This Friday, June 8, GoodTherapy.org is pleased to welcome Susan Orsillo, Ph.D., who will be presenting Acceptance-Based Behavior Therapy for Anxiety and Related Disorders, a FREE CE teleconference for GoodTherapy.org members available with 1.5 CE Credits. We encourage you to join us for this exciting event, so if you have not already, register today!
By Susan Orsillo, Ph.D.
Although fear and anxiety are natural, human experiences, many struggle with these responses on a near daily basis. The physical toll of anxiety is apparent in the tension, hyperarousal, sleep loss, and general fatigue that accompanies this emotional state. Constant worry pulls us out of the present moment, keeps us “lost in our heads” and frequently leaves us feeling like spectators in our own lives. But perhaps most damaging of all are the behavioral consequences of anxiety. In an attempt to stay calm and safe, we may pass up a career challenge, decline a speaking invitation, or cancel a date. Each refusal brings momentary relief, but over time avoidance restricts our options and erodes our quality of life.
More than 28% of adults in the United States experience diagnostic levels of anxiety, and countless more struggle with worry and anxiety over life stressors and transitions. Sadly, anxiety continues to wreak havoc on too many lives, despite mounting empirical evidence documenting the efficacy of cognitive-behavioral therapy (CBT). The vast majority of people with an anxiety disorder never seek treatment. And of those who do, only about a third receive minimally adequate treatment.
Fortunately, many in the mental health field are seeking new ways to engage clients struggling with anxiety in therapy and improve therapeutic outcomes. One promising new direction involves the integration of acceptance and mindfulness with traditional behavioral and cognitive behavioral approaches. But before considering this new approach, it is important to contemplate the successes and failures of CBT.
Why Hasn’t Traditional CBT Produced More Widespread Results?
Exposure therapy, with and without cognitive restructuring, is clearly helpful to many clients struggling with anxiety disorders such as obsessive-compulsive disorder (OCD), panic disorder, social anxiety disorder, and posttraumatic stress disorder (PTSD). Yet, some clients fail to achieve clinically meaningful and sustained changes in functioning as a result of CBT. And, the vast majority of individuals with an anxiety disorder never receive CBT.
Although exposure therapy can be extraordinarily effective in reducing fear, some clients are unwilling to accept it as a viable option. Anxiety sensitivity, or “fear of fear” is common among those with an anxiety disorder, which makes it daunting to consider purposefully engaging in activities likely to elicit these feared and dreaded symptoms. For some clients, the cost of experiencing painful emotions seems too great to contemplate the potential long-term benefits of exposure.
To set up an effective exposure exercise, the therapist must pinpoint the exact nature of the feared object or activity. For example, arranging a speaking engagement might be a good choice for a client with social anxiety, and touching doorknobs without washing could be an option for someone with OCD. But, for some clients it can be difficult to determine the target of their fear. Often as soon as one feared outcome is addressed, a client with generalized anxiety disorder (GAD) will develop a worry in a new domain.
Recently there has been much debate over the potential utility of cognitive restructuring in the treatment of anxiety. In our own past experiences as CBT therapists, we often found that gently encouraging clients to broaden their perspectives and consider multiple possibilities allowed them to face some of their fears. Having clients cultivate a stance in which thoughts are viewed as mental events, and not representations of the truth, can be an extremely powerful intervention. But, we have often struggled with other aspects of cognitive restructuring. For example, some of the clients we saw for social anxiety were indeed socially awkward. Chances were, if they got up the courage to ask someone out on a date, they would likely be rejected. In other words, the anxiety-producing thoughts the clients were struggling with were not entirely irrational. Sometimes our clients would engage in cognitive restructuring strategies that were counterproductive. For example, efforts to replace irrational thoughts with more balanced ones could sometimes elicit thought suppression. And experimental research documents that thought suppression strategies can ironically increase the distress and frequency of unwanted thoughts.
Back to Basics: Understanding the Struggle That Leads to Anxiety Disorders
In order to understand how to best improve on existing treatment for anxiety, it is critical that we understand how these struggles develop. We know that fear and anxiety are natural, adaptive states. Humans are hard-wired to experience fear, or the ability to quickly recognize threat and respond to it. We are also innately capable of imagining innumerable future threats and considering ways in which we can plan to avoid them—a cognitive style that predisposes us toward anxiety. But, if we are all born to experience fear and anxiety, how is it that only some of us find these states debilitating?
As it turns out, it is our responses to our anxious responses that set us on the course of distress and interference. We learn to judge and criticize ourselves for experiencing fear and anxiety if we believe these responses to be signs of weakness or pathology. People can be taught that fear and anxiety are all-encompassing and defining characteristics that serve as obstacles to a happy and fulfilling life. When this is the sort of relationship we develop with our anxiety, it stands to reason that we would pour our energy into efforts to avoid and escape these responses. Unfortunately, trying to suppress anxiety-related thoughts, feelings, and sensations often causes them to escalate, which fuels our self-criticism and hopelessness and sets off a cycle of anxiety. And, when these internal control strategies fail, we often resort to behavioral avoidance: passing up opportunities, declining invitations, making our lives smaller and smaller in the hope of achieving some sense of calmness and serenity that remains out of reach.
Some clients learn to fear and suppress their emotions because they are raised in an abusive household or one in which the expression of emotions is discouraged or punished. But well-meaning parents, trying to protect their children from harm, can also promote this learning. The dad who lets his elementary school aged son stay home from school because the boy is nervous about show and tell teaches a subtle lesson about the benefits and acceptability of avoidance. The mom who assures her daughter that there is “nothing to be afraid of” at swim team tryouts sends a message that it is not acceptable to be afraid and that such a response can be controlled.
How Can Acceptance and Mindfulness Help?
Mindfulness involves cultivating an attentive, compassionate, and curious stance toward our experiences. Whereas anxiety involves getting lost in one’s fears about the future, mindfulness brings us into the present moment. Rather than judging, criticizing, or fusing with our thoughts and emotions, mindfulness allows us to view them as they are—as transient human responses that come and go. Practicing mindfulness helps us to accept and allow our internal experiences and to let go of our struggle against them. When we are willing to experience the full range of human thoughts and emotions, including anxiety and fear, we can take on risks and challenges and fully engage in the activities that we find most fulfilling.
Our preliminary research suggests that acceptance-based behavior therapy (ABBT) can reduce worry, decrease depression, and increase quality of life among clients with GAD. We are currently comparing ABBT to other CBT approaches, but thus far we find this to be an encouraging option for many clients.
Dr. Orsillo, along with her colleague Dr. Roemer, has written the acclaimed book for professionals Mindfulness- and Acceptance-Based Behavioral Therapies in Practice and a self-help book entitled The Mindful Way Through Anxiety: Break Free From Chronic Worry and Reclaim Your Life. They have also received funding from the National Institutes of Health to develop and test this approach to treatment.
© Copyright 2012 GoodTherapy.org. All rights reserved. Permission to publish granted by Susan M. Orsillo, Ph.D., therapist in Boston, Massachusetts
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