What is missing is that the relationship to anxiety has not changed.
Search and Destroy: The Role of Subtle Avoidance
If we return to the basic concept that anxiety is maintained by avoidance, it makes sense to examine the role of avoidance throughout the entire process of therapy, including the patient’s avoidances when ready to end regular appointments.
Let’s look at our first type of recovery, where symptoms are managed and controlled, and the patient has made undeniable progress in expanding safety zones and reducing suffering. Still, there is significant avoidance, either because these patients lack the means or the motivation to continue with gains, or because they relish the opportunity to live with less anxiety in their day to day life. But they have not yet gained the most essential aspect to overcoming an anxiety disorder—the ability and willingness to embrace anxious feelings and so become less fearful of them. People who leave therapy with this type of recovery have a higher probability of relapsing.
But sometimes avoidance is not so obvious, and the assumption is that a patient leaves therapy with an altered attitude towards symptoms. But we can be wrong, because our patient has learned to control and avoid anxious feelings with numerous small, subtle, and often hidden, methods of avoidance. And we won’t know about them unless we ask direct specific questions about the patient’s experience during these times. Sometimes patients themselves aren’t aware that they are avoiding, and sometimes they are aware but consider them trivial. As discussed in Chapter 6, some of these subtle avoidances are conceptualized as “coping skills” by patients and they are loathe to give them up. Some are rationalized, like the always present bottle of water or the light-hearted distracting conversation designed to keep from noticing any signs of anxiety. All of them, however, prolong the experience of anxiety and create vulnerability to relapse.
This is a process we call “search and destroy,” because the goal is to help the patient focus on methods of avoidance and then systematically eliminate them. Ask a patient to make a list of any avoidant thoughts, behaviors, or rituals in which he finds himself engaging. One patient, who had previously avoided elevators, found that he systematically looked up at the display whenever he walked into the elevator, stood at the front near the elevator buttons, and turned his keys around in his hand as he rode. He reported that he felt no anxiety, but experienced some unpleasant emotions when he intentionally stopped these activities.
“Search and destroy” focuses on eliminating avoidances that remain.
Another patient with social anxiety disorder, who formerly was unable to speak to groups of people larger than two or three, comfortably presented to groups of 20 or more on a regular—almost daily—basis. Yet she said that she was never able to look into the eyes of men who were listening to her (as opposed to women), nor at much younger women. Her “search and destroy” avoidances were numerous and filled three sheets of yellow paper.
The Role of Psychotherapy in Relapse Prevention
Sensitization describes an overall level of nervous system arousal that makes it more likely to experience both physical arousal symptoms—such as muscle tension and increased heart rate, and mental symptoms—such as worry thoughts and hypervigilance. It can take considerable exploration and observation for each person to figure out their particular sensitivities—over and above the ordinary stressors that affect all of us, which include sleep deprivation, over-caffeinating, the day after alcohol intake, and feeling stuck in a quandary about something important.
Here is where exploratory psychotherapy fits: it is an opportunity to discover and work on the patient’s sensitizing issues and vulnerabilities. Some typical sensitizers are often found in anxious patients, and here we are probably venturing on familiar territory.
Exploratory psychotherapy is an opportunity to discover and work on the patient’s sensitizing issues and vulnerabilities. It is relapse prevention.
So, for example, patients with poor assertiveness skills and fears of anger, confrontation, or interpersonal conflict may learn that the reappearance of anxiety may indicate a need to address an interpersonal conflict—either internally facing how they feel or actually confronting the issue behaviorally. Other typical anxiety-sensitizing issues include an over-valuation of stoicism, for example. Patients often attribute acting strong, independent, or mature with being unemotional and may try to suppress or avoid their emotional experiences, because they are ashamed of them as well as fear them. Thus, feeling sad, helpless, or humiliated may be avoided, leading to patterns of behavior which may be interpersonally destructive, life-limiting, or sensitizing in and of themselves.
It is common for people to have early memories of separation anxiety (or separation guilt) and many anxious people are at the least ambivalent about being alone, both alone at any given time, and also alone in the world. Most people with anxiety disorders were raised by people with anxiety disorders. It is therefore often fruitful to explore the messages about the world that were taught and demonstrated by one or both anxious parents. It is often illuminating for patients at this phase of treatment to re-examine long-held beliefs about risk, relationships, safety, morality, and emotions. How they view the contents of their minds and how they make decisions about proceeding in the world may well have vestiges of anxious teachings by anxious parents. These are all well worth examining.
It is also the case that people with a lot of generalized anxiety and worry tend to be caretakers, overly nurturing, and have trouble with over-empathic permeable interpersonal boundaries. These issues identified as sensitizing can be addressed and explored with whatever psychotherapy interventions you find effective. We wish to be clear: it may well be that exploration of childhood schema, or gestalt two-chair techniques, or internal family system therapies will be enormously helpful at this phase of treatment. By now, the patient has developed the capacity to tolerate feelings that may be evoked by such work. He is less afraid to be uncomfortable, and he is no longer basing his decisions about what to do and what not to do based primarily on how anxious he feels. He is no longer ruled by a fear of fear, and is ready to approach the triggers and issues which set him up for periods of increased arousal. He is ready to approach living freely according to his values.
The Proper Place for Stress Management
Sensitized bodies and minds can certainly benefit from efforts aimed at directly reducing the overall level of arousal. The problem with stress management strategies as presented in health magazines and popular press is that they are not sufficient for dealing with full-fledged anxiety disorder symptoms. Anxiety disorders are stress-sensitive disorders: they are not caused by stress. They are not conquered by effortful attempts to banish stress. It is not uncommon to find someone with generalized anxiety and constant worrying to be exercising for hours each day, eating “healthy” in every possible way, following advice to take “me-time” away from the kids, putting aromatherapy products in the bath and sleeping on a magnetic mattress—and nothing seems to help. All that effort at stress management only serves to prove that the situation is hopeless or more serious or unfixable. It can be extraordinarily demoralizing.
Proper stress management requires that we address the two issues of timing and attitude. Introducing stress management at the beginning of treatment before the patient has understood the limits of what to expect will be counter-productive. If, every time a panic-disordered patient begins to feel anxious, she goes out for a run in order to calm down, she will be using exercise as a fighting tool that will eventually backfire. If, on the other hand, a patient learns that going for a run every morning lowers the overall tendency of his obsessive-compulsive disorder to rapid-fire intrusive doubt thoughts at him, that can be helpful. If stress-reducing changes in lifestyle are to be undertaken in a helpful way, they should be regular, unlinked to how a person feels at the time, and routine. They should be aimed at reducing overall levels of sensitization, not at getting rid of particular symptoms at a particular time. They are
a long-term project, not a quick fix. In the same way, any other healthy living endeavors—whether it be engaging in a hobby, going to church, or learning to say “no” to excessive requests from others—these changes in lifestyle, these kinds of stress management, should not be constantly evaluated to see if they are working to eliminate symptoms of arousal. It can also be helpful to take a look at time management issues as part of stress management strategies, since anxious people tend to have a difficult relationship with time in general. It can be helpful to pay attention to sleep hygiene and exercise routines and spiritual practice and the nurturing of healthy relationships. It can be helpful to resolve any ongoing issues which tend to arouse anger or frustration—or to make peace with unresolvable ongoing frustrations.
If stress-reducing changes in lifestyle are undertaken in a helpful way, they should be regular and routine, unlinked to how a person feels at the time.
However, a very important point needs to be made regarding what stress management is and is not. It cannot be emphasized enough that proper stress management does not mean “avoid stress” so that every time one feels stressed, back away. People often confuse the term stress with the appearance of anxious thoughts or sensations. Stress management most certainly does not mean “stay away from situations that feel stressful.” This is a formula for avoidance behavior and for development of generalizing phobic patterns. It is exactly the wrong message. We are trying to convey that it is okay—not dangerous—but helpful to expect and allow anxiety and to approach situations and internal experiences which produce anxiety. So it is easy to see why stress management suggestions at the very beginning of treatment can contain very confusing messages, and why they belong in the relapse prevention phase of treatment.
Stress management certainly does not mean “stay away from situations that feel stressful.”
Finally
Even if you do everything right, sensitized bodies take some time to wind down. Long after panic attacks have become rare, anticipatory anxiety will launch itself. There is no protection against random uninvited thoughts. The world will contain reminders and challenges and novel situations and triggers. When the anxious person has managed to overcome his fear, shame, and aversion to doubts, memories, sensations, and thoughts— when anxiety symptoms no longer mean anything bad, no longer carry a danger message, and no longer determine how to act—that is the best inoculation against relapse prevention.
There will always be issues to explore and curiosity about oneself, and these are legitimate and meaningful activities whenever someone wants to pursue ways to grow and change, including the self-examination of dynamic psychotherapy. So long as insight-oriented therapy is not framed as getting rid of anxiety by analyzing it away, then by all means, proceed!
Appendix 1
Additional Metaphors
Chinese Finger Trap
We have all seen the children’s “trick” toy. It is a cylinder made of woven bamboo with holes at both ends just big enough to insert a finger into each. Once you do, however, as you try to pull them out, the tube elongates and traps your fingers. The harder you pull, the more stuck you get. The key is to do the opposite of what seems right—push in, the tube expands, and pops off. That is same with anxiety. Do the opposite of what seems right.
Lean with the Motorcycle
Have you ever been on the back of a motorcycle? You may have had the experience of going around a corner. As it does, it leans. The driver leans with the bike. He does not try to compensate for the natural tilt. You need to do that too, or you will fall off or topple the bike. It is counter-intuitive to lean with the leaning, but when you are anxious, go ahead and lean into your anxiety: lean into, not away from, your discomfort.
On Allowing Anxious Intrusion
One patient found a wonderful way to deal with depersonalization, which she frequently experienced when shopping in fluorescent-lit stores. She imagined a baseball cap stuck to her head with a rubber ball on an elastic hanging from the brim. While she could easily see around the bouncing ball, it was always somewhere visible. She learned to shop while aware of the ball but doing nothing at all to try to remove the cap. In fact, she began to welcome the arrival of the imagined cap as it reminded her to accept the presence of her anxiety symptom and go about her shopping anyway.
On Accepting Panic Sensations
You are driving in a car which is rather strange because it is constructed like the human body. It has a gas pedal but no brakes. You are on a straightaway in the middle of the country on a flat road with no traffic and no ditches. You are going 55 mph. You decide you want to stop and rest for a while. You reach for the brakes and can’t find them. You then get frantic, scrambling all over the car trying everything to see if it might be the brakes. Accidentally, you keep hitting the gas while you panic. Then you realize the only thing you can do is just take your foot off the gas and the car drifts to a stop—not immediately, but when it runs out of fuel. Meanwhile you just have to let time pass and coast to a stop with it.
The Whack-a-mole Game
This refers to the carnival game whack-a-mole. When the game starts, fake-fur “moles” pop up and down in a random pattern from an array of holes in the game board. Your job is to whack the moles with a large soft bat before they disappear. The more you whack, the more points you get. And if you do it better than everyone else, you get a huge stuffed animal. You are competitive. You are good at this, and your reaction time is really fast. This time however, the game starts, you pick up your bat—and realize to your dismay that it is tied to the board with a two-inch cord, and there is no way to reach the moles. All you can do it watch them pop up and down until the round is over. You score zero. You can struggle and curse and complain, or you can laugh. It is your choice. It can be unfair and your dollar was wasted, or it can be absurd. Once again, it is your choice. You can choose how you react to the situation, but the length of the cord is out of your control.
Appendix 2
A Summary of the Labeling Process That Can Be Given to Patients
With feelings of terror, the first task is to try to label the feeling as anxiety, as opposed to danger. This labeling is very important, because anxiety is addressed in a totally different manner than danger.
The decision is difficult because there is no way to use feelings to help make a decision. Remember that the terror associated with real danger is exactly the same as the terror felt when experiencing anxiety. Feelings cannot help with this decision. It requires thinking, and relying on facts about anxious arousal.
Anxiety makes the thoughts feel like they are very likely to happen. This is the distortion caused by anxious thinking. Demanding certainty eliminates the possibility of progress, because certainty is not possible. Remember that certainty is a feeling and not a fact. So it might feel risky to label these feelings as discomfort and not true danger. This will be a leap of faith.
Even if the choice is to follow what anxious thoughts are saying, and you flee to avoid the feelings, they can still be labeled as anxiety. The eventual goal is to label the distress as anxiety, not to dignify it with a response, and therefore disengage from it. That is the beginning of de-fusion from anxious triggers.
Appendix 3
How to Learn Diaphragmatic Breathing
Like any skill, learning to breathe with the diaphragm takes practice. Good times to practice are before going to sleep and upon waking up, although any time when patients have a few minutes and a place to lie down will work. Each practice should be only a few minutes in length, so it is best to practice several times a day. Wear clothing that won’t constrict waist movements. Lie down on the back.
Start by placing the right hand on the abdomen, so that the palm of the hand is right over the belly button. Place the left hand on the chest. While breathing in, imagine that the air is bypassing the chest and moving directly into the abdomen, filling the stomach with breath. The right hand should rise with the inhalation and fall with the exhalation. Ask patients t
o try to make it so that their left hand hardly moves at all. It is best to breathe in through the nose and out through the mouth. While breathing in, some people are helped with image of turning the belly into an inflating and deflating balloon. If patients are having difficulty getting air into their belly, it often helps to place a rolled-up towel under the small of the back.
Make Exhalations Longer Than Inhalations
Relaxations are encouraged if exhalations are slightly longer than inhalations. There is a physiological reason for this. Inhalations stimulate the sympathetic nervous system, which is the part of the nervous system that speeds things up. Exhaling, on the other hand, stimulates the parasympathetic nervous system, the portion of the nervous system that slows things down. So spending more time breathing out than in tends to slow things down.
What Every Therapist Needs to Know About Anxiety Disorders Page 32