Reducing suffering without reducing anxiety - WHAT!?
I specialize in treating anxiety and so it might be disconcerting for you to read that reducing my clients' anxiety is one of my least important treatment goals. Hear me out though please...
The American Psychological Association defines anxiety as, "...an emotion characterized by feelings of tension, worried thoughts and physical changes like increased blood pressure. People with anxiety disorders usually have recurring intrusive thoughts or concerns. They may avoid certain situations out of worry. They may also have physical symptoms such as sweating, trembling, dizziness or a rapid heartbeat."
The problem with "treating anxiety" is that it doesn't respond well to us going straight after it. This is why so many extremely competent, smart, functional people end up in therapy offices after failing to fix their own anxiety. Anxiety is a monster fed by many factors, one of them being attention, and so the more direct attention we put on getting rid of it, the biggest and stronger it becomes. So rather than focusing on anxiety reduction, I focus on reducing the total suffering of the client at hand. Most clients have the following types of suffering:
1. Primary symptoms - In the case of anxiety, this may be physiological arousal, worrisome thoughts, and irritability.
2. Coping mechanisms - It takes energy to cope with anxiety and anything that takes energy away from other things in our lives is stealing from us or making us suffer. Coping mechanisms become their own type of suffering.
3. Fear of it getting worse - In all psychological disorders and especially in anxiety, sufferers fear symptoms getting worse or feeling forced to use maladaptive coping mechanisms (alcohol, drugs, self-harm, etc.)
4. Shame around the coping mechanisms, symptoms, and fear of worsening. Almost everyone with psychological suffering feels bad that they feel bad. They feel bad about what their symptoms have done to their relationships, jobs, or hobbies. They feel shame that they have turned to harmful coping strategies when the pain gets to be too much.
The problems with targeting only the first of these four factors are that first, anxiety itself is slippery. And second, the anxiety itself often comprises a minority of total suffering patients experience. So, I go backwards.
Let me explain using a couple of hypothetical patients that I created to represent typical courses I've observed in my practice. In the graph below, this hypothetical patient started with a total suffering level of 100. In this course of treatment, we targeted their shame around anxiety symptoms and coping mechanisms and did a bit of work on their fear of symptoms returning or having to use maladaptive coping mechanisms. We never targeted their anxiety or coping mechanisms themselves. The result was still a huge reduction in suffering - from 100 to 50.
More typically, a course of treatment does eventually influence actual anxiety or depression symptoms and not just the ancillary shame and fear. In the graph below, this hypothetical patient and I worked on shame and fear around anxiety symptoms and coping mechanisms. Because those were a big source of their worry and anxiety, they experienced actual reduction in worry and physical anxiety symptoms.
Does this mean we don't ever work with anxiety directly? Of course not! I teach relaxation techniques, meditation and mindfulness, some simple yoga practices, and other skills to help clients work more skillfully with their anxiety. The problem is that none of the four factors above will EVER get to zero. No one walking on this earth has zero anxiety, zero coping stress, zero concern about getting "sicker," or zero shame. So if I don't teach my clients how to manage the cycle of anxiety, coping, concern, and shame and only treat their anxiety symptoms, they will eventually get worse again.
Once clients let go of shame and begin practicing the cultivation of compassion for themselves, they feel less bad about their coping strategies, release worry about getting worse, stop needing as many coping strategies to get through the day, and have less anxiety overall. More importantly, they have a system to continue practicing throughout their lives so that after therapy is over and over time, they keep working to increase compassion and reduce shame and suffering.
Therapists don't take you to the end - we just help you get started on the journey.
A few of our favorite books on shame, self-compassion, and anxiety