How Psychotherapy Reveals — and Treats — the Roots of Anxiety

by Christopher Skeaff, LCSW, PhD

Anxiety is one of the main concerns that brings people to psychotherapy. Along with depression, it is the psychological equivalent of fever: a non-specific response to an array of underlying factors. Anxiety is not inherently a disorder. It is, however, a sign of something askew in one’s emotional life, one’s relationships, or some combination of the two. 

Whether or not people understand their difficulties in terms of anxiety, most pursue treatment because they have become afraid of some aspects of their experience. Anxiety, in effect, is a fear of distressing feelings. A considerable amount of the therapist’s work centers on helping patients to overcome such fear so that they might live more fully and freely. On the patient’s side, learning to follow the signs of anxiety to the sources of one’s distress is a crucial step toward meaningful change. 

So, how might you understand what anxiety is alerting you to? And what does it really mean to “work on” anxiety in therapy? Reduce it? Manage it? Master it? 

Anxiety’s Main Impact: The Vicious Circle of Avoidance 

Heart palpitations. Brain fog. A sense of dread. The direct experience of anxiety can range from disquieting to terrifying. For that reason, most of us have acquired highly sophisticated ways of avoiding situations and states of mind that could provoke it. Remain quiet during the discussion. Put off going to the doctor. Make self-deprecating jokes. It’s as though we have an internal GPS guiding us around life’s invisible boundaries and danger zones. In the ordinary course, we navigate these emotional parameters with exquisite sensitivity but little awareness of either being anxious or of driving defensively, so to speak.  

Anxiety often takes its toll indirectly, via developmental and functional distortions people undergo in their efforts to avoid anxiety-inducing experiences. My ability to perform certain tasks of daily living -- managing money, for example -- may be impaired if anxiety has led me to avoid circumstances where I could have acquired and practiced the relevant skills. Thoughts of saving money, or perhaps of spending it irresponsibly, may fill me with such panic that I avoid them if at all possible, which in turn hinders my ability to think clearly about the issue. Difficulties compound: I feel momentary relief when I don’t have to think about, say, budgeting for rent and food, but over time I find that I’m ill-equipped to handle, both logistically and emotionally, the challenges of living independently. What’s more, such avoidant tendencies steer me away from a clear appreciation of my feelings and desires, disconnecting me from my subjective experience and leaving me vulnerable to pursuing activities or embracing values that conflict with my most authentic self. 

Anxiety, we could say, has its main impact in a vicious circle of avoidance. The consequences of avoiding anxiety in the first instance tend to exacerbate one’s anxiety, given the skill deficits and developmental distortions they bring about. Efforts to avoid this secondary anxiety, in turn, make for similar limitations and further vulnerabilities.  

The question is how to break out of this circle once you find yourself there. And the short answer is that there’s no simple trick or workaround, only a working-through. You are best served by learning about the specific history and features of your anxiety, and by relearning how to experience the emotions that activate it. 

Sources and Signals of Anxiety

Children learn to be afraid of certain thoughts, feelings, and impulses, and to avoid situations that might evoke them. As they depend heavily on adults to protect and nurture them, kids perceive quite early the vital importance of adapting to the demands of their caretakers. Any feeling or impulse that might threaten the bond with caretakers stirs a child’s anxiety and tends to be avoided thereafter. 

What counts as threatening depends largely on how caretakers respond to a child’s emotions. A young girl, for example, notices that her frustration prompts her father to become impatient with her “angry outbursts.” In response, the girl begins to suppress her frustration; instead, she feels anxiety. Or, to take another example, a young boy sees that his sad feelings upset his mother, who is often sad herself. His father cautions the boy against “feeling sorry for himself” and encourages his son to “show mom how strong you are.” The boy grows into an adult who experiences anxiety about being sad. It’s especially our early experience of mixed feelings toward loved ones, of being enraged with a parent whom we depend on for our well-being, that trigger inhibitory emotions like anxiety and guilt and the sort of internal conflict that recurs at later stages of our lives, often in the context of other significant relationships. 

Related: Revising the Script: Making Changes in “Couples Therapy”

And yet, most of us don’t walk around anxious all day, if we can spare ourselves the distress. Our standard operating procedure is one of avoiding emotional conflict and anxiety. Full-blown anxiety signals that one’s usual -- automatic or reflexive -- defensive arsenal is failing and that “dangerous” feelings are now threatening to come into consciousness. In this apparent threat, however, lies a real opportunity for growth.

Treating Anxiety Through Exposure to Feelings

The most powerful and lasting form of treatment for anxiety involves exposure to fearfully avoided feelings and impulses. As a condition for such work, a patient needs to be able to bear a certain level of anxiety without resorting to avoidance and defense. While techniques of breathing, grounding, and tracking physical sensations can be indispensable, in this regard, for down-regulating anxiety, the point is not simply to reduce but to build tolerance for anxiety. If you can tolerate your anxiety then you can follow its signal to its source in underlying feelings and conflicts.  

Effective exposure to previously disavowed feelings facilitates greater mastery -- flexibility, fluency, agility -- in one’s emotional life. In psychodynamic therapy, specific kinds of talking and listening promote such exposure. For starters, the therapist helps the patient to notice and name an implicit thought or impulse, which can allow it into the patient’s experience more directly and prompt them over time to become more aware of what they’re doing, thinking, and feeling. The therapist also routinely calls attention to the patient’s defensive efforts, which fosters the patient’s awareness of them and gradually motivates the patient’s willingness to relinquish their defenses in favor of fuller exposure to feeling.  

In working with the patient to put words to an experience (“it sounds like you were angry with Trevor”), the therapist is also helping the patient to speak about seemingly “unspeakable” material so that it can become more acceptable and amenable to reflection. When effective, this exercise goes beyond an exclusively intellectual discussion about one’s feelings. Finding descriptions for their experience can also help the patient to re-experience warded-off feelings, a crucial step in healing and change. The patient may finally be ready to face and feel their anger toward Trevor; naming that feeling can intensify it, enable the patient to explore its resonances and possible uses, and ultimately to incorporate it more productively into their life. 

For exposure to be truly therapeutic in these ways, the therapist must afford the patient a sense of safety. Allowing the patient to approach distressing material gradually and to move at their own pace enhances their growing sense of mastery in handling internal and interpersonal difficulties. Crucially, as psychologist and psychoanalyst Paul Wachtel underscores in his book on therapeutic communication, the therapist must also enable the patient to confront previously avoided feelings and thoughts in a manner that does not feel demeaning. For what often feels most threatened by newly conscious impulses and desires is the patient’s self-esteem. 

The task of the therapist, then, isn’t simply to confront the patient with some truth that they had hidden from themself. It’s to empower the patient to become more self-accepting -- that is, more capable of integrating into an evolving sense of self the experiences and inclinations they had been warding off. 

 You don’t have to go this alone. 

*In response to the COVID-19 pandemic, we continue to offer telemental health sessions.*

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