With the advent of the Internet, our “hive mind” (the sum of all our thoughts and ideas) became a living, breathing thing in cyberspace, like Jung’s Collective Unconscious made manifest. This has led to a vastly increased sophistication about mental health matters among the general public.
When life coaching came along, it brought with it an (over?)abundance of advice on how to live a better life.
Add to this the challenges that come with a global population of 7.6 billion people, and you have a level of stress that is daily growing, and the need for solutions to that stress.
The result? Mental health awareness has never been greater.
But at the same time, mental health disorders are on the rise. And this has led some to ask “Does counseling actually help?”
The (I hope) obvious answer to this question is “of course!”–anxiety therapy techniques can help. We have plenty of psychotherapy outcome studies that prove the point. Nevertheless, we can and must do better. According to one meta-analysis from the Canadian Psychological Association, our success rate in treating various anxiety disorders only averages around 46 percent. In general, the meta-analyses show that cognitive-behavioral therapy (CBT) is the most effective technique available for anxiety. But in their study, Hofmann and Smits (2008)* conclude that “while CBT is effective, there is considerable room for improvement.” Clearly, this applies to counseling as a whole.
Since our interest is primarily on anxiety, let us examine the effectiveness of specific types of anxiety therapy. Of course, there are hundreds of different schools to choose from, but our Deconstructing Anxiety model** proposes that we can categorize them in three classes: those that emphasize insight, those that emphasize action, and those that recognize the need for a balance of both insight and action. We have addressed this topic in our last blog, discussing the point that what makes for the best anxiety therapy is the combination of insight and action, but will explore it here in the context of whether and why counseling can help.
Another point before we continue. When asking what is the best type of anxiety therapy, we must also ask who makes the best therapist for anxiety. The answer is the same: the therapy and the therapist that work with a balance of insight and action have the best chance of being effective.
Let’s see how this plays out now in three of the more well-known types of psychotherapy. Exposure therapy
Exposure therapy is one aspect of cognitive behavioral therapy, but it is also considered a stand-alone treatment. I propose, in fact, it is the essence of the action component involved in any effective treatment. Exposure therapy means, quite simply, that one exposes oneself to the problem, rather than defending against it. In popular lingo, this is similar to the idea of “facing one’s fear”. In such an exposure, one may have the direct discovery that nothing awful has happened, and what they were so anxious about, therefore, is nothing to worry about after all.
However, if the exposure is not joined with insight into the correct problem that one must face, it can not only be ineffective but hurtful. I have a client in practice now suffering from social anxiety disorder. He was originally working with an exposure therapist that advised him to face his fear of social situations by going to lunch with his work colleagues every day. He did so bravely, but to no positive effect. The problem, we discovered, was that he was holding a hidden thought that he would tolerate the exposure until he could get back to his cubicle at the office, and be relieved of his anxiety then. In other words, it was not a true exposure. With this insight, we were able to design an exposure where he could not “get out of” his anxiety. We devised ways to have him tolerate social situations for
longer and longer stretches of time, until he would reach the point that he no longer had to leave the scene. While still in the middle of treatment, his progress is significant.
Psychoanalysis and psychodynamic psychotherapy
This is obviously the oldest type of counseling for anxiety. Freud did us all an extraordinary service by introducing the idea that insight (into the unconscious) is a valid path to healing. With a deep enough insight, one can even discover a “cure” without apparently taking action. I propose, however, that if the treatment does lead to a lasting cure, it is because there was, in fact, an “action” that took place–the patient must have released the defenses that were keeping the insight hidden previously, in order for that insight to be achieved. As in exposure therapy, this is the action required for healing… again, “facing one’s fear”. All too often, however, psychodynamic psychotherapies fall. short on the action component. With its heavy emphasis on insight, progress is too often slow or absent.
Davanloo’s intensive short-term psychodynamic model has made an attempt to rectify this problem. He uses the dynamic insight to suggest ways to encourage action, using “pressure”, “challenge” and “the head-on collision” techniques.***
Cognitive behavioral therapy
Cognitive behavioral therapy is an umbrella term that encompasses many different approaches to resolving anxiety, including exposure therapy as mentioned above. In general, its thrust is to“dispute irrational thoughts“. This can involve a degree of insight, where one recognizes certain categories of irrational thoughts, such as catastrophizing, globalizing, etc. But in my experience it is often the case that a deep enough insight, one that can effect true and lasting healing, is not achieved. The action component can be found in what is sometimes called a “cognitive transformation“, choosing new thoughts to replace the irrational ones. Again, this action is taken internally, but it still represents action. And, of course, the practice of exposure therapy is all about action, as we have said. But without a deep enough insight and a concrete enough action, the patient/client may fail to make gains.
Again, this is only the briefest of explorations. My hope is that it suffices to illustrate the point that therapy can indeed help relieve anxiety, but in order to do so it must find an effective balance between achieving deep insight, and taking the corrective action suggested by that insight.
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*Hofmann, S. G., & Smits, J. A. (2008). Cognitive-behavioral therapy for adult anxiety disorders: A meta-analysis of randomized placebo-controlled trials. Journal of Clinical Psychiatry, 69(4), 621–32.
**Pressman, T. (2019). Deconstructing Anxiety: The Journey from Fear to Fulfillment. Maryland: Rowman and Littlefield.
***Davanloo, H. (2000). Intensive short-term dynamic psychotherapy: Spectrum of psychoneurotic disorders. In H. Davanloo: Intensive short-term dynamic psychotherapy: Selected papers of Habib Davanloo, MD. (pp. 1-35)