I often hear patients express concern about an event or a situation of some kind for which they are experiencing something known as "anticipatory anxiety." This is a heightened sense of worry and vigilance about some dreaded event or experience that the anxious individual fears might be overwhelming. It is what I call the "what-will-happen-next" fear.

Natasa Adzic/Shutterstock
Source: Natasa Adzic/Shutterstock

There is a natural tendency to back away from things or situations that create tension. When someone suffers from anticipatory anxiety—whether it is a single episode or a form of chronic anxiety—avoidance may provide temporary relief, but not help overcome the source of the fear. Supportive friends and family often assist the sufferer in his or her efforts to avoid the source of distress wherever possible.  Sometimes avoidance is seen as a reasonable response. If you can reduce or eliminate anxiety reactions by avoiding the feared object or situation, why not do so? This works adequately when the object of anxiety is easily avoidable for most people, e.g. snakes and spiders or public speaking. In other cases,  avoidance is unrealistic, as in fear of heights, elevators, flying, or dogs.

One of the treatment options for anxiety that results in avoidance is called exposure therapy. This involves exposure to the fearful stimulus in a safe and controlled setting; frequently the therapist's office. The patient is subjected to the feared stimulus as part of the therapeutic process. One simple form of exposure therapy is systematic desensitization, where exposure is gradually increased until the person is immersed in the fearful situation. Gradually the anxiety recedes and the fear itself fades away. This method of treatment is not for everyone, but for some, it can be very effective. It is the classic form of overcoming a fear by handling it rather than avoiding it. Another therapeutic intervention that promotes managing a fear is modeling. In modeling, the client observes others (the "models"), who are responding in a relaxed way when in the presence of the feared stimulus. The patient is encouraged to imitate the models, thereby reducing the patient's own response to the fear.

Claire entered therapy for a variety of problems, but her fear of riding in elevators was her greatest concern and the first issue she wished to tackle in therapy. Her fear had been present for several years and she believed it to be traceable to a friend's experience of being stuck in an elevator for over an hour in a New York City building. The friend shared her frightening experience in graphic detail, and Claire said "I haven't been the same since." Claire's handling of this fear consisted primarily of avoidance. For her, this meant walking up and down 22 flights of stairs to her office in a Manhattan skyscraper, living in a three-story brownstone building, staying in hotels with escalator access to low-floor rooms. Exposure treatment, which involved Claire and I spending many sessions near an elevator and eventually in it, was initially overwhelming for her, but in the end it worked. She successfully tolerated her anxiety which gradually diminished with repeated exposure. After years of avoidance, Claire felt the predictable empowerment of having truly overcome a fear by achieving mastery, rather than just "getting by" through the stressful and extraordinarily limiting avoidance of elevators.

There are countless conflict situations that require a direct approach and the courage to confront, rather than avoid. Where appropriate, patients find ways to handle the difficulties that they are confronting in their lives, rather than seek relief by avoiding them.

One of the important objectives of therapy for many people is to learn effective ways of handling the difficult and complex challenges of life. Whether asking for a raise from a stern boss, discussing a grievance with a romantic partner, or any other situation that creates anxiety, directly handling matters will always be a more effective response than avoidance.

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