Downloaded by [New York University] at 01:46 15 August 2016 What Every Therapist Needs to Know About Anxiety Disorders What Every Therapist Needs to Know About Anxiety Disorders is an integrated and practical approach to treating anxiety disorders for general psychotherapists. What is new and exciting is its focus on changing a patient’s relationship to anxiety in order to enable enduring recovery rather than merely offering a menu of techniques for con- trolling symptoms. Neither a CBT manual nor an academic text nor a self-help book, What Every Therapist Needs to Know About Anxiety Disorders offers page after page of key insights into ways to help patients suffering from phobias, panic attacks, unwanted intrusive thoughts, compulsions, and worries. The authors offer a rich array of therapist– patient vignettes, case examples, stories, and metaphors that will complement the work of trainees and experienced clinicians of every orientation. Readers will come away from the book with a new framework for understanding some of the most frustrating clini- cal challenges in anxiety disorders, including “reassurance junkies,” endless obsessional loops, and the paradoxical effects of effort. Martin N. Seif, PhD, ABPP, cofounded the Anxiety and Depression Association of America and was a member of its board of directors from 1977 through 1991. Dr. Seif is associate director of the Anxiety and Phobia Treatment Center at White Plains Hospital and a faculty member of New York Presbyterian Hospital/Cornell Medical School. He maintains a private practice in Manhattan and Greenwich, Connecticut, and leads Free- dom to Fly, an airport-based program for fearful fl iers. Sally Winston, PsyD, cofounded the Anxiety and Stress Disorders Institute of Maryland, where she is codirector. She is the inaugural recipient of the Jerilyn Ross Award of the Anxiety and Depression Association of America and has decades of experience treating patients, training therapists, and advocating for public awareness of anxiety disorders Downloaded by [New York University] at 01:46 15 August 2016 and advances in their treatment. She has given training workshops in the US, Canada, Asia, and Africa. This page intentionally left blank Downloaded by [New York University] at 01:46 15 August 2016 What Every Therapist Needs to Know About Anxiety Disorders Key Concepts, Insights, and Interventions Martin N. Seif and Sally Winston Downloaded by [New York University] at 01:46 15 August 2016 First published 2014 by Routledge 711 Third Avenue, New York, NY 10017 and by Routledge 27 Church Road, Hove, East Sussex BN3 2FA Routledge is an imprint of the Taylor & Francis Group, an informa business © 2014 Martin N. Seif and Sally Winston The right of Martin N. Seif and Sally Winston to be identifi ed as authors of this work has been asserted by them in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. The purchase of this copyright material confers the right on the purchasing institution to photocopy pages which bear the photocopy icon and copyright line at the bottom of the page. No other parts of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice : Product or corporate names may be trademarks or registered trademarks, and are used only for identifi cation and explanation without intent to infringe. Library of Congress Cataloging-in-Publication Data Seif, Martin N. What every therapist needs to know about anxiety disorders : key concepts, insights, and interventions / by Martin N. Seif and Sally Winston. pages cm Includes bibliographical references and index. 1. Anxiety disorders. 2. Anxiety disorders—Treatment. 3. Anxiety— Physiological aspects. I. Winston, Sally. II. Title. RC531.S37 2014 616.85'22—dc23 2013040802 ISBN: 978-0-415-82898-7 (hbk) ISBN: 978-0-415-82899-4 (pbk) ISBN: 978-0-203-51884-7 (ebk) Typeset in Minion by Apex CoVantage, LLC Downloaded by [New York University] at 01:46 15 August 2016 To David Seif and Emily Seif To Frank and Phyllis Margolick Downloaded by [New York University] at 01:46 15 August 2016 This page intentionally left blank Downloaded by [New York University] at 01:46 15 August 2016 Contents List of Figures and Tables xi Preface xiii Acknowledgments xvii 1 Why Details Make a Difference 1 Introduction 3 Reasonable Goals 5 Techniques Are Not the Answer 5 2 The Basics 7 Three General Characteristics of Highly Anxious People 7 Anxiety Feels Dangerous 7 How an Anxiety Disorder Differs from Plain Anxiety 8 The Three Types of Triggers 9 The Defi ning Aspect of an Anxiety Disorder 13 The Basic Principle: Identify and Treat Avoidance 14 3 A Contemporary View of Anxiety Disorders 15 Sensitivity and Anxiety 15 A Discussion of Causation 15 Insight: Cause Versus Maintenance 16 Primary Versus Secondary Gains 17 Downloaded by [New York University] at 01:46 15 August 2016 Studies on Causation 17 The Dilemma of Insight 19 Consequences of Affect Intolerance 20 The Value of Talking about Anxiety Symptoms 21 A Direct Approach to Treating Anxiety Disorders 22 The Neurological Perspective: Role of the Amygdala in Sensitization 23 The Value of Exposure 28 The Fear-maintaining Cycle 29 viii Contents Avoidance, Resistance, Neutralization 30 The Phenomenology of Anxiety: Anxiety Alters Consciousness 31 With Anxiety, Common Sense Makes No Sense 34 The Paradoxical Attitude 34 4 The Therapeutic Attitude of Acceptance 37 Approaching Anxiety Mindfully 38 Embracing Anxiety 39 The Role of the Therapist 42 Teaching Metaphors 45 Essential Elements to the Therapeutic Attitude of Acceptance 47 5 Getting Started 53 The First Contact Must Instill Hope 53 Immediate Help: Embed Information in Your Questions 54 Get the Details 56 Find Out What They Have Tried 60 Introduce the New Paradigm: Offer a More Profound Change Than Techniques 61 Provide Information and Answer Questions 63 6 Techniques Your Patients Have Probably Already Tried and Misunderstood: What They Are and How to Make Them Helpful 67 The Problem with Techniques 67 How Techniques Can Be Helpful 70 Techniques Are Temporary Help, Not Goals 70 Emergency Coping 71 Techniques That Can Be Helpful: “What Is,” Not “What If?” 73 Anxiety Management Tricks That Easily Backfi re 81 Diaphragmatic Breathing 81 Anxiety Management in Cases of Real Danger, Not False Messages 84 Some Issues in Determining Patient Progress 84 Downloaded by [New York University] at 01:46 15 August 2016 7 Diagnoses: An Annotated Tour of the Anxiety Disorders 89 Specifi c Phobias 89 Panic Disorder 92 Social Anxiety Disorder 93 Obsessive-compulsive Disorder 95 Generalized Anxiety Disorder 100 Traumatic Anxieties 101 Contents ix 8 Exposure: The Active Ingredient 105 Exposure in the History of Psychotherapy 105 Exposure Therapy Is More Than “Just Do It” 106 Role of the Therapist During Exposure: What to Say and Do 115 Exposure Can Be an Intrinsic Part of Diagnosis and Assessment 118 Exposure for Patients with Obsessive-compulsive Disorder: Exposure and Response Prevention 118 OCD with Purely Mental Obsessions and Compulsions 119 The Right Way to Practice Exposure 121 9 The Curious Case of Worry 126 Varieties of the Worry Experience 127 A Caveat: Generalized Anxiety Disorder—Rarely a Stand-alone Diagnosis 129 Worry Is Not an Affect: It Is Thinking—And Thoughts Are Not Facts 129 Productive Versus Unproductive Worry 130 An Important Insight: Some Worry Thoughts Raise Anxiety and Some Lower It 130 The Therapeutic Perspective on Worry 131 About Worry and Time: The Role of Urgency 132 Evaluating Worry 132 Rumination: A Different Kind of Worrying 133 Coping with Worry: What Doesn’t Work 134 Coping with Worry: Strategies That Work 136 10 Unwanted Intrusive Thoughts: All Bark and No Bite 144 How Unwanted Intrusive Thoughts are Maintained 144 Living with Joy Despite Unwanted Intrusive Thoughts 149 Treating Unwanted Intrusive Thoughts 150 Issues for Therapists: Varieties of Presentation 150 Issues for Therapists: Therapist Anxiety and a New Construct 153 Exposure to Unwanted Intrusive Thoughts 154 Downloaded by [New York University] at 01:46 15 August 2016 11 Classic Pitfalls: Common Mistakes Non-Specialists Make 156 Pitfall Number 1: Turning the Causation Arrow Around 156 Pitfall Number 2: Pathological Doubt OCD—Misidentifying OCD Thoughts as Issues and the Seduction of Co-compulsions 158 Pitfall Number 3: Intrusive Thoughts or Doubts about Sexual Orientation or Identity—Misdiagnosing OCD Thoughts as a Sexual Issue 160 x Contents Pitfall Number 4: Get Your Feelings Out 162 Pitfall Number 5: Mistakes in the Application of Exposure-based Treatment 164 12 Another View of Resistance: Issues that Interfere with Treatment 166 When People Come Back Without Doing Home Practice 166 Anticipatory Anxiety: When People Need Help Getting over the Hump 167 The Reassurance Junkie: When People Are Constant Callers 171 13 Some Hard to Treat Problems: A New Perspective 176 Illness Worries (Health Anxiety and Hypochondria) 176 Scrupulosity (Religious and Secular) 177 Emetophobia (Fear of Vomiting) 178 Paruresis (Shy Bladder Syndrome) 179 14 Relapse Prevention 181 Anxiety Disorders Are Chronic Intermittent Disorders: They Come Back 181 The Most Enduring Recovery Is When Symptoms Do Not Matter 182 Search and Destroy: The Role of Subtle Avoidance 183 The Role of Psychotherapy in Relapse Prevention 183