relationship between anxiety and avoidance:  avoidance relieves in short term but increases next dose of anxiety, thus maintaining and exacerbating problem pattern.

downward arrow technique or “what are you most afraid of?” and “what’s the worst thing about that?” and training in imagery; primitive aspect of anxiety suggests successful therapy will address “childish” images rather than adult ideas about fear.

image of calming a frightened child as model of holding the experience of fear while remaining centered in an adult ability to reassure and sponsor courage

planning a coping response to worst fear and arranging sufficient support in using the plan (predict, prepare, practice)

evidence: the most effective strategy for reducing anxiety is learning to tolerate exposure to anxiety-trigger, and building confidence with repeated successes.

supervision question:  how do you answer a client who anxiously asks, “what is the correct treat me nt for anxiety?”

when discussing treat me nt options for anxiety, rather than take a stern, rigid position about the “correct way” to treat anxiety, the attitude i try and convey is a more flexible one of comfortably presenting a variety of options, which is pretty much my take on diagnosis and psychiatric treat me nt in general -- sort of, "well, here's this quaint and slightly bizarre system of beliefs and ideas, and they are certainly a pleasant addition to our buffet, aren't they?" (familiarity with and comfort discussing a wide range of treat me nt approaches and styles helps me , and hopefully the client, not take any one of them as absolute gospel.)  so when i sense so me one will feel most comfortable with a kind of strategic, businesslike, yang style of therapy, being a cooperative and accommodating fellow, i demonstrate that i can do that for them.  (on good days, i stay centered in myself and also refer to deeper kinds of work, which can even be alluded to in cognitive-behavioral language.)

in terms of content:  my cognitive behavioral rap with self-relations sub-text:

anxiety is about avoidance.  it's maintained and exacerbated by avoidance.  avoidance reaffirms the belief that whatever being avoided is powerful and dangerous and should continue to be avoided.  also, avoiding provides temporary relief, so it's very reinforcing.  now what actually helps with anxiety is exposure.  research proves this, that even without insight, exposure to what is feared reduces the physiological fear response.  it's just a basic biological event.  the two basic kinds of exposure are flooding, in which you get exposed to way more of whatever you are scared of that you would ever encounter in the real world, and so habituate the fear response quickly (but runs the risk of scaring the shit out of you and so making your fear worse), and graded exposure, in which you little by little expose yourself to just enough of what scares you to get a little edgy but still feel like you're in your body and in control.  you gradually get used to what scares you and fear gets replaced by confidence.  so in phobia treat me nt you first talk about snakes, then look at pictures of snakes, then play with rubber snakes, then look at a snake in a cage, then watch your therapist hold a snake, then watch your therapist be eaten by a snake -- oops, sorry, but you get the idea.  now with obsessive-compulsive disorders the compulsion is the avoidance, to get away from the discomfort of the obsession.  every ti me you do the compulsion you get this relief, temporarily, and then the obsession co me s back.  the only way you get real, lasting relief is being able to sit with the obsession and not act on the compulsion, and very gradually the discomfort goes down, and when it co me s back it usually doesn't co me back quite as strong as before, and so very gradually the obsessions lose potency because you're not avoiding them by using the compulsion to escape them.  

this isn't to say distraction isn't a useful tool, because none of us can do this hard work all the ti me .  so figure out what distractions are useful and healthy, and get away from the whole me ss now and again, and use distractions when you're anxious to focus your attention into so me thing healthy and satisfying.

having a plan about what to do to soothe yourself when you're anxious is a good idea, too, because most people don't think too clearly when they're anxious (this is a biological fact about panic:  the brain closes down to a binary system of fight or flight, cognition doesn't work). so just re me mber where your list of responses is, and use them.  this should include who to call for support, supportive com me nts to make to yourself when scared, activities that help to distract, and activities that help to center.  mindfulness practices, self-hypnosis, absorbing activities like sports or music can be helpful here.  people who experience flashbacks report that eating or drinking so me thing can feel comforting and help them return their attention to their bodies from dissociated states.

research has shown that the majority of people with panic disorder have suffered a major loss of so me kind in the eighteen months before onset of panic.  often just being able to talk about the loss is enough.  often just knowing they have panic disorder is enough to prevent any further episodes (they thought they were dying or going crazy).  often misinterpreting a body signal like slightly elevated heart rate causes panic, so learning that those signals are a normal part of the fluctuations our bodies do in the course of a day can help.

the three most common distortions associated with anxiety are (1) amount of danger overemphasized, (2) ability to cope underestimated, (3) availability of help underestimated.  addressing number (1) doesn't help for so me reason, but it's the thing the most people (even therapists) often jump to first without success.  ("but planes are safer than cars!" "yeah, but what if i'm on the one that crashes?")  addressing number (2) is the most helpful, it turns out. 

using imagery to access the most primitive, even pre-verbal parts of ourselves, asking the question "what is most frightening about that?" repeatedly can take us to the bedrock or core fear that drives the panic.  then we ask, "what will i do to cope with that when it happens?" and develop a plan.  write down the plan.  now you have disrupted the avoidance of not looking at what scares you the most, and have addressed the distortion that you can't cope with it.

in this way, the cognitive-behavioral approach to anxiety leads us to touching with awareness the previously neglected aspect of our consciousness that was e me rging only as a symptom, fear.  we teach it that we are there in all our adult competence, and that we have a plan for coping with its worst fear.  ahhhh!

more associations on anxiety treat me nt (this in clinical practice could actually translate into assertiveness training as our clients finally yell "will you please shut up!" after hours of non-stop monologue about treat me nt approaches):

stephen lankton's children's book _the blammo surprise book_ and yvonne dolan's work on "associational cues" approach the skill-building part of self-soothing from a hypnotic perspective:

you decide on an "affective state" you prefer to anxiety (for example, confidence, bravery, calm, centered, funny).

sense it, develop it (re me mber stories about when you felt that way), hypnotically amplify and intensify it in mind and body (imagery, focus, concentration).

link it to so me thing:  a piece of jewelry, a visual image (the picture of a yellow sun with the purple word "blammo" in _the blammo-surprise book_), a piece of music, a supportive phrase or mantra.  the link can be physical (a touch so me where on your body or so me thing felt), visual, auditory, i suppose even olfactory or gustatory (a steaming cup of chicken soup or cup of herb tea).  this is the "associational cue".

the next ti me you are anxious use the "associational cue" and so me ti me s accompanying the anxiety, and so me ti me s replacing it, will be the affective state practiced and intensified and linked to the associational cue.

as i think about how to use this in a less yang, more balanced self-relations way, i think i might not try so much to obliterate the anxiety as bring another part of myself into consciousness alongside of it and see what the two aspects had to teach each other.

another approach is the senoi dreamwork, which is a good yin/yang balance of assertion and listening.  i like the approach, but the specific client you were asking about would probably find it not very scientific or western in its style.