Yes. This is hard work. Yes. You can expect to be miserable at times. Yes. You have to work at it every day. These are words I reiterate regularly during my week. These are spoken words in the context of explaining to my clients what exposure therapy is all about. Exposure Therapy Response Prevention (ERP) is a type of Cognitive-Behavioral Therapy (CBT). It’s a subset rooted in learning theory and used to target a clients behaviors and thoughts that maintain obsessions, irrational fears, avoidance, and safety behaviors. In a nutshell, ERP is learning to face ones fears. But it’s so much more than that. More than facing ones fears, it’s helping clients build confidence in themselves. It’s providing tangible evidence that anxiety is just a feeling, and nothing more. Most importantly, it provides actual data that feeling scared, anxious, and terrified is just uncomfortable; not dangerous. The process of ERP is recalibrating ones brain-and body to experience distress and discomfort without fleeing, or incorporating some type of safety behavior (i.e., “coping”) to manage the distress. ERP is simplistic. It’s easy to explain and easier to implement. There are no fancy chants, finger waving, breathing strategies, or finding your happy place. Its not sexy, but raw. It’s also underutilized greatly. This is bad news for those suffering with anxiety disorders. Anxiety disorders are the number one reason individuals seek services for mental health, yet experienced clinicians rarely use ERP. Logistically, using ERP as a tool to fight anxiety takes some consideration. A clinician must be prepared to get out of the office. Although many fears, obsessive thoughts, and distressing memories can be activated in the office, most reside elsewhere. A client suffering from harming OCD requires a clinician who will drive with them. A client with Panic Disorder needs a clinician by their side to climb a flight of stairs. A client with contamination OCD will benefit from their clinician sharing the experience of touching every garbage can in a three-block area and enjoying finger food together. A teenager with social anxiety is unable to challenge fears of interacting with strangers or engaging in small talk while sitting on a therapy couch. This has to happen in real time, with real people, to build real confidence. Exposure Therapy works. It works because clients commit to working hard, to being miserable on purpose in order to overcome their fears. Individuals with anxiety are miserable. At least when engaged in ERP their misery has a purpose. They evoke feelings of fear, danger, and distress on purpose and wait. There is no better example of courage
Eminem? Yes, Eminem. When teaching people about learning theory, behaviorism, and anxiety it’s usually in the context of therapy. I am trying to help them learn how to understand their anxiety. How to understand it, to beat it. In order to do this successfully I have found, as have many other clinicians, to use analogies. An analogy is a comparison. In this context, a comparison between anxiety and something else in their life. Something they can relate to, believe in, and understand.
This is where Eminem comes in. Well, it’s not exactly Eminem, but “B-Rabbit”, a character he plays in the 2002 movie, 8-Mile. B-Rabbit is a struggling rapper in Detroit’s 8-mile. In order to gain respect as a rapper he participates in rap battles. The movie opens with B-Rabbit struggling to perform during a battle, he chokes (not literally). It’s so bad, he gets booed off stage and spends the rest of the movie trying to redeem himself. The premise of a battle is to essentially embarrass, harass, and belittle the opponent, while demonstrating lyrical genius through clever rhymes and sophisticated vocabulary. Sound familiar? It should. The battle with one's anxiety is no different. Anxiety thrives on avoidance. In fact, without avoidance and other subtle behavior changes one's anxiety wouldn’t exist. B-Rabbit lost his confidence when he embarrassed himself. He feared feeling the shame and embarrassment he experienced, and initially chose to avoid rapping again.
Anxiety creates doubt. A thought that something bad may happen or that you may not be able to handle feeling bad. These thoughts influence your decisions and force you to avoid things (life). You can avoid and feel ok, temporarily. In the final battle scene of the movie, B-Rabbit goes against his rival, “Papa Doc.” He loses the coin toss and has to go first. In a genius strategy, Eminem gains support of the crowd and lays into himself. He raps about his terrible upbringing, living in a trailer park, getting beat-up, having his girl cheat on him, and being poor. He essentially uses all and anything Papa Doc could’ve used again him. The crowd goes wild and leaves Papa Doc speechless. What more is there to say? When we address our worst fears and challenge our anxiety it often runs away. Anxiety thrives on the premise of perceived fear, not actual danger. So when we look it in the eye and invite it, it’s usually nowhere to be found. Before getting back on stage, B-Rabbit is asked by a friend, “Aren’t you worried about what he’s going to say about you?” This simple question allowed him to quickly understand that if he took away the power of his opponent by verbalizing his worst there was nothing more to say. Anxiety is ruthless. It goes after everything you love. Identify your worst fears and change your relationship with fear. Challenge yourself to provocatively ask, “bring it on!” The worst that can happen is you may feel uncomfortable, something you likely already experience regularly.
FIGHT FEAR | FIND FREEDOM
Although coping seems pretty straightforward, it can be a tricky concept. It is mostly used within a positive context. A skill, a behavior, or anything that can help someone overcome something.
Many times, during a consultation, a client will say, “I need help coping with my anxiety,” or a parent will report, “My kid just needs to learn to cope with stress.” Despite these assertions many people fail to realize that they are indeed “coping” with anxiety and stress-albeit maybe not adaptively. Drinking, drugs, isolating, avoidance, and self-harming behaviors are all forms of coping.
In fact, many of these are rather efficient at helping us cope with unpleasant psychological stimuli. For example, skipping school to avoid the unpleasant anxiety associated with reading in class is an effective way of never having to manage the unpleasant experience. Drinking alcohol or using mood altering substances are effective means of subduing an anxiety attack long enough to get through the grocery store. Now, of course, there are more adaptive ways of coping with the aforementioned problems. The kid scared to read in class could learn to breath when anxious and hold onto a stress ball, or the panic stricken adult could take a prescription drug, shop during non-busy hours, or shop online even. These coping techniques would possibly allow the person to manage getting through the distressing situation unscathed. Coping is a big part of the tools that many therapists teach clients. These tools can be extremely effective, especially when helping someone get through a time-specific crisis, conflict, or problem. For example, helping someone cope with the loss of loved one can be invaluable until the person is ready to face the world again. Teaching self-care techniques to a heartbroken adult may ease the pain of initial loneliness and heartache, and learning coping strategies while quitting smoking is essential to ones success.
These rules, however, do not necessary apply to overcoming anxiety. If one coping technique is swapped for another, even a more adaptive one (e.g., learning to breath in response to anxiety vs. laying in bed, or drinking alcohol) than an individual continues to believe that they were (are) unable to tolerate the yucky feeling associated with anxiety; and the message becomes, “Yes, you were able to make it through that panic attack or horrible experience but only because of your medication; or only because your safe person was with you; or only because of your lucky rabbit foot). Coping with anxiety implies that one must do something to tolerate the distress. In fact, this isn’t true. The best way to overcome ones anxiety is to do nothing. If you do nothing, you don’t flee, avoid, get drunk, or cut yourself and the anxiety goes away or reduces than the conversation is different. It becomes, “Wait a minute, my anxiety is gone. My anxiety is gone and I did nothing. “ While this seems rather simple so many of us choose not to wait around and see if our anxiety reduces while we do nothing. We hate it and want to go away quickly, but don’t realize that these behaviors are in fact what keep it hanging around.
Steps to do nothing: