But, I already AM in pain, Dr. Goodman! I’m coming to you to get rid of my anxiety!

These are words I hear frequently in response to the notion of investing in discomfort. At the root of this is the belief that one should NOT have to feel uncomfortable in life. I grew up in a family that seemed to have this as their motto. If it feels good—do it. If it tastes good—eat it. If it feels bad—avoid it.

So what’s the problem with this?

Life is a mixed bag. Our emotional and physical states are constantly in flux. We feel better some times and worse at other times. Our experience of comfort/discomfort changes throughout the day and this is normal. A pleasant phone conversation with a friend might be soothing, while the traffic jam on the highway on the way to work might increase our feelings of stress or worry. This is NOT bipolar disorder—this is a fact of life for all of us.

Most people handle this through selective attention. They pay more attention to the pleasantness of life while tuning down the attention they place on normal discomforts. Yes, that conversation with the boss was unpleasant, but not catastrophic, and now I’m focused on the delicious Pad Thai noodles at dinner. They experience the normal discomforts, process it, and move on with life.

Anxiety disorders and OCD are often maintained by the sufferer’s pursuit of short-term comfort: Repeatedly washing your hands, avoiding the crowded store, straightening until it “feels right”, rushing to take Ativan, and so on.

This causes two problems:

1. You do NOT learn that a catastrophic outcome would not have occurred were you to confront that fear directly.
2. The more you avoid discomfort, the lower your ability to tolerate normal discomfort becomes. If you are always chasing comfort, your discomfort tolerance ability shrinks. Then, smaller and smaller things feel more and more distressing.

Investing in short-term discomfort for a more comfortable future, therefore, offers two benefits:

1. Facing your fear allows you to learn that catastrophe is not imminent. Anxiety is a false perception of danger. The fact that it is false is learned through experience. Avoidance prevents safety-learning from occurring.
2. Just like if you had weak muscles you could build them up through lifting progressively heavier weights, anxiety tolerance can be built up by seeking out and embracing your fear.

But I am feeling fearful already. Aren’t I facing my fear?

Most people with anxiety disorders or OCD do feel anxious in the face of certain internal or external triggers, but they are not really facing their fear. To the contrary, they are focused on doing what they can to escape from the anxiety—that is very different from facing it.

Facing your fear means FEELING your fear without escaping into avoidances or safety behaviors. When you run from your fear, it grows stronger. The goal of facing your fear is to stare it down until it shrinks. That might take five minutes or five hours, but the bully is bound to weaken over time if you show it that you will stand your ground. Mindfulness and other grounding activities can help you learn to “be in the moment” alongside your anxiety rather than expending energy to flee from it.

With repeated exposures, you may notice that the anxiety symptoms that used to bother you do so to a lesser degree. Also, once you have learned that you can face your fear without catastrophe ensuing, it frees you to live your life without letting anxiety narrow your choices.

Have a therapeutically uncomfortable new year!

Eric Goodman, Ph.D.

www.coastalcenter.org

Copyright secured by Digiprove © 2011

Without anxiety, we would take dangerous risks that would likely cut our lives short. Perhaps we’d all text while driving. Maybe we’d cease all exercise and eat whatever we want, whenever we want. Unprotected sex, may feel like a good idea at the time.

Perhaps that green fuzzy salmon in the back of the fridge would seem like a reasonable dinner choice. Study for tests? Forget that! Why not just wing it and see what happens. Flunk out? Ok, whatever. Perhaps that shortcut down the dark alley at three in the morning would seem quite appealing. Perhaps the threat of prison would not scare away those people intending to harm those around them.

Clearly too little anxiety can cause problems, too. Years back I evaluated a middle-aged man suffering from a severe case of NOT-CARING-WHAT-OTHER-PEOPLE-THINKS. This was due to a severe psychiatric condition known as schizotypal personality disorder. This person literally had NO social anxiety whatsoever. He owned one outfit (“I don’t have to dress for people”) which he wore daily and never washed. He lived alone and would urinate in his pants out of apathy for other people’s evaluations. He simply did not care.

If you had no anxiety what-so-ever, think of the trouble that this would bring you! For peak performance, optimal anxiety is necessary. If you are moderately frightened of public speaking, you can harness that energy for a more dynamic presentation, rather than sluggish lethargy from lacking in anxiety. That applies to taking tests, completing projects at work, putting your best foot forward during a blind date, and so on. Optimal anxiety can be a very good thing.

What is NOT helpful is when Anxiety is allowed to control our lives rather than protect from reasonable risk. When Anxiety is allowed to call the shots (rather than provide us with energy and incentive to take control of our own well-being) it tends to limit and impair our functioning. One might panic during a test rather than focus on the task at hand. One might avoid visiting loved ones due to fears of flying or even avoid leaving one’s home. Instead of using optimal anxiety to make a reasonably good impression during a blind date, one might avoid dating altogether.

We need Anxiety. A world without Anxiety would be more of a hell than a utopia. On the other hand, a world free of anxiety disorders, where people live based on their values rather than fears—now that’s a place worth living in.

Eric Goodman, Ph.D.
www.coastalcenter.org

Copyright secured by Digiprove © 2011

That’s a very adaptive thing for your body to do—if there really is a hungry tiger. But what if the hungry tiger is just a figment of your imagination? What if that tiger is really just your brain misinterpreting a harmless situation as dangerous? Ultimately, this is what happens when a person has an anxiety disorder.

If the best strategy for dealing with true danger is to fight or run away, what should you do when your fear is just an illusion? Psychologist Reid Wilson says that you should do the opposite of what you feel in that moment—instead of evading the “hungry tiger” you should run towards the roar. If Anxiety is scaring you with thoughts of death, doom, and gloom and your body is feeling panicked you should actually invite those thoughts and sensations to be there—with your permission. This acceptance-based strategy has been shown in research to be a powerful intervention when it comes to anxiety disorders.

Take this example. It is 3:00 in the morning and you still have not fallen asleep. You have a big presentation at work in the morning.

Anxiety: “You’d better fall asleep or you won’t be able to function! You’ll do a terrible job on your presentation and lose your job! Come on, fall asleep! Come on you’d better fall asleep right this minute! It’s going to be catastrophic if you don’t! Common fall asleep…now! Now! NOW!”

This is not an unusual scenario. And for many it leads to a desperate struggle against the fear of insomnia. Struggling to fall asleep and to push away the scary thoughts just adds fuel to the fire, making your heart beat faster and your thoughts race more quickly. The struggle is a fruitless attempt at evading a hungry tiger that doesn’t really exist.

What Dr. Wilson suggests is to stop fighting. Don’t argue with the anxiety, it is a debate that, in the moment, you cannot win. Instead see Anxiety’s arguments as “content” that is not worth mucking around in. What you can do is to first acknowledge the presence of anxious thoughts and sensations and the generic feelings of uncertainty and discomfort that accompany them. Then embrace them! “Gooood!” is the response the Dr. Wilson suggests you have in the face of uncertainty and discomfort, “I want to feel this!” In other words, run towards the roar. Alternative responses are, “I can handle this! I can take the hit!”

Why would you embrace Anxiety in such a way? It is because the struggle fuels Anxiety, making it more intense and increasing its’ duration.  Additionally, it is the struggle with Anxiety that takes normal discomfort and turns it into suffering. Struggling with anxiety narrows your life because while you are investing the energy in the struggle, you are not investing that energy in living your life.

Anxiety: “You’d better fall asleep or you won’t be able to function! You’ll do a terrible job on your presentation and lose your job! Come on, fall asleep! Come on you’d better fall asleep right this minute! It’s going to be catastrophic if you don’t!”

You: “It’s good that I am feeling this. I want it. I can handle it. Anxiety can say what it will, it’s welcome to do so, but I’m not going to debate it. If I don’t sleep that gives me the opportunity to practice embracing discomfort and uncertainty. It is ok for me to feel this.”

The nature of the roar is different for different people. It might be social situation, heights, panic attacks, public bathrooms and so on. Whatever it is, running towards your roar is the best way to run towards your freedom.

Eric Goodman, Ph.D.

www.coastalcenter.org

Copyright secured by Digiprove © 2011

If you think about anxiety as being on a continuum from normal anxiety to a severe anxiety disorder, it is easy to understand that millions of more people have “subclinical anxiety disorders”, anxiety that is not quiet to the level of a clinical disorder. With subclinical anxiety, you may be somewhat uncomfortable and avoidant, but have managed to cope relatively well and it has not disrupted your life.

Examples:

• Worry what others think about you more than most, but attends some social events without too much discomfort.
• Fears germs and compulsively cleans, but only fifteen minutes a day.
• Worries a lot, but considers it culturally normative.
• When you think of the night of your assault, you feel anxious, but you rarely think about it and don’t avoid reminders of it.
• Being a sensitive child or adult who feels emotions strongly, both positive and negative, and is mostly well-adjusted socially and occupationally/educationally.

So do you treat a subclinical anxiety disorder or not? That depends on the following:

1. Is the frequency and intensity of your anxiety or worry increasing?
2. Is the frequency or number of things avoided increasing?
3. Do your parents or other members of your family have a history of anxiety disorders?
4. Are you dissatisfied with your anxiety and want to do something about it?

In other words, if your anxiety or avoidance is increasing and you have a family history of an anxiety disorder you may want to nip-it-in-the-bud. It is easier to prevent a full-blown anxiety disorder than to treat it once it has really taken root.

Eric Goodman, Ph.D.

www.coastalcenter.org

• If you spend ten times as long on a task as other people in order to get it just right…you might be a perfectionist.
• If you receive an A- on a school assignment and get upset that it wasn’t an A+…you might be a perfectionist.
• If you obsess about minor flaws in your appearance, despite evidence that other people think you look just fine…you might be a perfectionist.
• If you agonize over even small decisions (Coco Puffs versus Lucky Charms)…you might be a perfectionist.
• If you clean things that most people would think are already clean…you might be a perfectionist.
• If you can’t stand to be around people because everyone has something about them that really bugs you…you might be a perfectionist.
• If nothing you do can ever meet your expectations…you might be a perfectionist.
• If you procrastinate because you know that you cannot possibly do as well as you demand…you might be a perfectionist.
• If you are still reading this article…chances are, you might be a perfectionist!

So just what is a “perfectionist”?

The simple answer is that it is someone who cannot stand the thought of doing at least certain things imperfectly.

There are many reasons why someone might feel that way. Some are just hard-wired for perfectionism, as is the case with many people with OCD. Other people might have had parents who demanded perfection and punished mistakes. Some have the mistaken belief that they can only feel good about themselves if they are flawless. Whatever the case may be, perfectionism, by definition, is a miserable way to live a life. Since no one and nothing can be perfect, the perfectionist is doomed to failure and frustration at every turn. No wonder so many perfectionists procrastinate to such a large degree!

So if perfectionism feels so unpleasant, why do people continue to behave perfectionistically?

1. First there is a triggering event, for example:

• Going to a party
• Noticing a bodily sensation
• Seeing one’s reflection in the mirror
• Undertaking a school or work project

2. The triggering event “activates” perfectionistic thoughts and beliefs

• All-or-nothing thinking
  • If I am not 100% perfect I is will be rejected!
  • It is either an A+ or I am a failure!
  • This pimple means I am hideous!
• Catastrophizing
  • If I am rejected then I will never be loved and will be alone and miserable forever!
• Belief that it is possible to achieve perfection
• Belief that it is desirable to achieve perfection
  • Yes, maybe in some cases it would be desirable, but most of us dislike people who are perfect know-it-alls. Most people like others who are imperfectly human…like us!
• Unfair Comparisons
  • Life is terrible unless I am smarter than Einstein or prettier than a supermodel!
• Shoulds
  • I should (must, ought to, have to) be perfect in my appearance and everything I do!

3. In the face of such rigid beliefs the stakes of performance seem very high. This can lead to anxiety and dread.

4. In order to decrease these negative emotions, the perfectionist engages in avoidances and/or safety behaviors, such as:

• Procrastinate
• Over-prepare
• Checking, rechecking, rechecking, rechecking, rechecking……
• Desperately hiding perceived flaws
• Obsessive cleaning, straightening, worrying
• ETC!!!

5. In the end, the catastrophic fear does not come true

• I was not horribly rejected.
• The C- on the paper did not “count” because I really did not try my hardest.
• I was not killed by germs

6. The FACT that nothing catastrophic happened is attributed to the avoidances and safety behaviors (rather than the fact that nothing catastrophic would have happened anyway).

• “My avoidances and safety behaviors are serving a useful function!”
• Had I not done them, I would have been in big trouble!

7. This reinforces the belief that you had better strive for perfection!

• You do not get to learn that being imperfect will not lead to catastrophic consequences!

How can I learn to NOT be a perfectionist?

Well first of all, are you sure that you want to give up perfectionism? Just think of what you’d be losing out on: Hours upon hours of stress, anxiety, frustration, and perceived failure.

If you spend a hundred hours trying to write the perfect paper, you may get a better grade. But is it worth the cost? How else could you have spent that time that would ultimately lead to a more rewarding lifestyle?

Would you truly be willing to only strive for excellence at some of the things you do? And for those other things, could you simply allow for “good enough”?

The most important step in decreasing perfectionism is to commit yourself to the goal of decreasing your perfectionism.

It is then important to challenge your perfectionistic beliefs.

• Is life truly ALL-OR-NOTHING? If your belief is that you are either perfect or worthless, perhaps consider that life is not so black-and-white. Begin to look for the shades of grey. I may not be the most attractive person, but I am not the least either. I may not be the best student, but I’m doing well compared with many of my peers. I may not be suave like James Bond, but I’m no Woody Allen either.
• Is it true that I SHOULD perform perfectly? MUST I always be loved and accepted by everyone I meet? Do I really HAVE TO give one-hundred percent effort into everything that I do? Why? Who says?
• If I want to survive I must have food, water, and shelter. Other than that, life is truly all about preferences. I can prefer to strive for excellence, because I prefer to have a well-paying job—but I don’t have to!
• Is imperfection truly CATASTROPHIC?
• Is it really helpful for you to COMPARE yourself to EXTREMES? Must you look better than a super-model, be smarter than Einstein, and have more money than Bill Gates in order to be happy? Since when did N.O.R.M.A.L. become a four-letter word?

Still reluctant to decrease your perfectionism?

How about learning to be more selective in picking your perfectionism battles? Maybe you could put more effort into major exams and be willing to put less effort into minor quizzes or extra credit. Maybe choosing a breakfast cereal should take less analysis than whether to propose to your girlfriend. If you’re obsessing over wearing the perfect outfit to a formal party, maybe you could fret less over what you’re going to wear to the grocery store.

Another strategy is to re-define your definition of “success”. Instead of defining success as an outcome, you can define it as a process. If you ask a potential romantic partner out on a date and you define success as an agreement to go on a date with you then you take the success out of your hands and give the power to the other person.

Instead, you could define success purely based on what you have control over:

1. Dress in an attractive way (success)
2. Agree to attend three social events (success)
3. Brush up on current events (success)
4. Go to the social events and make small talk with five potential romantic partners (success)
5. Muster up your courage and ask one person for a date (success)

If you have a big presentation to give at work you could define success if you:

1. Brainstorm for ideas and select a topic (success)
2. Prepare an outline (success)
3. Rehearse once or twice (success)
4. Present your material at work in a pleasant and professional manner (success)

If your presentation is a hit, then that is icing on the cake!

Think about the object/s of your perfectionism. Can you break the task down and set reasonable goals? Could you consider declaring victory if you achieve your reasonable goals…despite the actual outcome?

Now I have a more radical idea for you to consider. Maybe imperfection is not such a bad thing. In fact, maybe imperfection is a good thing.

Consider this. Maybe perfectionistic strivings have not served you so well, after all. Maybe the successes you have had have not been because of trying to be perfect, but despite your perfectionism. Maybe perfectionism has been a chain around your neck dragging you under as you fight to stay afloat.

Imperfection has its value. If you imagine someone who is perfect: Dresses flawlessly, make-up artfully applied, not a single hair out of place, knows everything about everything and expresses it with professional eloquence, never makes a single mistake…ever. How would you like to spend the next 50 years married to that person? I thought not. We like people who validate our own humanity by being wonderfully flawed, just like you and I. In words: SOCIAL PERFECTION IS A MAJOR SOCIAL FLAW.

Perfectionism often leads to indecision. If you can’t be certain you are making the perfect decision then you may agonize endlessly. If you are willing to make decisions imperfectly then suddenly you are free to make decisions…you are free! Is an imperfect decision catastrophic? Probably not. If you pick breakfast cereal A over cereal B, what are you risking? Maybe B is slightly more tasty or healthier than A, but isn’t that a small price to pay for the freedom to make decisions. If you are trying to decide between college A or college B, it is impossible to know with 100% certainty which one will be best. College A might give you a slightly better academic experience, but B might be the place where you will meet your soul mate. The point is to risk making the slightly “less good” decision (not a catastrophic decision) in order to have the freedom to make decisions without years of agonizing delay. If you wait to make a decision until you are 100% convinced it is the perfect decision, you might be waiting your entire life.

If you treat each task as if it was your life’s work, you will put massive amounts of time and energy into it while neglecting other areas of your life. Perhaps the quality of your work will be better on a given task (if you can get yourself not to procrastinate), but the QUANTITY of your work will suffer. In other words, you can spend one hundred hours getting one task done exceptionally well, but if you settled for just doing a good job (say ten hours’ worth of work) you could get ten times the amount of work done. And, if your goal was to do a good job, rather than perfect, you can feel good about the work you did, rather than being consistently disappointed by chasing the impossible goal of perfection.

Ultimately, I am making the case that although the reality imperfection is our destiny, despite what we want, embracing it makes for a freer and more rewarding life. If you have been a perfectionist, I do not expect that you’ll believe this without proof. I recommend that you seek that proof.

Try this:

Take a task that you push yourself to be perfect on. Instead of 100% effort, try 90% effort. Back off a little bit. Did the sky fall? Maybe you even performed adequately. How about your level of enjoyment of the task versus how striving for an impossible level of performance feels? If that turned out ok, how about experimenting with 80% effort or even less? See if you can decrease your standards while increasing your emotional well-being and enjoyment of life. Wouldn’t be nice to see that 75% of your usual effort produces good-enough results with less stress?

The bottom-line is that perfectionism leads to a life of hopeless struggle. No matter how successful you might become, it will never be good enough…it will never be perfect. If you are a perfectionist and would like to change this frustrating condition than first of all accept that you have (and may always have) perfectionistic thoughts. The perfectionism devil sits on your shoulders and yells, “DO BETTER, DO PERFECTED, IT’S NOT GOOD ENOUGH!” You can benefit from learning to accept this devil, but disregard its message as so much background noise. Choose your level of effort and learn to be satisfied with good enough. Notice that everything and everyone is wonderfully imperfect and that it is ok to embrace the reality of this.

Note: I have strategically placed errors throughout this article. If you have found them all…you might be a perfectionist.

Eric Goodman, Ph.D.

www.coastalcenter.org

Who

Who is going to take part in your exposure? Who will be the targeted people?

Depending upon the nature of your fear, you may find that having certain “comfort” people accompany you may decrease your anxiety level. This may be ok early-on, but as your confidence builds, the nature of your fear might be better addressed going solo. “Targeting” certain types of people (gender, level of attractiveness or education, and so on) may make your exposure more or less challenging. It is okay to initially start with challenging, but easier people, and then progressing to more difficult targets.

What

What specifically will you do for your exposure?

Varying what you do, even a little bit, may make your exposure more or less challenging. It is ok to start with low to moderate exposure goals before progressing to more challenging ones. If you are socially phobic, for example, you could start out by just being in the presence of other people, then move on to eye-contact in passing, then to brief small talk, and so on.

When

What day or days of the week and time or times of the day will you do the exposure/s?

Some exposures may fit in best before or after school or work. Some exposures may be made more challenging in the daytime or nighttime depending upon the nature of the fear. Working your way up to the most difficult times of the day or week may enhance the exposure challenge.

Where

Where will the exposure take place?

Will your exposure be made easier or harder if it is done at home or in public? It is ok to start with challenging but easier places and then progress to more difficult locations. Sometimes going out of town, among people you will never see again, is easier than in places where you may bump into people you know. The opposite can be true as well, depending upon the nature of the fear. In order for you to “generalize” your exposures to your everyday life, you will probably need to face your fear in a number of situations.

Why

Ask yourself two questions.

(1)    What might I learn as a result of the exposure that might be helpful in the future?

Successful exposures tend to lead to the realization that the situation was not as dangerous as previously believed and that even if a negative outcome results, it tends to not be as bad as feared and you can cope adequately. Over time, successful outcomes tend to lead to “habituation” or a lessening of anxiety in those situations.

(2)    What do you stand to gain if you successfully face your fears?

Make a list of all the things that you will gain if face your fear. What are you losing out to the anxiety and how will your life be better if the anxiety no longer calls the shots? Read this frequently in order to bolster your motivation.

How

ERP involves going towards the feared situation either in your imagination or in the “real world” without engaging in avoidance or “safety” behaviors.

Plan B

If you design an exposure that turns out to be significantly more anxiety-provoking than anticipated or you find that you just can’t get yourself to follow-through have a back-up exposure planned that is less challenging (though certainly not overly easy—where would the growth be in that?).

Feared Outcome

Before an exposure, write down, specifically, what you (or Anxiety) fears will happen. What is the catastrophic outcome that is anticipated?

Actual Outcome

Record what actually happened and keep those results handy so that you can see the proof that ERP is working for you!

Follow the steps above to design optimal ERP activities.

How does this happen? Let’s look at a few examples.

RELATIONSHIP OBSESSIONS

It used to be that many relationships in our lives had a beginning, middle, and an end. The end of a romantic relationship, for example, typically involved a severing of that relationship—painful, but done. Closure could be achieved following a length of healthy grieving. Today, however, relationships often don’t end. You may no longer be sleeping with your ex, but there’s a good chance (at least among today’s tech-oriented young adults) that he or she is still your Facebook friend. You may still receive occasional, texts, pokes, tweets, or e-mails. You continue to see their lives played out via photos and videos placed on their Facebook page.

Not only does this make it difficult to move on, but some people become obsessed with checking online information about their ex. They may then come to idealize that past relationship, which may jeopardize their happiness in their current non-idealized relationship. Fantasies of reconciliation can be further fueled by reading too much into their ex’s online gestures (Just what did that ;0 mean?).

Some people take this to an extreme and begin “Cyber-Snooping” on their ex. This may involve spending hours a day analyzing every detail of their online information, trying in vain to find certainty about whether their ex is open to taking them back or trying to find out as much as they can about their ex’s current romantic pursuits. This can go on for months or years and makes the person with the obsession miserable with uncertainty. Some will know their ex’s website logins and passwords (note- after break-ups it is important to change these) and will also check their bank and credit card statements, phone records, and much more.

Maybe it is okay for relationships to end. Maybe we don’t need to keep ex’s as online friends, followers, and so on. Do they really need to be on the receiving end of that group tweet? So—let them go, grieve your loss, and change your passwords. It may be more painful at first, but in the long run you can reinvest your emotional energy in a new relationship.

HEALTH OBSESSIONS

For people with health anxiety, the internet is often a source of torture. They search desperately for some piece of information that will convince them that they are not suffering from a catastrophic illness. However, they can never get 100% certainty—and Anxiety demands nothing less than that. They go from website to forum, to listserv, to chat room, to website. Perhaps they find a hopeful shred of information here and there and feel some fleeting relief. It doesn’t last long, however, and soon they are back to the web, desperate for their next reassurance fix. The more they check for certainty, the more uncertain they remain. More than one client of mine has described it as “hell on earth”.

PERFECTIONISM

Perfectionists are drawn to the internet by the hope that they can achieve perfection if they can just get enough information. If they are going to buy a TV or purchase airline tickets, they might spend hour upon hour for months trying to ensure they are getting the perfect product at the perfect price. This is a hopeless attempt at achieving certainty. Other people may spend hours researching information just for the sake of NEEDING TO KNOW. It can be upsetting to them to have imperfect knowledge or an unanswered question.  The problem is that we can’t know everything and we can’t know anything perfectly—no matter how much we try. Perfectionists are often chronic contemplators, wanting to make a decision, but since they cannot be guaranteed that they will make the perfect choice they put off making the decision in favor of more and more internet “research.”

PORN

Porn in the internet age is popular—no doubt. For some, however, the never ending stream of novel sexual stimuli begins to eat more and more time out of their daily life. This can create an “addiction” to novelty. I read somewhere recently (sorry I do not recall the source) that this is like having “sexual add”. In other words, nothing sexual can hold their attention very long. This can keep them coming back for more, newer, and more novel pictures or videos. The cost is that monogamy to them really becomes synonymous with monotony. How could one person (or a hundred for that matter) possible compete with an endless stream of novelty? It is not uncommon for people to lose sexual desire for their partners altogether.

The internet can be a wonderful thing, but has the potential to foster obsessive and anxious rumination. The research into the consequences of this is in its infancy, but therapists are seeing increasing instances of cyber-obsessions. Treatment involves learning to use the internet in ways that are adaptive and not destructive.

Eric Goodman, Ph.D.

www.coastalcenter.org

There is no debate about whether anxiety exists. It is real and we all have it to a certain degree at certain times. If we accept that fact, we can learn to cope effectively with it.

The Great Anxiety Debate is the conversations you have in your head with Anxiety. You try to convince Anxiety that something is safe and Anxiety tries to convince you that you are catastrophically wrong.

When you have an anxiety disorder, Anxiety can be very persuasive in trying to get you to do its’ bidding:

• “Don’t touch that or you’ll get sick!”
• “Don’t go to the party because everyone will reject you!”
• “Don’t fly in the airplane or you’ll die in a crash!”

While it can be helpful at times to seek some basic information (e.g. Flying is so safe that, statistically speaking, you have to fly every day for 16,000 years before being in a fatal plane crash) no amount of information will bring 100% certainty that something is safe (occasionally a plane will crash). Anxiety knows this and will always try to throw that in your face in order to win The Great Anxiety Debate. It goes something like this:

Let’s say you have a social phobia and have been invited to a party. Anxiety will try to out-debate you in order to keep you home snug and safe (and lonely).

Anxiety: “You’d better stay home and not go to the party!”

You: “Why should I? I really want to make some more friends, maybe meet someone special.”

Anxiety: “Why you ask? Because no one will like you! They will think you are a pathetic, awkward, boring loser…that’s why not!”

You: “That won’t happen.”

Anxiety: “Are you sure! Are you absolutely certain! If you are going to go, you have to be absolutely certain!”

You: “I guess I’m not really sure.”

Anxiety: “See, you aren’t even certain! What were you thinking! If you go, they will all reject you. You won’t be able to show you face around any of those people ever again! You’ll be alone and depressed forever!!!”

You: “Maybe you’re right. Why take the chance? Let’s see what’s on TV.”

You can’t win The Great Anxiety Debate. It will always come down to you not being absolutely 100% certain of the safety of the situation. We can’t really know anything with 100% certainty. For example, are you 100% certain that you are really awake right now and that you are not just dreaming that you are reading this article? I know, I know…you are convinced that you are awake at this moment. Let me ask you this…when you were asleep last night and dreaming that you had shown up to work in your underwear, weren’t you certain at the time that it was really happening (that you were awake when you were really dreaming)? I thought so.

So we cannot be certain of safety. If your goal is 100% certainty of safety before facing your fears then Anxiety will always win. Let me suggest another strategy.

• Take reasonable risks
• Be willing to embrace uncertainty and discomfort
• Observe the outcome
• You choose your behaviors based on your goals and values—Anxiety doesn’t get a vote
• Accept that you and your experiences cannot (and doesn’t have to be) perfect

If you have an anxiety disorder, you are probably not a good judge of the safety of your feared situation. If you are terrified to fly, you probably have an exaggerated notion of the dangerousness of flying. Take yourself out of the equation. What do MOST people (who are not phobic of flying) think about the safety of flying? What would most people say about the likelihood of contracting HIV or hepatitis by using a public bathroom? Would most people agree that talking to an attractive person at a party (or even spilling a drink at a party) is a horribly risky thing to do?

While these activities could possibly result in a highly undesirable or traumatic outcome, most people would agree that it is unlikely. If the fear is of jumping out of an airplane without a parachute, most would agree that it might not be such a good idea—that it’s an unreasonable risk.

Still, no matter how overwhelming the evidence of safety is, there is no certainty. Although trying to think in terms of how most people would rate the safety of a situation can be initially helpful in determining a reasonable risk, endless reassurance-seeking (“Are you sure it’s safe…how do you know?…”) in order to chase certainty is not helpful.

Once you enter your feared situation, Anxiety will attempt to engage you in debate (“How do you know this is safe? It looks dangerous to me!”). Instead of participating in the debate how about acknowledging and accepting Anxiety’s presence, both the “debate” thoughts and the uncomfortable feelings, and committing yourself to focusing on the present moment and observe for yourself whether the experience is truly catastrophic? The situation, your comfort level, and your performance don’t have to be perfect (in fact THAT is a guarantee) but you can still move forward in the world and go after what you truly desire (taking that flight, talking to people at parties, giving that speech, and so on). Remember—Anxiety only gets to vote on your behaviors if you give it that power.

The next time you courageously choose to face your fears, you can be sure that Anxiety will be there desperately trying to engage you in debate. You can choose to let Anxiety debate all by itself. Let it be a one-sided conversation that you choose not to participate in nor even attend to. Go out and live your life and let Anxiety jabber on in the background without a debate partner.

Eric Goodman, Ph.D.

www.coastalcenter.org

You’ve identified and read up on which anxiety problem you want to tackle. You’ve identified your avoidances and safety behaviors. You’ve generated you’re Exposure with Response Prevention (ERP) hierarchy and you’re ready start.

I have one more suggestion that might make your treatment go more smoothly—chart your daily progress! Systematically recording your progress can enhance your motivation to persevere through tough exposures when you can look back and see all that you have accomplished in your previous exposures. Also, looking back on your exposures can help pinpoint particular problem areas.

What type of information should you record?

• Date
• Exposure type
• Amount of time spent on Exposure
• Initial discomfort/anxiety level on a scale of 0 to 10 (0 = no anxiety, 5 = moderate, and, 10 = panic attack!)
• Ending discomfort/anxiety level on a scale of 0 to 10 (0 = no anxiety, 5 = moderate, and, 10 = panic attack!)

I also like to include the following:

• Initial resistance to the discomfort/anxiety level on a scale of 0 to 10 (0 = no resistance, I am accepting it fully, 5 = moderate resistance, and, 10 = I’m resisting the discomfort as if my life depended on it!)
• Ending resistance to the discomfort/anxiety level on a scale of 0 to 10 (0 = no resistance, I am accepting it fully, 5 = moderate resistance, and, 10 = I’m resisting the discomfort as if my life depended on it!)

Remember, start with the moderately challenging exposures prior to progressing to the more difficult ones. Try to do your exposures as many days a week as you can and allow sufficient time.

Given a good exposure plan and consistency, you can make progress towards your anxiety goals! If roadblocks emerge, contact an anxiety specialist.

Eric Goodman, Ph.D.

www.coastalcenter.org

Below are the highlights of the talks I attended. I am not endorsing or critiquing this information, but simply reporting.

-          Hoarding is a severe psychological disorder that in the past was lumped under the OCD umbrella. It is now NOT believed to be OCD, but a completely separate disorder.

• It can be very treatment resistant due to defensiveness, dissociation, lack of insight, and lack of motivation on the part of the hoarder. Typically it is the family that suffers the most.
• Treatment adherence and success is more likely if in-home coaching from a friend, family member, organizer, etc., is utilized very frequently.

-          Readiness for Change Therapy

• This is a therapy designed by Dr. Alec Pollard and involved vigilance on the part of the therapist to client‘s lack of follow-through with their treatment plan. He suggests immediately stopping formal CBT treatment and focusing 100% on the client’s Treatment Interfering Behaviors (TIB) and only agreeing to continue treating the anxiety or obsessive-compulsive disorder once the TIB is resolved.
• He states that therapists ought to stop therapy right away rather than go along with half-hearted client follow-through. His rationale is that half-hearted attempts will fail and the client will blame the therapy and give-up on their best chance for improvement. Better to not try then try half-hearted.

-          Clients with “poor insight” tend to have significantly worse treatment outcomes. The hoarder who thinks they are just a little messy or the 98lb girl who believes she is 300lbs are unlikely to make significant progress without some loosening of their rigid beliefs.

• Sometimes low-levels of an anti-psychotic can help.

-          Severe and persistent depression is associated with worse treatment outcomes.

-          With clients who are not responding to standard outpatient CBT (1-2 x per week) MORE frequent and more intensive treatment can be helpful.

-          If a child/teen refuses treatment then working with the parents is a potentially good option.

-          More frequent contact can improve treatment outcomes. This can be through increased sessions, longer sessions, and/or e-mail or phone check-ins.

-          Social Phobia

• 75% of clients report significant treatment gains (though that also means 25% do not).
  • Although the treatment gains can be significant, they do not tend to be huge—the socially avoidant person does not necessarily learn to feel comfortable being the life of the party.
  • Due to the nature of social anxiety, most people never seek treatment and out of those who do only half receive adequate treatment.
• Self-help via books, web-based programs, or minimal therapist contact can be effective if the client is motivated.
• Changing maladaptive beliefs (e.g. I’m a social outcast, people are harsh and rejecting, etc.) is a primary strategy and exposures are designed to disprove maladaptive beliefs.
  • Meds can help enhance biological/physiological control/regulation, but it does not change beliefs.
  • ACT therapists would argue that behaviors need to change while belief change is secondary and not necessary as long as someone is moving towards their goals.
• Social skills training is not important for most people with social phobia. There is a wide range of acceptable behavior and trying to behavior in narrowly prescribed ways can become a maladaptive ritual. Decreasing inhibition and increasing verbal and behavioral output is much more important for most.

-          OCD treatment bottom-line is to learn to co-exist with obsessive thoughts. Anything that tries to force OCD thoughts away tends to make it worse. Even ERP, the main treatment for OCD, can become a safety behavior if the person with OCD uses it to GET RID OF THE THOUGHTS.

• Main treatment goals are to increase uncertainty/anxiety tolerance and to behave flexible (go after what you want in life) despite obsessive thoughts.
  • Genuinely caring less about whether anxiety or OCD thoughts are reduced tends to lead to actual decreases in anxiety and OCD thoughts for most people.
    • Goal then is to increase genuine willingness to experience anxiety and OCD thoughts. Need to develop the ability to feel what you feel rather than fighting it.

-          Behavioral Activation (BA) involves planning your days ahead of time, filling your time with pleasurable and mastery experiences. This can be a very effective intervention for many people with anxiety and depression (“live by the daily planner”).

• Here’s part of the theory behind it: Something negative happens (panic, rejection, embarrassment, etc) which creates negative emotions. The negative emotions lead the person to avoiding future things that might have the same outcome. As a result, they will not learn that they can handle similar situations and they will miss out on opportunities for positive experiences, further exacerbating negative emotions.
  • The goal then is adaptive behaviors in the face of negative events rather than avoidant behaviors.
• May need to do values clarification exercises first to come up with personally meaningful activities.
  • “What was important to you before you got anxious/depressed?”
• BA treatment has five stages
  • Orientation and commitment
  • Getting active
  • Problem-solving
  • Setting goals and sub goals
  • Practice, practice, practice…

-          Long-term strategies for the treatment of anxiety disorders

• A significant number of people drop out of treatment that includes ERP.
• Treatment gains are maintained better with regular therapy booster sessions (1 x month for a while after treatment is completed).
• People with panic disorder and agoraphobia that do not respond to adequate CBT treatment may need to switch from CBT to medication therapy.
  • Continued treatment with either meds or CBT over time does seem beneficial for those who are initial treatment “non-responders.”

-            Dr. David Barlow, who is one of the most eminent psychologists and researchers in the field of anxiety disorders stated that once someone has an anxiety disorder, they are always at risk for relapse even if it goes into remission. Good news is that continued treatment, even self-guided, decreases the risk and can manage anxiety relapses if they occur.

-          Perfectionism is a rough way to live one’s life, though many perfectionists adamantly refuse to consider lowering their standards.

Much more interesting information was presented at the ABCT conference 2010 and the above is simply highlights from the talks I attended.

Eric Goodman, Ph.D.

www.coastalcenter.org