Exposure therapy is conducted by creating a hierarchy of situations that provoke increasing amounts of anxiety. Starting with the least challenging situation, your partner will be encouraged to stay in each situation until her anxiety decreases. Once this becomes manageable, she’ll move on to the next step in the hierarchy. If a situation proves to be too anxiety provoking, she can return to a previous step and wait for the anxiety to subside before working on the next step again.
Let’s say your partner has a fear of heights but wants to be able to visit the observatory at the top of the Empire State Building during an upcoming trip to New York City with friends. Right now, anytime she looks out a window above the third floor of a building, she starts sweating, gets nauseous, and feels dizzy. Her exposure hierarchy might look something like this:
Look out the window from the ground floor of a building for one minute.
Go to the second floor of a building with a support person and look out a window for one minute. If any anxiety symptoms arise, she can use the breathing and imagery techniques described in chapter 5 until she feels better.
Look out the second-floor window for two to five minutes, still with a support person present.
Look out and down from a second-floor window for one to two minutes without a support person present.
Repeat steps three and four on the third floor, then the fourth floor, and so on, moving up two to three floors per session. At first, sessions should last no more than thirty minutes, and the duration can be shorter if your partner reaches a point where her anxiety is too intense.
At the beginning of the next session, your partner should start on the floor below where the previous session ended. So if she ended the previous session on the fifth floor, she should start the next session on the fourth floor. If the fourth floor is too overwhelming as a starting place, she can start on the third floor instead.
Your partner continues in this way, moving up floor by floor, until she feels more relaxed about heights. Once the fear of looking out of high windows is under control, she can add a new challenge; for example, working on being comfortable on an outdoor balcony, rooftop garden, or fire escape.
Sometimes people find that they are unable to master and move beyond a particular item on their hierarchy—for example, your partner might find it impossible to get above the twelfth floor despite repeated attempts. In this case, it may be that adjusting the hierarchy to include some intermediate steps will help.
The purpose of exposure therapy is not just to eliminate a particular fear, but to teach people that they can tolerate discomfort and give them an opportunity to practice techniques for reducing anxiety in a safe and controlled environment. What seems like an insurmountable fear can be broken down into smaller steps that can be mastered, eventually leading to freedom from the fear.
Disorder-Specific Interventions
The following sections describe disorder-specific strategies for responding to anxiety. If your partner has been diagnosed with a particular anxiety disorder, the two of you can try the approach described in that section. Even if your partner has not been diagnosed with a specific anxiety disorder, reading through the following sections will still be worthwhile. The techniques and case examples may give you ideas about additional ways to help your partner with her anxiety. By the way, the communication skills you learned in chapter 4 will probably prove invaluable as the two of you implement these strategies.
While these strategies can be very effective, it’s also essential to seek help from a mental health professional who is trained in treating anxiety. Your partner’s therapist will take a thorough history of your partner’s symptoms and develop a treatment plan specifically tailored to her needs. The therapist may ask that you attend several sessions with your partner so that you will also be informed about the treatment and how you can help support the goals of treatment in day-to-day life, outside of sessions. The therapist may also recommend that your partner consider medications to alleviate anxiety symptoms. It’s best to work with a psychiatrist on medications, as they tend to be more well-informed about appropriate antianxiety medications and dosages.
Panic Disorder with Agoraphobia
If your partner has panic disorder with agoraphobia, it’s likely that the two of you have developed a pattern in which you typically accompany your partner on forays outside your home, and that you’ve taken on the responsibility for shopping, errands, and other tasks that require leaving the house.
Being by your partner’s side when she’s out in public allows her to rely on you to provide a sense of safety. Without you, she may feel as if the possibility of having an embarrassing panic attack in public is a genuine threat. However, as discussed, this kind of accommodation is actually counterproductive in the long run. It may seem like a way to show care and concern for your partner, but it prevents her from learning that she can overcome her anxiety and live a full life. An approach based on exposure therapy can help change this pattern so that your partner becomes less dependent on you:
Identify the responsibilities you’ve taken on that your partner needs to regain confidence about handling herself, such as shopping, driving the kids to school, or attending appointments alone.
Create a hierarchy of activities from those that seem easiest for your partner to accomplish to most challenging. (An example hierarchy for fear of heights appeared earlier in the chapter, and you’ll find another example later in this chapter in the section on specific phobias.)
Work together to decide what steps need to be taken to tackle the first item on the hierarchy. For example, let’s say the first item is for your partner to take over grocery shopping again. The two of you would then work through a series of exposures to the grocery store to help your partner learn to manage her anxiety and eventually feel confident enough to go alone. (The following case example, of Kathy and Tyler, demonstrates this approach.)
The two of you would then complete three steps for each of the exposures: Prepare for the stressful situation ahead of time, discussing your goals, the feelings each of you are having about the upcoming exposure, any difficulties that might arise during the exposure, and how you’ll handle them.
While in the stressful situation, your partner should express her feelings to you instead of trying to avoid unpleasant emotions. Your role is to listen, validate, and encourage your partner to ride out her feelings until they pass. If both of you feel your partner needs to leave the situation, you can take a time-out, but you shouldn’t leave the situation altogether. Once your partner uses some calming techniques, reenter the situation.
Once the two of you are home again, discuss the experience. Each of you should describe your experience, give praise for what was accomplished, and discuss anything that needs to go differently next time.
As your partner develops more confidence, your role in the outings will decrease, but your partner should continue to discuss her experiences with you so you’re aware of her progress and so you can offer ongoing encouragement.
Case Example: Kathy and Tyler
Kathy, forty-two, and Tyler, forty-four, have been together for twelve years. Kathy developed panic disorder with agoraphobia after having a panic attack in public five years ago. Since then, the environment in which she feels she can function independently got progressively smaller, to the point where she rarely left the house without Tyler at her side. In therapy, Kathy has been working on learning to manage the physiological symptoms of her anxiety. The next step is for her to start relearning how to be in public without Tyler at her side. She and Tyler made a list of activities that she needs to reengage in, and together they decided that the first one to work on was decreasing her avoidance of grocery shopping.
Kathy and Tyler decided they would make their first outing to the grocery store on a Tuesday evening, since that tended to be a quiet time at their local store. Once they got there, they would just walk through the front of the store together slowly, and they would leave after five minutes. Befo
re they left home, they discussed their plans for the outing and their feelings about it. Kathy rated her anxiety level at 6 on a scale of 0 to 10. She and Tyler decided that they would monitor her anxiety level while they were in the store and take a time-out if she reached a 9. Tyler told Kathy that he felt good about Kathy’s ability to be successful during this outing.
When they arrived at the store, Kathy said she felt that her anxiety level was at 7. They sat in the car for a few minutes, and Kathy practiced some deep breathing techniques to reduce her anxiety. When she felt her anxiety was at 5, they got out of the car and approached the store, side by side but not touching each other in any way (holding hands, linking arms, and so on). They went through the doors and stepped to the side so they wouldn’t be in the way but would still be inside the store. Kathy rated her anxiety level at 6. As they stood just inside the door, Kathy quietly verbalized her feelings, and Tyler encouraged her to keep at it. Kathy’s anxiety peaked at 7. When the five minutes was up, they left the store and drove home.
Once they arrived back home, they discussed their experience and made plans for the next outing. They agreed that next time they would go farther into the store, stay longer (ten minutes), and, for a few minutes, spend time at opposite ends of an aisle so that Kathy could see Tyler was nearby but begin to learn that he didn’t have to be right with her at all times.
Obsessive-Compulsive Disorder
Assisting your partner in overcoming OCD behaviors largely revolves around two key strategies: not participating in the behaviors yourself, and consistently encouraging your partner not to engage in the behaviors. Although it might alleviate your partner’s distress in the moment if you, for example, check the stove and make sure all of the small appliances are unplugged, doing so actually reinforces her fears.
If you’ve been trying to alleviate your partner’s fears by giving continual reassurance or arguing that her fears are illogical, you need to stop that behavior as well. Not only is it ineffective in relieving your partner’s distress, it’s also likely to make you frustrated and angry with her.
Case Example: Brian and Paul
Brian, thirty-two, and Paul, thirty-five, have been partners for four years. When they met, Brian had been experiencing some symptoms of OCD for as long as he could remember, including a fear that the stove or oven would be left on or that an appliance in the house would accidentally spark a fire. During the first few years of their relationship, Paul tried his best to reassure Brian that everything was fine when they were out of the house, but he often found himself returning home with Brian to check on the house. Over time, Paul became more and more frustrated with Brian’s fears and how they affected their ability to be social and live full lives.
Paul finally convinced Brian that he needed to work with a mental health professional to address his obsessions. He attended several sessions with Brian so he could learn how to best support Brian in his recovery. With the therapist, they discussed patterns of behavior they were engaging in to accommodate Brian’s anxiety and agreed on ways to gradually reduce Paul’s accommodations. For example, if they were out shopping and Brian became anxious about the stove not being turned off, Paul would say, “I appreciate that you’re concerned about the stove being on. I understand that you’d like us to go home and check, but we agreed that the best thing to do is to help you learn to manage these feelings that you’re having instead.” Another behavior they agreed to work on changing was Paul’s reactions to Brian’s requests that they check the appliances in the kitchen “one more time” after leaving the house but before getting in the car to depart, which Paul had been accommodating in the hope that doing so would prevent Brian from later insisting that they return home to check on things. They decided that they wouldn’t do that final check, and that if Brian became anxious, they would practice abdominal breathing together as they drove to their destination to help Brian calm down. With time and practice, Brian’s fears lessened significantly, as did Paul’s frustration level.
Generalized Anxiety Disorder
People who have GAD may seem similar to those who have OCD in that they have frequent fears that aren’t alleviated by continual reassurance, and their fears are often things that many people worry about, such as finances, job security, or health problems, but blown out of proportion. People with GAD often catastrophize, taking their worries to an extreme level and assuming that the worst will always happen, even if the actual probability is quite low. If you have a partner with GAD, trying to remain calm and provide reassurance, despite your words not helping, can wear you down. You may finally reach a point where you decide you aren’t going to try to help your partner feel better, given that it doesn’t make any difference when you try to do so. In addition, people with GAD often have physical complaints, such as headaches and an upset stomach, that can interfere with emotional and sexual intimacy. Listening to a partner’s continual complaints about these symptoms can also become annoying.
Couples in which one person has GAD often go to therapy because of the underlying tension the anxious partner’s thoughts and behaviors are causing in the relationship. The therapist often provides psychoeducation, teaching both partners about GAD, and helps the couple examine the patterns in their relationship that maintain or exacerbate the anxiety. For example, some people develop GAD because they feel their partner is closing them out from participating in major decisions, such as how money is spent or invested, or feel that their partner makes all the decisions for the family and neglects to consult them or consider their opinion first.
Another issue is that people with GAD may develop a fear of inadequacy and believe that nothing they do is good enough for their partner or family. As a result, they might overcompensate by trying to make everything perfect all of the time, or underperform, not doing anything because they believe their efforts will be judged as wrong. Since GAD is a form of chronic anxiety, a therapist will help both partners look for long-standing issues that are fueling the anxiety and help get to the heart of the issue so that changes can be made, if possible. These changes might show up in many areas of life, including money concerns, health issues, levels of responsibility for family matters, job stress, sexual dissatisfaction, differences in parenting styles, and poor communication skills, to name just a few.
The therapist might also teach both partners cognitive restructuring, a technique that involves changing thoughts. This approach involves learning to recognize thoughts that are increasing anxiety and then challenging the anxious thoughts by assessing the likelihood that the anxiety-provoking event will actually occur. If your partner has GAD, her therapist may have her practice whatever is causing her anxiety during their sessions together, such as rehearsing a speech, making phone calls, or going out in public together, in order to assess the level of anxiety generated and practice challenging the thoughts that arise. The therapist may also ask your partner to keep a thought record or thought log between sessions that they can use to identify patterns and discuss alternative perspectives on whatever is fueling your partner’s anxiety. The technique of helping your partner practice alternative thoughts (described in chapter 5) will also be useful here.
Case Example: Beth and Dan
Beth, fifty-five, and Dan, fifty-six, have been married for over thirty years. Beth is a self-described worrier who has always been concerned about the kids, finances, and the future. Dan has joked many times over the years that if he wants to know the worst-case scenario in any situation, Beth will have an answer. Now that their children are grown and out of the house, Beth and Dan have been redefining their relationship, and without the distraction of children, tension between them has been increasing because Dan can seldom escape from Beth’s near-constant fretting.
At Dan’s encouragement, Beth started seeing a therapist, who has helped her learn to challenge her worrisome thoughts, doing reality testing to assess how realistic her fears are. At the therapist’s request, Dan attended several sessions so that the three of them could d
iscuss long-standing patterns in the relationship that are maintaining Beth’s anxiety and devise ways to change. The therapist encouraged Dan to be empathetic and gentle when helping Beth challenge her fears; for example, by saying something like “I hear that you’re worried about the kids traveling at night, but they’ve been safe drivers for many years, and there’s little reason to believe tonight will be different.” The therapist also encouraged Beth and Dan to do relaxing and enjoyable activities together, both to relieve Beth’s anxiety symptoms and to bring them closer together as a couple. They now regularly take walks on the trails near their home and go out on dates, and they’re making plans for travel after they retire. Recently, Dan has noticed that Beth is less anxious in general, and that she’s better able to challenge her thoughts when her anxiety is increasing.
Social Phobia
As discussed in chapter 1, social phobia can take many different forms. To name just a few, it can prevent your partner from engaging in social activities, make going to work difficult, or lead to problems in creating and maintaining relationships. One of the techniques therapists use to help clients overcome social phobia is conducting experiments in which the person tries a feared behavior and examines the results. For example, if your partner is afraid of attending parties because of a fear of rejection, her therapist might ask her to go to a party and bring back examples of being rejected. If your partner has none to report, that provides data they can work with in session. They might discuss whether there was anything different about this party that resulted in your partner not feeling rejected, or whether perhaps your partner altered her behavior in some way to make herself more “acceptable.”
Loving Someone with Anxiety Page 11
