Dear Therapist:

I am 46 and have been living with anxiety my entire life. Every few years I go back to therapy for a while until I start feeling better. Then I stop with my therapist and it gets me through a year or two then it gets bad again and I wind up back in therapy again. I tried medication for a while a few years back but the side effects weren't really worth it. I have done 2 rounds of CBT where I analyzed my thinking patterns and how they affect my emotions and I spent 2 years discussing my childhood and life history with another therapist. They all helped but none of them stuck for longer than 2-3 years after I finished. My question is this: Is this the way it will be? Will I need to be in therapy every couple years forever or is there a method I haven't tried that could help my anxiety become manageable forever? Have I just not found the right therapist? Should I revisit medication? I guess I am fine continuing therapy if that's what's needed. I just wonder if I could be getting a more effective therapy? Thanks



There are many approaches that can be used to help decrease or eliminate anxiety. The particular approach or approaches used and the point in the therapy process at which they are used will depend on many factors. These include severity, progression, patient goals, therapist training and experience, and recognition of underlying factors.

The therapy that you have done may have only dealt with the surface (conscious) aspects of your anxiety. This often helps people to reduce symptoms in the short-term. When properly done and followed up, it can also have lasting effects. However, this can be a long process that requires time and effort.

There are therapy approaches that aim to identify and treat the underlying (unconscious) issues that trigger anxiety. Though the cause of an anxious feeling may seem clear, there is usually an unconscious source for the feeling. For instance, I may feel highly anxious at a party. The cause seems obvious; being around a large group of people makes me anxious. This may be so obvious to me that I never stop to ask myself why this is so. Even if I do, my response will likely be something simple like: I feel uncomfortable because I don’t really know anyone. I don’t recognize that there is a negative emotion that is always looking for an excuse to surface.

In my experience, the most common and fundamental underlying cause for negative feelings is low self-esteem. Although low self-esteem is listed as a symptom of depressive disorders, I have found that it is often at the root of both depression and anxiety. If I don’t feel good about myself on an intrinsic level, my unconscious mind is always on the lookout for “proof” that I’m not that great. At a party where no one approaches me, it’s easy for my unconscious mind to tell me that there’s something wrong with me. If I stammer or say something dumb, I feel like I’m an idiot and that everyone is thinking the same thing. I believe that the negative feelings that I have toward myself are duplicated in the minds of everyone.

Intrinsically based self-esteem does not rely on anything external to define oneself. It allows us to feel good about who we are rather than things like what we look like, what we do, or what we accomplish. Although conventional wisdom refers to external factors to help build self-esteem, I have found that this typically helps only on the surface, and often on a short-term basis. Building intrinsic self-esteem allows us to feel generally better about ourselves, often decreasing or eliminating feelings of anxiety and depression.

Knowing your goals in therapy and having a sense of any unconscious influences can help guide your therapy in the right direction. Regardless of your particular underlying triggers and insecurities, a good therapist can help you to uncover these, helping you to put your anxiety to rest once and for all.

Yehuda Lieberman, LCSW

 psychotherapist in private practice

 Brooklyn, NY   |   Far Rockaway, NY

 author of Self-Esteem: A Primer / 718-258-5317