Research has shown that up to twenty-five percent of people with an anxiety disorder will refuse to engage in exposure with response prevention therapy (ERP, the main non-medical treatment for anxiety disorders). “You want me to ride in an elevator? There is no way!” Out of those who agree to participate in ERP, another twenty-five percent will drop out of treatment shortly after starting. “This is NOT for me!” Some other people will chronically cancel appointments, not follow-through with ERP “homework,” and try to spend the therapy hour focusing on side-issues in order to “run out the clock.”
The reality is that the vast majority of people with anxiety disorders will make significant progress if they can stick with the treatment as prescribed by a competent anxiety specialist (or even a competent self-help book). This is assuming they have access to treatment and are free from other conditions that make anxiety treatment much more challenging such as certain other severe mental health issues and/or acute non-related life crises (which would need to be addressed first).
What remains as the primary issue in determining whether someone seeks out and follows-through with treatment is MOTIVATION.
Let’s be frank, no one wants to do ERP. It is a time consuming and often unpleasant activity, requiring one to do things that are very uncomfortable and that might even feel dangerous. Clearly it takes a significant amount of motivation to get oneself to follow-through. I often avoid unpleasant activities such as taking out the garbage and I’m not afraid of it. So how does one muster the motivation to face their fears?
I recommend the following activity:
Take out a piece of paper and draw a line down the middle, forming two columns. Title the first column, “What anxiety is costing me now and what anxiety might cost me in the future.” (WACME for short, imagine anxiety whacking you on the head with a large mallet). On this column write down everything you are losing or might lose to anxiety. Common responses might be: peace of mind, specific relationships being harmed, adverse vocational consequences, lack of travel and other fun activities, freedom, and so on. Please spend time giving this adequate thought. Title the next column “What I stand to gain if I defeat anxiety” (insert your own clever acronym here). How, specifically, will your life be better (now and in the future) if you successfully face your fears. Again, spend adequate time on this and be specific.
On another piece of paper, write down the disadvantages of facing your fears. ERP can be time consuming. This time has to come at the expense of another activity (watching TV, working, spending time with family, etc.). ERP is certainly uncomfortable, not only during the ERP activity, but significant anticipatory anxiety prior to ERP is normal, as well. Some of us have more tolerance for feeling this discomfort than others. Also, when you face your fears you are taking risks, though typically very improbable risks. The dog could bite, the plane could crash, your child could get harmed if you send them to school, someone could die…anything is possible (which is NOT the same thing as probable). Part of recovery from an anxiety disorder is accepting normative risks and uncertainties.
If the advantages (what you stand to gain) of facing your anxiety significantly outweighs the discomfort, time commitment and risk of facing your fears, then move on to developing your ERP action plan either with an anxiety specialist or ERP-based self-help book. If, however, after giving it some thought you find that the advantages of facing your fears does not significantly outweigh the disadvantages then it is NOT time to start an ERP program. Learn more about your anxiety disorder, talk with friends and family, perhaps see a therapist to help you explore the role your anxiety disorders has played in your life, and then re-evaluate at a later time. Sometimes due to time or other life-constraints it IS better to hold off on anxiety treatment until later.
Sometimes people, especially children and young adolescents, have a hard time understanding that doing something uncomfortable in the short term can lead to a more comfortable future. They might not understand that you need to go towards a fear in order to fear it less. In these cases bribery can be a powerful motivator. By “bribery” I mean setting up an incentive program. Every time they do their ERP they get to earn a token that at a later time can be exchanged for something they find reinforcing. This can be a powerful way to bolster motivation in the unmotivated. Motivation can also be bolstered by not accommodating a loved one’s anxiety. For example, if you have a spouse with OCD and a germ phobia, his or her motivation is not enhanced by helping them compulsively clean the house.
Bottom-line: To overcome an anxiety disorder you must be willing to invest in short term discomfort in order to have a more comfortable future. Is it worth it to you?
Eric Goodman, Ph.D.