I was consulting with a non-clinician recently who was supporting a woman suffering with anxiety that is manifesting as agoraphobia and social isolation and the following is a snapshot of what we discussed. The woman at this point had not left her house in over a year. In this case it was a woman who was struggling with these symptoms, but this of course could be a man, too. Please note that troubling anxiety should be discussed with a physician to rule-out any underlying physical problem that may be contributing to symptoms.
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In the realm of anxiety disorders it is our avoidance strategies that create our prison.
Avoidance does not treat anxiety; it is a symptom of it. Avoidance reinforces our fear response. It becomes a maladaptive coping strategy, and it creates a self-reinforcing prison over time.
Non-drug treatment for anxiety-based disorders like agoraphobia and social anxiety will include exposure therapy, done slowly and in small steps over time with the support of a trained counselor. The client has to learn to develop a different relationship with fear and how she copes with those unpleasant sensations in her body. The risk is a temporary increase in distress as she moves toward her fears but the distress and the symptoms abate through the exposure therapy over time.
The longer she avoids her fears the more she programs the fear centers in her brain and nervous system to respond to her environment as dangerous which will increase her anxiety symptoms. It is self -reinforcing. Her narrative (cognitive distortions) will support the rational for her avoidance strategies. This is why working with relaxation and exposure along with CBT to look at and soften rigid beliefs will support her recovery.
Unfortunately her body is flooded with fear chemicals due to a reliance on avoidance as a coping strategy and of course this doesn’t feel good and leads to more anxiety and panic attacks and more exhaustion and this reinforces her narrative that she is still sick and stuck and can’t do anything about this. It is truly a vicious cycle.
One way to look at this is that our fear centers are designed for discreet moments of potential life threatening danger; they are not meant to be relied on chronically. When they are, they become maladaptive. They become sensitized and hyper alert to even minor environmental cues or triggers that can stimulate a full blown physiological threat response such as distressing anxious sensations or even anxiety attacks. We hate experiencing these distressing symptoms, of course, so we use avoidance strategies to make sure we won’t feel that way again, but in doing so we reinforce the threat centers in the brain and nervous system to interpret more and more of our environment as life threatening and dangerous. These primitive threat centers are designed to help us to provide us with anxious energy so we can fight, flee, or freeze. And it is helpful when we are truly in danger; not so when we are just trying to get through a normal day.
To make things worse, our current culture has reinforced the idea that avoidance is a helpful strategy with popular trends circulating such as “trigger warnings” to avoid stumbling upon any material that my trigger unpleasant feelings, memories or associations when we are moving about in the world. We miss out on the opportunity to strengthen our coping skills. Meanwhile, the avoidance then further reinforces the belief (cognitive) that environmental cues and triggers are life threatening and dangerous, which increases symptoms of anxiety and possibly even panic (biological) when we are in the world.
Pretty soon we are avoiding life.
We do not treat anxiety or even symptoms of PTSD with avoidance; we treat it with exposure therapy, CBT, and relaxation techniques that calm us while we are feeling anxious distress. There are all sort of different techniques to do this, but at the heart of all of them is almost always some form of exposure to the very thing we fear.
Avoidance is a reinforcing symptom, not a cure.
If a person is not ready, no amount of talk is going to convince her to move forward. This woman is very smart and can be provided psych-education to understand the connection between anxiety and reinforcing avoidance strategies, and how this actually increases her symptoms even though her intention is to of course minimize her distress. Since she has done therapy in the past I suspect this connection was addressed and she may not have been ready yet to face her fears.
(I myself was told years ago that to deal with social anxiety I would have to expose myself to social events I find distressing; I remember feeling nauseated at the thought and even the sound of the words “exposure therapy” made me feel shaky. Later, I slowly did more exposure therapy and it was helpful. We have to make changes in our life at our own pace.)
If she continues to avoid non-life threatening aspects of the environment it will continue to reinforce her anxiety symptoms. Avoidance is a symptom, not a cure. We treat fear of social situations or leaving the house or snakes or pretty much anything…. with slow, titrated exposure to the very thing it is we are avoiding. The threat centers learn through repeated exposure that you are safe and so it becomes less reactive, meaning you have less anxious distress and less symptoms over time.
In some ways this can be similar to an addiction model; many of us have to hit rock bottom and/or the cost of our avoidance has to become so painful that we are willing to suffer exposure (face our fears) to get better. She may not be there yet. You are doing all you can do, so you should feel good about the support you are providing her even if she is not ready to face her fears. It is ultimately up to the individual to decide what she wants to do and on her own timing. You can offer information and support but ultimately each individual has to decide for themselves how they want to proceed with addressing anxiety.
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