This document summarizes an expert's approach to treating anxiety using Acceptance Commitment Therapy (ACT). It notes that anxiety is commonly reinforced by seeking medications or avoiding uncomfortable feelings. ACT aims to help patients accept their feelings, be present in the moment, and commit to valued actions rather than escaping discomfort. The expert discusses techniques like mindfulness, compassionate self-talk, and identifying values to move patients from suffering to living engaged lives.

1. DEALING WITH
ANXIETY:
THE TRAP OF
REINFORCING THE
SYMPTOM
JOSEPH A. TRONCALE, MD FASAM
RETREAT PREMIERE ADDICTION TREATMENT CENTERS

2. ANXIETY AS THE MOST COMMON
COMPLAINT IN MY PRACTICE
• If you could be a fly on the wall in my office, by far the
phrase that I hear the most is: “Doctor, I need help
with this anxiety.”
• People are suffering a great deal.
• Let us look today at what causes this great suffering
and what we can do about it.
• Also let us look at what we should avoid in our
attempts to help.

3. PATIENTS THAT I SEE HAVE ALREADY
BEEN CONDITIONED TO LOOK FOR
MEDICATIONS
• I work in drug and alcohol treatment, so people with
addictions look for a “fix” in or out of their addiction.
• (This is no different than non-addicts, however. Non-
addicts can “get away” with more drug use because
they suffer fewer consequences, so it is less of an issue
generally.)
• So what should our approach be to anxious people
who come for advice, counsel and treatment?

4. THE OUTLINE FOR TODAY
• What is anxiety?
• Do we, as therapists, have a approach that we feel
confident is helpful?
• I would like to discuss some pitfalls in the treatment of
anxiety.
• I plan to share my experience with the use of
Acceptance-Commitment Therapy (ACT). What it is
and how I use it.

5. WHAT PERCENT OF YOUR PATIENTS
PRESENT PRIMARILY WITH ANXIETY?
• 0-25%
• 26-50%
• 51-75%
• 76-100%

6. HOW IS ANXIETY DEFINED?
• “It is helpful to think of anxiety as a reaction to stress.”
Thomas Fogarty, MD
• “a feeling of worry, nervousness, or unease, typically
about an imminent event or something with an
uncertain outcome”
Oxford Dictionary

7. HOWEVER…
• We know that anxiety may have nothing to do with an
“imminent event”
• It may be just sitting there with no known association
or be paired with a past event
• It may be associated with something that will never
happen.
• It may be associated with something that would
otherwise be considered wonderful by an outside
observer.

8. WHAT IS PANIC?
• Panic is the extreme anxiety of actually worrying about
being anxious.
• Anxiety likes to feed on itself and intensifies as one
attempts to suppress it.
• It is the “Chinese finger trap” of psychological process.
The harder you try to escape, the more surely you are
caught and stuck.

9. SO…
• Can we conclude that anxiety has a timeless quality?
That is, anxiety knows no time frame?
• If so, we basically put the parameters on our own
anxiety…
• But anxiety is not something that we are able to
consciously deal with once it gets past a certain point.
Where is “THAT” point?

10. “THE POINT OF NO RETURN!”
• Think about your own “anxiety breaking point.”
• How much can you tolerate before “losing it?”
• What situations can you think about in your own life that have
taken you from feeling in control to feeling the inner chaos to
feeling fear and reactivity?
• How quickly does it happen? What is necessary for the point of
true anxiety to appear?

11. HOW MANY TIMES HAVE YOU BEEN
TOLD: “DON’T WORRY ABOUT IT!”
• “Stop worrying!”
• It is like asking the passenger in the back seat of the
car to stop the vehicle.
• More helpful perhaps: “What are your possible actions
given the current circumstances?”

12. CONTROL
• Control is the great illusion of anxiety.
• There is no brake, there is no button to push, there is
no computer mouse, no fire extinguisher, no nothing.
• In the end, there is nothing to control anxiety.
• But our brain can’t easily accept the fact that
circumstances cannot be manipulated to do what we
want all of the time.

13. SO WHAT DO WE SEE IN THE
ANXIOUS PERSON?
• Fight or Flight
• The common denominators are rigidity, autonomic
overdrive, and fear in some form(s).
• It may be physical rigidity or hyperkinesia
• It may be psychological rigidity or distraction
• It may be relationship rigidity (doing the same thing all of the
time or doing nothing the same all of the time)
• It may be communication rigidity (not listening, rapid speech,
too much verbiage)

14. THE FIVE LAYERS OF ANXIETY
ACCORDING TO FOGARTY
• Masked anxiety
• Anxiety
• Depression
• Emptiness
• Inner Death
• Inner death is the hopelessness associated with the idea
that there is only anhedonia from here on out.

15. CLINICALLY, IT IS IMPORTANT TO
RECOGNIZE THESE LAYERS…
• To move people out of whatever layer they are in is
not up to us as therapists or doctors, but it is
important to support the person where she/he finds
him/herself emotionally. If people are paralyzed with
fear or anxiety, then medications or hospitalization is
indicated. If, however, the person is not to a point of
paralysis, then there is the opportunity to work outside
of critical care parameters.

16. “WHY” IS NOT A GOOD QUESTION IN
THE TREATMENT OF ANXIETY
• Treating anxiety is generally about diffusing the laser-
like concentration of emotion and going two or three
feedback loops back in the person’s psychological
timeline.
• The psychological timeline should be differentiated
from the person’s actual life.
• You may be thinking about something in the future or
far distant past which may be the last thing on your
psychological timeline.

17. THE MYTH OF “THE ANXIETY-FREE
LIFE”
• Anxiety is a part of life, not an aberration.
• It is an adaptive mechanism, not a fault
• Perfectionism is an escape mechanism, not an
achievable goal.
• Catastrophic thinking is not a cushion to keep bad
things from happening, it is another escape
mechanism so that defeat is incorporated into what
would otherwise be normal life.

18. TRADITIONAL WAYS OF TREATING
ANXIETY
• Medicate (either by prescription or by not.)
Something of a quick and dirty solution…
• Gets rid of the feeling temporarily
• Generally reinforces not dealing with causality
• “Talk it through” (Mostly a temporary fix)
• Distract (Escape)

19. MEDICATION
• Self-medication with alcohol or drugs
• Prescription medications such as benzodiazepines can
lead to addiction, but more importantly have a
rebound effect of increasing the symptom over time
and resetting neurochemical receptors.
• The more gamma amino butyric acid (GABA) receptors
you fill, the more you make. The more alcohol or
benzodiazepines you use, the more anxious you
become when you run out of alcohol or drugs.

20. WHEN MEDICATION IS ESSENTIAL
• For individuals who are suffering with anxiety
secondary to severe trauma, there may be no way of
helping the individual until the limbic system is
brought down to a “fight or flight” level that is
acceptable.
• This can be done with non-addictive medications that
calm deep limbic structures so that the individual can
begin to work on what will make changes in the
anxiety symptoms.

21. TALKING IT THROUGH
• Talk therapy of various forms can be helpful if it does
not reinforce the idea that “talk without change” is
useful.
• A good therapist will know how to avoid circular
thinking of this sort, but a lot of people talk to non-
professionals with their anxiety and it only serves to
harden the anxiety.

22. ENTER ACCEPTANCE-
COMMITMENT THERAPY (ACT):
• Developed by Steven Hayes and Russ Harris
• Third Wave of Cognitive Behavioral Therapy
• Basically states that an individual can accept feelings
and move toward values or the individual can escape
feelings and move toward suffering.

23. MOVING FROM SUFFERING TO
LIVING
• Simple concept, but anxiety ruins it for people.

24. THE ACT “TRIFLEX”
• There are three behaviors that lead to what is called
“Psychological Flexibility”
• These are:
• The ability to “open up”
• The ability to “be present”
• The willingness to “do what matters.”

25. OPEN UP
• ACT discusses the concept of “fusion”
• “Fusion” in the ACT model is, as Russ Harris says,
“Getting entangled with our thoughts and getting
pushed around by them.”
• In my opinion, anxiety, without clear and present
danger, is the manifestation of fusion. That is, anxiety
is the inability to recognize thoughts as constructs
rather than as reality.

26. EXPERIENTIAL AVOIDANCE
• When individuals have uncomfortable feelings, they
tend to avoid them rather than face them.
• Who wants to face pain? Yet, if we do not, we store up
emotions that will eventually “come out sideways.”
• The “beach ball” analogy.

27. DEALING WITH FUSION
• Creating awareness of experiential avoidance:
• What are your thoughts when you are anxious?
• If you kept a diary, what percent of the time would you be
anxious?
• What do you struggle with in your thoughts?
• What do you do to resolve the issues?
• What negative talk to you hold on to?

28. NEW THOUGHTS
NEW MANTRAS
• The Three-Chair Exercise in Emotion-Focused Therapy
• Set up three chairs
• Have the patient (Jim) sit in chair #1
• “Jim #1, talk to Jim #2 and tell Jim #2 all the negative things
you tell yourself about yourself. Now move to chair #2 and Jim
#2 defend yourself to Jim #1.
• Move client to chair #3 and have Jim #3 speak compassion to
Jim #1 and Jim #2.
• What will you get?

29. ANXIETY BRED FROM SELF
HATRED AND NEGATIVE SELF TALK
• Trying to keep people out of chair #1 and chair #2.
• Putting oneself down and defending oneself in an
exercise in futility, anxiety and primitive thinking.
• Only by sitting in chair #3 and practicing self-
compassion can one achieve an anxiety free state.

30. BE PRESENT
• We all know about mindfulness.
• It is important that we help train our patients/clients in
the discipline of staying in the present moment.
• There are 4 states of being in this paradigm.
• Past (associated with shame and guilt)
• Future (associated with anxiety)
• Nowhere (associated with escape into numbing, perfectionism,
overwork, catastrophic thinking)
• The Present (what is at the moment)

31. DO WHAT MATTERS
• What is a value-driven life?
• How do you identify what you value?
• Are you escaping your feelings and moving away from
your values or are you actually doing what YOU want
to do?
• The “bus-driver” analogy

32. WILLINGNESS IS NOT THE SAME
AS TRYING
• “Trying is Dying.”
• Many of my patients tell me that they are going to
“try” to make the changes we have suggested.
• Saying “I’ll try” is a socially acceptable response to
suggestions, but it does not cut the mustard with
regard to ACT. Willingness is the key whether we are
talking about changing addictive behaviors or anxiety-
associated behaviors.

33. IN CONCLUSION
• Anxiety is suffering
• Suffering is a part of life
• Some forms of anxiety require medication
• Most forms of anxiety require a willingness to
“unhook” from feelings, move toward values, and stay
in the present.
• It takes practice and discipline as well as the belief that
change is possible.

34. THANK YOU VERY MUCH
• Joseph A.Troncale, MD FASAM
• Retreat Premiere Addiction Treatment Centers
• josepht@retreatmail.com