Preventing and Overcoming a Lapse
It’s not uncommon to experience a resurgence of symptoms—a lapse—after treatment, especially during stressful times, Abramowitz said. “We want people to recognize that this is entirely normal.” CBT helps clients recognize signs of an impending episode so that they can take action to prevent it, Norton said. Usually, this involves creating a plan with a series of signs — like not leaving the house for two days — and actionable steps — like reviewing your anxiety workbook or calling your old therapist.
“This helps prevent a lapse from turning into a relapse,” Norton said. Whereas a lapse is a hiccup — like having a double cheeseburger when trying to eat healthy — a full relapse involves reverting to old patterns, where anxiety and avoidance dominate your life, he said. If you do experience a relapse, you may need several booster sessions.
So the work doesn’t just stop at the end of therapy. Norton likened this to reaching a healthy weight: You don’t stop exercising and eating well after getting to your goal weight. Norton helps his patients develop long-term plans for managing and challenging their anxiety. For a socially anxious person, part of the plan may include signing up for Toastmasters, an organization that helps members develop their public speaking and leadership skills in a nonthreatening environment.
Common Challenges in Psychotherapy
- Lack of time and energy. Weisberg’s research found that a large proportion of patients believed that they were too busy for psychotherapy. Corboy sees many successful clients who work 60 to 70 hours a week while raising families. Yet, others might have so much on their plate — barely making ends meet, no babysitter — that they can’t attend therapy in the first place. Norton usually refers these patients to a psychiatrist for pharmacological treatment and asks them to stay in touch as things ease up. For patients who have milder symptoms, Norton recommends purchasing a self-help anxiety workbook—preferably one grounded in CBT—and creating their own hierarchy. Some workbooks still rely heavily on relaxation techniques, which are a good way to reduce anxiety in the moment but not long-term, Norton said.
- Active participation. In the beginning, patients may not be used to actively learning and practicing new skills. CBT requires a strong commitment and lots of work outside of therapy, Abramowitz said.
- Tackling anxiety head-on. To effectively treat anxiety, you have to be willing to confront your fears, so you may feel worse before you feel better. This means challenging anxiety “on a regular basis, between sessions,” Corboy said. The one hour in therapy pales in comparison to the other 167 hours in a week.If you’re having an especially difficult time applying the skills you learn in therapy, discuss it with your therapist. It might be that the exposure task is too frightening at this time, and your therapist may need to adapt it. Also, “it may be empowering to realize that avoidance is actually a choice,” Weisberg said. “Although no one chooses to have an anxiety disorder, they do choose to avoid certain things.” Weisberg works with patients to help them decide if they’d rather experience anxiety for several weeks during exposure therapy or live without ever doing a particular task. Facing your fears in the present leads to a calmer future, Abramowitz said.
Finding a Therapist
Because CBT is the gold standard for treating anxiety disorders, it’s important to find a therapist who’s well-trained in the technique and has extensive experience working with patients with anxiety disorders. Here are several suggestions for finding a qualified therapist:
- Visit the therapist finders at the Association for Behavioral and Cognitive Therapy for CBT-trained therapists and the Anxiety Disorders Association of America. Therapists listed on ADAA don’t necessarily specialize in CBT. Also, check whether your local university offers special services, which tend to be inexpensive treatments that use cutting-edge techniques, Norton said.
- Familiarize yourself with CBT. Dr. Roy-Byrne suggested reading a CBT patient manual from the series Treatments that Work. This will give you a good idea about what to expect from treatment and the kinds of questions to ask therapists.
- When speaking with a therapist on the phone, ask how he or she will treat your anxiety disorder, Abramowitz said. Does it line up with what you’ve read? He suggested also asking: How many patients with anxiety disorders have you worked with? What kind of training have you had in treating anxiety disorders and CBT? Attending several workshops isn’t enough. “You don’t learn CBT in a day; it takes years,” Abramowitz said.
The type of anxiety disorder, its severity, the presence of co-occurring disorders and level of distress typically will guide the medication you’re prescribed, the starting dose and the length of treatment. For someone with panic disorder, physicians usually prescribe a low dose of a SSRI — lower than that for depression or social anxiety disorder — because these patients are particularly sensitive to the effects of medication, said Michael R. Liebowitz, M.D., Professor of Clinical Psychiatry at Columbia University and Managing Director of The Medical Research Network.
In principle, patients take medication for about a year, but in practice, this can be longer, Dr. Roy-Byrne said. If someone is experiencing stress and still has some co-occurring anxiety, phobic, or depressive symptoms, it’s very likely he or she will relapse after stopping the medication, he said. Some anxiety disorders, such as obsessive-compulsive disorder (OCD), generally take longer to treat, Dr. Liebowitz said.
For more information on medication, see here. If you can’t afford medication, consider participating in clinical trials. In Dr. Liebowitz’s studies, participants receive six months of free treatment after completing the clinical trials.