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.