The video introduced a day-one exposure practice with an agoraphobic client whose biggest fear was being trapped in an elevator. As the client stood in the back of an elevator, crying, her whole body shaking, the therapist stood in front of the elevator door with her finger on the “open” button. She asked, “Are you ready for me to let the doors close?” The client hesitantly nodded, the therapist dropped her arm, and the doors began to close. The client quickly took one giant step forward and extended her arm to block the doors from closing. Just as quickly, the therapist reached over with her hand and pushed the client’s arm down, saying, “Don’t do that.” The doors closed.

I was shocked. The therapist touched the client. Forcibly stopped the client. Admonished the client. I’d never do that! Even as a therapist conducting exposure practices, I was using a kinder, gentler approach. I’d have permitted the client to stop the elevator, and we’d have backed up to plan skills she could use to tolerate that closed space next time.

Later I asked Barlow what the therapist was saying to the client in the elevator as they were on their way up to the fifth floor for the first time. Was she reminding the client to practice her relaxing breath? Did she reassure her that the doors would open again in a short 45 seconds?

Nope, he replied. The therapist didn’t “help” at all. She only smiled and excitedly said to the client, “Look at you! You’re doing it! You’re doing it!”

Barlow was moving exposure practice to the extreme. He wasn’t easing clients into their behavioral assignments: he directed them to drop their crutches, their sacred rituals, and their compulsive efforts to feel safe. His view was that clients needed to learn to tolerate feeling profoundly unsafe. He had an eagle eye for even the smallest ways people shield themselves from distress. If a client sat down in his office and began to take off his jacket, Barlow would ask him to leave it on, just in case he was trying to get cool and relaxed. From Barlow’s perspective, a comfortable client wasn’t working on getting better.

The Relationships of Anxiety

Following my exposure to David Barlow’s approach, I studied everything I could about how people use safety behaviors to protect themselves from what they fear. Then I made it a point to help my clients peel away their crutches, including the breathing skills that had been the cornerstone of my work.

Next, I began to attend to a bigger picture: clients’ struggle with uncertainty and the anxiety it produced. All anxious clients enter treatment fighting or avoiding their doubt and distress. For the first half of my career, I’d focused on skills to help clients accept symptoms of anxiety, permit themselves to feel uncomfortable, and tolerate not quite knowing how things would turn out. Now I sensed that the best maneuver for clients was to provoke the doubt and discomfort they feared, regardless of where it appeared.

Once again, I began to experiment. The model I shaped is built around two relationships—my relationship with clients and their relationship with their anxiety and doubts. In terms of the therapeutic relationship, I believe my clients and I need to create a special partnership of mutual curiosity and exploration as two people with complementary assets joining together to solve a problem. As I gain rapport with clients, I ask questions at every turn, not to probe, but to defer. If I explain a principle, I stop to verify, “Does this make sense to you?” If it doesn’t, I work until it does. When we’re about to do a behavioral practice, I ensure that the client not only understands the instruction, but agrees with the logic behind the action.

I defer to clients because my ultimate goal is to hand everything over to them. If they can participate in the construction of the protocol, they can “own it.” If they own it, they can continue to use it in the future. This is the piece that so often gets lost in exposure treatment. Evidence-based CBT relies on a formula. Therapists describe how clients can recover from the disorder through repeated, graduated exposure to their fears over a number of weeks. Then they present the treatment steps and give the instructions for each step. Such therapists figuratively, and sometimes literally, “follow the manual.” This can cause them to lose track of an essential task: helping clients metabolize the strategy.

The second relationship I’ve built my model around is the one between clients and their doubt and distress. They enter treatment seeking to remove their doubt, to know for certain that events will turn out in the best possible way, and when they can’t guarantee the outcome, they become more anxious and avoidant. My primary intent isn’t to give clients reassurance and comfort about the specific themes of their worries, but rather, to help them shape a new way to relate to their uncertainty and discomfort. We don’t simply focus on solving the presenting disorder, even though that’s what clients first expect. Anxiety disorders continue throughout life; therefore, clients must change their relationship with the disorder, which is what generates their distress.

An example: Mary came in for two sessions last year to address her classic symptoms of claustrophobia, the fear of restriction and suffocation. Parking structures were tough. “With their low ceilings, I feel like I’m going to be crushed in there.” Elevators and traffic were a struggle, especially if they were crowded or slow.

In session one, as I learned about the extent of her difficulties with feeling closed in, I asked how she coped with the problem. I was looking for her safety crutches, something I wouldn’t have done in the past. However, I knew that she and I would need to create a plan to reduce her dependency on her distress-avoiding maneuvers.

“I avoid closed-in places—parking garages and tunnels,” she said. “If I have to go in a parking garage, I always try to go in the daytime and park where there’s the most light. I also try to get others to drive me.”

As we continued, I asked her about her expectations of the sessions.

“Well, I’m hopeful and a little nervous,” she replied. “Earlier you said, ‘You have to go through the eye of the needle.’ So, of course, I started thinking, ‘Is he going to lock me up in a small place and test me?’

I teased her about her response. “There’s an idea! Do you have others for me?” She was right that we’d soon be doing some provocative exposure practices, but I wanted us to conduct them within a trusting partnership. Being playful is one of the ways I develop rapport.

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.

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.

Photo © Sis / Richard Tuschman