Treatment

Learning about anxiety: Based on my experience treating people with anxiety disorders, I have found it to be overwhelmingly the case that those clients who educate themselves about their anxiety benefit most from treatment. This means that they learn to identify the situations, conditions, circumstances, and people in the presence of whom they typically get anxious. It is for this reason that I encourage you to become a student of your anxiety. In other words, strive – as best you can – to raise your psycho-educational (PE) level. Two of the ways you can accomplish this important goal include:

Reading:
There are a number of helpful books on the subject of anxiety. Please see the heading RESOURCES to review the suggested reading list. In most cases, I will suggest one, but never more than two, books for you to read. The book(s) recommended will be tailored to your particular needs and personality. They are well written and easy to read. Naturally, doing some reading is entirely your option. It is merely a suggestion that I feel can be beneficial to you during the course of our work together.

Didactic Learning:
During our individual counseling sessions you will learn about both basic and advanced concepts related to anxiety. I normally spend three to four sessions covering this vitally important material. By the end of that time your knowledge about anxiety will have expanded considerably. This increased knowledge will add to and enhance your repertoire of anxiety-management skills. Some of the more important concepts you will learn about anxiety are discussed below:

1. Measurement of Anxiety: The frequency, intensity and duration (FID) scale, (see the section IS ANXIETY ABNORMAL) is a convenient acronym that allows clients to more easily conceptualize and communicate the important details of an anxiety episode. Thus, someone who suffers from panic disorder for example might use the FID scale to describe a recent panic episode to her therapist: “Last night I had a level #9 panic attack that lasted 20 minutes.” This type of detailed description is helpful because it gives the therapist a clearer understanding of what the client is experiencing. Also, using the FID scale enables clients to target a level of anxiety tolerance that is acceptable to them and that can serve as a long term therapy goal.
   Most people find that an anxiety level of about 2 or 3 (higher numbers indicate more intense anxiety), is tolerable and does not interfere with their ability to function or manage life. Anxiety tolerance levels, however, are a personal matter. Naturally, as a long term goal, you would want to target a level of anxiety that is acceptable to you.
   
   
2. Mastery & Control: Fairly early on in my work with clients, I like to point out that the ultimate goal of treatment is not to rid oneself of anxiety entirely. Nor is it to make the anxiety go away. Why? Because this goal may not be a realistic one! So rather than lose credibility with my clients, I encourage them to adopt realistic, achievable goals, ones that with hard work and dedication, they have a good chance of attaining. With this in mind, perhaps it now makes sense to you that the proper goal worth striving for is to achieve mastery and control over your anxiety. This does not mean that you will never again get anxious. Rather, it means that even if you do experience some anxiety from time to time, it will not be incapacitating or intolerable. Bear in mind that most people are able to tolerate level #3 anxiety quite comfortably, without undue disruption to their lives. Therefore, hereafter, you may wish to embrace and internalize the mantra, Mastery and Control is the goal!
   
   
3. Personal Meanings of Anxiety: Just as you would probably not ignore intense pain occurring somewhere in your body (e.g., severe stomach ache), neither should you ignore the presence of severe or persistent anxiety (i.e., abnormal anxiety ). Why? Because like the pain in your abdomen – which tells you that medical attention may be necessary – your anxiety is very likely sending you a message that psychologically (i.e., mentally/emotionally), something is wrong with you.

   If this were not true, it is doubtful that you would be experiencing excessive or persistent anxiety. I hope you agree this makes intuitive sense. And, that these important messages are certainly worth paying attention to!

   Now the important question is, why? Why does anxiety sometimes become overwhelming and unmanageable, resulting in symptoms of physical illness (e.g., palpitations, dizziness)? The truth is there are a number of possible reasons. Some of the more typical psychologically-based reasons are:

   • The presence of too much stress in one’s life;
   • Feeling burdened or “overwhelmed” by responsibilities;
   • A traumatic experience that occurred some time ago but remains unresolved;
   • Extreme worry or concern about an upcoming event of great personal importance, the outcome of which one feels highly uncertain about; or
   • Finally, as occurs in some instances, severe anxiety attacks that seem to “come out of nowhere” (i.e., situations in which one is unable to identify a cue or apparent source of the anxiety).

   Regardless of the source or reason(s) for the occurrence of abnormal anxiety, the singularly important point is this: Severe or persistent anxiety, that is psychologically based, invariably occurs for a reason or reasons that may not be immediately apparent. Almost always, however, they represent an important, underlying personal meaning. Once this personal meaning is discovered and fully comprehended, the anxiety very often diminishes significantly.

   What follows is the first of five actual Case Studies. This case is especially pertinent to our discussion because it illustrates the often inextricable relationship between anxiety and personal meaning. Further, the example underscores the critical importance such meanings can have on the outcome of therapy.
   

   CASE STUDY #1: Driving Phobia
   Some years ago, a young woman in her late twenties (we’ll call her Sarah), came in for therapy because she had developed a driving phobia. Interestingly, the onset of the phobia coincided with the death of Sarah’s father. Almost immediately following his death, Sarah discovered that she was not able to drive her car without a relative seated next to her at all times. This became both impractical and inconvenient. It was also her main reason for seeking help.

   During the course of her therapy, Sarah made a most important discovery. She realized that: “my father was my anchor and losing him left me feeling lost, insecure and unstable.” Soon after grasping this important connection (i.e., between driving and her father’s death), Sarah began to drive on her own. Gradually, she increased the distances she drove. She also began driving on a variety of different roadways (e.g., expressways, interstates). After about six months Sarah was virtually symptom free and could drive anywhere she wanted.
   
   There can be no denying that severe and/or unrelenting anxiety is difficult to live with. As this example demonstrates, abnormal anxiety – and sometimes phobias – usually sends a message to us. Often, these messages–which typically manifest in the form of physical and mental symptoms–contain important personal meaning.
   
   In Sarah’s case, the meaning associated with her anxiety symptoms appears to be fairly obvious: she had lost her most important anchor, her father. This loss destabilized her psychologically, because her father was a major part of her support system.
   
   But once she understood – at a deep emotional level – that losing her father had significant personal meaning for her, the effect was quite liberating. Thereafter, the progress she made in therapy accelerated. Not only was she able to drive without undue fear or anxiety, but she became emotionally stronger and more independent.

   Thus, the central point to bear in mind is this: If we ignore these messages and their associated meanings, we do so at our own risk. So, though it may be difficult for you, try to not wish for your anxiety to “go away.” Instead, do yourself a favor – think about what happened to Sarah. Yes, I’ve said this before, but it is so important, it bears repeating. Remember, your true first task is not to “get rid of anxiety.” Rather, your initial and proper goal should be to discover the underlying reason(s) that buttress your anxiety; to understand why it has intruded into your life and become unmanageable.

4. Nature versus Nurture: For quite some time, psychologists and behavioral scientists have debated the question of whether anxiety is the result of genetic or environmental factors. To this day, the issue remains unresolved. But, there are several reasonable assumptions that can be made concerning this important issue.

   First, it is clear that some people inherit a definite predisposition to experience anxiety more regularly and across a greater range of situations than others. This is something I have confirmed numerous times in my work with clients. In addition, both my wife and I can personally attest to the fact that my daughter inherited this predisposition. Since she was two years old, we have noticed that she is inordinately fearful. She also exhibits clear signs of anxiety that positively are not the result of learning or environmental factors. How do we know this to be true? We are certain because her brother was raised in the same environment, and exhibits no signs of anxiety whatsoever. This strongly suggests the presence of a genetic link.
   
   Second, it is also the case that adverse circumstances can sometimes cause or contribute to the development of anxiety-related suffering. The best example of this is the occurrence of a traumatic event such as the terrorist attack that occurred on 9/11. Even after successful therapy is concluded, trauma sufferers sometimes experience symptoms of residual anxiety for quite a long time.
   This suggests that traumatic episodes create an emotional vulnerability, or psychological imprint that is sometimes manifested in the form of physical anxiety symptoms (e.g., accelerated heart rate, shallow breathing, etc.).

   Finally, it is highly probable (though as yet scientifically unproven), that the propensity towards anxiety is, in some instances, a combination of genetic and environmental factors. This seems to make intuitive sense. It is also a notion that I have fairly well confirmed from having treated numerous individuals with anxiety disorders.

   So, if you should find yourself lamenting or feeling badly about yourself because you are prone to feeling anxious, remember that it is entirely possible the anxiety you experience may stem from factors that are completely beyond your control.

5. Empirical Validation: An extremely important tenet of my therapy work with clients is the notion that empirical validation can be a highly effective therapeutic tool. Put simply, empirical validation means proving something to be true through observation (e.g., watching a pencil fall to the ground provides empirical validation of the effect of gravity). Rather than be overly didactic, I am more inclined to help clients discover for themselves the factor(s) that cause or contribute to their anxiety. An example that is highly typical of an actual case may help to illustrate this idea. Without realizing it, anxious persons who come in for counseling often practice an exceedingly self-destructive habit which I call negative ruminating. This is simply the tendency to mentally dwell on negative thoughts for long periods of time (e.g., “I’m afraid I’ll have an anxiety attack if I drive on the expressway, or give oral presentations”). Not surprisingly, negative ruminating often leads to…that’s right – anxiety episodes! The point is this: As a therapy client, you are more likely to be convinced that a habit such as negative ruminating is harmful to you, if you can directly verify its harmful effects, in your own experience. How? By remembering a specific instance in which you had an anxiety episode, as a direct result of negative thinking (or negative ruminating).

   Suppose that during the course of therapy, you came to realize that you had a deeply entrenched habit, such as a tendency to dwell on the many bad things that could go wrong for you throughout the day (i.e., a form of negative ruminating). As often happens with clients, you reached the point in therapy of making an important discovery. We might even say you had an “epiphany” that,

   “…every time I ruminate for more than a minute or so about bad things happening to me, I tend to get anxious. I have noticed this pattern during the past several weeks. In other words, without meaning to, I seem to be causing my anxiety episodes to occur by my habit of thinking negatively about things that could go wrong in my life!”

   What does this demonstrate? If you’re thinking the answer is empirical validation, then you are quite correct! I hope this notion of empirical validation is beginning to make more sense to you? I have also learned that, in the context of therapy, the most important discoveries are those made by the clients themselves, not by the therapist. For me to tell a client, “your anxiety is caused by negative ruminating,” may indeed be helpful, but when the client makes this discovery, the impact is much greater.

   For purposes of illustration, I shall now present a case study involving social anxiety. This case highlights the importance of empirical validation to the therapy process. It is for this reason that I endeavor to help clients make important discoveries concerning the nature and cause(s) of their psychological suffering – for themselves. I refer to this process as “connecting the dots;” and when clients are successful in making these connections, the effect is generally very positive.
   
   CASE STUDY #2: Social Anxiety
   
   About a year ago, a young man in his early twenties (whom we’ll call Adam), came in for treatment of severe social anxiety. Adam was 6’2” tall, had “movie star” looks, and an IQ in the 140-150 range. Despite his considerable assets, however, Adam was highly uncomfortable around people. He could not engage in conversation or interact with virtually anyone other than family or friends. In fact, Adam was so nervous during his first and subsequent meetings with me, that his left leg would shake uncontrollably throughout most of the sessions.

   Not surprisingly, it took some time for Adam to feel comfortable just being with me. Therefore, in the initial stages of treatment we simply got to know each other. Gradually, Adam’s level of comfort increased. He became more relaxed (his leg stopped shaking so much), and his optimism concerning treatment also increased. Noting this, I encouraged Adam to explore the “meaning” of his anxiety. Why was it so strong? What was it trying to tell him? What purpose did it serve? He took up my suggestion and gave serious thought to the matter. After about four months, Adam made a most important discovery: He realized, by examining instances that preceded his anxiety, that he found it extremely difficult to make requests of people – other than friends or family – to oblige him. Even the thought of making requests of others unnerved him.

   Some examples that Adam cited were: asking a stranger the time of day; asking for directions; taking up an interviewer’s time, or even “chit-chatting” with people (which to Adam meant that he might be taking up their time by subjecting them to boring conversation). In each of these cases, Adam felt he was, in some manner, obligating the other person; In other words, by asking of others – what he considered to be “favors” – he was, in effect, imposing on them.
   The reason he felt this way was because Adam considered himself to be a highly moral person, and to him, obligating or imposing on others is wrong.

   This realization was unmistakably a breakthrough for Adam. Why? Because he now understood the reason for his anxiety – it arose each time he felt he might be obligating or imposing on others.

   The most important point is this: Adam had obtained empirical evidence concerning why he became anxious in social situations. By the process of empirical validation, he discovered the source of his anxiety; his belief that by imposing on or obligating others, he was violating his moral code. To his considerable delight, once Adam confirmed that the basis for his anxiety was for the most part irrational, his anxiety dissipated almost entirely. Following this, he felt both relieved and greatly liberated. Importantly, Adam also improved in other ways: his self esteem increased; he felt more confident, he became more assertive, and finally, he even completed several medical school applications, and got a part-time job at a nearby hospital and enrolled full-time in a Masters Degree program.