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.