Building Effective Collaboration with a Highly Anxious Client

A common scenario that many of us see in our practices is the over-functioning wife with the anxious-avoidant husband. He is a highly anxious procrastinator  and is often not accountable for what he says he will do.

Working with this dynamic can be challenging because of the extensive intrapsychic issues that exist with the longstanding painful pattern of avoidance and criticism  between the two partners. Last past month in my online training program, a therapist presented a case with this pattern.  Here are just a few of the challenges presented by the husband:

  • He self-sabotages and doesn’t stick with anything.
  • He has social anxiety and has difficulty looking for work.
  • He smokes pot to manage his anxiety and fear. Chronic pot smoking prevents him getting motivated to do the things he wants to do. He uses his chronic substance dependency to sabotage his efforts to do things and he has a hard time committing to giving it up.
  • He has never been faithful in relationships.
  • He has an approach-avoidance relationship with his mother. He can speak to her freely on the phone but can not tolerate being with her.

Pete did a role play, transcribed  below, to demonstrate how to start uncovering the value of his anxiety.

Husband:  I don’t know, I think sometimes anxiety gets to me – social anxiety. I have things that build up in my head that aren’t true. I think of turning my application in and talking to someone. I think of a million reasons why I shouldn’t. It’s not that I don’t want to. I get real bad social anxiety about how the person is going to deny my application anyway. I can talk myself out of things. It’s my fear of failure without trying. I get caught in these cycles.

Pete:  First of all I appreciate your insight and your awareness on this. Good for you. You may not even fully appreciate the value of your anxiety. Do you have any idea what I’m talking about, that your anxiety might serve a useful function?

Husband:  No.

Pete:  Wow, well if I share my observations how it might be useful. Is that ok?

Husband:  Sure.

Pete:  Think about this for a minute. If you get anxious, what happens is you don’t move forward or take action. Is that right?

Husband:  Right.

Pete:  And if you don’t take action, then you don’t risk getting what kind of feedback?

Husband:  Negative feedback.

Pete:  Yes, negative, painful, critical, judgemental feedback. If you don’t take action you avoid that negative feedback. How much negative feedback did you get growing up?

Husband:  Lots.

Pete:  Lots. So if I’m in your shoes I don’t want to put my finger back in that pencil sharpener again and risk emotionally getting rejected, humiliated, or embarassed with negative feedback. So as painful as it is not to take action, it’s even more painful to take action and get that kind of rejection. So in one sense, I imagine  your fear serves a positive purpose for a part of you…                                                                           What do you begin to feel as I say this to you?

Husband:  Wow, you’re completely right. It helps me this way.

Pete:  Fear often serves a purpose for some  part of us, and you got such a belly full  of criticism, rejection, beatings, no wonder a part of you says, “I don’t want another helping of this.” So if I’m in your shoes, why would I want to sign up and risk another helping of that? I don’t think I would.

Husband:  That’s exactly what happens.

Pete:  Yeah, now here’s what’s interesting. We can go back  to some of those early times in your life when you felt that fear –  that huge painful judgement –  and I can help you  take some of the pressure and pain out of the emotional brain so you can remember without as much emotional intensity from that memory. This may free you up to take more action that relates to what another part of you wants to do to get on with your life. How does that sound?

Husband:  That sounds great.

Let’s review what is behind Pete’s interventions.

First he does the unexpected. He gives the husband a compliment (being insightful) instead of jumping in immediately to challenge the symptom of avoidance.

Then Pete proceeds to uncover the positive element of the anxiety instead of approaching the problem head on as something that needs to be mastered or controlled. He asks the husband if his anxiety might serve a useful function.

It is rare for partners to appreciate the usefulness or value of their symptoms. Internally they create a struggle in an attempt to dominate or eliminate the symptom. This dynamic is unfortunate as it mostly increases their distress.

Sometimes therapy minimizes the value of the symptom and focuses on more empowered thinking as a better way to cope. But minimizing the protective function of the symptom paradoxically slows down the incorporation of new perspectives.

When Pete asks if he could share his observations, it subtly suggests that the husband is in control and has the power to say yes or no. The reality is almost no one will say no. However, Pete is sowing the seeds to create effective collaboration. So far Pete’s interventions are subtle and nuanced but they add up to making substantial inroads in a short time frame.

Pete then says, “Think about this for a minute.” Basically Pete is instructing him to get out of a helpless emotional state and shift to more effective engagement.

Pete asks what kind of kind of feedback the client avoids. Pete continues to engage the thinking brain and reduce the regressive pull into victimhood. He empathically embellishes and justifies the client’s desire to avoid negative, painful, critical, judgemental feedback.

Then Pete makes the connection between the client’s current avoidant symptoms and his early life experiences, connecting the dots and describing why his symptoms have a positive intent.

Next Pete checks out the impact of his interpretation by asking the client what he feels.

Pete continues to describe the value of the symptoms which potentially helps reduce some of the shame and guilt. Then Pete sets the stage to do two-chair gestalt work along with EMDR or energy psychology work to enable the two alter egos to be collaborative instead of adversarial.

In summary, it is a skilful example of helping a client move from resistance, shame and passive-aggression to effective participation in therapy. Pete makes it look effortless.

He repeats the process later with respect to a different issue – potential infidelity. I’d like to share Pete’s explanation and then use it as a springboard for discussion.

Pete says, “The part of you that’s afraid you’ll be unfaithful is understandable, and one of the ways I understand it is that thinking about infidelity gives you an escape hatch from having to depend on your wife. You feel less trapped. It’s totally understandable. One part of you really wants to connect with your wife and do things differently and another part of you gets so scared. You start getting really tight around the collar when you think about being trapped, you hear ongoing criticism. And there’s no way out. Infidelity is your escape hatch – it’s totally understandable that a part of you would feel that way.”

Do you think Pete’s explanation will help stimulate change? Why or why not? Can you think of other situations where couples might benefit from your explaining the value of their symptom?

I always look forward to reading your responses.

A special thanks to Jozeffa Greer, a Sacramento-based Couples Therapist, for bringing this case forward.

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Paul McCandless, MFT
Paul McCandless, MFT

In many ways people’s greatest fear engaging with therapy is fear of having a professional confirm they are “crazy.” Insofar as they are often dragged to couples therapy by their totally frustrated and hopeless partners, this fear is often alive and well in men. So doing anything I can do to normalize or make sense of what they are doing is often especially helpful. Particularly in the early stages of treatment. But it is also important to make certain they do not view this as positive reinforcement. This also must be linked to how their coping strategy may not be eliciting the same results for them as it once did.

Carmen Cubillo, LAC, LAMFT
Carmen Cubillo, LAC, LAMFT

I really liked how Pete approached this clients anxiety about the coming to therapy issue directly and showed that the anxiety helped to serve a purpose and also how Pete quickly connected the feelings to some point in the past time and shoed how those feelings were being repeated in the present, that works great,…the phrase “freeing up” part of the self is catchy and one gets this visualization of a computer clearing memory, creating some space for new information to be available or making a cleared space for new possibilities. This opens up hope as well, really useful.

The part I have a slight problem with is the second part. The case study tells us that “He has never been faithful in relationships” that never, is a big one…. Pete downplays this and says …”the part of you that is afraid you will be unfaithful.”…I do not think he is afraid to be unfaithful, in fact he has a history of infidelity. It is just not a “thought” as Pete suggests.
Doing this however, does save face for the guilt he “might be feeling”. We are not told that the client has said he feels any guilt, he might or he might not. This really depends on the client and the situation. Is the wife in this session as well? What is she feeling hearing this in the first session? Did she get any support in this session too? Sometimes creating a real “long shot” new narrative can save relationships and I think this was Pete’s goal here, downplay it for now to connect with the client.

The client says he suffers from “social anxiety”, yet he is able to successfully continue engaging women to cheat with, so “part of him” is not so socially anxious that he can’t s interact sufficiently get new girlfriends. Yes, I agree with Pete that the infidelity could be being used as an “escape hatch”, but it could also be true that the infidelity is motivated by less reactive and more selfish ego driven motives.

The client might want to keep an imbalance of power in the relationship or keep his options open, just in case he sees anything better. There might also be the joy or rush of conquest and pursuit, addiction issues, loss of “in love” feelings and many other reasons. With time I would explore more as far as the infidelity issues, not just jump to the “escape hatch” theory so quick. I think it would be unfair to his partner not to explore it in greater detail, so this pattern or behavior can finally be understood and hopefully finished.

It does give the client a very easy out and that might have been necessary if the client was so anxious that Pete could have lost him (and that would be a decision for Pete to make from what he is observing in session). Pete might have needed to use this quick “escape hatch” metaphor to get the client to really engage in therapy, build rapport and not run. I think using EMDR and the Gestalt were an excellent way to finish. I wish Pete would have given us more detailed information on this and how the client reacted after these interventions.

You are right, Pete does make it look easy, ties everything up rather well, with a difficult situation and a less than willing client. Thank you for presenting this and allowing feedback on your techniques. It is very helpful to read other therapists comments as well on your site.

al potash
al potash

Carmen, You rock !
I feel that we can empathize and almost collude with patients and give them a ” credible” rational to stay stuck. You really hit it with acknowledging the power imbalance. A friend once referred to it as the “tyranny of the helpless”.
It is my belief that the above techniques quickly establish rapport but, they have to be balanced with accountability. The clients grandiosity and entitlement have to be addressed, as well as his pot addiction. I Wonder if he ‘s really “sweating it”. He gets to stay home smoke pot and act out all from a victim, helpless role.The only down side is that he has to deal with a “nagging wife” .
Carmen, I’m glad you brought up the wife. It would be crucial to know why he’s in therapy. Has he “bottomed out” or has he been been compelled by his wife. Is she “fed up” and ready to kick him out. If so this can be important leverage to motivate him.
Empathy has be balanced with accountability. How fed up is she? Is she willing to do this for another 5 or 10 years?
Sometimes the client needs clarity of consequences. That his behavior may not be open ended . How ls it that the wife accepts this behavior? How long will she tolerate it? Perhaps she needs to be empowered, reminded that she has choices and options and that he is not as helpless as he presents .

Paul McCandless, MFT
Paul McCandless, MFT

Carmen you make some great points. With regard to the vague reference to infidelity, the vignette fails to make clear to what extent, if any, there has been unfaithfulness. So, at the risk of being accused of defending adulterers (which I am not), I do question whether all infidelity has to do with “selfish ego driven motives” “an imbalance of power in the relationship” or keeping one’s options open in case something “better” presents itself. Can’t infidelity come in a variety of shapes and sizes? What about online porn? Is that an “affair?” Many non-participating partners will react as if it is. How about workaholics? Aren’t the conflicts about a partner spending too much time at work similar to the conflicts that arise after the disclosure of an affair? Certainly, the trauma of an affair is more intense in kind and quality but, affairs and their perhaps less traumatic cousins do have some features in common. My point is that Pete’s intervention I think illustrates an approach to helping the client see that there may be wisdom in their behaviors and thoughts but those same behaviors and thoughts can, at the same time, be maladaptive. Gently moving the client into the dilemma they have created for themselves might just generate enough “healthy anxiety” so as to move the client to contemplate change.

Kathy Pauley
Kathy Pauley

Thank you for this blog. I love working with couples, and very much want to take a training from you guys. Do you have any on-site trainings in the near future, or possibly next year sometime?

Kathy Pauley, LMFT
Kathy Pauley, LMFT

Thanks again for the blog.


HI Kathy,

Please visit, which is a link to our great online training course. It’s full at the moment, however we are going to open it in the next few weeks for registrations. Add yourself to the waitlist and you will be notified when it’s open.

Beverly Zagofsky
Beverly Zagofsky

I would also add that the patient may be betraying his wife to avoid feeling trap but also because he has so much anger. It is a passive aggressive way of hurting his wife with out telling her.

Dr. Ellyn Bader

Dr. Ellyn Bader is Co-Founder & Director of The Couples Institute and creator of The Developmental Model of Couples Therapy. Ellyn is widely recognized as an expert in couples therapy, and since 2006 she has led innovative online training programs for therapists. Professionals from around the world connect with her through internet, conference calls and blog discussions to study couples therapy. Ellyn’s first book, "In Quest of the Mythical Mate," won the Clark Vincent Award by the California Association of Marriage & Family Therapists for its outstanding contribution to the field of marital therapy and is now in its 18th printing. She has been featured on over 50 radio and television programs including "The Today Show" and "CBS Early Morning News," and she has been quoted in many publications including "The New York Times," "The Oprah Magazine" and "Cosmopolitan."
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