The primary non-medical treatment for anxiety disorders is Cognitive-Behavioral Therapy with an emphasis on Exposure with Response Prevention (ERP).
Basically, it involves directly facing your fear/s in your imagination (Imaginal Exposure) and/or in real life (In Vivo Exposure).
Phases of treatment include:
- Assessment
- Education
- Treatment Planning
- ERP
- Other Skills, as needed
- Treatment Wrap-Up
ASSESSMENT
Therapist’s Responsibility: The therapist’s job is to assess for the presence of anxiety and related disorders, assess for the level of severity of any disorders present, and communicate the findings to you. The assessment includes an extensive interview, questionnaires, and in some cases mild exposure to your anxious triggers in order to evaluate the level of distress or the nature of your reactive thoughts. The formal assessment phase typically lasts between two and four sessions, but is considered ongoing during treatment as new information arises.
Your Responsibility: The client’s responsibility is to arrive on time, answer questions honestly, fill out questionnaires accurately and return them on the next appointment. During exposure to your anxious triggers, your job will be to pay attention to your physical and mental reactions and relay them to the therapist.
EDUCATION
Therapist’s Responsibility: The therapist will then try to help you to understand which anxiety disorder/s you have, what the cause might be, what is likely maintaining it, and how to treat it. This will include discussion in session, hand outs, and often recommendations of self-help books and/or internet information sources.
Your Responsibility: The client’s responsibility is to pay attention, ask questions when the material is unclear, and follow through with outside reading assignments in a timely manner. If you disagree with the information being presented, you need to speak up. After learning about the basics of what anxiety treatment includes, your responsibility is to discuss any concerns you have with your therapist and if you do NOT want to move forward with treatment, this is the time to let the therapist know.
TREATMENT PLANNING
Therapist’s Responsibility: Your therapist will work with you to come up with a list of situations that trigger your anxiety. You will be asked to rate the degree of anxiety each situation causes. Plans for exposure to the target situations (or thoughts, sensations, or emotions) will be made, as well as which safety behaviors to discontinue or wean off.
Your Responsibility: Since only you know the full extent of what you avoid and the nature of the “safety precautions” you take in the face of anxiety, you will need to play a major role in creating your “exposure hierarchy”. Coming to therapy with such a list already generated can be a great help to your therapist.
ERP
Therapist’s Responsibility: Your therapist will likely begin initial ERP in session. This will consist of you being exposed to an item on your anxiety list and feeling the anxiety fully without engaging in behaviors designed to minimize or distract you from your fear. You’ll be encouraged to stay in the situation and feel the anxiety until the anxiety comes down on its own (at least by half). Your therapist will then send you home with the assignment to REPEAT, REPEAT, REPEAT until that item on your list is no longer a trigger for your anxiety.
Your Responsibility: It is important to show up on time for ERP sessions (unless your exposure is to be late, of course) because you want to allow enough time for your anxiety to come down (habituate) during the exposure. You will likely feel uncomfortable anticipation prior to the exposure and you might feel mildly to significantly nervous during the exposure. You will be asked to give your “anxiety level” frequently during the exposure, which helps the therapist monitor your progress and make changes when necessary. You will need stay with the discomfort and do your best not to fight it (fighting it makes it stronger and last longer). You will then need to repeat your exposure on your own, perhaps in different contexts and for different lengths of time. You will be expected to follow-through and report back to the therapist. Therapy homework might involve daily exposures for up to an hour or more, depending upon the nature of the anxiety and realistic time constraints. If you do not do follow-through with treatment recommendations then your therapist will likely be unable to help you. In most cases, the bulk of the treatment progress will occur outside of the therapy session during your individual ERP (the exception to this is intensive treatment programs where you will spend significantly more time with a therapist during ERP).
OTHER SKILLS, AS NEEDED
Therapist’s Responsibility: Your therapist will evaluate your need for additional skills such as stress management, time management, problem-solving, decision-making, relaxation, sleep skills and so on. He or she will instruct you in these skills, provide you with a handout, or recommend a relevant source of information (such as self-help books, groups, or web sites).
Your Responsibility: Let your therapist know if other problems are interfering with your anxiety treatment, learn the relevant skills, and implement them (if you use a skill, you own it. If not, it will be forgotten).
TREATMENT WRAP UP
Therapist’s Responsibility: Your therapist will assess your progress towards your treatment goals each time you meet. When treatment goals are met, treatment will either be discontinued or sessions will be spaced out. In some cases, booster sessions (check-ups) will be scheduled one or more months away to ensure that treatment progress is being maintained. Your therapist will advise you on ways to minimize the likelihood that your anxiety disorder will “sneak back in”. Occasionally, treatment will be discontinued because of lack of follow-through with the treatment plan. If that is the case, you will likely be invited to re-start treatment when treatment adherence is no longer a problem.
Your Responsibility: You will be responsible for continuing to face your anxiety when it arises and not to fall back into avoidance and safety behaviors once treatment is complete. If you notice that your anxiety is worsening, you will need to first use the skills you learned to manage this escalation and if you continue to have difficulty, to contact your therapist for a booster session before anxiety starts to gain too much ground.
Eric Goodman, Ph.D.