Working with the Anxious Client | Social Anxiety
By Rob Nielson, LMFT, Clinical Director
Social anxiety and performance anxiety are more pervasive among students than people might realize. Anxiety (fear can be used interchangeably with anxiety) is the source of most problematic behaviors that bring youth into treatment. I know that it often doesn’t look that way. Most presenting problems are the results of layers of protection that these youngsters have placed around themselves. At first glance, the presenting behaviors often don’t resemble anxiousness at all. As a hypnotherapist, I consistently find hurt, shame, embarrassment, and humiliation at the core of triggering events. Frankly speaking, I am still looking for an exception to these feelings.
Anger is commonly used to defend against hurt. Drugs, computer addictions, and seeking acceptance from toxic peer groups become addictions more readily when they are used to escape from unpleasant situations. Certainly habits can be, and are, formed by actions taken in anticipation of a benefit. Add to this the drive to escape from unpleasant issues and these behaviors become considerably more compelling. Resolving the anxiety (including trauma, grief and loss, etc.) and resolution of presenting issues become much easier to achieve once clients perceive the ultimate benefit of facing their fears. Since 1996 the therapy component at Cedar Ridge has taught students how to construct and use the “Fears Chart.” By utilizing “Trigger Sheets,” students are able to identify situations that create uncomfortable physiological reactions and what they habitually have done to get relief from these stimuli. The students then learn what they need to do to reduce the intensity of uncomfortable stimuli. The “Fears Chart” is an outgrowth of my formal education and my work experience with clients since 1982.
I recently took a course on the treatment of social anxiety, Social Anxiety: The Untold Story, presented by Jonathan Berent, LCSW, ACSW, who is considered an expert in the field of treatment for anxiety disorders. Current and evidence-based, the course is profoundly stimulating and soundly supportive of the way therapy is conducted at Cedar Ridge. (I encourage anyone interested in the treatment of anxiety to go to Mr. Berent’s website socialanxiety.com and order the ten hours of DVD content. Thirteen CEU’s are available to professionals by ordering the course from PESI.)
I required every teacher, our admissions staff, and all lead staff to view and discuss this program. Additionally, all of our current students have watched the DVD’s. Because our treatment paradigm so closely matches what Jonathan Berent teaches, I can proudly affirm that Cedar Ridge uses a “state of the art” approach to working with anxiety. I can also say that we have 18 years of experience working with anxiety using these methods. Because we continually strive to improve our treatment methods, this course on social anxiety will find us incorporating some new ideas.
“When you avoid, you attract what you fear.” I had originally stated that when you avoid, you tend to attract what you fear. Experience has convinced me that the first statement is more correct. Whether the trigger to avoid is termed anxiety, a fear, or a habit, the action taken to seek relief becomes reinforced, resulting in progressively stronger visceral reactions when the anxiety-provoking situation presents itself or is anticipated. Jonathan Berent presents a strong case for necessary intervention, because, contrary to a lot of popular opinion, the avoiding behaviors that reinforce the anxiety do not simply go away.
Dealing with or “approaching” the source of their anxiety seems like the wrong thing to do for those who struggle with it, especially within the younger population. Jonathan Berent uses the term “addicted to avoidance” when talking about those who have social anxiety. By the time someone becomes a teenager, avoidance strategies are firmly in place and resistance to making changes has typically reached a sophisticated level of rationalizing and justifying. When I teach the students here about going against primitive instinct in the face of anxiety-provoking stimuli, I use the term “counterintuitive.” Dialectical Behavioral Therapy (DBT) uses the term “opposite action” to convey the same idea, and Jonathan Berent uses the term “paradoxical thinking.” In each case the goal is essentially to teach the client to change course and move in the opposite direction from which they have been moving.
Mr. Berent makes a strong statement regarding enabling behaviors on the part of well-intentioned caregivers/parents toward their socially anxious charges. According to Mr. Berent, enabling is almost always present. Schools are guilty of enabling as well. When seeking help for their child, parents often look for programs that provide activities for which the child has a strong preference. Fun and play are important elements in successful outcomes but can be also used to avoid. Treatment professionals must carefully analyze this tendency as there is the potential of, once again, enabling the teen’s propensity to avoid exposure to anxiety producing stimuli and thereby hindering real progress. Educating and securing a solid therapeutic alliance with the parents is a crucial part of treatment. All caregivers, including program staff and parents, need to be willing to make a considerable investment in teaching these principles to get ‘buy-in’ from the students. Empathy and nurturance from caregivers becomes an invaluable tool in helping the teen risk the vulnerability inherent in making necessary changes.
Investing in changing course requires courage from the teenager. In their Cedar Ridge therapy groups, the students are repeatedly asked to share what they did during the day to get out of their comfort zone. As an alternative to that, they might be asked to reflect back on the day and identify what “little acts of courage” they performed. By the time the students make our level 700, they have constructed a Fears Chart that lists the fears (anxiety triggering stimuli) they have, the ways they typically avoid, and the ways (predominately written in the form of actions to take) they plan to use to approach. This process is also termed “Exposure/Desensitization.”
Exposure/Desensitization as a therapeutic process has recently received attention at some treatment facilities. With this renewed interest many referring professionals have re-examined the Fears Chart that Cedar Ridge uses and have recognized us as pioneers in using this model of treatment. In truth, many of the exciting changes in therapy are really the re-discovery of past, and distant past methodologies. We are able to verify much of what was taught in the past because of recent breakthroughs in brain research. The Cedar Ridge treatment model/Fears Chart incorporates mindfulness practices, physically activity, meditation, and play to help mitigate anxiousness. We now know how neurogenesis is stimulated through physical activity coupled with novelty and enrichment. Our karate classes are fashioned and optimized to take advantage of, and focus strongly on, being a delivery method for neurogenesis. The workouts are an excellent way to build new neural networks, something Jonathan Berent stresses.
Ultimately the deciding factor in a successful resolution of anxiety will be a combination of how well the intensity of a trigger can be reduced (desensitized) and how well the client can master acceptance or the reframe of how to respond when adrenaline kicks in. It won’t be how much fun they had that matters but how much exposure they committed to the process of anxiety resolution. Proof of a successful outcome will be in how well that person can engage in the activities that they once avoided. Proof will be in the ability to soothe oneself rather than self-medicate. Proof will be in how well the client can love and nurture the self and still effectively deal with the everyday stressors that come with being a productive human being. Handling those stressors is the ultimate goal of treatment via the Fears Chart.