Coping Skills and the Anxiety Tug-of-War: Why I Don’t Like Coping Skills Training for Anxiety

By Ferdinando Palumbo, MSW, LCSW, Director NorthernNJCBT.com     

I routinely get calls seeking treatment from exasperated clients that go something like this, “hi there, I was in anxiety therapy for six months, I learned coping skills but they don’t work anymore. Can you see me?” Or, “I learned coping skills to deal with my panic attacks but they still keep happening, can you teach me better skills?” In a group training I was conducting for licensed therapists, a therapist asked me “what are your go-to coping skills for people experiencing panic attacks?” I might not win many friends but, in general, I don’t do any coping skills training for any of my clients experiencing anxiety, OCD, panic or associated symptoms. It would seem that there’s a cultural presumption that if we’re feeling some sort of emotional distress, this will require some sort of behavior on our end to neutralize or reduce the distress—this fundamentally underestimates our ability as humans to endure anxious emotional states.

Many mental health therapists rush to coping skills training when their clients are reporting anxiety, panic, or OCD symptoms. I suspect this is because of our own discomfort as therapists when we see a client in distress. Perhaps we feel pressure to “fix” the emotion for our clients or we can’t stand the idea of our clients being frustrated or distressed. Before I thought differently about distress, I would default to teaching my clients progressive muscle relaxation, mindfulness, deep breathing, and grounding exercises. However,  I think we will find that the application of coping skills training to anxiety, OCD, and Panic Disorder is largely devoid of scientific evidence to support the usage of this approach for anxiety and, in fact, can, in some ways, be problematic or undermine the actual goals of anxiety treatment.

In a meta-analysis examining treatment studies of panic disorder, Meuret and colleagues (2012) found that coping skills training did not improve outcomes when added to Exposure Therapy in most of the studies they examined. Now, I should be clear: the coping skills training wasn’t harmful; it just didn’t really add anything to more traditional Cognitive challenging coupled with Exposure Therapy.

To me, the goal of Anxiety Disorder treatment is to learn that the uncomfortable sensations one is experiencing are completely and utterly irrelevant. I think it is difficult, if not impossible, to both respond to anxious sensations and treat them as irrelevant simultaneously. I call this the anxiety tug-of-war the harder we pull to escape the sensations, the harder the sensations pull back at us. I think this is why I get those calls which I described in the first paragraph, they are unwittingly stuck in a game of tug-of-war. We therapists often invoke the metaphor of the felt anxiety sensations being like a faulty alarm. All the “alarm bells” of an emergency are there but there is not an actual emergency. I would argue that the more we respond to that “false alarm,” even to reassure ourselves that it is merely a false alarm or to lessen the intensity of the alarm bells, the harder it is to learn that the “false alarm” is completely irrelevant to us doing whatever it is we want to do.

After explaining this to a teenage client, he very thoughtfully asked me “well what should I do if I’m feeling anxious?” I responded, “Whatever it is you were doing or want to do. If you are writing an essay and then have a panic attack, write that essay while having a panic attack. “ That is how we treat the anxious sensations as if they are irrelevant.  In Acceptance and Commitment Therapy (ACT—pronounced like the word act), there is a focus on accepting things outside of one’s control and taking values-based action, i.e. doing what matters to you. I think this is a helpful lens to look at distressing emotions in anxiety disorder treatment. We might not be able to get rid of the unpleasant emotion but we can change our relationship to the unpleasant emotion. We can learn to treat the unpleasant sensations as irrelevant and free ourselves from the tyranny of demanding comfort.  We can’t control whether we experience a distressing emotional state, but we can control what we do next. I would encourage readers to choose to do what matters to them rather than fall into the anxiety tug-of-war by trying to reduce of eliminate anxious sensations.