THERAPIST: So you check to make sure they are okay?
PATIENT: Yeah, but not just once. Over and over again. I worry that maybe I didn’t pay attention, and so I try to read the email out loud so I can remember what I said and be more sure.
THERAPIST: Do you see this as part of your OCD?
PATIENT: Absolutely. At least right now I know it is. But when I’m about to press the send button, I get this terror and I have to make sure again. And then I read it over and over again and it gets out of hand and I’m losing myself because I just want to be 100 percent sure. And then I just lose it.
THERAPIST: Okay, I understand what is happening. And here is what I would like you to do: write an email and tell yourself that of course you are going to want to check. And when you start to worry about cursing someone out in the email, ask yourself if you can label this as anxiety triggered by doubting thoughts that come into your mind.
So we see that labeling the fearful distress as anxiety is often intertwined with the difficulty of accepting uncertainty. We want to help them take that necessary leap of faith that allows them to label the next episode of chest pain or intrusive thoughts as acceptable instead of dangerous. Simply asking oneself the question, “Is this an OCD thought?” or, “Is this a false alarm in my body?” is already the beginning of perspective on the anxiety experience. This beckons the observing self to question the automatic sensitivity and the call to action or avoidance. As we will explore in some detail later on in the book, anxious thoughts are identified not by their content, but by how they feel and by the accompanying urge to respond as if they are a real and present danger. Once there are good explanations for the thoughts and sensations, patients become increasingly aware of an inner “wise mind” that knows it is a panic attack or an obsessive thought and not a heart attack or an uncontrollable urge to do something crazy. The part that knows is just not certain, but wants to be certain. Grayson (2003) has an interesting thought experiment he proposes to help people access their wise mind without demanding certainty, which he calls the “gun test.” (See Chapter 6 on techniques for details.)
Anxious thoughts are identified not by their content but by how they feel and the accompanying urge to respond to them.
How many have received anxious calls from patients complaining about cardiac symptoms, fearing they are having a heart attack? Do you wonder out loud why they called you, rather than 911 or some other emergency medical person? Your patient called because there is some part of him that is aware it is probably not a heart attack, but wants reassurance to be sure. This issue will be addressed in some detail under the topic of “The reassurance junkie” in Chapter 12.
Appendix 2 contains a summary of the labeling process that can be given to patients.
Surrender the Struggle
The goal is to experience anxiety without becoming disappointed, angry, guilty, or ashamed. To neither fight off their symptoms, nor pretend they are not there. Both routes only exacerbate distress. Surrendering the struggle means accepting one has an anxiety disorder, and anxious arousal is the defining symptom. The emergence of anxious thoughts or sensations is neither a failure nor a flaw. Symptoms are just thoughts and feelings, and feelings and thoughts are not facts. Accepting these thoughts involves the paradox of not reacting to them and not entertaining them. Surrendering the struggle means to stop actively trying to relax. Fighting the thoughts and feelings will make them more intense, intrusive, and disturbing. That which we resist will tend to persist.
That which we resist will tend to persist.
It is easier to surrender the struggle when there is a clear distinction between “first” and “second” fears. Help patients accept their “first feelings” of anxiety, without trying to fight off, control, or ignore them. Patients cannot make them go away, and trying to do so will only make their anxiety more intense. It is often helpful for patients to rate their anxiety from zero (no anxiety) to 10 (panic) and observe that it fluctuates up and down. Self-talk can help during these times. Patients can remind themselves with statements similar to these: “Accept—don’t fight.” “I can feel anxious and still do this.” “I will accept this anxiety and continue doing what I must.” “It is okay to be anxious. It is okay not to feel in control.”
Surrendering the struggle is part and parcel of accepting the discomfort of anxious arousal, and accepting the reality of uncertainty when a patient is pleading for certainty. But certainty is a feeling, not a fact. The feeling of certainty is elusive when feeling anxious, and patients must strive to accept that nothing is risk-free or guaranteed, and that doubts may arise about anything and everything. We go on making decisions “as if” things were certain. If not, anxiety can paralyze us by denying the everyday illusions of safety and certainty.
Surrendering the struggle also requires the acceptance of limited control over thoughts, sensations, and emotions. Our brains are structured so that most of those functions are outside of our awareness and our control. There are benefits to accepting this truism so that we are able to focus on what gives us most pleasure and satisfaction, and less distracted by messages that are irrelevant, unchangeable, or both.
Carbonell (2004) suggests these words to describe what we call surrendering the struggle:
Here I accept the fact that I’m afraid at this moment. I don’t fight the feeling; ask God to take it away; blame myself, or anybody else. I accept, as best I can, that I’m afraid in the same way I would accept a headache. I don’t like headaches, but I don’t bang my head against the wall in an effort to get rid of them, because that makes them worse. Overcoming panic attacks begins with working with, not against, my panic and anxiety symptoms (p. 146).
Acceptance and commitment therapy suggests the following metaphor—imagine you and your symptoms are involved in a tug of war, struggling back and forth for control and power. Now, instead of trying to win the war, drop the rope. Observe what happens (Forsyth and Eifert, 2007).
Actively Allow Anxiety
Actively allowing is not the same thing as “putting up with.” Sometimes people accept the sensations, thoughts, and urges, but then count the minutes, wish and hope for it to stop, hold their breath until it is gone, and “white knuckle” their way through the experience. This is not the same as actively allowing it to go on as long as it happens to go on. Allowing is one step further than accepting. It entails willingness not only for the symptoms to be there, but also willingness to be uncomfortable (Twohig, Hayes, and Masuda, 2006). It engages passivity in the face of instincts that seem to be screaming for action, since the most therapeutic way of coping with anxiety is to leave it alone. Again, it is the resistance to anxious arousal that intensifies and empowers it. So the best thing to do—which is also the hardest thing—is to do nothing. Surrender to the anxiety. Float with the feelings. Allow it to be there. Ask patients to thank their amygdala for doing its job. Actively give permission for symptoms to remain as long as they will. Again there is the additional task of tolerating uncertainty—of not knowing when the symptoms will abate, of not knowing “what to do,” of simply letting things be what they are.
Actively allowing is not the same thing as “putting up with.”
It is helpful to stay in the present while allowing time to pass. Patients make judgments that their fear is something to be avoided, and so devise ways to try to control it. Remind your patients that it is not their fear that is taking them out of the present and propelling them into frightening “what if” scenarios, but rather their resistance to the fear. Actively allowing anxiety also means learning to be patient. Patients sometimes need to practice the art of doing nothing. Especially when anxiety is telling them to move; that is the time to practice staying still. It is not easy, but it is a skill that can be learned. It is important to temper self-discipline with gentleness and practice the skill of letting time pass. The key is to surrender to what one cannot control. Ask your patients to feel their anxiety, feel their own resistance, and observe how they int
eract.
Chapter 5, Getting Started, presents information that can be utilized right away— information that helps to create a safe and therapeutic connection between therapist and patient, and gives the patient information essential for beginning to counter the false messages of anxiety. Chapter 6, Techniques Your Patients Have Probably Already Tried and Misunderstood, reviews the range of anxiety management techniques, and explains how they can be best utilized to help patients recover. Techniques can be helpful or harmful, depending on the attitude with which they are implemented. Proper therapeutic attitude is the essential bedrock to which both information and technique are tethered.
Proper therapeutic attitude is the essential bedrock to which both information and technique are tethered.
References
Kabat-Zinn, J. (1994) Wherever you go, there you are: Mindfulness meditation in everyday life. New York, NY: Hyperion.
Kabat-Zinn, J. (1990) Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York, NY: Delacorte.
Wegner, D. M., Broome, A., and Blumberg, S.J. (1997) Ironic effects of trying to relax under stress. Behaviour Research and Therapy 35(1) 11–21.
Koch, H. (1970) The panic broadcast: Portrait of an event. New York, NY: Little, Brown.
Niebuhr, R. (1943) The serenity prayer. Bulletin of the Federal Council of Churches.
Wells, A. (1990) Panic disorder in association with relaxation induced anxiety: An attentional training approach to treatment. Behavior Therapy 21(3) 273–280.
Grayson, J. (2003) Freedom from obsessive compulsive disorder: A personalized recovery program for living with uncertainty. New York, NY: Berkley.
Carbonell, D. (2004) Panic attacks workbook. Berkeley, CA: Ulysses Press.
Forsyth, J. P. and Eifert, G. H. (2007) The mindfulness and acceptance workbook for anxiety. Oakland, CA. New Harbinger Publications.
Twohig, M. P., Hayes, S. C., and Masuda, A. (2006) Increasing willingness to experience obsessions: Acceptance and commitment therapy as a treatment of obsessive-compulsive disorder. Behavior Therapy 37(1) 3–13.
5
Getting Started
Many of our patients have been suffering with anxiety for years. Many have been in therapy as well as on medication. Some may have been in and out of therapy over the years. They are either a little bit better but still suffering, or perhaps getting worse. They might feel fed up, demoralized, ashamed, afraid, and bewildered. They come to us understandably skeptical about their chances for change, but still hoping that our expertise in treating anxiety disorders will offer something new and helpful. The first contact is often through our websites or word-of-mouth. Many are sophisticated about both anxiety and treatment, but some have avoided information because of their anxiety. Some have misinformation from sources varying from family members to popular media. Some know very little.
The First Contact Must Instill Hope
The first session is important for many reasons, but most important is the instillation of hope. Here are the messages to impart within the first hour of seeing a new patient with significant anxiety symptoms.
What you are suffering from has a name and there is now a significant body of knowledge about how to help people just like you.
There are a lot of people like you.
You are not going crazy or losing control.
High anxiety—even a panic attack—is self-limiting. It will not go on forever.
You are not in danger.
It is actually quite possible to be this disabled and/or this deeply distressed and still not be in danger.
There are very good reasons, none of which are your fault, why everything you have been trying to help yourself has not been working or stops working.
You are going to get a good explanation for how and why your mind and body are acting like this. The explanation will show you why what you have tried does not work.
There is a new way to go about relating to your anxiety experience that will make a huge difference. We are going to give you keys. We are going to figure out together what you are doing that inadvertently keeps your anxiety going and interrupt these cycles.
Everyone who is anxious avoids, but avoidance makes anxiety worse in the long run.
It may not be obvious yet, but you are afraid of the feelings inside of you. The external object or situation just triggers the feelings inside.
Inadvertently and despite your best intentions, you are somehow maintaining this anxiety. Once you learn how you do it, you can then learn how not to do it.
You are courageous just to walk in to this appointment and this is admirable.
Working on your anxiety can be uncomfortable, but there is every reason to believe your work will result in a lot less suffering.
You are safe to say anything here. Your thoughts and feelings do not scare me. They are thoughts and feelings. Not facts or signs.
Immediate Help: Embed Information in Your Questions
The initial interview of someone suffering from an anxiety disorder may depart from the typical intake or evaluation session in a number of ways. Assessment is an extended process, first establishing a formal diagnosis but then continuing over a period of several sessions and often revisited in the course of therapy. The goal is to construct a theory of how this individual maintains anxiety. This requires obtaining detailed phenomenological information about the nature of the anxiety experience.
Be immediately helpful by embedding new information within the initial evaluation.
In the first contact, the aim is to intersperse history gathering with initial psycho-education, so that the patient leaves the first session already aware that there is a lot to learn and ways to approach recovery different from what they have already tried. This helps to instill hope.
Here are a few examples of embedding psycho-education in the initial history-taking process.
THERAPIST: So this condition tends to run in families. Any idea which side of the family has an anxiety disorder?
PATIENT: Well no one that I know has ever had a diagnosis.
THERAPIST: Some of this is pretty embarrassing and hide-able with excuses.
PATIENT: Well, my father hates crowds and often did not join the rest of us when we went out. But he drank.
THERAPIST: Well it is not unusual for people to stumble into drinking as a way of trying to deal with anxiety. Maybe the “hating” was really “being afraid of”? Would that have been something your Dad might have been able to acknowledge?
PATIENT: No way. Come to think of it, his sister had “spells” all her life and we always thought it was her nerves. And my cousin, her son, is on medication for anxiety.
THERAPIST: It looks like this probably comes from your Dad’s side of the family. When they were handing out bodies, you got in the “anxiety body line” through no fault of your own, and now you are going to learn how to manage this anxiety body.
Another example:
PATIENT: So when I am driving I start getting dizzy and feel like I am going to pass out, so I won’t drive on highways where I can’t pull over safely. Bridges and tunnels I can’t do for the same reason.
THERAPIST: Are there other places or situations where you feel the same?
PATIENT: I always get that way in elevators and for some reason whenever I have to talk to my boss if he is standing in the doorway of my office. But I stick it out and it goes away. I guess if I pass out at work or in an elevator, no one will get hurt, but I could cause not only my own death but someone else’s if I pass out while I am driving.
THERAPIST: Before I go on and ask you a lot of questions about all those situations in which you feel trapped and start to feel panicky, there are a few important facts to know. Let me ask—have you ever actually passed out?
PATIENT: No, not ever, but I get really close.
THERAPIST: Well also, are you actually dizzy? The room spinning? Or are you light-headed? What we call feeling “fainty” because it “fe
els” like it.
PATIENT: I guess it is not really dizzy. But it is really strong. I can barely think.
THERAPIST: So you are afraid of having a panic attack when you feel trapped. This is great news because actually panic attacks do not cause fainting. Your blood pressure is going up, not down. In fact, if you were actually about to faint for real, like from pain or malnutrition, best thing you could do would be to have a panic attack. Anxiety actually protects you from fainting.
Another example:
PATIENT: I am here because I am afraid I am going to hurt my partner. I love her and would do anything for her, but I have these terrible thoughts. I have been praying for hours every day for God to take these horrible thoughts away. I can’t tell her why I am here. But there is something wrong with me. I am a non-violent person. I grew up around violence and I swore I would never do anything to hurt someone I love. What if my childhood is catching up with me? They say abused people can become abusers. I need help.
THERAPIST: This may sound like a very strange thing to say, but does OCD run in your family? Because these are “harming obsessions,” not violent impulses.
PATIENT: You mean hand-washing and getting stuck with everything having to be exactly arranged? I don’t have that.
THERAPIST: Well, OCD can take many forms and sometimes is pretty subtle. It can look like excessive worrying or phobias or quirky behavior—or “bad thoughts” that won’t go away.
PATIENT: My grandmother never left the house. I never knew why.
THERAPIST: Well, we can take a look at where you inherited the tendency to have sticky thoughts, but for right now, I want you to know these are harmless intrusive thoughts. I have no worries for your partner’s safety.
What Every Therapist Needs to Know About Anxiety Disorders Page 10