At our recent Core 2 CBT for Anxiety Disorders workshop, we asked participants what is helpful in managing anxiety? What is not helpful?
Individuals with anxiety disorders unwittingly maintain their conditions by their behavioral strategies and their beliefs.
Avoidance is a hallmark of anxiety. Sometimes the avoidance is blatant, when, for example, an agoraphobic client does not leave the house. But sometimes it is quite subtle. For example, one of our panic patients tightly gripped the steering wheel while driving. A client with obsessive compulsive disorder tries not to think about an idea which is unacceptable to her. One of our most recent clients with social anxiety avoids making eye contact and tries to control his shaking hands.
Worrying is also unhelpful for people with anxiety disorders. Sometimes clients believe that it is important for them to worry in order to prevent danger; however, worrying actually leads to their continually overestimating danger over time. Our anxious clients have beliefs such as, “The world is dangerous.” “I have to be on guard. I need to anticipate any problems that could possibly arise; otherwise I’d be irresponsible.” “If I worry, I can figure out exactly what I should do.” Then, when the predicted catastrophe doesn’t happen, instead of recognizing that it was not likely to occur, they tell themselves, “It was good that I worried about it or else it might have happened.”
Anxious clients also demand certainty. A client we saw this week told me, “I have to know for sure that nothing bad will happen.” But many outcomes in life are unpredictable, or can’t be predicted with absolute certainty. Assuming that certainty is possible and demanding that they obtain certainty keeps anxiety going. One dysfunctional strategy clients use to demand certainty is constant reassurance seeking. For example, a client frequently seeks reassurance from her husband that he still loves her and will never leave. Demanding certainty is also associated with her attempts to over-control herself, her husband and children, and even her co-workers. For instance, she’s constantly texting her husband and children to make certain they’re ok, and will keep on frantically texting them until she hears back.
Another habit anxious clients have is paying too much attention to their anxious thoughts. People without anxiety disorders often do an automatic reality check and/or engage in problem solving when they notice anxious thoughts. Or they dismiss them as “just thoughts” and refocus their attention back to the task at hand. When an anxiety disorder is present, though, clients focus on their anxious thoughts, treat them as “facts;” their anxiety increases, and they often engage in an unhelpful action (such as the thought suppression, worry, or reassurance seeking mentioned above).
Perfectionism is also sometimes involved in maintaining anxiety disorders. Another recent client of ours believed, “I should be perfect because if I’m not, I’m vulnerable to bad things happening. I should figure out the perfect solution to any problem. If things aren’t perfect, everything will fall apart.” The problem with perfectionism is that it’s impossible to be perfect. When our client doesn’t meet her perfect expectations, she doesn’t think it’s because her standards are unrealistic, but instead, takes it as more evidence that she’s vulnerable to bad things happening, which keeps her anxiety elevated over time.
Finally, clients with anxiety disorders have difficulty tolerating, much less accepting the experience of anxiety because they are “anxious about being anxious”. One client we mentioned above believed that anxiety was bad and that if she didn’t try to control it, it would get worse and worse until she just couldn’t stand it and would “lose control.” You can think of anxiety as energy for a challenge, so when you believe experiencing anxiety is a challenge, you end up getting an additional level of anxiety whenever it shows up.
Fortunately, a large body of literature now supports the efficacy of Cognitive Behavior Therapy in effectively treating anxiety disorders. And treatment has become even more effective in recent years as therapists have added mindfulness to their repertoire of techniques, helping clients label and accept the experience of anxiety and learning, not how to try to rid themselves of it, but how to move anxiety to the background as they focus on whatever valued activity they are engaged in at the moment.