Introduce the New Paradigm: Offer a More Profound Change Than Techniques
The fourth goal of initial contact is to show that recovery involves changing one’s relationship to symptoms so that they cause no suffering or limitations in living. This is the therapeutic attitude of acceptance. We usually begin this discussion by talking about goals for treatment and a reasonable model for full recovery. Discussions often look like this:
Goals for treatment and a model for full recovery belong in the first sessions.
PATIENT: I have to control my anxiety. It is ruining my life. I want to be rid of it once and for all. I can’t stand worrying all the time about things that ought to be easy. It takes the joy out of looking forward to anything like travel or special occasions or even everyday getting together with friends.
THERAPIST: This kind of therapy is aimed at you taking back your life and its joys and freedom just as you want. However, it may surprise you that we are going to do that in a different way from what you might expect. If there really were fantastic tools we could give you that would permanently achieve those goals, we would be the first to be giving them out. But as we have discussed, you have a brain and body that tends to do anxiety so easily that we are going to teach you how to make anxiety not matter, whether it shows up or not.
PATIENT: Are you saying that I have to accept that I will always be an anxious person? Because that is not okay with me.
THERAPIST: Actually what happens when anxiety symptoms no longer matter is that you stop dreading them and you stop avoiding things, so your anticipating and worrying subside and then your confidence builds. Then you are indeed not so anxious. And your symptoms happen a lot less. But you are also inoculated so if your symptoms pop up again, they don’t shock and demoralize and take over again. They never get to take over again once you really get the learning and practicing principles you will learn here.
The following dialogue with a patient suffering from GAD tries to create a new perspective on her toxic worry, a new paradigm. Rather than looking at ways to stop or control the worrying, or to reason herself out of it, the therapist introduces the idea that worry is a series of false questions that are best ignored.
PATIENT: I’m a worry wart. It’s driving me crazy, and driving my family crazy. I worry about everything and I can’t stop it.
THERAPIST: Can you give me some examples?
PATIENT: Well, right now I’m worried that a mole on my arm is melanoma, and I’m waiting for the biopsy result, which the doctor told me he is doing only because I’m so worried. He says it isn’t melanoma, but how can he be sure? But I already know what I’m going to worrying about when that comes back okay. My husband got a PSA result that went from 1.4 to 2.7, and I don’t know how I could possibly survive without him. But my daughter just turned 15 ½ and wants to get her driving permit. I can’t imagine how terrifying it will be to have her on the road by herself. I just know this isn’t good for my health, and I never get any exercise because I’m always so busy, and that is terrible for me also. With my worry and my stress I just know I am destroying my immune system. How will my children survive without me? [Patient starts to cry.]
THERAPIST: I got it. You are a worry-wart, I agree.
PATIENT: I try to stop worrying, I keep on telling myself to chill out or relax or think of something else, but it never works. It’s actually getting worse. I’ve always worried about melanoma, and then I found this thing on my arm.
THERAPIST: Let me ask you a question that might seem very strange. What would happen if you worried in some foreign language that you didn’t speak—like Hungarian or Mandarin?
PATIENT: That makes no sense. I wouldn’t understand anything going on in my head.
THERAPIST: Exactly.
PATIENT: I wouldn’t understand it and I couldn’t know what was going on.
THERAPIST: Yes, and then you would be hearing all these foreign sounds in your head with no obvious meaning and you wouldn’t be able to respond to them.
PATIENT: But then how would I know what to do?
THERAPIST: Well, that is the point I want to make. Worrying like yours always starts out as a form of planning—as a way of solving problems. But then worry becomes a problem in itself. You are always asking yourself questions and then trying to answer them. But you are going into territory you have no control over. So the questions just raise your anxiety, and then you search for an answer to lower your anxiety, which engenders yet another question. But suppose you understood that the questions aren’t real questions that have real answers? You can’t stop yourself from asking the questions, but you can refrain from trying to answer them. So if you could magically think in a foreign language, it would be easy not to answer the question, because you wouldn’t understand it.
PATIENT: But suppose there is a real problem that could hurt me if I didn’t solve it?
THERAPIST: That is an excellent question. Part of our job is to help you differentiate worry questions, which our goal is to have you disengage from, and real questions, which require answers. Real questions are more like planning. We don’t want to interfere with your planning.
In this interview, the therapist establishes a diagnosis and then briefly outlines the content of the worried self-talk. But then a new way of coping with this is introduced: not to stop the worried thoughts, but to figure out a method to disengage from them.
Provide Information and Answer Questions
The fifth goal of initial contacts is to provide information about symptoms and what happens during anxious arousal. Sometimes facts about anxiety can be remarkably effective at reducing anxiety. When patients are afraid of the anxiety symptoms, placing the symptoms in an understandable context removes much of that added fear, reducing anxiety sensitivity.
About Anxiety in General
Is anxiety/panic dangerous? No. It just feels dangerous. When we respond to initial normal arousal from anxiety by being afraid of it, it gets amplified. This fear of fear is what we can help with right away. The more you understand the less afraid of it you will be.
Will I go crazy? Will I lose control? Psychosis and anxiety are completely different. You have an anxiety disorder. You just “feel” crazy. A thought is not an impulse. Derealization and depersonalization are normal responses to anxious breathing and peak anxiety. Anxiety makes you believe that your terrifying thoughts are really going to happen. Anxiety is an altered state of awareness that makes thoughts feel predictive.
Isn’t my chest pain a dangerous cardiac symptom? The pain in your chest is caused by tension in the intercostal muscles around your ribcage, which become tense and tight during periods of high anxiety. The pains from intense anxiety are not indications of a serious illness. It is also possible that you are having reflux in your digestive tract, also not dangerous (but easily treatable).
Why do I get so light-headed? It is the way you are breathing when you have anticipatory anxiety or panic. We can demonstrate this.
Why do my hands and feet and lips get numb? This is caused by hyperventilation, which affects the acid-base balance of the blood. There is plenty of oxygen; it is just giving you harmless symptoms. You can learn how to breathe in a way to make these sensations less intense.
Why does my heart race? This is the adrenalin surge preparing your body to be an efficient fighter or runner. It is the fight, flight, freeze response in action.
Why do I keep imagining terrible things? You must be focused on the future in order to feel anxiety. The more you are able to stay in the present—in the “here and now”—the less you will be engaged with anxiety. Try to stay with “what is” as opposed to “what if?” Switching from thinking to sensing will be helpful. You will be learning how to do this.
Why do I feel like it is going to reach the point where I just won’t be able to stand it anymore? Anxiety is not an all or nothing experience. There are varying intensities of anxiety, and it is to your benefit to begin to observe this. There is an illusion of unbearableness. I
t is actually a false message.
Why doesn’t mentally reassuring myself seem to work? It is a form of avoidance, and keeps your anxiety going. This is a completely understandable habit of the mind which we will teach you how to change.
About Panic Attacks
What is panic? A cardiovascular workout you did not ask for. The body’s normal emergency response system coming on when there is no real emergency. It is fear of fear.
Am I going crazy? Panic attacks can make you fear you are going crazy, but people who panic do not go crazy from panic attacks, even though panic often produces strange and frightening sensations. The neurotransmitters involved in anxiety are not the same ones as those that are involved in psychosis. These are different disorders. There is nothing you have told me that I have not heard from people with anxiety disorder.
Am I causing long term damage by having panic attacks? Panic attacks don’t hurt you, even though they are very uncomfortable. You won’t damage your body or make yourself sick. This is the body’s emergency response system turning on unexpectedly in a false alarm situation.
Will panic attacks make me faint? No, if anything, they protect you from fainting by boosting your blood pressure. (Just a bit, not enough for a stroke!) This is why we call it “faintiness,” as it has nothing to do with fainting. In fact, if you were likely to faint from malnutrition or shock or pain, best thing you could do would be to have a panic attack.
About Obsessive-compulsive Disorder
Why do I have to do things which I know don’t make any sense? People who have OCD feel like they have a nagging warning danger alarm system in one part of their mind and a second “wise mind” that realizes that the OCD is somehow not telling the truth. We are going to help your wise mind learn to scoff at and get distance from the OCD mind and not take everything you think so seriously. The things you feel compelled to do are things you are “hooked on” as ways of trying to reduce the anxiety, whether or not they make sense. You will be able to stop doing them when you understand them differently.
Why am I afraid of things I never used to worry about? You are afraid of the thought that you forgot to turn off the gas. Every time you check to make sure you didn’t, you are making the thought seem more probable and more frightening. The way to reduce frightening thoughts is to stop checking their validity.
Why do I doubt myself? People with OCD have a hard time with tolerating not knowing something with a sense of certainty. There is a feedback loop that is stuck in their brain. It is not your fault. You will be learning all about this.
Why am I plagued by thoughts that are horrifying and disgusting to me? These are stuck thoughts called obsessions. They are harmless obsessions, and they are neither wishes nor impulses. In fact they are the opposite of wishes. They get stuck by how hard you resist them. And until you understand they are harmless, most people naturally put up a lot of resistance and make them even more stuck.
About Social Anxiety
Why am I so afraid of people? It is not people you fear but the feeling of humiliation or shame or embarrassment that you might have if they judge you badly or if you just think they are judging you badly.
Why am I especially afraid when I eat in restaurants, or have to sign my name on the credit charge? Your body is in anxious arousal during those times, and you might be aware that your hands are shaking somewhat. You fear that others might notice that and judge you harshly.
I can’t use a public restroom. It is physical but my urologist says it is due to anxiety. How can this be true? It is a fairly common condition called paruresis, and there are plenty of ways for you to overcome that limitation. Thank goodness you are brave enough to ask that question.
About Generalized Anxiety
Why can’t I stop worrying? You are diligently trying to answer unanswerable questions and find a way to reassure yourself about things that cannot be made certain. The strategies you are using are backfiring. More of the same won’t help. There are different ways to handle worry thoughts than trying to solve them, no matter how intelligent you are. We will be exploring these.
What is wrong with me that I can’t relax? You were born with a jumpy sensitive body and a sticky mind. Just fighting these predispositions is actually not productive. But there are ways to “ride” this kind of body and mind that are counterintuitive and will make a huge difference.
6
Techniques Your Patients Have Probably Already Tried and Misunderstood
What They Are and How to Make Them Helpful
The media is awash with techniques for managing anxiety: breathing, relaxation, thought stopping, distraction, food supplements, yoga, exercise, and aromatherapy are just a few of the techniques that are offered as antidotes to anxious arousal. Often there is confusion between managing anxiety and managing external stress. Despite all these available techniques, anxious patients continue to suffer, and anxiety disorders continue to remain the world’s most common psychological problem.
So clearly there is something amiss here, and we must acknowledge that simple applications of techniques are not an effective way to banish anxiety. We stress that techniques—like any set of tools—can be evaluated only within the context and appropriateness of their use. The value of techniques lies in the relevance of their desired function and how they address the underlying attitude towards anxiety.
Techniques are not a form of non-chemical tranquilizers. They are not equivalent to popping a Xanax, and they are not anxiolytic per se, although they can be helpful during anxious arousal. Techniques are not “in order to” reduce anxiety, although techniques play an important role in that function.
Techniques are not a form of non-chemical tranquilizers.
The Problem with Techniques
Remember the story of Dumbo and the “Magic” feather?
Dumbo was a young circus elephant with huge ears, and his odd appearance caused great grief in his short life. Dumbo’s only friend was a mouse named Timothy, and one day Dumbo and Timothy woke up in a tree. Bewildered by this seeming impossibility, Timothy concludes that Dumbo is capable of flying by using his huge ears as wings. Dumbo cannot believe this, but Timothy tells him that by holding onto a magic feather Dumbo will be able to fly. Using this psychological trick, Timothy is able to get Dumbo to fly by holding the feather. At the circus, Dumbo jumps from a high tower and flies around the tent, grasping the feather, with the mouse Timothy on his trunk. But one day, Dumbo drops the feather as he flies, starts to fall to the ground, and Timothy tells Dumbo that there is nothing magical about the feather at all. He can fly on his own! Dumbo stops falling and begins to soar.
This is the problem with the misapplication of techniques. They are like Dumbo’s magic feather. Patients believe that anxiety goes down because of techniques, and ignore the most important aspect of the entire process: when techniques are applied correctly, patients react differently to anxious arousal. Dumbo was able to fly on his own, but connected to and utilized his soaring aspects only when he held the feather. He attributed his ability to stay in the air to the power of the feather, but he flew on his own. In an analogous manner, patients attribute anxiety reduction to the effectiveness of techniques, and ignore that it is they who are reacting differently.
There are two problems here, and they are closely inter-related. The first is one of attribution. When a patient successfully utilizes anxiety management techniques, what accounts for that success? Is it the patient or the technique? Patients need to learn that techniques actually do nothing to lower anxiety, but can help them approach their symptoms in a different mindset, with an attitude that will promote new learning and change the experience to become more manageable. That, in turn, will lower anxiety.
This is not just word-crafting. Techniques are counter-productive when they hide a patient’s own accomplishments. Techniques are not supposed to feel like a tranquilizer. How many of you have had highly anxious patients accomplish something that took considerable courage, yet ended their self
-evaluation with “I don’t think I could have done it without the Ativan.” True or not, the goal is to allow our patients to feel empowered in relationship to their anxious symptoms, and not give one additional bit of power to their anxiety.
Patients can become reliant or dependent on techniques to lower their anxiety. Whenever something is done that reduces anxious arousal, those behaviors are reinforced, and there is a natural tendency to repeat what has already been successful. But this is problematic for a number of reasons. First, it encourages rigidity, and, second, it ignores that therapists sometimes want to encourage the experience of anxiety, in order to better learn how to manage it.
When someone needs a technique or coping skill “just in case,” it subtly reinforces the idea that anxiety is dangerous and must be avoided. When anxiety yells, “Emergency!” the most effective tool is to respond to that message with “I don’t actually have to do what you say.” Any technique which buys in to the emergency message will not be helpful in the long run. When patients attribute favorable outcomes to the technique, they remain vulnerable to this false message. Sometimes coping skills work only because the patient believes that anxiety won’t get out of control when the technique is used. It is these beliefs that make the technique seem to work, not the techniques themselves. This is why a parent’s voice on the cell phone can comfort right away, even before anything calming has been said or any plan for action has been discussed. It is not the wisdom of the parent’s advice; it is the patient’s own belief that “I will be okay” that lowers anxiety.
What Every Therapist Needs to Know About Anxiety Disorders Page 12