Effective Anxiety Treatment Must Focus on Effort Versus Outcome

As professionals tasked with helping our patients overcome debilitating anxiety, we need to continually seek ways to motivate patients to face their worst fears. This is no small feat! Essentially, we need to create a therapeutic environment that praises effort rather than outcome. By framing our therapy from this perspective, we help the process of exposure-based therapy generalize to life circumstances outside of the therapy room, and even to circumstances that arise years after face-to-face therapy meetings have terminated.
To determine why this shift is important, let’s consider the differences between a focus on effort versus outcome for a student who suffers from Social/Performance anxiety. Perhaps a student meets with his or her therapist to be able to overcome test anxiety so that he or she can perform better on standardized tests for college.  Outcome-based therapy will develop a hierarchy, exposures and perhaps relaxation and mindfulness techniques all with one goal in mind: better performance on the standardized test. Therapy is a considered a “success” if the student achieves an acceptable score on the test.
Is there a down-side to this scenario? Yes.

While the therapy has targeted and alleviated the identifiable symptom of Social/Performance Anxiety, the therapeutic process has done nothing to address the core underlying fear and therefore the symptoms are likely to arise in a different format in the future. An effort-based therapy is based on the assumption that Social/Performance Anxiety stems from a fear of judgement or criticism that accompanies the poor score, and the belief that the individual will not be able to tolerate the judgement or criticism. Therefore, we need to expose the individual to criticism or judgement. Paradoxically, this conceptualization means that the individual will only perform better once he or she accepts that failure is an option.
Here are some basic principles for creating effort-based therapeutic interventions:
1) Psycho-education. First, normalize the fear and the patient’s fear response. Typically, this is done by explaining the Fight or Flight Response and how our innate wiring for survival sometimes sends miscues that cause us to perceive non-threatening stimuli as a risk to our survival. Of course the individual is reacting in an irrational way – their brain is telling them to fight for their life or run for their life! One purpose of therapy is to teach the individual how to respond differently when their Fight or Flight response is triggered by non-threatening stimuli.
The basic principles of CBT are founded on the premise that we cannot control our feelings or our thoughts. (We can only control how we react to our maladaptive feelings or thoughts.) However, we can control our actions or our behavior. This normalizes the faulty thoughts and feelings, and also offers a solution for the person who is suffering: doing something different in the face of fear is in fact allowing you to ultimately beat the fear. Most importantly, this message reframes the situation for the individual who is suffering: The focus is on the effort behind the action (effort-based therapy) rather than the presence of fear or faulty thoughts (outcome-based therapy).
Psycho-education must also emphasize the efficacy and purpose of exposure-based therapy.
2) Establish clear goals. The goal is to target the cause of the symptoms, not the symptoms themselves. Regardless of the diagnosis, be clear that the purpose of therapy is to decrease self-criticism and avoidance in the face of discomfort or fear. Therapy will teach the individual that they can handle fear, and that they are capable of tolerating high levels of distress without avoiding the situation that makes them feel uncomfortable. Therapy will not necessarily make the fear go away, it will make the presence of these intense feelings more tolerable.
3) Develop a List of Rules based on things the person can control. At RFC, we introduce the concept of “rules,” which are things that anxiety dictates the individual must do in order to gain relief. For example, in Contamination OCD, a “rule” might mean that someone has to wash excessively. For Social Phobia, a “rule” might be that a person cannot raise their hand to ask a question. A general “rule” for anxiety is to avoid situations, people or places that bring fear.
In effort-based therapy, we want to focus on breaking the rules, rather than outcome-based therapy which will focus on not feeling afraid or thinking bad thoughts. This keeps the outcome of therapy within the individual’s control and rewards a concept that can easily generalize, which is, “Even when I am afraid, I can still live my life without allowing the anxiety to interfere with my ability to function.”
4) Continually reinforce bravery. In this sense, bravery means to continue a task in the face of fear. Being brave is an effort.  For children, I have had success in encouraging families to create a “bravery points” reward system. Children can earn points for anything that is brave, not merely breaking rules from our pre-determined list. This also helps to generalize the response, and instill the concept of bravery as part of that child’s personality. A similar concept can be applied to therapy with adult patients; while a check and balance reward system may not be appropriate, we can encourage an adult patient to keep an Accomplishment List and write down every moment they were brave. Be sure to have the adult include circumstances that are not necessarily related to their anxiety, so that the concept generalizes. For example, an adult who has a specific phobia of bridges could list an accomplishment as standing up to a bully at work. Superficially, bridges and confronting bullies are separate issues; at the heart, both require “bravery.”