I THOUGHT I UNDERSTOOD Cognitive Behavior Therapy (CBT), or had certainly heard enough about it, until making a mistake in reading a schedule unexpectedly landed me in an anxiety workshop at the recent Psychotherapy Networker Symposium in D.C. At first I took random notes without understanding if anything new was being said.
Then came two videos of actual therapy sessions showing the speaker, Reid Wilson, psychiatry professor at the UNC School of Medicine, putting into practice the concepts he was explaining. The videos were a revelation.
Anxiety disorders, the most common type of mental illness, are mental conditions in which intense, irrational feelings of fear and anxiety are expressed frequently and to a debilitating degree.
Because anxiety disorders are disorders of uncertainty, Wilson warned the auditorium full of therapists: patients “can’t trust you but must act as if they do.” As Wilson’s patients spoke about their fears — in front of a video camera for public consumption, no less — they appeared to grow more comfortable and more sincerely trusting. While Wilson’s responses made the CBT formula appear somewhat simple and obvious, they also suggested a proficiency gained over decades of practice.
The first video’s patient had generalized anxiety disorder (GAD), the most common in a list that includes social anxiety, phobias, panic attacks and obsessive-compulsive disorder. She was a middle-aged woman who worried often about her grown son, newly on his own in a big city. Following Wilson’s suggestion to “step back” and examine what’s going on, she figured out that the days she worried most about her son were also the days when she felt insecure about work or concerned about personal health issues.
Wilson urged her to separate the worries about her son from her own concerns — which he calls separating the signal (the immediate cause of anxiety, something that could benefit from action) from the noise (background worries, for which no imaginable action would help). “Separating the signal from the noise” at first sounded jargonny and confusing. But after the patient did just that — and then breathed a sigh of relief, sat up straighter, looked more in control, and sounded as if she could, quite suddenly, think more clearly — CBT began to make more sense and to seem like something worth trying before signing on to more time-consuming traditional therapy.
Recognizing our own insecurities or unhappy feelings can be unpleasant, Wilson explained, because as children we were told not to pay attention to ourselves. Worriers learn to avoid their fears, whereas he urges them to seek out and be okay with feeling insecure or clumsy or awkward or even panicked.
(Wilson acknowledged that worry has its uses: “When worry plays a role in helping us to solve our problems, it does a fantastic job. But when it becomes a bothersome noise in your head, it has no redeeming value.”)
Mindfulness — also recommended for anxiety — is fine, he said, but insufficient. The first homework Wilson gives his patients is “self-talk:” to “approach, personify, exaggerate and talk directly” to their anxiety — to ask yourself, how can I create some anxiety here; how can I practice being willing to be anxious? Worrying and avoiding stress heighten physical reactions by raising adrenaline levels, he said, whereas looking directly at and moving toward fears can be calming.
The second patient, Mary, had a 10-year history of claustrophobia: in elevators, airplanes, parking garages, she worried that she might suffocate or have a heart attack. Wilson explained how to use the content of fears (the parking garage) to stimulate doubt and distress — the by-now familiar habituation therapy for phobias. Exchanging the old response of “look how shaky I became” for the new “I did this!” can “change the prefrontal cortex,” he said.
In Mary’s first of just two sessions, she described her fear that a parking garage could collapse and crush her, with the worst damage occurring if her car was parked in a dark, interior spot. Wilson advised Mary to change her interpretation of the fears: instead of pushing them away, to say to herself, “I want these feelings.”
At the second session, Mary described making a trip on purpose to a parking garage; driving to the darkest place she could find, a challenge with the Southern California sun streaming in; and trying “to make it as unpleasant as I could” — while at the same time telling herself, “it’s not going to collapse.”
As she spoke, Mary appeared pleased by her success as well as more relaxed and actually prettier. Wilson noted the importance of Mary preparing herself ahead of time by repeating reassuring phrases and by anticipating that the garage would be hot and crowded, both of which replaced her accustomed approach of waiting for panic to strike. Short clips from the sessions are available online.
The strategies of CBT are paradoxical: the patient must “purposely and voluntarily choose to seek out uncertainty and distress,” according to Wilson’s latest book “Stopping the Noise in Your Head.” In his books and lectures, Wilson creates diagrams of a stick figure pushing a child’s swing, with each push causing the swing to gather strength and come back more strongly than before. Pushing away whatever is worrisome serves only to strengthen the anxiety for the next time that situation arises.