I’m so grateful for this post from my dear friend and anxiety specialist, Dr. Marianne Stout.
(My apologies for the awkward line breaks; I’m still not very proficient with WordPress!)
In my training as a therapist I became interested in working with anxiety disorders
after encountering many clients with anxiety and having no idea how to treat them.
Simply talking about one’s fears or worries did not lessen their symptoms and the
worry, panic attacks, obsessions, and compulsions continued. Many people also
reported that it felt pretty good to explore their relationships with friends and
family, but that while this helped those relationships, it did not stop the anxiety. I
was doing something wrong and I felt incompetent as a practitioner since I could
not help. At the same time I had friends in other psychology programs who were
learning specific skills for treating anxiety and I wanted to know what they knew.
They were using cognitive behavioral therapy (CBT) to treat anxiety disorders such
as generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, and social anxiety, but I did not know specifically how they did this.
CBT was developed by Albert Ellis and Aaron Beck and is a heavily researched
theoretical approach to treat a host of psychological disorders by aiming to change
behaviors or challenge maladaptive thoughts and thus influence emotions. The
theoretical premise is that thoughts, feelings, and behaviors are directly related and
thus someone with panic disorder may say, “I must sit in the back of the classroom
so I can easily escape if I begin to have a panic attack.” The belief is that sitting in
the back or escaping will keep them safe and avoid the embarrassment of having a panic attack in front of fellow students. The behavior is sitting away from others or
physically removing themselves from the situation when their heart begins to race,
their breathing increases, their chest tightens, they feel nauseous, or any of the host
of symptoms that occur during a panic attack. The subsequent feeling could be fear
of dangerous panic attacks, fear that they are “crazy,” or sadness that they cannot
enjoy a class they are interested in like other students. The work of a CBT counselor
would be to work with a client to expose them to anxiety inducing behaviors at
a gradual pace. This may mean having them sit in the second to last row in the
classroom and eventually lead up to them sitting in the front row or having them
stay in the room during a panic attack. A CBT approach would also challenge the
maladaptive thinking that panic attacks are dangerous (they are uncomfortable,
annoying, and tiring, but not dangerous) or that it would be embarrassing to have a
panic attack in front of others (classmates would likely be sympathetic).
In my fifth year of graduate school I began a practicum working under an anxiety
specialist, Diana Damer, PhD. While she used CBT to treat anxiety disorders, she
also incorporated an interpersonal approach exploring underlying relationships and
issues contributing to anxiety and explored the relationship between the client and
therapist. Research shows that regardless of theoretical orientation, the therapeutic
alliance, or relationship between therapist and client, is an important predictor of
success in treatment outcomes (Krupnick et al., 1996). This approach made sense
to me. Treating symptoms of anxiety as well as their underlying causes seemed very
effective and still acknowledged that the client was a relational being.
Since that time I completed my internship, post doc, and became a licensed
psychologist specializing in anxiety disorders. I have also come to include
acceptance and commitment therapy, which has a strong focus on meditation,
in my work as it can be difficult to ask someone to sit with the discomfort of
anxiety without giving them the tools to cope with said discomfort. I have begun a
meditation practice for myself and while I may go weeks without meditating, I find
that when I do life seems to make more sense. A wonderful book that understands
and treats anxiety in a way very similar to my own practice is Panic Attacks
Workbook by Dave Carbonell. Dr. Damer, another colleague, Thomas Smithyman,
PhD, and I recently opened a private practice focusing on anxiety disorders (http:/
/www.anxietyaustin.com) and it has been wonderful to work with like minded
psychologists who are as energized by the treatment and understanding of anxiety
as me. We welcome other professionals in the community who focus on anxiety
disorders to come to our Friday meetings and are always looking for new ways to
engage with the community on this topic.
The role of the therapeutic alliance in psychotherapy and pharmacotherapy
outcome: Findings in the National Institute of Mental Health Treatment of
Depression Collaborative Research Program.
Krupnick, Janice L.; Sotsky, Stuart M.; Simmens, Sam; Moyer, Janet; Elkin, Irene;
Watkins, John; Pilkonis, Paul A.
Journal of Consulting and Clinical Psychology, Vol 64(3), Jun 1996, 532-539.