Issue # 1

Welcome to Issue #1 of my newsletter.  My goal is to provide information that might assist both health professionals who work with anxiety disorders and individuals who experience these disorders.  In each issue, I will comment on journal articles that have influenced my thinking.  I will summarize points that interest me most and then give you my reactions. I will also review books that I believe make a contribution to our learning.  And, from time to time, I will include original writings.   Here are the topics for this issue.  

• Do You Really Ever Get Rid of a Learned Fear?

• Should We Bring On Symptoms to Reduce Symptoms?    

• Can Medications Interfere with Progress?

• Playing It Safe Just Slows the Work 

• Can We Help Kids Not Become Anxious Adults?

• An Ounce of Prevention Actually Works 

Let's begin! 

Do You Really Ever Get Rid of a Learned Fear? 
Think of the end result of extinction as achieving that state where the feared stimulus no longer causes you to react to it with your same fearful response. You master control in that situation so that you don’t become inappropriately threatened.  Does that mean that the original learning—to be notably afraid of that stimulus—has been eliminated?  There is strong opinion and growing evidence that extinction doesn’t reflect a destruction of the original learning.

A relapse back to the original fear response can be caused by four mechanisms: Reinstatement, Renewal, Spontaneous recovery (of the fear response), and Reacquisition.  In summary, these terms mean that the fear response can still return if the person is again faced with the feared stimulus (the unconditioned stimulus), particularly if that stimulus is reinforced in some way or is manipulated in some way, or if the stimulus is presented in a new context. 

What does this mean to us?  It means that the old, fearful learning is lying in wait, ready to take advantage of any moment that is vulnerable to a return to the fearful state.  It means that we need to be vigilant about not only conducting exposure practices that lead to extinction but bolstering patients’ skills for when they are out in the world encountering old, new or altered stimuli.  

How do we accomplish this?  First we need to understand how people can remain vulnerable to the return of that old fearful learning.  

One way they stay vulnerable is that people don’t remember some of the cues associated with having achieved extinction during therapy.  And they don’t remember them at the most inopportune times: just as they are entering a situation that is a strong reminder of the fear!  Helping people remember what they have accomplished—and how they accomplished what they accomplished—is the task here.  Generating “cue cards” with their skills listed or reminder cards with the most important principles of overcoming their fear—that is a start.  Then helping patients remember to use them as they are moving into a practice situation—this becomes the key to their benefits: a reminder of their strengths and accomplishments just before they enter a threatening situation.  Doing visual rehearsals—where patients imagine themselves entering feared situations, becoming somewhat distressed, and then utilizing their skills to manage their fears—is a method of reinforcement.  The “successful task imageries”, described in the skills section of the panic disorder part of the website http://www.anxieties.com/index.php?nic=panic-step7d , are examples of how to do this. 

It also means that we need to encourage patients to face all situations that might provoke their feared reaction.  Have they mastered elevators, but only when there are fewer than four people on them?  Then find some crowded elevators.  Do they only practice when they are well rested?  When it isn’t raining?  In private bathrooms but not public bathrooms?  As long as no one asks them a question while they are speaking?  As long as their heart isn’t racing?  The best treatment inoculates patients through exposure to all situations and as many modifications of those situations as can be predicted to occur. 

This also draws our attention to the use of medications in the treatment of anxiety disorders.  When patients take medications to reduce anxiety, this can lead to state-dependent fear extinction.  Facing the fear while on medication is the “state”.  This can  preserve the original anxiety, allowing it to lay in wait for a time when these folks are no longer on the medication (no longer in that “state”).  Learnings from one state (the medicated state) are not necessarily transferred into another state (the withdrawn-from-medication state). So, as I will mention again later, it is best to make sure that cognitive-behavioral therapy (CBT), especially exposure, is used during and especially after, withdrawal from medications.  For instance, patients may go through a behavioral treatment program for their anxiety disorder, but decide to remain on their anti-anxiety (or anti-depressant) medication.  If they later decide to decelerate from that medication, suggest that they return for a “refresher course” of CBT during that time. 

Article: Mark E. Boulton (2002). Context, ambiguity, and unlearning: sources of relapse after behavioral extinction. Biological Psychiatry, 52, 976-986.   

Should We Bring On Symptoms to Reduce Symptoms?

This article, in the same issue of Biological Psychiatry, extends some of the principles of Boulton’s article, above.  First, Otto reiterates that evidence is beginning to support the idea that including occasional aversive outcomes (such as a panic attack) during exposure practice may help inoculate the patient to relapse in the future.  In other words, therapists need to know--and need to educate patients--that it is helpful to actually have some strong symptoms on purpose during the exposure. Again, here is a strategy to help inoculate the patient with anxiety in order to reduce future anxieties. 

Article: Michael W. Otto (2002). Learning and “unlearning” fears: Preparedness, neural pathways, and patients, Biological Psychiatry, 52, 917-920.

Can Medications Interfere with Progress?

This same article also lends support to the theory that medications, while helping to reduce strength of symptoms during exposure (therefore helping patients be more inclined to do the practice) can lead to a greater likelihood of relapse later.  This may be because the blocking of anxiety by the medication creates a “context” that is too narrow to generalize from.  In other words, the mind might conclude, “the reason I handled this situation well is because this much chemical was active in my brain at this moment.”  In a future practice, either with no medication or even with a different active dose in the brain at that moment (such as a different time during the day), the mind may conclude, “I haven’t practiced in this circumstance before.  I don’t think that other learning applies here.”  And the patient thus feels a return of the threat.  So, medications may block symptoms in the short run but leave patients at risk later.

This leads to the same point as the Boulton article: use a “tail” of cognitive-behavioral therapy as patients decelerate from medications. 

Playing It Safe Just Slows the Work

Otto then highlights the value of cognitive strategies to solidify the learnings from exposure practice.  For instance, in social anxiety disorder, “the simple instruction to attend to actual external consequences rather than internal (anxiety) stimuli appears to increase the effectiveness of social exposure”.   He also reminds us of Wells’ (1995. Metacognition and worry: A cognitive model of generalized anxiety disorder. Behavioral and Cognitive Psychotherapy, 23, 301-320) identification of “safety signals”, the subtle behaviors that patients use to help themselves cope with social situations, like not making eye contact while talking. In Facing Panic, I call these “safety crutches,” and on pages 42-45 I list about 85 of them that people with panic disorder use.  Drawing on these subtle behaviors during exposure appears to dramatically decrease the effectiveness of the intervention.  This is primarily because the person concludes that there is only a narrow context in which they can feel safe (“I was OK only because I did not look up while talking”). So the original fear association intact by being unchallenged in many contexts.

Can We Help Kids Not Become Anxious Adults?  

This question has the attention of a growing number of researchers and theorists.  In this article, Rapee declares that the withdrawn, inhibited temperament of children is a strong and principle risk factor for anxiety later in life. He reviews evidence for these patterns unfolding quite early in life.  “Compared with nonclinical children, mothers of clinically anxious children reported that their child was more difficult in their first year of life, had a greater number of fears in the first 2 years of life, and showed more difficulty settling and being calmed throughout their life.”

The literature shows two factors of child rearing that are associated with anxiety: overprotection/control and criticism/lack of warmth.  The strongest association was between anxiety and parental overprotection.  The evidence is beginning to point to parental over involvement is the key contribution to inhibited temperament in the child.

An avoidant style of coping with potential threat.  A related factor is parental anxiety.  Parental anxiety is related to offspring temperament through shared genetics, but it may also play a shaping role through its interaction with other environmental risk factors. A parent who is over involved with or overprotective of the child can increase the degree of inhibition and increase the risk for later disorders.  It is speculated that this overprotection may act to support and enhance the child’s tendency toward avoidance.

Of course, several other risk factors are likely to be integral to the development of anxiety disorders, most obvious among them being negative life events, but we are concerned here only with risks that have the potential to be modified.

Here is a study that reinforces this sense of contribution. “We asked anxious children to listen to a brief, ambiguous sentence and then indicate a likely course of action.  Following this response, the child and his or her parents were asked to discuss the scenario and possible courses of action.  The stated aim was for the child to arrive at an ultimate response (that could be the same or different from that given earlier) and for the parents to aid the discussion.  Following the family discussion, anxious children showed a marked increase in the likelihood of providing an avoidance response.”  So here we have that early training taking place, in which the parent implies: “The world is a dangerous place; listen to me and I’ll tell you how to be safe.”  What follows will be an instruction to be avoidant. 

In another study they found that high-trait –anxious mothers expressed fearfulness in front of their children more often than low-anxious mothers and that the mother’s expression of fearfulness predicted the child’s level of fearfulness. 

Studies have already begun to indicate that loosening of parental control can lead to less withdrawal.  Now we need to find out if less withdrawal then leads to less anxiety later.  But our hypothesis is that it will. 

The author points out that “several other risk factors are likely to be integral to the development of anxiety disorders, most obvious among them being negative life events, but we are concerned here only with risks that have the potential to be modified.”   

Article: Ronald M. Rapee 2002 The development and modification of temperamental risk for anxiety disorders: Prevention of a lifetime of anxiety? Biological Psychiatry, 52, 947-957.  

An Ounce of Prevention Actually Works 

Gardenswartz and Craske studied 121 college students who had at least moderate anxiety sensitivity, but no diagnosis of panic disorder, and no current treatment for an anxiety disorder.  The students were randomized to a waiting list or to a single-session workshop.  The workshop educated them about the nature of panic and agoraphobia, cognitive restructuring, and exposure to feared somatic sensations of anxiety.  It included instructions for in-vivo exposure to avoided situations.  At the six-month follow-up of  the participants showed the development of panic disorder in 13.6% of the wait-list group.  In contrast, only 1.8% of those attending the prevention workshop developed.  I think this is a dramatic illustration of the potential of psycho-education in preventing the development of the anxiety disorders.   

Article: Gardenswartz, C. A. and Craske, M. G. (2001). Prevention of panic disorder. Behavior Therapy, 32, 725-737  

Self-Help & Professional Update:
Dismantling the Comfort Zone: 
Common Themes in Anxiety Treatment
PART 1

(I am offering this longer, original article in two parts: in this issue and the next. A briefer version of this article appeared in the Psychotherapy Networker)

Dorothy’s story 

Looking across at Dorothy, I saw little that belied her decades of affliction.  Seventy-two years old, she wore a colorful pantsuit, a grandmotherly hairstyle, and her round face smiled genuinely.  But as she began to talk, this persona quickly broke away into tight, nervous features.  Worry seemed to seep through each added phrase, until I felt her vocally tugging at me to understand her predicament.  Yet she was not asking for help. While her hands would reach out expressively to shape a point, they would finish by plopping down heavily into her lap.  Resignation had long ago settled into her bones.  

Her panic attacks began after the birth of her second child, when her husband came home one night in a drunken rage and brutally beat her, fracturing her jaw and causing a concussion.  Even after divorce and a restraining order, her ex-husband continued to appear at her house without warning, day or night, sometimes breaking through the door or window to demand “visitation rights.”  Dorothy lived in constant fear for three years, then finally moved with her children to another town, far enough away to end the harassment.  

Half a century later she describes her current situation,  “I don’t actually go someplace and panic, because I just tell myself I can’t go.  I never leave Chapel Hill.  Anytime I travel in town I have someone with me.  If I go into a restaurant I have to sit near the door.  I very seldom go to the movies, and when I do go I take the aisle seat.  I have to walk out to the lobby from time to time, and I always leave before the end of the show.  I haven’t had any anxiety symptoms in years, because I never push myself.  I stay away from all things that might produce this trapped feeling.”

“I don’t drive because I'm afraid if I had a panic situation driving somewhere – if there was a detour or if traffic backed up – I’d have to escape -- either get out and run, or jam on the brakes, knock everybody down."  Dorothy's fear, that she might become momentarily insane, causing destruction and even vehicular homicide, is enough to keep her out of the driver’s seat.  Dorothy has experienced agoraphobia for almost fifty years now, but hasn’t had a panic attack in over thirty years!  Long ago she learned that if she keeps herself comfortable she can avoid panic, and that is what she does.  Within this zone of comfort, Dorothy has created a well-worn path that ensures her safety from panic.  She has elevated the need for certainty above all other priorities; she screens every potential activity to confirm that she will be in control.  

The physical abuse and reign of terror by her husband severely traumatized Dorothy.  It was a direct cause of her fearful coping style.  Unfortunately, this style became engrained as a conviction that physical comfort leads to security.  It is at this point that her dilemma epitomizes that of most anxiety patients.  By honoring her comfort, Dorothy trades her autonomy for submissiveness .  By giving comfort her highest priority, she sacrifices the many personal freedoms available to her and she remains forever dependent.  

How we got started 

Dorothy is not alone. According to a 1999 National Institute of Mental Health review, there are currently 19 million sufferers of anxiety disorders in the United States, including social anxiety, obsessive-compulsive disorder (OCD), generalized anxiety, and a variety of phobias.  This is a larger population than either those who suffer from depression or from alcoholism.  Analysis of this same data by Dorothy Rice at the University of California, San Francisco show that the social and economic costs of these disorders are more than $65 billion a year, representing 32% of the total costs for all mental disorders. 

Effective psychotherapy for anxiety conditions began in the late 1950’s with the initiation of behavior therapy.  Psychiatrist Joseph Wolpe’s groundbreaking work with his colleagues in South Africa on reciprocal inhibition served as the first major rejection of psychoanalytic techniques for eliminating irrational fears and phobias.  Rather than trying to remove a phobia by analyzing its symbolic meaning, he suggested that direct exposure to the feared situation, coupled with relaxation, would reduce the person's anxiety.  This application of conditioning theory, called systematic desensitization, became the most widely used behavior modification technique of the next three decades.  During that same time, psychologist Edmund Jacobson led pioneering studies in the use of formal muscle relaxation exercises to control a variety of anxiety conditions.  By the early 1970's behavior therapy was firmly entrenched as the number one intervention in both the research and the treatment of anxiety.

In the next decade, great strides led researchers and clinicians away from methods based on conditioning theory to specific empirically driven interventions for targeted symptom clusters.  By the late 1970's psychiatrist Aaron Beck’s cognitive therapy reversed the principles of behavior therapy.  Instead of focusing on teaching the client to physically relax as a means of creating new associations to a feared situation, Beck suggested that the client pay attention to his thoughts.  If he can notice which thoughts are associated with increased anxiety, then he has an opportunity to replaces them with thoughts more conducive of security or safety.  For the socially anxious client, the thought, “I might turn red in front of that audience” is more likely to generate anticipatory anxiety.  By purposely changing that thought to, “I can handle whatever happens during the talk,” he increases his likelihood of calming down.  

During this same time, the research community gave very little attention to obsessive-compulsive disorder, in part because they erroneously believed that the OCD population was quite small.  Yet psychologist Victor Meyer’s lone efforts in OCD in the mid-1960s broke with traditional behavior therapy thinking.  He suggested that if you can encourage a person with OCD to perform threatening activities without performing their compulsive behavior, they will gradually recover.  This process of exposure and ritual prevention (ERP) leads to habituation: the ability to tolerate the stimulus without undue anxiety.  

The continued efforts of hundreds of researchers throughout the world have clearly identified successful, evidence-based treatment approaches for all the anxiety disorders. These psychosocial approaches are commonly called cognitive-behavior therapy, and are considered the gold standard treatment for all the anxiety disorders.     

Pharmacological treatment progressed on a similar timetable.  Psychiatrist Donald Klein and his associates published findings in 1964 that the tricyclic antidepressant imipramine seemed to block panic attacks.  For over 25 years imipramine was the primary medication used for pharmacological studies of panic disorder.  Beginning in the 1980s, successful studies of the antidepressant clomipramine drew attention to the influence of the neurotransmitters serotonin and norepinephrine on both panic disorder and OCD.  While the tricyclic antidepressants were successful in blocking panic, they had a number of undesirable side-effects and they required four to six weeks before therapeutic effects were evident.  During that same period the Upjohn Company conducted an ambitious panic disorder study, carried out in 8 different sites, of alprazolam, a member of the minor tranquilizer family called the benzodiazepines.  Trade named Xanax, alprazolam became a well-prescribed medication for panic.  It had the advantages of being fast-acting (within 45 minutes) and potent in blocking panic attacks.  Side-effects were less than the tricyclic antidepressants, but they did produce a physical dependence and could be quite troublesome during withdrawal.  In the early 1990s, the selective serotonin reuptake inhibitors (SSRIs) came to the forefront of the psychopharmacology research.  First approved by the Food and Drug Administration as antidepressants, studies found that they improved upon the side effect and dependency profiles of the older medications and offer broader treatment options for panic attacks, social anxiety, and OCD.  Today, other medications have been added to the therapeutic agents for anxiety.   The mild tranquilizer buspirone is effective with generalized anxiety disorder; the beta blockers propranolol and atenolol help manage social anxieties; and the monoamine oxidase inhibitors phenelzine and tranylcyromine are useful for panic attacks and possibly social anxieties. 

Today

For some clients, medications play a significant role in the recovery process.  Over half the clients I see are taking medications when they begin our treatment.  The others either have tried drugs and found them ineffective, have been unwilling or unable to tolerate the side effects or want a drug-free treatment approach.  Obviously, some clients are treated successfully with medications alone and never need to enter psychosocial treatment. 

These approaches -- standard cognitive-behavioral therapy, medications, or a combination -- work well, and early in my career they guided my treatment of anxious clients.  They outclass any other available therapies, but they are not a panacea.  Dorothy was one of the first agoraphobic clients I treated.  She was terrified to change, and none of my efforts overcame her fear.  While typically appearing weak-willed, she staunchly refused any medication for fear of side effects.  In a session she would agree to some behavioral homework, but return the next week without having ventured forth.  Her current lifestyle was severely restricted, but it was more comfortable than any of the treatment options I offered.  Dorothy showed few signs of change when we parted, but I took with me that question common to all therapists, "How could I have helped?"   

For over fifteen years I gradually modified cognitive-behavioral treatment – relaxation training, breathing skills, cognitive restructuring and exposure strategies – to address the special issues of the anxiety disorders.  By 1992, for instance, I employed dozens of discrete techniques, some old standards along with some new procedures, to help my panic disorder clients alleviate distress.  But as the years passed, I felt that technique alone was insufficient.  The belief systems of some clients seemed to ride roughshod over the therapeutic strategies I employed.  Even when a technique helped, a client would often drop it and return to the status quo.  It was out of this frustration that I began to reevaluate my own beliefs about the nature of anxiety and its tenacious hold on so many people.  

The Three Errors of Anxiety Disorder Thinking 

The psychological components of anxiety conditions are generated out of beliefs about how we should handle arousal and solve problems.  People with serious anxiety troubles tend to make 3 errors in thinking, all related to their strong common tendency to worry. They use it as a strategy to be sure of their decisions and to increase their comfort.  

We all like to worry -- we believe it provides us drive, motivates us to prioritize our tasks, get them done.  We use it to kick-start the problem-solving process.  During stressful times -- our steady income seems threatened, an unfamiliar physical symptom is persisting, a son begins driving, a daughter begins dating -- most of us worry a little too much.  The situations are common.  Worry becomes our talisman to ward off discomfort.  Somehow we forget that mistakes have always been an essential part of our learning process.  Instead, because we feel threatened, we worry to make certain we don’t commit any errors in judgment. 

The first mistake people with anxiety disorders make is to exaggerate this worry.  They mentally and physically brace for the worst possible problems or symptoms.  They use worry to anticipate troubles and be ready for them.  Second, they hold back from acting until they can be certain about the outcome of their decisions, and often avoid action entirely rather than risk a mistake.  The third mistake they make in response to the trauma of their anxiety is to manipulate their world in service of physical and emotional comfort. 

Attempted Solutions that Cause Problems 

Where do such strategies come from?  Imagine someone standing in front of an audience and suddenly being unable to think clearly enough to speak his next sentence, finally stumbling through, putting a quick death to his speech and walking out of the room in humiliation.  It would be expected that he would worry about how bad the next time might be, even envisioning himself in a repeat performance.  Picture a person on a bumpy flight, unexpectedly becoming terrified of deadly danger, and not being able to calm herself until the turbulence ended.  It would be no surprise if she avoided future flights anytime the weather seemed less than ideal.  Consider the father suffering from obsessive-compulsive images of choking his infant daughter.  That graphic horror would compel any loving parent to avoid being alone with his child.  Exaggerating worries, holding back instead of acting, and rearranging one's world to feel safe will come almost instinctually in response to such staggering traumas. 

Many people with anxiety disorders want to stay physically and mentally on top of things, avoid getting tense, and keep their minds off distressing thoughts.  They believe that losing control of their feelings or circumstances can come quickly and easily, so it is best to stop any losses as early as possible.  That erroneous thought is a powerful motivator.  But to avoid symptom-arousing situations (like Dorothy, many don’t want to walk into any scene that might cause discomfort), they have to imagine themselves having trouble to know how to avoid it!  And, they want to stop the uncomfortable symptoms as soon as they arise.  If their heart starts racing and their head gets woozy, they fight to get rid of those discomforts as fast as they can. 

These goals make perfectly good sense given the crippling anxiety people have experienced.  Except that these moves increase the problems that they are designed to prevent.  When we resist the physical symptoms of anxiety, we ensure that anxiety will continue.  Anytime we generate a fearful thought like, "I better not get anxious here", we essentially say, "Uh, oh" in the cortex.  The cortex sends that "uh, oh" message to the hypothalamus, who signals the adrenal glands sitting on top of the kidneys.  The adrenals secrete that muscle-tensing, heart-racing epinephrine through the body, the brain matches it, and we become more anxious.  From "uh, oh" to anxiety takes less than a tenth of a second. 

Nevertheless, these tactics become powerful forces that drive decisions once people believe that they are the only options.  To help those like Dorothy, we need to prioritize our attention to what is motivating them.  If they are directed by their need for certainty and comfort, and if they believe that worry is the most essential tool to promote their control, then we need to respect these mind-sets.  As therapists, we need to step back from our reliance on specific relaxation-based interventions and cognitive restructuring exercises.  While most can be helpful, they should be in service of changing the person’s orientation to worry, certainty and comfort.  

Kim comes into treatment with her husband in tow, wanting treatment for OCD.  Every time he uses the bathroom, Martin feels compelled to wash his hands for 45 minutes, even though he reports that he doesn't feel contaminated.  And each day as he comes home from work he must wash for three hours.  After we handle the preliminaries of the first session, I pull out my clever bag of tricks. 

“How do you wash for three hours?” I ask.  He sits on a stool while scrubbing his hands in the sink.  When bored, he takes several breaks, walking into a nearby room to watch TV, all the while holding his hands up like a surgeon entering the operating room.  I offer his first homework assignment – remove the stool and turn off the TV – and send them on their way.  When he returns the next week, the washing ritual is cut in half, to 90 minutes.  Success!  

And it was my last victory with Martin.  All my other clever tricks failed miserably.  The next week I suggest he feel free to wash as long as he’d like.  However, every three minutes he is to take a one-minute break and dry his hands.  Then he can wash again, repeating this wash-dry cycle as much as he wants to.  He returns to say, “Didn’t do it.” 

I’m a little puzzled, because this is a usually successful early intervention of mine.  You keep enough of the symptom pattern so that the client isn’t too threatened by the change, but you also modify it enough to initiate the process of change.  But I’m not really worried about Martin yet, because I’ve got lots of other tricks.  I’ll just come at him again, but I’ll offer something even less threatening.  

“Show me how you wash your hands.”  He dry-washes for me, in an elaborate simulation, with a specific sequence of scrubbing each digit in order, then the back of the hand, the palm, then the equally thorough rinsing.  I suggest for homework that he continue washing, simply change up the sequence:  “Start by washing each palm, then each back of hand.  Then wash every other finger on each hand.  Finally, scrub the four you missed, and rinse.  Do it for as long as you’d like.”  He agrees, with consternation that foreshadows our failure, and leaves for another week.  He returns one final time, reporting no attempts at change, and that is the last I see of him. 

Like Dorothy, Martin wanted his comfort, and he wasn’t about to comply with my instructions if it meant he had to feel any distress.  I failed to respect the strength of his need to protect himself.  Despite his denials, his three-hour rituals reflected a powerful commitment to certainty and comfort.  By not attending to these themes, I didn’t give the treatment a chance.  If I were to see Martin again, I might eventually offer the exact same techniques, but first I would assume he was much more frightened than he appeared.  My first job would be to help him identify those hidden motives -- to feel assured of his safety and comfort -- and then to persuade him that if he wanted freedom from the rituals, he would need to learn new ways to feel safe and comfortable.  In the process he must be willing to feel uncomfortable.  He would need to trust that this short-term pain would lead to long-term gain.     

Interrupting the Pattern 

Much of my understanding of these drives--to avoid discomfort and seek certainty at all costs--grew out of years of failures spread among the successes.  Clients would not follow-up on homework assignments, or they would become confused after leaving a session.  If I were especially effective in persuading them of the importance of practicing skills, they would simply drop out of treatment.  Gradually I recognized these common denominators, and then I had to begin the extended task of generating therapeutic responses to these stances.  Again, trial and error chiseled out the rough framework of my approach.  Fortunately, I wasn’t alone.  My guides were Victor Frankel’s paradoxical intention, Paul Watzlawick’s reframing and Milton Erickson’s fractionation and pattern disruption.  Frankel’s work encourages the client to generate the physical symptoms he most avoids. Watzlawick and his colleagues were the first to define reframing as altering clients’ perceptions of the problem, its solutions or their resources in such a way as to reinforce therapeutic interventions.  Erickson’s fractional approach and pattern disruption center on making small changes in the pattern of clients’ behavior and its surrounding circumstances instead of directly contesting it. 

My goal is to persuade clients to go out into the world and look for opportunities to get anxious.  Learning the skills of relaxation can be a great asset to recovery.  But in training to win over anxiety, it is counter-productive to try to stay relaxed.  It is best to seek out discomfort, and then take care of yourself.  This is one of the biggest early struggles for clients in treatment: to honestly take the stance of wanting to face the symptoms. 

Purposeful Panic

I help clients purposely provoke symptoms in the therapy session, an approach That Dr. David Barlow calls interoceptive exposure.  We start by hyperventilating together.  I learned early on that people hate to hyperventilate in front of you; they think that they look like a fool, with their mouth gaping open and their chest heaving.  Now I do it with them, so we both look like fools!  It becomes the first time in their lives that they are laughing in such close proximity to panicking.  

This joining with them goes a long way to persuading them to experiment with some of the other exposures while I observe.   I spin them in a chair, they hold their breath for as long as possible, they breathe through a cocktail straw for two minutes – all in service of our goal to get more anxious, not less.  As long as they don’t perceive the symptoms as too strong, and as long as they feel like they can end the exercise when they want, these procedures work where others fail.  Once they have practiced enough (mostly during the session, but occasionally as homework), then they react with less anxiety, even when the symptoms seem intense.  The outcome I seek is for them to build that attitude of tolerance and acceptance of anxiety. 

Resisting and Not Resisting 

In the past, whenever the work began to go astray, whenever the client became “resistant”, I used to redouble my efforts to create some new trick or gimmick, just like with Martin.  Now I realize that anxious clients don’t need my cleverness.  They need therapeutic principles powerful enough to offset their faulty beliefs that they must battle anxiety and must become relaxed again quickly.  Now I begin treatment by introducing these principles; I keep constant focus on them throughout the weeks of therapy; and when the client or I get stuck, we revisit them.  The principles that my therapy is based on don't contradict the basic tenets of cognitive-behavioral treatment, but are enhancements that appear to reduce dropout, boost patient compliance and thus increase their success rate.  Their most valuable element is keeping in the forefront of clients' attention an active set of stances toward their particular form of anxiety.  Whatever action they are about to take can be guided by these principles, which are often counter-intuitive.   

To prevail over anxiety, here is one of the central confrontations to clients' instinctual responses: let emotional and physical arousal come forward, without resistance. Our job is not to think our way out of anxiety.  It is to learn to tolerate the symptoms, to be able to say, and mean, “It’s OK that I’m anxious right now.”   We reverse a common American catchphrase by saying, in the face of anxiety, “Don’t just do something, stand there!”  When enough epinephrine pumps through the body, the brain will yell, “Run!”  Consciously overriding this impulsive message takes great courage, but pays great dividends.  It differs from desensitization, where we help the client gradually approach the feared situation under relaxed conditions.  Here we confront their instinct to seek out comfort and encourage them to remain physically anxious and mentally as calm as possible. 

The Three Principles 

The points for each disorder will vary, and each client’s list might have a few nuances, but the principles supporting my work with anxiety clients are unwavering.  First, challenge their belief that worrying is productive.  Second, help them experience the rewards of making decisions while they simultaneously feel uncertain.  Third, teach them to seek discomfort as their ticket out of suffering.  In its simplest form, the attitude shifts that I promote are paradoxical ones.  Here is a sampling of how they can be expressed in the treatment of panic disorder, OCD and social anxiety disorder.  ¨     

For panic: try to get out-of-control physically and mentally; relax your guard; and encourage any symptoms that show up.  

Marilee suffered panic attacks throughout her day, including most mornings upon wakening at 6:30 AM.  For each morning episode, she felt tightness in her chest and a sense that she couldn't breathe.  She immediately worried that she was about to die.  She took a Xanax at once, got up out of bed, and restlessly paced the house, struggling with the fear that she would not survive this episode.  We devised the following intervention, to be implemented for the next seven days.  She was to set her alarm for 5:30 AM (arising before the panic).  Once symptoms started she was to begin writing her will.  If she had trouble catching her breath, she was to exhale completely and not purposely inhale again.  We discussed each of these actions in the context of our general paradoxical strategy, and I did not allow her to agree to the homework until she understood their function. 

Marilee returned the next week reporting that she did none of those assignments.  Instead, each morning as the symptoms began, she lay in bed and imagined the memory of a pleasurable canoe trip she took with her husband the previous summer.  She allowed the symptoms to run their course without any of her dramatic reactions.  She reported no daybreak panic attacks that week, and few ever again. 

I didn't care that she totally revised our plan.  I was ecstatic that she attended to the principles, and used her creative intelligence to invent an application of them. ¨     

For OCD: ignore the content of the worry; seek out uncertainty; get distressed on purpose, and stay that way.

Vann came into treatment struggling with checking rituals up to five hours a day.  Often his concern was that he had missed seeing something he should have noticed: new scratches or dents on the trash can, dust particles under the telephone, an inappropriate item in the basement.  Other times he checked as a way to prevent a disaster: An electrical cord will be wrapped around the trash can; his son will trip over some item on his bedroom floor; a fire will start in the kitchen or a flood will occur in the basement.  Some days Vann would check a particular item over a hundred times. 

Our first ploys involved gently modifying his relationship with his symptoms.  For instance, he would check the trashcan, but only in slow motion, ever so gradually picking it up and unhurriedly rotating it in his vision.  Or he would study the telephone, but not allow himself to touch it.  These were his first explorations into uncertainty and distress.  By the sixth session we added postponing.  He might have an impulse to check the basement, then wait 30 minutes before he acted on that urge, again learning to tolerate his discomfort.  Through this gradual exposure to the principles, by session nine he was able to avoid locking his house for five days. 

Here is how he described his progress by session 10: 

In the past I would pull out the backseat of the car, and if there were dirt there, I would have to clean it up.  If a bolt was there I would look at it and get stuck on the backseat, focused on that bolt.  Now I do all of this intentionally.  I lift up the backseat and try to make something really bother me, try to feel anxious.  I feel that anxiety, replace the backseat, shut the back door of the car and walk away. 

When I first started walking away I felt really anxious.  I wanted to go back and look at something under that seat again.  I felt as though I didn’t look at it hard enough, and I’d want to look at it again.  I would sweat a little bit, my heart would beat faster, I’d become very irritable, and I felt very compulsive.  I wanted to go check again!  But I just decided I wasn’t going to do it.  

Sure enough, about two hours later the desire went away. Vann completed his treatment in eleven sessions over 5 1/2 months.  Today, twelve years later, he remains symptom-free and medication-free.

For social anxiety: perform poorly; experience others’ disapproval; embrace your inadequate self. 

When I met Jesse she was 39 and had suffered from fear of speaking since high school.  For the past 15 years, since her second year in law school, she has endured embarrassing bouts of perspiring during times of social stress.  Her anxiety mounts as she anticipates any kind of meetings with authority figures or job interviews, small group sessions, lunches with associates, attending church, making presentations, even signing her credit card slip in front of a grocery store clerk.  Droplets of sweat begin to form on her forehead.  If her tension lasts, then before long her hair will become moist with perspiration. 

But her worry is as disturbing as her physical symptoms.  Serving as the county’s chief public defender, no event causes greater apprehension than a court appearance.  Whenever possible, she defers cases to another attorney in the office.  She admits, with a sense of shame, to encouraging plea bargains as a second maneuver to avoid any court appearance.  When court sessions are unavoidable, Jesse worries for days.  Then, when in the courtroom, her only secret ally is the bailiff.  With a subtle nod of her head, she signals him to notch down the thermostat, cooling off the room.      

In our third session, Jesse comes in with a smile. This week she decided to stop hiding.  It is her method of throwing down the gauntlet against her social anxiety, accepting who she is at this moment in her life.  Yesterday in court, for the first time ever, she placed her handkerchief in plain view and was ready to wipe her forehead without all her clever disguising moves.  This week she attended meetings, even participated in an impromptu press conference, with a commitment to face the fearful situations and accept her body’s anxious responses.  Did this shift stop her perspiring?  No.  Neither of us expected that.  But it did increase her activity.  More importantly, it was the all-important first step to her mastery of the problem.  

She was not using some kind of pseudo-acceptance, in which she thinks, “It’s OK if I sweat (now I hope that thought will keep me from sweating).”  Instead, she thought, and believed, that she was unwilling to be blackmailed by the symptoms any longer.  She would face the day’s challenges and manage the consequences.  This is a simple stance that doesn’t rely on any fancy mental tricks.  But it does require courage, and Jesse found hers. 

One of the biggest enemies of the socially anxious person is worry about public ridicule.  “What if my hands shake?  People will see.  Will they think I’m an idiot?  I could be humiliated!”  This week Jesse took a second stance in her commitment to recover: “I don’t have to know what they’re thinking.” She was ready to embrace the possibility that others disapproved of her.  By giving up the struggle to control other people’s thoughts, she could concentrate on supporting herself during these stressing times (which included learning to stop calling the problem “stupid”). Jesse started taking on all her feared situations in rapid succession over the next eight weeks: Sunday church, a wedding, lunches out, and several all-day court sessions.  Then she moved back to her home state for a job opportunity, and we lost contact.  Two years have passed, and last month I got a letter.  “Dear Dr. Wilson: I have been appointed Assistant State Attorney General.  Our time together came to mind the other day.  I had a private, 45-minute meeting with the Governor.  I was at ease and not sweating.”