Category: Anxiety

Reid Wilson on Strategic Treatment of Anxiety Disorders

Posted on by rezendevknowfully.com

What is Anxiety?

Victor Yalom: So, Reid—good to be here with you. I guess a good place to start would be to define what anxiety is and how you distinguish between normal, healthy anxiety and irrational or counterproductive anxiety?
Reid Wilson: Well, that’s a broad question. We’re programmed to be anxious when we feel threatened—whether it’s an immediate threat or a distal threat—so anxiety disorders break down, in some ways, like that. Someone with panic disorder is threatened by an immediate danger; someone with generalized anxiety disorder tends to worry about things coming far in the future. We define people who have anxiety disorders, loosely, as those who have irrational fears of those kinds of threats.But the body responds impeccably to false messages. That’s part of the trouble of trying to help people get better—so much of the anxiety disorder symptoms have to do with naturally occurring responses to a perceived threat. So in many ways, as we do the treatment, we work against nature for a while until we can bring someone into balance.

VY: Before we get into treatment, let me try and understand that a little better. Anxiety is a natural mechanism to protect us against threats, but when it becomes counterproductive, or when our sensation of anxiety doesn’t match what’s going on in our environment, it becomes a disorder.
RW: Right.
VY: And the range of anxiety disorders is quite diverse, right? You have general anxiety disorder, panic attacks, specific phobias, OCD, PTSD. Is there a commonality among those? Is it useful to think of those together, or are there things that are quite discrete?
RW: I think that the most difficult one to sort out is post-traumatic stress disorder and there’s a tremendous number of researchers who are trying to figure out what the common denominators are within post-traumatic stress disorder. With the other disorders, there is a great deal of commonality. People with anxiety disorders have an intolerance of uncertainty and distress, and much of what we need to address in treatment is about resistance—about all the fighting and pushing away of symptoms that people with anxiety disorders use to stay out of discomfort. It’s not so much that someone’s having uncomfortable symptoms, it’s their response to their symptoms. Their tendency is to go, “This is terrible. I can’t handle this. I need to escape,” and we need to change that response.What varies is the contribution of genetics. Obsessive-compulsive disorder is almost completely genetic, whereas someone with a specific phobia of animals can have little or no genetic influences and be much more influenced by traumatic experiences or environmental factors.

In terms of how people respond, there’s a lot of commonality as well. That’s why part of what I’ve been trying to work on over the years is how to peel away all these innovations and exercises and structures that we use for people with anxiety disorders down to the lowest common denominator.

VY: I’ve seen you work with clients, and this idea about changing their response to their symptoms seems to be a core of your approach, but it’s kind of counterintuitive to clients as well the therapist. Can you say a little bit more about that?
RW: Sure, but it’s not like I have invented a system that hasn’t been around for a while. If we look at what’s been going on with mindfulness approaches to treatment, some of the work that’s been done in Buddhism for a couple of thousand years has to do with stepping back and observing the present moment, not reacting to it personally, and not taking the events to heart, as most people do. Part of what I have been trying explore is how you get people from point A to point B as efficiently as possible.

From Resistance to Detachment

VY: And what’s point A? What’s point B?
RW: Point A is what we’ve been speaking of, which is the resistance, the fighting, the trying to get away—“It’s bad or wrong that I’m experiencing this.” Point B is detachment. When people resist their experience of anxiety or panic, there is a significant amount of psychic energy invested in that resisting. When working with people, I try to respect the degree of energy that’s going into the fight.To expect our clients to move from the intense energy of resistance all the way to detachment is too grand an expectation. That’s why we have a lot of trouble keeping people in treatment, or even having people begin the treatment to start with. When you’re shopping around for help with your anxiety, what you hear is, “You’re going to have to do exposure over a number of weeks or maybe months. You’re going to have to go toward these terribly uncomfortable feelings and sit with them for a length of time, and then you will begin to notice a change.” But people who suffer from anxiety disorders are concerned with the immediate moment. Everything gets very tight for them. Their concern is, “but what do I do right now?” That’s what I want to present to people.

VY: Just so I understand, when you talk about resistance and all the energy that goes into resisting, how would this work with panic disorders? Is it that lot of time and discomfort is about anticipating and fearing the panic attack rather than the panic attack itself?
RW: Certainly. A panic attack, which lasts for 30 seconds—actually that is a relatively long panic attack—is less than .1 percent of the day, but people will focus the entire day on trying to prevent themselves from experiencing another panic attack. Somebody with obsessive-compulsive disorder may only wash their hands for 25 minutes a day, or check the doors and locks and windows for a half hour a day, but when you ask them how long they spend obsessing, they might say, “eight hours.” It’s very consuming psychically. All that bracing is the energy that needs to be redirected toward getting better.
VY: So how do you get from A to B?
RW: I attempt to honor and respect the energy of the resistance and help clients use that energy in a different way. The opposite of being frightened and bracing against a sensation or a pending dangerous experience is to let go. But letting go doesn’t represent a change in the emotional state. I believe we need to maintain the degree of emotion—so the opposite of terror is, to some degree, excitement or desire.In other words, we’re going to move toward that which we fear with a sense of zeal. It really gets crazy. It’s already paradoxical to move toward it and here we’re doubling down. It’s not, “Oh what I need to do is face my fear, therefore I’m going to step into that crowded elevator”; it’s, “I’m seeking out that state that I’ve been afraid of.”

Exposure Plus

VY: So that’s what you mean by “strategic therapy” or “paradoxical therapy”—encouraging people to go towards their fears with a kind of relish?
RW:

Strategic therapy is messing with patterns. So we’re going to find the pattern, and then mess with it.

Strategic therapy is messing with patterns. So we’re going to find the pattern, and then mess with it. Telling people to go toward what they fear is exposure, but we’re trying to do exposure plus. Go toward it and change my emotional state to, “I want this feeling. I want this experience.” But we need to be clear about what we are asking people to seek out. People with anxiety disorders have an intolerance of uncertainty and distress, so what they need to seek out is not that crowded elevator, not that battery they perceive is contaminated, but the generic sense of uncertainty and distress.

That’s a really the hard sell for people because it requires them to separate from the content of their worries and invite in more generic uncertainty and distress. And then the frame becomes, “I want to get better. I want to be with my family again. I want to be able to take the job on the 23rd floor. I want to fly to my cousin’s wedding in three months.”

Habituation is a fundamental element of exposure therapy and we know from the research that it takes three variables to get fully habituated and get better: frequency, intensity and duration. So if they want to get better they need to have enough distress, frequently enough and for long enough to make this practice count.

But I want to teach them the most generic way to do this as possible, because what we know is that anxiety disorders run the life cycle. Somebody can finish treatment with us and be doing great and be down to “normal” in terms of anxiety, and then three years later have a whole other brush with either the same disorder or another anxiety disorder. So we want to train people in a protocol that they can brush off again and start using if and when they encounter the disorder again.

The Art of Persuasion

VY: How do you propose this to your clients in the first place, and how do you get them to that state of wanting to go towards their fear?
RW: Persuasively. That’s my job—to find any and every mechanism to help change their mind. So I’m going to work at the level of frame of reference and I’ll use examples of other patients. I’ll use metaphors, I’ll give analogies, I’ll use logic, whatever I can use. I told a woman the other day, “If your son were in fifth grade and had to play the guitar every night, you could imagine him going, ‘Darn, I have to practice now.’ But if he sat down with his high-school cousin who plays in a rock band, and saw how cool it was, this fifth grader would begin to want to practice guitar every night. You can imagine the difference between a fifth grader having to practice for an hour, and a fifth grader wanting to practice for an hour.” That is the kind of shift I’m seeking for my clients and I’ll use these kinds of analogies to help them understand it on a deeper level. Every angle I can find to start loosening up their rigidity and resistance.
VY: We recently filmed you treating two clients for a new video series on Strategic Treatment of Anxiety Disorders that we’re releasing along with this interview, and one thing I noticed about you is you really take charge. You’re very directive. You tell the clients what to do. You tell them what may happen.It’s very different than a lot of therapists are trained. I think whether we’re trained from a more client-centered or psychodynamic point of view, that legacy of therapists being somewhat passive and letting the client lead the way has seeped into so much of our training as therapists. I’m wondering if you’ve observed that therapists have a hard time with taking charge in the way that you do.

RW: I would challenge what you’re saying because, yes, I’m dogmatic and I boss people around and I can be very dominant. On the other hand, I also try to come across one-down in certain situations.

Yes, I’m dogmatic and I boss people around, but I also try to come across one-down in certain situations.

“I’m not sure about what I’m saying right now, but what do you think?” I turn back to them to find out whether they’re starting to understand what I’m saying. I give them a protocol but say, “It’s an experiment. Let’s gather information about it.” There is a balance between coming on very strongly to somebody and, at the same time, accessing a sense of curiosity.

When I train therapists to do this, it’s somewhat intimidating to them and counter to how they have learned to do treatment. But we’re also talking about therapists who come in to get trained because the patients or clients that they see are pretty tough nuts to crack and they need some therapeutic leverage to help people move along. So I think they are also receptive to the ideas.

VY: One client that we see you working with in Exposure Therapy for Phobias, presents with a fear of flying, which, upon exploration with her, you narrow down to claustrophobia—a fear of enclosed spaces and suffocation, not being able to breathe. You do classic exposure therapy with her—which I had heard and read about but never seen in action—where you actually put a nose clip on her, put a pillowcase on her head and wrap that pillowcase with tape. Later you get her to go inside an enclosed box. That requires, first of all, that therapists get out of their cozy chairs and stand up and move around. That’s something that many therapists have no experience doing.
RW: Sure, it’s a big step but people are relatively motivated because we have a certain percentage of people with anxiety disorders that have very rigid belief systems. If you don’t find a way to start cracking that belief system open, it’s very frustrating for you as a therapist.

Chasing the Anxiety Boogeyman

VY: So give us a sense of how this works over time. I get the general principals, but how does it actually play out over sessions?
RW: Well, I work at the level of principles so I am not technique-focused, and that already makes me a little different than other CBT therapists. I don’t start with, “Here’s how you get better.” I start at the level of, “Here’s how I perceive what’s going on now for you. Help me understand. You know yourself—let’s see if we’ve got a match here.”

Psychoeducation is a big part what I do, particularly around the physiological and neurological aspects of these disorders. I talk about the neurology of fear and what happens with the amygdala when we are scaring ourselves.

Psychoeducation is a big part what I do, particularly around the physiological and neurological aspects of these disorders. I talk about the neurology of fear and what happens with the amygdala when we are scaring ourselves. It’s important for everyone to understand this aspect, which has to do with bringing the amygdala into the threatening situation and letting it just sit there and experience the situation and discover that it’s secreting too much epinephrine. We do that by quieting the prefrontal cortex. We need to stop scaring our amygdalas so that we can be present in the elevator, in the grocery store, with our heart rate accelerated, and discover that it doesn’t need to make me us excited.

A lot of the crazy kind of talking we engage in has to do with refocusing the attention of the prefrontal cortex so that it doesn’t keep continually saying, “Uh oh.” We’re trying to override that message with an executive voice that says, “I can handle this. Let’s go toward this.” So we need that in place.

And then we’re sending people out with experiments to do in which they notice those thoughts popping up or have that sensation in their body that’s been scaring them and then step back enough to go, “It’s happening—it’s okay this is happening,” and then transform it to, “I want this. Give me more.”

My orientation is a set of principles founded on the notion that content is irrelevant. That’s the first step that I need to get across to everyone. Then I personify the anxiety disorder to help them detach from the content of their worries. I’ll say something like, “The anxiety disorder hooks you by picking a topic that is personal to you. That’s how it creates doubt and resistance in you.”

So, for example, if you’re a single mother with three kids and have just lost your job and are not sure how you’re going to pay the rent in two months, that’s very stressful for you and it certainly is going to cause you to worry. But if you develop a sub-routine of worrying throughout the day about it, there’s no redeeming value in that process. So in your case I’ll say, “the anxiety disorder picks the fact that you’re going to have a hard time paying your rent and taking care of your kids. That’s a topic that’s threatening to you as a parent with young children.”

VY: But why do you personify? Why do you say, “it picks?” Do you actually believe that, or is that a tool that’s helpful?
RW: Do I actually believe that? What we’re trying to do is put into language something that’s unconscious, so I believe not so much that as—
VY: There’s no an anxiety boogeyman out there trying to get us, right?
RW: Well, maybe. What I believe is that to perceive it in that manner is therapeutic. It is a way to begin to get a sense of what’s going on. That’s what I want to do—help clients get ownership in comprehending the disorder. What is the nature of the disorder? Why is it running me? In many ways, I’m unconscious of the game that’s being played on me, so I want to bring that up to consciousness.
VY: Alright. So going back to the example of the single mother and her worrying throughout the day, what do you do with that?
RW: First off is to distinguish the content. If I don’t distinguish the content from the process, she’s going to think I’m crazy, because she should be worried. So first we isolate out worries that are signals: “I need to go find another job and I need to go to the government to see if they can help me for this period of time”—these are worries that she actually has a responsibility for and can take some action on, and now is the right time to take action. That would be the definition of a worry that is a signal, and we’re not working on those so much, though we certainly have to problem-solve.
VY: That’s what you would call normal or adaptive anxiety.
RW: Right, exactly. We’re separating that out. We do need to do problem-solving. If I can help you with that, then I’m going to work with you on that too. But on the other side is the worry that is just noise—repetitious, unproductive thinking that causes distress. That’s the content that is irrelevant and that’s what we want to isolate. So we’ve got the circumstances of your life, and then we’ve got how the anxiety disorder has come in and taken hold of that.Another example: If you’re afraid to fly, I’m going to try to teach you interventions to relax on the plane; but if you think the bolts are going to fall off the wings, there’s nothing I’m going to do to help you be comfortable. That would be inappropriate.

If instead we can change the story and get somebody who has a fear of flying to understand that the discomfort they’re feeling is inside them, is their responsibility—it’s not about the pilot or bad mechanics—then perfect. That’s what I want. People come in with a list of 15 things they don’t like about flying, but if they can say, “basically it comes down to feeling out of control,” we’re in business. That’s a theme of all anxiety disorders that we want them to understand.

The second piece is coming to accept their obsessive thoughts. Whether it’s, “when can I pay my bills?” or “was that battery contaminated?” their job is to accept them, to be fine with them. That can seem like a crazy intervention for people because we don’t go the route of reassurance around content. Instead we’re asking them to say: “It’s fine. That thought popped up because I have an anxiety disorder. That’s what we do. We generate thoughts that freak us out. And so instead of freaking out about it, when it shows up, I’m going to accept it.”

In order to get to the place of acceptance, we’re going to play some kooky games, like, “Give me your best shot” and “I’m not worried enough—make me more worried.”

The Anxiety Game

VY: You use the term “games” a lot. What do you mean by games?
RW: Perceiving the disorder as a mental game. Personifying the disorder. When I have an obsessive thought or an anticipatory worry or dread that I know is noise, I want to step back and notice it. That, in itself, is an intervention: “Oh, I’m worrying again. Oh, there’s that thought.” Now the next thing I am asking people to do, if they’re going to play the game vigorously, is to ask the disorder to increase those reactions that they’re having.So, for example, if I’m having a worry about not being able to pay the rent at the end of the month and that’s scaring the bejeezus out of me, I’m going to step back and notice it, acknowledge I’m feeling afraid about it, and request that the anxiety disorder increase my worry: “Please give me another fearful thought. That really scares me, but not quite enough.” So I’m always turning to the disorder and requesting it increase what it just gave me.

Viktor Frankl was the first person to write about paradoxical intention, and how he framed it was: Look for your predominant uncomfortable sensation and ask that sensation to increase.

VY: This is what was referred to as “paradoxical therapy.”
RW: “Paradoxical intention” was what Frankl wrote about in Logotherapy. And I did that for 20 years or so, but about 10 years ago I made a little switch—from asking my heart to beat faster to asking panic disorder to make my heart beat faster.That does an interesting thing which is, “I’m no longer responsible for increasing my heart rate. The panic disorder is responsible for it. I can now turn my attention back to my task of the moment.” Now, when you’re really anxious, you’re not going to get very far away from your fear; your obsession may show up again in eight seconds. But my position is to return to that request—”Please make my heart beat faster.”

VY: It sounds kind of ludicrous.
RW: It’s absurd.
VY: Right.
RW: And that’s what we’re looking for.
VY: And how do clients respond to that, typically?
RW: Well, as long as I have them long enough. If they heard me in a lecture hall, they might walk away shaking their head, but if I have enough time with them, they can see what it’s like. We go through it for a while and, if I can convey it to them well enough and convince them to try it out, in low-grade experiences where they’re not highly threatened, they can experience themselves getting better. Experience is the greatest teacher. That’s why I want to convince them to experiment with it to one degree or another.You really have three choices: Resist, permit or provoke. And I think much of the treatment of anxiety disorders over the last years has been to “permit” symptoms, to “allow” myself to be anxious. Allow things to sit there inside me. Allow the worries to show up. But that’s where people are going to finish the work; it’s not where I think people should begin the work—which is to provoke that which they’re afraid of.

VY: I had the pleasure of getting to know you a bit making these videos with you and I must say you’re a funny guy. When you do these paradoxical interventions, there’s a humorous side to it that fits with your personality. But does that work for everyone? Can therapists who have more sober personalities find a way to play with this?
RW: I don’t know how much humor is required in these protocols, but it’s a resource that I have and we use what we have. The most important thing, I think, is the resource of making contact and getting rapport with people and you can do that from the very beginning; and then it’s trying to access curiosity. I don’t think you have to have humor in order to authentically invest in being curious about, “What will this do for you if you try this out?” You know, I do talk about principles, but this is psychotherapy and it takes some finesse to help someone. I think people who have a lot of training in psychotherapy know how to do some of that stuff.
VY: I know it’s very hard to make generalities in therapy, but do you have a typical length of treatment for certain types of disorders?
RW: We typically have a 12-session intervention for people with panic disorder but we’ve got new data published that they’ve brought it down to five sessions. If we can unbundle what we’ve been doing and go to that lowest common denominator for intervention, we can shorten things up. It takes longer with Axis II disorders because those are woven into the fabric of the personality, so even though we can create a protocol, and they can use that protocol, it may take months for them to finish off that work for themselves, versus somebody with panic disorder who, in a very brief period of time, can be up like a phoenix.The interesting research that’s being done now is on ultra-brief treatment of panic disorder—even of post traumatic stress disorder—where they have been able to put a protocol in place successfully in five sessions with somebody with PTSD, which seems pretty remarkable to me.

VY: But many therapists, whether they’re in private practice or some kind of agency or other setting, tend to see clients that are a mixed bag. They come in for relationship problems or work issues or some anxiety and depression and, whether they’re Axis II or just have general life problems, their anxiety disorder is only a part of the clinical picture. How do you use these techniques within the context of a longer-term therapy?
RW: When I do presentations for therapists who are treating clients with anxiety disorders—whether they have other comorbid disorders or not—I try to get them to think about how they can structure their sessions in such a way that clients leave each session looking for an opportunity to experience some degree of uncertainty and distress regarding the themes of their anxiety.That’s a pretty simple protocol for the therapist. It doesn’t take a rocket scientist to figure out how to do this work—look at me. It’s a difficult treatment, but it’s not a complex treatment

VY: What makes it difficult for therapists? What’s hard to learn about this?
RW: It’s difficult because you’re looking at somebody who’s been entrenched in their way of solving the problem for a long time. You’ve got a client who does not tolerate not knowing how things are going to turn out. You’ve got a client who, as they try to experiment with something you’re suggesting, must trust you and trust the protocol without knowing how it’s going to turn out.That is the difficulty, because the disorder doesn’t allow them to feel confident. And if you listen to clients when you talk to them as they’re intently trying to learn what you have to give to them, they’re looking for security in what you offer them. “I’ll be glad to do what you tell me to do as long as you’ll give me a 100 percent guarantee I’ll have zero symptoms ever again.” And that’s not going to work. Einstein said: ““You cannot solve a problem from the same consciousness that created it. You must learn to see the world anew.” That’s the thread that runs through all of the treatment.

VY: I would imagine it’s also hard for therapists because they’re natural caretakers, they’re empathic, they want their clients to feel better…
RW: We do have this tendency in our field to keep rapport and be gentle, to not get people too upset. I think a lot of people gravitate to the treatment of anxiety disorders because they have an affinity to that arena. They know what it’s like to be anxious, they may have anxiety problems themselves, they’ve figured out some techniques and want to help others with it. But this is a contact sport. It’s aggressive. It works better when you’ve got a therapist who is already a risk taker.

This is a contact sport. It’s aggressive. It works better when you’ve got a therapist who is already a risk taker.

It’s like the primary care physician who’s trying to help you decelerate from a benzodiazepine that you’re dependent on. When they’re really kind and gentle with you, it sometimes takes forever to get off of them. When they’re a little tougher with you and push, then sometimes it works out better for you.

VY: So you need to be comfortable pushing a client into discomfort.
RW: That’s right.

The Meaning of Anxiety

VY: Existentialists such as Rollo May, who wrote the classic text, The Meaning of Anxiety, and other existentially-oriented psychotherapists would and have argued that there’s meaning in anxiety and we can learn about ourselves, about life, have insight, by delving into it—that it’s not something that should be brushed aside. Do you think that there’s meaning in anxiety?
RW: Well it’s fine to look at it that way, and on an individual-to-individual basis you may have to delve into that. But it does not mean that someone has to continue to express their anxiety in such a primitive fashion. People with panic disorder are expressing conflict very primitively. I certainly believe with panic disorder—and I’ve written about this—that there are benevolent purposes of the symptoms. And to look at those and understand those are helpful, but once we understand them, let’s negotiate another way to get those needs met.
VY: What are the benevolent purposes of the symptoms of panic disorder?
RW: It’s often to keep from being abandoned. There’s some data that a certain percentage of people with panic disorder suffered early childhood loss. Let’s say my father died when I was four, and my mother got severely depressed and laid on the couch every day. There are a lot of ways that I would have learned to cope as a child with that kind of loss. As I grow up, that stuff, existentially, kind of becomes who I am in the world. If my mother turns away from me because my dad left or my father left and never talked to me about why he left, I begin to think that I am not worthy as a human being. What parent, who loves his child, would abandon his child? There must be something inherently wrong with me. Some people with panic disorder use it unconsciously to maintain relationships so that their partner, their parent, whoever, won’t abandon them. That’s a benevolent purpose.
VY: So there’s secondary gain in that.
RW: That’s kind of a derogatory term, but it’s something like that. If we can step back and look at how the unconscious might have stepped in to take care of me, based on my belief about who I am from long ago, then there is a benevolent purpose behind why it showed up.I had a patient who came to me with OCD. She had two children with a workaholic physician who didn’t help with the kids at all. Her biological clock was ticking. She wanted to have another baby, but was concerned about her ability to take care of three kids instead of two. One day, she saw her son chasing her daughter with a kitchen knife and instantly she developed obsessive-compulsive disorder. She couldn’t stop thinking, “Oh my God. Could I hurt someone with a kitchen knife?” She had to get rid of all the knives in the house, everything sharp, all the scissors; no children could come over and be in her home for fear she would harm them. And of course, she was then too sick to have another baby.

So that’s another example of a benevolent purpose of the disorder. I think we do want to look around for some of those things and begin to take care of those, too. If the unconscious is driving some of this stuff that we aren’t aware of, then we’re going to have trouble helping people get better. The other definition of “strategic treatment” is doing whatever is necessary to help somebody get better. So if we need to do some family therapy or psychodynamic work or couples work or Sullivanian work—whatever it takes to help them turn the corner.

VY: It’s nice that there are cognitive-behaviorists who acknowledge unconscious psychodynamics. You’re very integrated. It seems like you really strive to hone in on what works.
RW: I hope that’s true. We just got some new data that suggest that that can help people more rapidly change their relationship with the disorder. We just did a study of people with obsessive-compulsive disorder going through this protocol, 80 people at a time, for two days. And the changes that took place were pretty remarkable, in terms of the measurements of the reduction of their obsessive-compulsive disorder and in altering their beliefs.If you just think about OCD being one standard deviation beyond the mean, where people get so totally caught up in obsessions and rigid belief systems, it’s quite amazing that we can bring about lasting change after only a few days.

Getting to “Aha”

Some folks have done some interesting research on what we called “applied relaxation,” which is learning relaxation skills and applying them to a variety of situations. In six sessions of an hour and a half each, then another six sessions of 45 minutes each, with practice homework throughout that time period, the major thing that these people changed after all this work was their beliefs.

If that’s true, then

I think we should be leading with belief change instead of leading with interventions that require a great deal of time to give someone insight and then for them to go, “Aha.”

I think we should be leading with belief change instead of leading with interventions that require a great deal of time to give someone insight and then for them to go, “Aha.” That’s how exposure and response prevention happens. We’re going to run them through this protocol until weeks or months later they go, “Oh, I see now. I don’t have to do my compulsion to get rid of my obsession.” Can we speed that up? I think we can.

VY: Final question. What advice would you give for students or early career therapists treating this population? Any pearls of wisdom?
RW: Look for any way to sit in on someone doing treatment with someone using these kinds of protocols. See how this works. That’s part of our motivation to get these anxiety disorder videos out there, so that people can immerse themselves moment-by-moment in this protocol. Whenever I do a workshop to teach these skills for therapists, it would be totally and completely fine for clients to be sitting in on the workshop as well because they can understand it just as easily.When I was in training and working with couples or borderline personalities for the first time, I’d go into supervision and say, “Okay. She said this. Now what do I say?” And he would help me figure that out. And then I would say, “Yeah but what if she responds like this? Then what do I say?” It can be daunting if you’ve not done this and observed it directly.

VY: Well I have always felt that we are a strange profession. You wouldn’t have dental students read about doing a filling and then send them off to do it without watching someone and then come back a week later to meet with a supervisor in a closed room and try to recall how they did their fillings. In fact, that was one of the reasons I started making training videos in the first place.I’m grateful that you consented to have your sessions recorded and I’m excited to release them and make them available for people who want to learn about the innovative approaches that you developed. So thank you so much for taking the time to go into this level of detail.

RW: Well, thank you as well for giving me the opportunity.

Philip Kendall on Cognitive-Behavioral Therapy

Posted on by rezendevknowfully.com

Working with the Masters

Deb Kory: Hi Philip. You’re a researcher, scholar, clinician, and a professor at Temple University. You’ve done a great deal of seminal work on treating anxiety disorders in children and adolescents, as well as cognitive behavioral theory, assessment and treatment. In doing research for this I opened up your CV and noticed that it was 127 pages long. You’ve been rather prolific over the course of your career and have worked with some of the great masters in the field of cognitive behavioral therapy. This month we’re releasing two DVDs that contain interviews with Albert Ellis and Aaron Beck. Can you tell us how these guys influenced you and what it was like working with them?
Philip Kendall: Tim [Aaron] Beck had an influence because my first job was at the University of Minnesota and I was hired to do research on children and adolescents in treatment and outcome. I worked with Steve Hollon there, whose office was adjacent to mine and he had just finished working with Beck on the first outcome study for cognitive therapy for adult depression. So I was influenced, in part, by Beck through that process.
Years later I now live about 10 or 15 houses from where Tim Beck lives here in suburban Philadelphia. He’s 91 now and moving into a townhouse in the city, but up until a few months ago we were neighbors and I’ve seen him at movies and restaurants and such. But the intellectual influence was the manualization—or manual-based approach—to treatment and its systematic, organized evaluation, which I was doing with kids and he was doing with adults.
DK: And how about Albert Ellis and Rational Emotive Behavior Therapy (REBT)?
PK: A number of years ago I did a paper with Albert Ellis that was intended to correct a slight trajectory difference. Tim Beck had succeeded nicely in pursuing the research side of cognitive therapy, whereas Al Ellis had succeeded beautifully in the practice side of rational emotive therapy, but not quite as much on the research.
So we collaborated on a paper that was intended to outline what was known and what were the next needed studies in REBT to try to correct its trajectory, which didn’t include as much research. I would say the focus is similar. Al Ellis focused more on neurotic styles and Tim Beck focused more on the diagnosis of depression. But, interpersonally Al Ellis was much more the New Yorker and in your face and Tim is not. And so, you have some therapist personality differences.
DK: What was it like working with Ellis?
PK: I guess I would say this: I found him to be very true to his view. His theory would say things, many of which are very insightful and smart, like, “you can’t be liked by everybody,” and “you can’t worry about what someone else is going to say if you say what you think is true.” And I found in my interactions with him around several things that he didn’t pull punches.
DK: He “called a spade a spade,” as he was fond of saying.
PK: Yeah, and I found it a likeable quality. And to be candid, in the paper that I ended up writing, it included some comments that were less than supportive, so we had a little back-and-forth and he accepted my criticisms.
I would say he was a little bit more inclined to want to look at the literature from a view that supported what he thought. I would say he [Ellis was a little bit more inclined to want to look at the literature from a view that supported what he thought.] And I would come from a perspective that says, “let’s look at the literature and think about what we know based on what we found.” That’s a slightly different read on how you process information.
DK: What other major intellectual influences would you cite?
PK: Don Meichenbaum was probably just a few years past his PhD at the University of Waterloo and he was working with kids. He had written some materials and they were literally printed on an old dot matrix printer and when he and I were communicating it was snail mail. So I would get these correspondences in the mail and I would send him our papers. I didn’t realize at the time that he was a leading thinker on this theme and that I was involved early in a major shift in our discipline. Mike Mahoney, Al Kazdin and Ed Craighead were colleagues at Penn State at the time and some of their work was also important and influential.

“These Kids Think“

DK: How did you come to psychology and to CBT in particular?
PK: I would say my initial training in psychology was with learning. First with animal learning, where you study the acquisition of behavior patterns in fish, mice, monkeys, white rats, that kind of thing. One of the features that we were studying was called “avoidance learning,” where animals learn to make responses that they think are helpful but, in fact, aren’t. And they just can’t unlearn those unhelpful avoidance responses, which is a very behavioral learning theory view of anxiety.
Then in graduate school, while doing a lot of behavioral work, the animals were no longer the animals. The animals were people. And it became apparent not just to me but to others that these kids think. And how they think alters their behavior. So we started talking about cognitive behavioral therapy as a way to take learning theory and still pay attention to the cognitive processing of the participants.
DK: Did you have any psychoanalytic training?
PK: I never had graduate level psychoanalytic training, but I did have several courses that were psychoanalytic and I remember reading a book that was about children and adolescents that was psychoanalytic, but it kept blaming the parents, and showed no reflection of normal development. It seemed like everything a normal kid would do or say was seen as a symptom, and that’s very disrespectful of the fact that normal development includes times of sadness, times of anxiety, times of conflict. Psychoanalysts didn’t seem to be informed by what we know about human development.
Psychoanalysts didn’t seem to be informed by what we know about human development. So I kind of rejected it, thinking it’s a rich theory and a couple of things seem right about it, but so much of it seems not based on what we already know.I hate to say it, but I think that was in 1974. Oh my goodness.

DK: That was the year I was born.
PK: And I was getting my PhD, oh my God.
DK: Well…and 450 publications later here you are.
PK: Yeah, it seems to have gone by quickly because time does pass quickly as you age.
DK: I’ve noticed that.
PK: But it also seems to have been relatively cumulative. What we know now is informed by studies that were done in the last two decades. And that’s a good feeling.

CBT Then and Now

DK: That leads to my next question. How have you seen cognitive therapy change over that time? Looking at Aaron Beck’s cognitive therapy and what you today call cognitive behavioral therapy, are there any majors differences?
PK: My hunch is it’s very, very similar. For example, in cognitive therapy for depression, even though the word “behavioral” isn’t in the title, it’s in the implementation of the therapy. There’s homework, there’s practice, there’s even scheduling and rewards. Those things are out of the behavioral tradition. In cognitive behavioral therapy there’s certainly practice and reward and homework, but there’s also the cognitive part. It’s just the title that was popular at the time.As far as what’s changed, there’s the good and the bad.

One of the dilemmas is that CBT has become more accepted and more popular—that’s a good thing—but in the popularization, more people seem to misunderstand it than understand it.

One of the dilemmas is that CBT has become more accepted and more popular—that’s a good thing—but in the popularization, more people seem to misunderstand it than understand it. I think our profession is well informed, but people outside the field have some long-standing misconceptions. “CBT—Isn’t that the power of positive thinking?” No, it’s not. “Oh, isn’t that where you tell yourself not to be depressed?” There are these simplistic, if not buzz-word answers that are just wrong and a misperception.

In addition, you have a sort of knee-jerk reaction among some—“Oh yeah, I read about that. I tried it. It doesn’t work.” But when you actually ask them, they didn’t really experience it or try it. Those things are unfortunate.

What’s changed for the better, I think, is the cumulative part. Psychology and clinical psychology is not a breakthrough science. It doesn’t change overnight based on one study. It’s a cumulative process that takes decades, not days, for things to go from point A to B to C to D. And when I see the American Psychiatric Association say they require clinically supported treatments such as CBT taught to their residents, and I see empirically supported treatments reviewed at a government level or by a state like California, and the programs that qualify as empirically supported are largely CBT, it’s showing the positive progress of cumulative knowledge.

DK: You’re being generous in stating that most therapists really know what CBT is. That’s not been my experience. We didn’t get a lot of CBT training in my graduate program. I’ve found in professional circles that CBT is often conveyed as kind of wooden, lacking in spontaneity, not focusing at all on the quality of the relationship, etc. Can you speak to that conception or misconception?
PK: Sure. And I’m kind of smiling. If we were on Skype you’d see a big grin because we just finished two large and, I think, important papers on the role of the relationship in CBT for anxiety in youth. The first is based on 488 kids treated at six different universities by close to 40 different therapists. The supervisors rated the therapists. The therapists had to send us tapes, which we watched and rated. The methodology of the study is really good.The bottom line is that therapists who are “teachy”—as in “Hi, Johnny, you’re anxious about this. Here’s what you should do”—don’t do as well as therapists who are more like coaches.

Therapists who are “teachy”—as in “Hi, Johnny, you’re anxious about this. Here’s what you should do”—don’t do as well as therapists who are more like coaches.

A coach would be more likely to say, “Johnny, you’re anxious about that. Hmm. What are some things we could try? What are some things that might have worked for other kids? Which one of those do you want to try?” And then try it out and say, “Hmm, that one seems to work okay for you. What do you think?” The coach style had better outcomes than the teachy style. Clearly that reflects different therapeutic relationships, different ways of interacting.

When you do an exposure task in treating anxiety, you take an anxious kid and you put them in a situation that makes them anxious. For years people thought, “Oh, that damages the relationship.” But the second study we did, also looking at the relationship, found that conducting exposure tasks does not rupture the therapeutic alliance. The challenges that are brought to a kid in CBT do not damage the relationship. It holds up pretty well. The relationship’s important. There’s variability in the way therapists do treatment. But relationship alone is not sufficient. It may be necessary, but not sufficient.

DK: There’s a lot of emphasis these days on more experiential, emotion-focused therapies that draw upon the adaptive potential of emotions and work to elicit deeply emotional responses within the framework of an empathic therapy relationship. CBT seems to focus primarily on cognitions and behaviors, but there is a fair amount of empirical support for the efficacy of emotion-focused therapies. How does CBT work with emotions?
PK: Again I have a little bit of grin on my face. Although the words are different—“expressed emotions” and “emotion focused” might not be the way we describe it—we’re doing much the same thing. For example, a child says, “I’m afraid to talk to people I don’t know.” So on Thursday at two o’clock, if she has an appointment, we set it up so that there are three other kids who are going to be there and this child is going to have an opportunity to meet one of them and have a conversation.And we say to this child who’s coming for the two o’clock appointment: “We have it set up that you’re going to meet someone else. What do you think is going to happen? How are you going to feel? What happens if you get all nervous? What happens if you feel your heart racing? What are you going to do if you get confusing thoughts? What are you going to do if you have to go to the bathroom? What are you going to do if you can’t think of what to say? What are you going to do if they ask you a question?”

Then we’ll go into the room. We’ll have the child being treated meet a new kid and every minute or two during that experience we’re going to say, “How are you feeling now? What’s your set rating? How anxious are you?” And then we’ll keep those ratings. Then when it’s over we’ll go back to the therapy room and say, “How’d it go? We can talk about it here. That was great! You said you were uncertain about what you were going to say, but you were able to come up with questions and he had the same interests you did in comic books.”

If you were to not call it CBT, you would see that anxiety, which is an emotion, was the primary focus. We were in the experience totally. We were getting their set ratings on a minute or two minute interval and we were very much focused on how he was reacting and feeling. It’s just somebody’s lack of understanding that contributes to the misperception of differences.

DK: So you’re saying there’s not a real split here between CBT and EFT?
PK: Right. There’s a common undertaking with the use of different descriptive language.
DK: Exposure therapy throws you right there into the midst of whatever really intense emotions you have.
PK: Exactly, but with proper preparation.
DK: But there certainly are some real differences in how emotions are conceptualized and responded to. In EFT or psychodynamic or existential therapies, the therapist often will dig into the emotions to better understand the meaning underneath the emotions. Isn’t there a real risk in trying to change the emotional response before it is fully understood?
PK: There are different opinions, with many folks saying that there is a degree of understanding within CBT, but in other schools of thought, the understanding alone is not enough. I would fall in this group.
DK: What about the unconscious? We certainly have plenty of empirical evidence that there is much outside of our conscious awareness, and as you know, in psychodynamic therapies excavating and bringing to light our unconscious beliefs, desires, drives, etc. is seen as an essential part of healing and becoming an integrated person. How does CBT conceptualize or make use of the unconscious—if at all?
PK: When asked if I believe in the unconscious, I answer “Not that I am aware of.” Kidding aside, the “underlying cognitive beliefs” are exposed as part of CBT. But, again, simply getting this to be more aware is not the end point, only a part of the goal.

CBT with Kids

DK: You’ve done a tremendous amount of research over the course of your career. In fact, you are one of the most frequently cited individuals in all of the social and medical sciences. I noticed that pretty much all of your research has been with children and adolescents. What’s the name of the clinic you founded and is that where the majority of your research is done?
PK: It’s called the “Child and Adolescent Anxiety Disorders Clinic” and I started it in 1985. Every child or adolescent who comes into the clinic pays a fee, but it’s a reduced fee. In exchange for the reduced fee, they agree to participate in research and complete all of the measures. So literally every child who comes through our clinic is a participant in research. And that allows for them to get carefully monitored services, including very detailed analysis of what’s going on and what happens in the end and pre- and post- and follow-up measurement and things like that. But it also allows us to have real clinical data with real patients. We have a small group of graduate students who are doing their master’s or their dissertation with funding we receive from NIMH, who are able to do a lot of pretty sophisticated work. So I think that helps the research productivity a great deal to have external funding, a real clinic, and bright, motivated staff and colleagues and graduate students.
DK: What was it about working with children that appealed to you?
PK: There’s a professional answer and then there’s kind of a silly one. The professional answer is that if you’re going to have an impact on how someone experiences life and thinks about the world, if you wait until they’re 20 or 30 or 40 years into it and have established biases and perceptions, your task is quite daunting and challenging.If you get to them early you can prepare them for these life experiences and catch—if not correct—some of the potential misperceptions when it’s developmentally appropriate. A first sleepover at age 12 is a meaningful social event; a first sleepover at age 30 is a different thing, you know.

DK: Indeed.
PK: The silly answer—and I have to be careful how I use the word patience here—is that I lose patience with adults. They can be rigid, misguided, less motivated and not quite as willing to try things. And I find with kids, they’re more willing to try things when they’ve got an adult who’s giving them some confidence to give it a try. And then it’s their own experiences that convince them to go forward. With adults there’s a lot of interference and baggage.
DK: I don’t automatically think of kids as having a lot of meta-consciousness around their thoughts and ideas. I think of therapy with children as being play therapy, where the therapist is making meaning of symbols and introducing ideas and concepts through a reparative relationship based in play. Do you still play with kids in CBT therapy? How do you incorporate concepts like homework and exposure into the play? Do they get homework?
PK: I’m going to do the homework part of the question first. We definitely have homework. Kids are accustomed to workbooks at school. They have math problems or other homework. So they also have homework in the “Coping Cat” workbook we developed, which they use as they go through their anxiety treatment.Rather than making treatment complicated and difficult, I try to make it acceptable to kids. So we’ll talk about a cafeteria of things like relaxation or talking back to your anxiety or trying things out to see how they work. You kind of walk through the treatment as a cafeteria, where you don’t have to eat everything that’s offered.

At first the homework is easy: remember your therapist’s name; write down a time that you had fun; write down a TV show that you’ve watched and enjoyed. You know, simple things.

But gradually that homework becomes the very challenge they need to do to overcome their anxiety. So homework later on in treatment, let’s say after 14 weeks, might be to enter a new group at school. Join the drama club, join the chess club, try out for a play, start a club with remote control cars. The aim is to do something that’s an initiation that might have been something they were so afraid of even thinking about months before.

So the homework becomes the practice of the skills that we teach them. It’s a very important part of CBT, because one hour a week sitting with us in a safe environment isn’t the real world.

So the homework becomes the practice of the skills that we teach them. It’s a very important part of CBT, because one hour a week sitting with us in a safe environment isn’t the real world. But if they’re out there doing what they’ve learned with us multiple times a week in the real world, that’s got some punch.

The other half of it you mentioned was play. And I have to be careful how I say this because I often put my foot in my mouth, meaning I misspeak. We do play with kids. But play is not the goal or the vehicle that’s crucial. Play is just part of what you do with kids to communicate with them. It’s more the context of building a relationship onto which you’re then going to add the challenges.

So as an example, if we’re talking about a misperception, a social misperception or a probabilistic misperception—and I wouldn’t use these words with kids—but the kid will think, “Oh, I can’t do that because lightning will strike me.” We might say, “Oh, yeah, lightning. What would happen if you got struck by lightning? Let’s look it up on Google or let’s do some homework. What are some things that increase the chances? What are the things that decrease the chances? Holding a metal rod increases the chance. Golfers hold golf clubs. Let’s see how many people play golf, how often, that have how many clubs,” and then you’re playing. But in the game you come up with the conclusion that it’s one in 64 million people who might get a bolt of lightning on a golf course with a golf club. The probability isn’t that high.

DK: So you’re disconfirming the fear.
PK: Right. And again it goes by that coach notion. When a kid comes in and says, “I can’t call a friend on the phone. I don’t interact with peers at school. I don’t raise my hand. I’m scared of what’ll happen,” we think of it as, okay, in 16 weeks we want the kid raising his hand, calling a friend to ask about homework and having a sleepover.In other words, the things that are difficult are the things we’re going to do. And how would a coach get there? A coach wouldn’t say, “You have to do it today,” because you haven’t taught them how. Just like a piano teacher wouldn’t say, “Perform your recital” the first day of your lessons. You have lessons, you practice and then you have the recital at the end.

So in our 16 weeks we’ll have lots of practice at pretend-calling people, at pretend-raising your hand, actually raising your hand in front of a staged audience, having catastrophes happen and helping you deal with them. So that when the kid goes to school and part of their homework is to raise their hand and ask a question, they’re kind of into it and practiced and know what to do. And that’s part of that coach notion that we allow them to have practiced at the things that may or may not happen so that they know how to deal with them if and when they do happen and it’s no longer so frightening or new or novel, it’s, “I’ve done that before.”

DK: Well that sounds different from one of the conceptions or misconceptions that people have about CBT, which is that the therapist is the “expert”–as opposed to, say, a more non-directive Rogerian approach or even the semi-directive approach of motivational interviewing, which guides clients with open-ended questions and seeks to “meet clients where they are.”
PK: In our approach we look at it a little differently. We say, “You’re the expert on you, Johnny. I’m sort of the expert on what other kids have tried and learned from. But I can’t do it without you and maybe you can’t do it without me. So we have to really collaborate on this. And I can give you some ideas for you to try out, but you have to tell me what works and what doesn’t work.”
DK: These approaches certainly make a lot of intuitive sense, especially when there is some clear behavioral change that is desired. But how does CBT think about situations where the emotional response of the clients seems appropriate—e.g. a girl is understandably distressed about her parents’ divorce, and she really just needs someone to talk to and work through her own feelings. Does CBT have anything specific to say about a situation like this?
PK: In general, the goal of “treatment” is to remediate an identified problem. For emotional disorders, for example, there may be irrational thinking or illogical processing that is interfering and maladaptive. These problems need to be treated.In cases where someone has a “genuine and real” reaction to a real situation that is not excessive (though reasonably distressing), the rationality isn’t faulty nor is the thinking illogical. Rather, these are relatively normal processes that don’t meet criteria for disorder and don’t necessitate treatment.

If someone wants to have “personal growth” and learn about their thoughts, feelings, and behavior, that’s fine, but it’s not the same as effective treatment for an identifiable problem.

“I Must Be Doing Something Right”

DK: Of your many roles—teacher, researcher, writer, clinician—what’s your favorite?
PK: How do you pick a favorite child?
DK: Well, parents usually secretly have one….
PK: I don’t think I can pick a favorite. I can maybe rank them on different dimensions. I get a great deal of satisfaction from mentoring and seeing people go on and have their own careers flourish. I get a great deal of pleasure out of kids who were scared shitless (pardon my language) when they came in, going on to do things and 16 years later we’re in touch with them and they’re doing well. I like that stuff. That’s very satisfying. And then professionally I like doing good research and publishing it in good journals because I feel like that communicates to my colleagues, even though I recognize that the impact takes a long time.
DK: Okay, final question. I’m just starting out. I’m about to get licensed and I’m just wondering what advice you have for new therapists in the field.
PK: Every happily married person had been turned down prior when asking for a date. Every successful book author has had a proposal not go perfectly well. Every successful scientist has had a paper not accepted on first submission. And the best basketball player on the planet, Michael Jordon, shot 49.9 percent for his career. So having things not go well should be expected. And doing the best treatment you can might mean four or five out of ten get better. And if you do that, you’re doing better than most. Our profession is such that we remember the ones that don’t work and we blame the treatment we’re doing for its failures, rather than an objective view which states that this treatment response rate of 60 percent is 20 percent better than anything else, so I must be doing something right.
DK: That’s lovely. Thank you.

Where’s the Bear?

Posted on by Psychotherapy.net Team

In an early chapter in my general psychology textbook's discussion of behavior, it said, "I see a bear; therefore I run." That seemed sort of obvious to me. The next line went on —"I run; therefore I see a bear." The more I thought about that, the less I got it. So I asked my professor. He said that it was probably the most important thing I would ever learn in psychology and that I should think about it until I understood. It's taken many years but he was right. It's an enormously important metaphor. Let me show you how it works.

“If you act frightened, you'll soon find something to be frightened of.” 

Acting As If

Mary and John were considering divorce. Her trip through menopause had coincided with the end of his career and they quarreled about everything. The content of their bickering wasn't as important as the tone. "You're wrong," was the first response out of either of them. Each of them saw the other as critical and demeaning. Even after many sessions of therapy, they continued to demean each other.

On a Tuesday at their regular appointment, I asked them to act "as though" they liked each other a lot. They looked at me as though I was crazy. "I'm serious," I said. "Move your chairs closer together and hold hands while we talk. After you leave here, go for an ice cream cone and look at each other with soft, loving eyes as you lick your sweets. I'd like you to keep that kind of pretending up until you come back here on Friday."

"But," Mary protested, "that's like lying."

"Yup," I said. "It's called acting."

On Friday, they came in laughing at a private joke. The animosity was gone and they were excited. "Maybe there is hope for us," said John. "I'd just about given up. Why did pretending work?"

"If you act frightened, you'll soon find something to be frightened of," I replied. "If you act angry like you and Mary were, you turn each other into enemies."

Finding Something to Fear

Another application of this metaphor is what happened after 9-11. We were frightened and the enemy was, for the time being, unknown and unseen. When people feel afraid, they tend to look for something to explain their feelings, seeing an enemy or danger around every turn. Anything to somehow justify the fear, even when there is no bear. Wars are begun over such things.

This is the same principle we put to use upon walking into a scary situation: taking a deep breath, standing tall, holding our heads high. Often, if we do this, our anxiety vanishes and we find there is no "bear" there.

Edna Foa on Prolonged Exposure Therapy

Posted on by rezendevknowfully.com

Exposure Therapy Explained

Keith Sutton: Welcome, Dr. Foa. To get started, why don’t you tell us a little bit about what exposure therapy is. Many of our readers may be unfamiliar with, or may not remember much about, this type of therapy.
Edna Foa: Exposure therapy is used mostly with anxiety disorder. The idea is that people who suffer from anxiety disorders—who get anxious when they confront safe situations or objects—are taught through exposure therapy to become less afraid, or not afraid at all, of the things they’re fearful of. So if the fear is a normal fear—like the fear of driving on the track when you see the train whipping by very fast—you don’t want to teach people to get over it. You don’t want to change people’s fear of driving over the track just in front of the train, because normal fears protect people from doing things that will harm them. The idea behind exposure therapy is that the therapist helps patients to confront or approach what they’re afraid of, because the things they’re afraid of are intrinsically not dangerous. Through exposure to these situations, they learn that there is no reason to be afraid of these situations. The disaster they expected does not occur. Originally, exposure therapy was derived from animal studies. In these experiments, scientists condition a mouse to become afraid of a red light by pairing the light with electrical shock. And after a certain numbers of pairings, the mouse will start showing fear responses when the red light is presented, even when it’s not paired anymore with shock. We call this response a conditioned fear. Then if we want to eliminate the mouse’s fear of red light, we present it with a red light without the shock. After repeated presentation of the light without shock, the animal stops showing the fear reaction to the light. That’s called extinction. In the ’60s and the ’70s, several experts, in England and the United States, translated the animal results to human beings and said, "Let’s suppose that the anxiety disorders—such as claustrophobia or fear of heights—are like a response that was conditioned. The person was conditioned to be afraid of elevators even though being in an elevator is not dangerous. So how do we eliminate the fear of elevators? We instruct the person to ride on an elevator many times until the fear is extinguished."

KS: Is that what’s called the flooding of the anxiety?
EF: Well, it’s called flooding if the therapist conducts the exposure very abruptly. And it’s called systematic desensitization if the therapist is doing the exposure very slowly in small increments, and if he pairs the exposure with relaxation. There were big debates in the '60s and the '70s about what works better, and whether flooding is dangerous. Some experts, like Wolpe, thought it was dangerous to do flooding because the person will actually become more rather than less fearful.
KS: Yeah, common sense would make you think that, wouldn’t it?
EF: No, not really. According to some theories, flooding should make the patient feel worse. But according to other theories, abrupt exposure should extinguish the patient’s fear more quickly, so it is actually more efficient.
KS: One of the central ideas around the exposure is that the anxiety peaks within a reasonable amount of time and decreases. Is that right?
EF: Well, it depends. Not necessarily. Let’s say that somebody is afraid of going to the supermarket. People with panic disorder, you know, are afraid of going to places where they cannot escape quickly, like sitting in the first row at the movies. It takes longer to get out from the first row than from last row. Experts did abrupt exposure, getting patients to sit in the front seat from the start of the therapy, and other experts said, "Let’s do it incrementally—let them sit in the last row first, and then in the row before the last, and then two rows before the last, and then five rows before the last."
KS: Is that the exposure hierarchy?
EF: Exactly. Gradual exposure gets patients used to each one of those stages, and eventually the patient will sit in the first row. Now, studies have found that doing abrupt exposure is as effective as doing gradual exposure, except that the patients in the gradual exposure suffer less. But flooding doesn’t really make them worse, as Wolpe thought. So we know now that we can do flooding, or we can do systematic desensitization. Both work. Today, experts don’t quarrel about this issue anymore; all therapists use more or less a gradual exposure, but not as gradual as systematic desensitization, because that takes too long and is unnecessary.So that’s what exposure is. Now, how does exposure work? It works because of a mechanism that we call extinction. Extinction is not unlearning what you learned, but rather it’s learning something new—it’s learning that what you were afraid of is not dangerous. Some experts say that the mechanism is the reduction of the anxiety—that gradually you’re less and less fearful. This is called habituation. But habituation is not an explanation for why patients get less fearful with exposure therapy.My theory is that exposure reduces fear and anxiety because the patient learns that the bad thing he thought would happen to him does not happen. Therefore, it’s very important to plan in a way which will ensure that the thing the patient is afraid of will not happen during the exposure. Let’s say after being raped a woman starts to be afraid of going anywhere by herself after dark. The therapist then plans exposures to places that are not safe after dark, and she is attacked again. That’s not a good exposure, because it doesn’t teach the patient that what she was afraid of does not happen.I always give the example of a person that is afraid of big dogs, but not of small dogs. The therapist decides to treat him by exposure to dogs, and brings to the session a small dog. Well, because the patient is not afraid of small dogs, this exposure will not work. Exposure needs to include the things that the patient is afraid of. The therapist then brings a big dog to the therapy session to do exposure. The patient enters the room, sees the dog, and gets very fearful. With the encouragement of the therapist, the patient slowly approaches the dog, which the therapist holds on a leash. When the patient gets close to the dog, the dog jumps on him and bites him. This is again not a successful exposure, because what does the person learn from it? He learns that he was right all along, that big dogs are dangerous.
KS: It reinforces that belief.
EF: Exactly, it reinforces rather than extinguishes the fear. So that’s the way exposure works. In order to implement therapeutic exposure, the therapist has to find out what the person is afraid of, then make a list of these things and organize this list from the not-so-fearful situation to most fearful situation, in a kind of hierarchy. In order to create a good hierarchy, the therapist teaches the patient to assign a number, on a zero-to-one-hundred scale, to each situation. This number signifies how much fear the patient would have if he would be confronted with this situation. It is important that the therapist makes sure that the situations on the list are not really dangerous.The therapist chooses a situation by saying to the patient, "Let’s choose a situation that is about forty on the scale. Which of these situations do you think you are able to do for homework next week or in the session with me?" The patient selects a situation and begins to practice approaching it, staying in the situation until he feels that the anxiety goes down and realizes that the fear is not realistic.So exposure works through two mechanisms. The first is that the situation elicits the patient’s fear—there is a match between the situation that the therapist is presenting to the patient and the patient’s own internal fear. The second mechanism is that the exposure situation contains information that is incompatible with the information that the patient has in his mind. In the example I gave you about the dog-phobic, if the patient is afraid that large dogs will bite him and the therapist presents him with a large dog that, over several instances, does not bite, the patient will cease to be afraid of big dogs. Patients don’t really need to be in the situation a long time—they don’t need to wait until the anxiety dissipates completely. They just need to be in the situation long enough to realize that what they feared would happen does not happen.