By Ron Taffel
Johnny says I'm a faggot. I'll rip his arms out--then we'll see who's gay! "Bitch!" How did Jenny get that tattoo? I'm going to throw up. "Just do it!" A lot of kids are going to crash that party. "Parents, the antidrug." Mom will kill me--wait I'm at Dad's this week. "Get the stuff!" I want Game Boy, Play Station 2 . . . . "You've got mail!" "Wazzup! Hey, everybody does not think I'm bipolar!" "New standardized tests . . . ." Shit, I don't get this math. The test's tomorrow, but first, I have to check my e-mails and then listen to the CD I just burned and . . . . "Twelve more killed in . . . . " I'm so tired, but what's that noise outside? "Order in the next 30 minutes and . . . ." "Mom, I am not too young for a thong!" "New unemployment figures . . . ." Valerie's father died and Betsy's parents just split up and Bobby's family is moving away. "You're a teenager now, deal!" I just can't take it anymore!
Listen to enough kids and it often sounds like they're coming apart at the seams. Teens and preteens today pulsate with anxiety in a pressure-cooker youth culture and an explosive world, ever at the edge. Not that you'd know it when you first meet them. For the most part, they don't act particularly scared. They don't come in with raging guilt, repression, or conflict--the traditional, "gold-standard" symptoms of neurotic anxiety. They rarely present with PTSD as their main complaint and, in fact, seem quite removed from the world-worries that the media, parents, and trauma experts seem so focused on.
Indeed, today's children and adolescents often present such a convincing front of sophistication, such a steady stream of activity, such articulate, pop-culture babble that they virtually shimmer with techno-energy. No, this 21st-century teen anxiety is different. It's at once chaotic, chronic, and cool--more invisible than the air we breathe. And make no mistake about it, all of this began well before September 11th. We attribute great psychological significance to that horrific day, but September 11th didn't create the new anxiety among so many kids today. It just finally got adults to notice what had been building in our children for years.
Spend time with teens and preteens and you gradually become aware that beneath the seemingly jaded precocity is a fretful undercurrent of worry and fear, unimaginable for 11- or 13- or 15-year-olds just a decade ago. Get into the nitty-gritty of their daily lives and you'll find their thoughts racing, like overheated jet engines, from one source of stress to another--the next make-or-break standardized test, the next totally unsupervised after-school bash, the next late-night, midweek concert they have to be at. Explore a little farther and you'll pick up palpable dread about going on-line with kids who regularly torment them. You'll feel their agitation about whether they should have oral sex after school. You'll catch the gnawing fear that their parents may break up, like so many others, or suddenly move the family halfway across the country.
Over the last decade or so, I've talked to, literally, thousands of parents, kids, and professionals all over the country and across practically all socioeconomic groups. I've gotten the same message in a crescendo: kids everywhere are overwhelmed by a tidal wave of culturally induced anxiety. There's not a town or city--unless it's completely free of rapidly morphing family configurations, impossibly frenetic overscheduling, 24-hour, 500-channel TV access, unlimited cell phone and Internet connections--that doesn't exhibit the signs of epidemic anxiety among its youngsters.
What we used to refer to as the "presenting" problem that presumably masked the real "underlying" issue has become something that requires less clinical detective work: often the problem is the struggle to handle the stress of normal, everyday life. Fifteen-year-old John has been drinking too much and ends up in my office. Yes, his drinking is a troubling concern, but not compared to the viselike grip of anxiety he feels about 30 hours of homework a week, 4 hours of basketball practice every night, 3 hours a week of community service, and, of course, 2 parties a weekend. What about Julia, who's in therapy because of her almost failing grades? Sure, she's worried about school. But what really preoccupies her is the phenomenon The New York Times recently called the "whore wars." She's caught in a bind. She feels she must show as much skin as possible, but how can she do this when she's obsessed by the fact that so many different parts of her body are "absolutely grotesque"? Of course, girls have lived with impossible standards of physical perfection for decades, but now it's happening at younger and younger ages--Julia is 11. And her friend Ethan, also a preteen, is one of the growing number of young boys I know who are obsessed about their bodies, too--not buff enough, too skinny, too small. "Might as well be dead."
Thirteen-year-old Peter is in my office because he's isolated and he turns people off. What's really going on beneath his haughty presentation, though, is that he's been typed as gay. Why? He once put his arm around another boy in a moment of friendship, and, since then, he's been accused of being "ass hungry." Mona's got it all--the perfect look, the perfect body, and she's super-smart. So, what keeps Mona so fearful? Precisely because of her magnetism, she's the object of anonymous Internet insults, online come-ons, and, lately, direct threats on her life. What keeps Michael up at night is that he can't turn himself off after an ordinary evening. What's ordinary? Being online with six people at once while talking on the phone with two friends on call waiting, burning a CD for a pal, doing his homework with a friend, and listening to the TV in the background--just "to keep him company."
Don't reflexively blame their mothers or fathers. Most of these kids have reasonably responsive, competent parents, who feel as helpless as their kids about how to lessen the grip of this half-crazed pressure. After all, they live their own version of the same bind, stretched to the breaking point by their own impossible work schedules, endless social obligations, and gut-wrenching economic worries. Parents feel hard-pressed to protect and soothe themselves, much less their kids, from external pressures that have essentially colonized the family.
And kids know their parents feel helpless. Many teens have lost faith in the ability of adults to protect them from a culture running off the tracks. Studies repeatedly show that when the unthinkable happened--sadistic bullying, death-defying parties, or schoolyard killings--kids knew something was up, but hadn't approached parents or other adults for guidance. In a vicious circle, the less comfort and trust kids feel at home, the more they gravitate to what I call the second family of the peer group and pop culture to meet their needs for a sense of self-worth and a feeling of connection. But the second family carries its own freight, its own pressures, and its own terrors. Like the culture that shapes it, the second family is a world increasingly gripped by anxiety and flying off the hinges.
The Therapeutic Response
So what's a therapist to do? Does the diagnosis du jour--ADD, AD/HD, PDD, OCD, bipolar disorder--help us, past a certain point? Does any one therapeutic framework or technique, such as cognitive-behavioral, insight-oriented therapies, or EMDR, get at the pervasive anxiety that's as much a cultural issue as a personal problem? Can family therapy make a dent if it incorrectly views the family system as powerful enough to counter the larger social angst?
Living in their parallel universe of overstimulation, endless exposure to disturbing information, and constant change, teens need an ongoing relationship with a grown-up. Therapy is a chance to create exactly those experiences and support those values that are missing in the rudderless, anxiety-driven world that surrounds them. When there's often no follow-through in kids' lives, therapy can offer follow-through. Amidst the chaos at large, the consulting room can be a predictably safe harbor. In a world where adults are seen as two-dimensional figures, a therapist can be a three-dimensional person whose thoughts and feelings command respect and attention.
I think of the critical issues around which a different approach to therapy with kids needs to develop as the "four R's"--Rules, Rituals, Reasons, and Regard. Though simple and straightforward--almost too ordinary for technically accomplished clinicians to be concerned with--they're radical, from the standpoint that they've largely disappeared from family life today.
"I'm sorry I'm late. Everyone was talking after school, and I lost track of time. . . ." "The bus broke down and I wasn't near a phone, so I couldn't call you to say I couldn't come." . . . "We went to the pizza place and just hung out.". . . "I thought insurance was paying you directly . . . ." "There's a big reading test tomorrow, and I have to stay home and study."
When many of us began doing therapy years ago, we believed our young clients' anxieties often resulted from too many rules and too much authority. So our training taught us that a warm, fuzzy therapeutic embrace was a godsend for children. At the same time, many of us--feeling hounded and harassed ourselves by the convoluted regulations of managed care companies and mental health agencies--are uncomfortable in the role of rule-enforcers. But today's kids are anxious partly because there are few rules that matter. We need to recognize that today a laissez-faire therapeutic frame is indistinguishable from the everyday chaos many of our young clients experience.
Establishing clear rules in therapy creates exactly the secure frame that young clients and their parents need to begin managing the disorder in their lives. In fact, addressing the concrete issues of maintaining commitments, setting priorities, and being serious about the process can bring to the surface issues that might otherwise undermine therapy. Instead of just skipping appointments or prematurely terminating therapy, families held accountable start talking about financial concerns or other fears that are threatening to devastate the home. When therapists challenge a family's casual attitude about showing up on time, parents may begin to openly discuss the everyday chaos that can be so frightening to children. In addition, almost without fail, when a preteen or teen is late to therapy, the missed appointment time is used for the very problem that the family is seeking help for--substances, after-school acting out, and so forth.
I was recently seeing Craig, 14, a very nice boy, who couldn't make friends. Like so many kids, he reverberated with anxiety, which he tried to overcome by being loud and forcing himself into people's conversations, much to the disdain of his schoolmates. Craig and his family were prone to cancel appointments at the last minute. After about the third time this happened, I reviewed the rules with them: they had to show up on time or reschedule within 48 hours. Reluctantly, they began to talk about their everyday concerns. Mom had been laid off and Dad wasn't making enough to meet their expenses. In fact, they were canceling at times when they didn't have the cash to pay for sessions. They felt humiliated and crushed by the pressure, and the situation wasn't at all helped by their son's increasingly expensive tastes for the latest fashions.
We began by cutting therapy back to every other week, and then talked about what the mother might do to activate her job search and how they could reduce some of Craig's expenses. Discussing how to weather this economic crisis avoided a premature ending of the treatment and had a stabilizing, anxiety-reducing impact on the whole family.
Concrete rules run counter to the incessant, 21st-century messages to kids (and adults) about the need for instant gratification. Rules protecting the therapeutic frame provide reassurance that the therapeutic relationship won't, like so much else in kids' lives, melt into thin air.
"Dinner is ready and we're all sitting down. Okay, okay, but as soon as the show ends, come get something to eat." "I have to work late tonight, but there's some of that macaroni and cheese mix in the cupboard that you can make." "We're too tired to go to church tomorrow. I know it's the third week in a row. . . ." "I don't care if it is time for our family meeting. Everybody's busy. Johnny's working on the computer, Lisa's doing her project. The little one's watching TV. We'll skip it just for tonight."
By now, we all recognize that the simple routines that were once part of everyday family life are rapidly disappearing under a tidal wave of overscheduling. I've asked hundreds of children what in their lives they wanted to have happen more often. Over and over, I've heard the same deceptively simple responses: "pizza and a video," "reading before bedtime," "walking with my father to the school bus," "playing board games with my mom and sister," "cooking together."
Clinicians have long understood the significance of ritual, but mostly through a narrow, trauma-related lens. After a loss or a difficult life transition, we help people create rituals that heal and rebuild. Unfortunately, only a few therapists consider simple rituals in the consulting room sophisticated enough to help with anxiety. Yet research shows that the repetitiveness of rituals helps clients not only heal, but also open up. Simple rituals in therapy can soothe fears, help kids communicate, and inspire families to develop their own satisfying routines at home.
The rituals that have worked best in my sessions are invariably those discovered by my young clients. My role is simply to go with the flow. Fourteen-year-old Jeremy suffered from excruciating self-consciousness and anxiety, which provided fodder for other kids' taunts. He was as self-conscious in therapy as outside; he couldn't talk about his life or his feelings. At the time, I happened to have in my office a football-shaped, stuffed hedgehog for the younger children. One day, Jeremy picked it up and, somehow, we began tossing it back and forth. This seemingly boring, nontherapeutic behavior became an anchoring ritual. At every session, the first thing Jeremy did was seek out the hedgehog; if he didn't find it, he'd ask me where it was. And from the first, while throwing and catching it, he could open up about his problems with the other kids.
Soon Jeremy got his father to play a weekly game of catch. During these games, he began to talk about what was going on at school. "What do you think you might be doing that makes the kids act that way?" his father asked as they played. An ongoing conversation ensued with his father and mother about what he could do to improve his image at school--how to initiate conversations, how to ask questions in a way that wouldn't turn everybody off, when and how to respond to kids when they taunted him, and when to walk away. Jeremy's anxiety didn't magically disappear. But over time, these routine games of catch helped him share his schoolyard fears and helped his parents become better listeners and problem-solvers.
Rituals that work are entirely idiosyncratic. Patients make their own preferences clear, often quite insistently. Twelve-year-old Elena was a mass of adolescent angst, dressed in full-Goth garb. Contrary to her anarchistic attitude, she constantly obsessed about what everybody thought of her and worried nonstop about how she looked. She wanted me to listen to the CDs she'd burned between sessions and would invariably jam a few CDs into my boom box and play her ferocious music for me. Listening to the lyrics gave us an easy entree into conversations about her week, her friends, what she was thinking and feeling. If I forgot to ask about her latest CD, she'd remind me.
Eventually, after Elena talked about our "music sessions" at home, she and her mother (who quarreled often and fiercely) established their own music ritual. Mom played that "crunchy-granola '60s crap," while Elena blasted out her hard-edged punk sounds. These interludes became a buffer of peace during which mother and daughter could briefly suspend hostilities and begin to understand each other better. Elena didn't entirely stop obsessing about her looks or what people thought about her, but she did begin to acquire a little less moody perspective. The ritual, as so often happens, provided a structure for a connection with her mother that was both comforting and reassuring.
Other kids read from journals or e-mails at the beginning of every session. And almost every child or adolescent snacks with me. Food rituals have become a staple of my therapy with kids. There's something about sharing a "meal" that seems to calm and soothe. And it can't be just any old food, either; no, they want the exact same goody every single session. Regardless of what's happening in their lives, none veers from a particular choice. Once I asked Lydia, a 13-year-old girl who'd taken a shine to the saltine crackers that came with my take-out soup, why she always wanted the same food--wasn't it boring? "Different is boring," she said, munching away contentedly, "the same is good." In fact, it's the sameness of a ritual that makes it reassuring, and an opening for conversation.
Fifteen-year-old Mary says, "I went to the guidance counselor because there are these kids who keep saying horrible things about me and threatening me. I can't avoid them; they're on the school bus, they're in my class, they're online sending me gross messages. I wanted to know what I should do. So what does the guidance counselor say? She says, 'Tell me what you think you ought to do.' Do you believe that? Why the fuck does she think I asked her in the first place? Is this supposed to be helpful? What is it with you people, anyway?"
Mary's complaint is well-founded. Unfortunately, counselors and parents are often terrified of offering advice to kids and giving good reasons for not engaging in bad activities. But there's never been a time when kids needed more unapologetic adult direction. The fear factor is everywhere. Whether it's elementary-school ostracism or middle-school taunting or high-school revenge, binge drinking, drug use and shoplifting, or Internet threats for anyone old enough to sign on, kids face scary issues every single day.
What in the world is this child to do, and why in the world don't we tell her? Well, many clinicians and parents have long bought into the theory that telling kids what to do will somehow stunt their emotional development. But kids' anxiety is, in part, a reaction to being left virtually on their own. The children of ineffective parents, stymied by a youth culture that often seems to dominate our entire social landscape, need a therapist who isn't afraid to give advice that supplies reasons, creates dialogue, and ultimately strengthens kids' thinking. In fact, behaving like an adult with kids, drawing on adult authority and knowledge, challenging them on their often screwy assumptions, dangerous desires, and unwise choices engages them at a visceral level. They feel they're in touch with a force that's real--authentic, strong, trustworthy, and dependable--utterly unlike the will-o'-the-wisp ethos of their own world. Straightforward advice based on experience relieves anxiety. And most therapists have a lot of solid advice to offer.
Advice isn't something to hide from your supervisor or peer supervision group; it's an absolutely essential aspect of treating 21st-century teens. There's nothing wrong with saying to young clients: "Read your e-mail to me and I'll tell you whether, in my opinion, it sounds okay to send. . . . When they get into your car, it's your responsibility what happens. . . . It'll be almost impossible to keep crashers from your party; it's a huge worry to deal with. . . . If you approach that kid in front of his group, he'll most likely turn down your offer. . . . Don't think that will be kept a secret; everybody will know by the end of the day." But certain guidelines are important. To give effective advice in treatment, a clinician needs to get the whole story, with as many nitty-gritty details as possible, while trying to suppress the almost hard-wired therapeutic urge to ask, "How does that make you feel?" It's also very important to let kids know that their situation deeply touches you; this isn't the time to retreat behind clinical neutrality. And, finally, it's essential you say that you won't be there to see whether your advice is taken.
For example, Jimmy, 16 years old, asked me if I thought he should drive a bunch of his friends to a party after the prom ended at 2 a.m. The prom would include tequila-braced punch, and the after-prom party was 100 miles away. Jimmy had a beat-up old car, a girlfriend to impress, and a couple of pals he'd already made promises to. Jimmy's parents weren't thrilled about this plan, but told me, "This is what kids do now. We basically trust him; he's a good driver, and he'll have a cell phone." Jimmy was ambivalent--he felt important, but was worried about the responsibility.
Me: How much will you have had to drink by the time you leave the prom?
Jimmy: Somewhere between six and eight drinks--but it's over a long night, and the drinks are pretty weak.
Me: And your friends?
J: Oh, they'll be wasted. I'm the designated driver. That's why I have to drink less that night.
Me: And you think six to eight drinks is taking it easy, right?
J: Yeah. I'm not going to be chugging. I'll be eating all night, and look, I weigh almost 175 pounds.
Me: I think you're absolutely out of your mind. I know I can't stop you, but I don't think you should do it. No way!
J: What are you talking about? My parents know about it and they think it's okay. The school even wrote a flyer home about it.
Me: I don't care who thinks what. It's going to be really late. You'll have had too much to drink and you're legally responsible for everybody in that car.
J: I don't believe that. They know what they're doing and they're responsible for what they do.
Me: No! You're responsible, even if they don't buckle up their seat belts. Look, I'm telling you again, I won't be there and can't stop you, but this is a crazy, insane, lunatic idea, and I'll do anything I can to talk you out of it."
We argued over every detail until the last minute of the session--what his girl might think, what his friends expected, why he thought he had to do it. I had absolutely no idea of what he'd do, but the anxiety Jimmy came in with had now been transformed into engagement between us and at least a few questions within himself. Two weeks later, Jimmy came in again. The prom was long forgotten by now, a distant speck on an adolescent's constantly shifting horizon. "The after-prom?" I nudged. "Oh, we didn't go. I was too tired. We were all wasted, and it felt pointless to drive 100 miles. So we crashed at somebody's house and went to sleep." Not a single reference was made to our heated discussion.
It doesn't matter. The therapeutic action is the dialogue in which the advice is embedded. Engagement "holds" kids, calming them just enough to allow reason to begin trickling down into their feverish, revved-up psyches. In Jimmy's case, his inchoate, almost unrecognized, anxiety was transformed into a good kind of resistance to me, like bumping up against a familiar object after racing through pitch-black darkness. In their lightning-paced, careening lives, kids have few adults to slow them down. Twenty years ago, a teen's reaction to all this might have been, "Stop preaching; you sound like my parents!" Today, more often than not, it's relief.
"Express yourself!" "Think it, write it, send it. Now!" "At least my parents aren't involved in a vicious divorce the way yours are!" "You think you're special just because your mother died?" "Don't come to school tomorrow, if you plan to stay alive." "You're fat, you're bulimic, you're a loser." Mean Girls . . . Bad Boys . . . "Hey, is that any way to talk to your therapist?!"
From playground back-talk to schoolyard mean-talk to high-school rap-talk to online death-talk, casual communication between kids pulsates with a verbal brutality that makes most adults wince, turning "the wonder years" into years of anxious vigilance.
And this carries over into the home, where many parents tolerate enormous abuse from kids because they're frozen in place by 30-year-old pop-psychology bugaboos: if kids aren't allowed to freely express themselves, they won't talk and develop proper self-esteem. Yet kids today are verbally abusive, not so much from deep, festering rage or rebellion, which might once have been the case, but because they genuinely seem oblivious to the impact of their own actions on others. They've never been taught that what they do and say actually matters, that laserlike one-liners can deeply wound people. And when you don't have to face the person whom you insult--via cell phone, beeper, e-mail--it's even easier to do. As one 12- year-old told me, "I can say anything I want online because I don't have to see how it makes the other kid feel."
The parental reaction is all too often a post-Freudian, pseudo-Rogerian, Zenlike acceptance of kids' communication. Just about every clever utterance no matter how hurtful, every negotiating ploy no matter how outrageous, every power play no matter how maddening is okay in the name of self-esteem, self-expression, and mental health. Until, of course, the inevitable adult explosion--a blast of unenforceable threats ("You're grounded for life!") or fits of physical force (8 out of 10 parents still believe in hitting their kids). It's clear which is more dangerous, but which is more anxiety inducing: the out-of-control abuse of parents or out-of-control threats by parents?
Both. At home, in school, on the soccer field, or online, kids are rarely asked by adults to feel the impact of their actions. By "regard", I mean that in 21st-century treatment, we need to help a child feel the impact of who she is and understand that what she says to other people makes a difference. It's about turning treatment into a microcosm of interpersonal dialogue in which both participants understand their own experience and their impact on the other.
Fifteen year-old Nick was in therapy because he had such a hard time making friends, and didn't know that his imperious demands turned people off. At lunch, for example, he'd go to a table full of classmates and shove his way into a seat, saying something MTV-ish, like "move your ass!" The kids at the table weren't impressed; they'd tell him to get lost. So, time and again, Nick's anxiety about his lack of friends would spike.
I quickly began to understand why he had difficulty making friends, because Nick acted the same way with me, demanding, "Where's my food?" After a few times of grudgingly going along, I told him, "You know, usually I look forward to these snacks. But I don't feel like eating with you when you talk like that." Looking deeply puzzled, he said, "But that's just the way I always talk."
"And what do the other kids say when you start telling them, 'do this, do that?'" I asked.
Nick paused and thought. He wasn't defensive--when I ask these kinds of questions, kids often aren't. They're just surprised; it hasn't occurred to them that an adult might have feelings about what they do and that there may be a reason why peers don't find them inviting. Over the course of several months, he developed a little more self-awareness. At school, Nick gradually learned when and how to ask if he could sit with others. Slowly, he was accepted at the outer edges of the "nonloser" table--not the highest rung on the adolescent social ladder, to be sure, but better than before.
Mandy was a sweet girl of 15, who "mysteriously" alienated other kids. After a few sessions, it became clear why. Mandy got so wound up telling me a story that she'd repeatedly leave her chair and stand directly in front of me, completely lost in the details of her experience. I felt myself shrinking back in my chair. Mentally pushing aside the neat diagnosis of "nonverbal learning disorder," I decided to respond in the moment, saying, "Please, Mandy, move back a little and tell me from a little farther away. I can't concentrate with you practically on top of me."
She stopped, looked surprised, and said, "You mean I'm making you nervous?"
"Yes," I said, "I really feel pushed."
She looked taken aback.
"I know you don't mean badly and want to tell your story," I continued, "and maybe I'm doing something that makes you feel I'm not getting it. But it really is too much for me when you get that close."
Mandy was quiet for a minute. "You sound just like my parents. They say the same thing to me." I asked if she ever noticed anybody else shrinking away from her. "Oh, no, never."
"Well," I suggest, "maybe you could just watch and see if this happens at school."
The next week, Mandy again started to stand up as she got into her story, but this time, she saw the look in my eye, caught herself, and sat back in her seat. "You know, I did notice that I get right in kids' faces--and talk louder and faster. It makes me very nervous when I think people aren't listening."
As it turned out, I discovered that Mandy's mother was also a "close talker." When Mom felt Mandy needed to know something, she stood over her daughter and delivered high-decibel lectures. I worked with her to establish a more user-friendly style of communication, emphasizing simple, basic techniques: when Mandy needed to know something, tell her in a calm tone of voice, make it short, and then leave. Of course, like all of us, parents often fail at first-time assignments, so a little family-of-origin work (and eventually, some cognitive testing for Mandy) became part of the treatment.
Both of these situations required a number of interactions to get the point across. But teens take honest feedback to heart. Its directness pales in comparison to what they're used to hearing at school or at home. And the chance for kindly discussion is a true gift. Developing regard for an adult's experience increases kids' awareness of the world and lessens the out-of-control feelings that engender anxiety in so many of them.
Creating rules to protect the therapeutic frame, establishing rituals to soothe children and open up dialogue, offering passionate advice to encourage reasoning, and asking to be treated with respect may seem, at first glance, unsophisticated, especially compared to the hundreds of clinical approaches now on the therapy marketplace. But at a time when the stable building blocks of family and society are disappearing into the maw of a ravenous mass culture, these old standards of civility and security make a lot of sense, and are good therapy. For all their apparent bravado, kids need the felt presence of adults---the undeniable evidence that we can be emotionally there for them, keeping them safe and providing them with the structure and guidance they crave in a frighteningly chaotic world.
Nothing less seems to hold their anxiety, or capture their digital-speed, supersaturated attention. The other night, I gave a talk for parents and kids in a suburban high school. "How do kids want adults to talk to them?" a parent asked. A sudden jolt of electricity ran through the teens and preteens, "Why don't you just tell us what you really think, for a change" one shouted, with the nodding approval of her buddies. "Only, keep it short, will you?!"
"Rules, Rituals, Reason, Regard--not a bad way to work with kids. Cell phone's ringing. Hmmm, maybe it's a referral. "Refinance, now!" Wait, my continuing-ed application is due tonight--when am I going to get it done? "You've got mail!" I can't believe Sam and Julie are splitting up! They've been married 25 years. "Dear member, your group's medical coverage is being dropped as of . . . ." Tim has cancer, and they don't know whether they caught it in time. "Today's new unemployment figures are out." I'll have to stay late at the office again. But, I promised the kids I'd be home in time to kiss them good night. Oh, no!
Ron Taffel, Ph.D., is founder of family and couples treatment at the Institute for Contemporary Psychotherapy in New York. He's also the author of the professional guideÂ Getting Through to Difficult Kids and Parents . His latest book on adolescence is The Second Family . Address: 155 Riverside Drive, New York, NY 10024. Letters to the Editor about this article may be e-mailed to Letters@psychnetworker.org.
By Graham Cambell
Several years ago, my wife and I were at the end of a rather long line waiting to be seated in a popular local restaurant. Tired of standing, we took a seat in an alcove secluded by a large pillar. As we sat talking, a former client strode into the lobby. Sue (of course, this is not her real name) had come to me for treatment of a severe panic disorder. The condition had been impervious to the efforts of three previous therapists and a stress-reduction program, and, since she was pregnant, Sue refused medications. Consequently, I took the case with considerable fear and trembling. We had eight or nine sessions together, but the therapy helped only minimally and she dropped out.
Hurrying to the front of the line, Sue began talking energetically with a man I recognized as her husband. He had been holding their place while she waited in the protective isolation of the car. But Sue had become impatient, and now she had decided to assert herself. In sessions, she was always unassuming, quiet and polite, so I was startled by what ensued.
In a voice audible to everyone in the small crowd waiting for a table, Sue began to argue with the host about where she and her husband would be seated. She wanted a table near the window, and she made it clear that she wanted it now . I glanced in that direction and saw that all those tables were taken.
"No, a second-row seat will not be acceptable," she snapped. "I need to be next to the window. Why can't you seat us in the courtyard? That is where we sat the last time, and it was excellent. That is why I came back here."
The host was calm and seemingly imperturbable, "Unfortunately, the outside area is closed," he said. He could have also mentioned that it was a cold and windy October night, but chose not to. "If you would like to wait until a window seat..."
"No, we have waited long enough," Sue declared. "Why don't you take reservations like most good restaurants do? Perhaps we should just leave."
"If the bitch doesn't want the seat, I'll take it," a man near us mumbled.
I had to agree that Sue was being more than a little abrasive, but as her former therapist, I was privy to information that the other patrons didn't have. It was clear to me that Sue was either in the midst of a panic attack or was trying desperately to stave one off. Her rudeness was simply a means of coping with her anxiety.
"If you can't seat us in a timely fashion..." she continued.
The host interrupted, "Allow me to see if we can set something up outside." He and another staff member cleared the doorway and in a few moments, Sue and her husband were seated in the windy courtyard.
To understand why Sue chose to dine in a stiff breeze, rather than in a cozy restaurant, it helps to examine the situation through her anxious eyes. In the shape she was in, Sue's primary concern was to avoid public embarrassment. The easiest way to do that was to become invisible. Hence, her original desire to be seated near the window. Not only were those seats on the periphery of the room away from most of the other diners, but they came with a reassuring view of the world she could escape into if panic overwhelmed her. But with no window tables available, Sue began agitating for an alternative that offered her even greater anonymity, and the opportunity to depart unobserved if the need arose. Sure it was chilly outside, but a little gooseflesh was a modest price for that kind of security.
Anxiety, as Sue and others experience it, is not only ever-present, it is ever-threatening. It is a phantom that steals their freedom. Living with panic attacks is like belonging to a street gang: one must always be on the alert for personal slights or threatening movements. Combating the phantom of anxiety requires constant vigilance over one's honor, status and territory. Everyday experiences, such as being seated in a restaurant, become crucial battlegrounds.
Anxiety attacks anything and everything in a person's life. Sometimes the targets are the mundane activities that others take for granted. At other times, it attacks more fundamental functions, such as one's ability to work or to love. We are used to thinking of people who are afraid to speak in public or to drive across a bridge as anxious. We are all familiar with a few stereotypical worrywarts. But anxiety influences a much broader range of behaviors. To the ordinary observer, people who are rude in a restaurant, obnoxious at their child's soccer game or overly exacting of their employees might seem simply self-centered. But often, these individuals are dealing with a wide variety of inner phantoms.
The novelist Stephen King understood this. In Delores Claiborne , his novel of domestic violence and sexual abuse, he has Vera explain to Delores: "Sometimes being a bitch is all a woman has to hang on to." An anxiety disorder is not simply an enervating jumble of symptoms; it is an intensely circumscribed way of life.
Treating Anxiety Disorders
When I began working with anxiety disorders 10 years ago, I had little understanding, training or experience with these conditions. But I worked at a mental health clinic that was inundated by people suffering from panic attacks, and I saw this as an opportunity to broaden my skills and experience.
Starting from scratch, I began developing my expertise in obvious ways. I went to training seminars and read everything I could get my hands on. At one point, in the early 1990s, I had read every article about anxiety that had been published in The American Journal of Psychiatry and several other professional journals in the previous 10 years. I also sought supervision, and consulted with colleagues. And, of course, I observed and met with as many clients as possible. For a while, I saw everyone with an anxiety disorder who came into the clinic.
Eventually, I settled on the treatment program outlined by David Barlow in Master of Your Anxiety and Panic . In addition, I found the books Don't Panic by Reid Wilson and Finding Serenity in the Age of Anxiety by Robert Gerzon most helpful. The Barlow-inspired model I employed involved a time-limited, symptom-focused, cognitive-behavioral approach to therapy. It focused on teaching skills that enabled clients to deal with symptoms. Early in the process, I discovered that this model did what it purported to do--something of a rarity in the field. In addition, it placed great emphasis on education. I found that compelling because I know of no condition for which the dictum "knowledge is power" is more true.
Thus, I became an advocate of diaphragmatic breathing, progressive muscle relaxation and self-talk, and an example of an old therapist's (or at least a middle-aged one) learning new tricks. What I did not foresee was that cognitive-behavioral techniques, rather than obviating the need for a more probing therapeutic approach would, in many instances, prepare clients to benefit from deeper work. Developing new therapeutic tools for anxiety has broadened my therapeutic range and, paradoxically, confirmed my faith in my old tools.
In my initial session with clients, we develop a detailed history of the occurrence of their attacks. I also ask them to keep a record of each attack they experience during the first few weeks of therapy. Our goal is to understand what triggers these attacks. Even a partial explanation can help a client feel a greater sense of control and, not surprisingly, a sense of relief.
Early in therapy, my clients and I also discuss their diets in some detail. Because caffeine intensifies anxiety, I insist that they eliminate coffee, tea, chocolate, colas and all other forms of this seductive stimulant from their diets.
During the second session, we usually begin to practice diaphragmatic breathing and progressive muscle relaxation. I also give clients a tape recording of a 30-minute relaxation program. For homework, I instruct them to practice the breathing for five minutes, three times each day, and to listen to the tape daily. We take considerable time during our sessions practicing these techniques, but the clients need to practice at home, too.
If by the third or fourth session a client is not practicing breathing and using the tape, therapy is unlikely to be successful. I have tried numerous times to explore other issues or confront resistance at this point. It rarely helps. Sometimes clients are simply not ready to do the work necessary to create change.
But clients who commit themselves to learning to breathe and to purposefully relaxing when confronted with anxiety-producing events progress quickly. They begin to believe they can regain control over their lives, and often, they do. In most situations, these clients are usually able to end this episode of therapy after eight or ten sessions.
Anxiety and Medication
One issue that often arises during these early sessions is whether a patient should take medication. I prefer that they do. Obviously, there is no absolute therapeutic consensus on this point. Some writers suggest that drugs may interfere with the impact of the cognitive-behavioral approach. They are concerned that clients may come to rely on medications for success in treatment. This is an interesting theoretical concern, but my experience is that clients who refuse medications often refuse to engage in diaphragmatic breathing, progressive muscle relaxation and self-talk. In a slight variation on this theme, some clients do not directly refuse medications, but take minuscule amounts at irregular intervals. These same clients are very likely to practice relaxation once a week, turning it into an empty ritual.
Dealing with anxiety "naturally" is a wonderful idea that I support wholeheartedly. But the refusal to take medications often indicates that a client is unwilling to confront his or her condition and to make other changes. (This is not always true, but it is very common.) For these clients, control is such a central issue that they refuse to give it up to a pill or to muscle relaxation. Ideally, clients who are established on appropriate medications can begin to gradually cut back on them, with their physician's supervision, as they master coping skills.
Medications are also essential for clients who are simply too rattled to concentrate on therapy. I learned this lesson from an elderly client--feisty, articulate and humorous--who looked me in the eye and said, "Now, Doc, just wait a minute. I believe I'm about to die of a heart attack at worst, or that I'm going crazy at best or probably both. And you want me to sit in a chair and take deep breaths! First, get me something to calm down, and then maybe I'll try it." This client visited his primary care physician, who started him on an appropriate medication. Within three months, he was calm enough to learn breathing, relaxation and self-talk. Within a year, he was tapering off medications, attending a yoga class, meditating daily and heading into a new spiritual phase of his life.
As this case illustrates, cognitive-behavioral therapy, often in conjunction with medications, can produce remarkable results. It is often the only psychotherapy that my clients need. Often, but not always.
Getting to Deeper Issues
In many clients, anxiety obscures deeper issues. It is not uncommon for these people to complete a brief, successful course of therapy for panic attacks and then return a year or two later with related problems. Usually they have become aware of something behind their anxiety, something that drives and intensifies it. Often the problem was present during the earlier therapy, but the client was not ready to deal with it. For example, it is relatively common during the cognitive-behavioral therapy for clients to describe their spouses as supportive, kind and gentle. Upon returning to therapy, however, clients frequently reveal that there have been years of infidelity, domestic violence, financial irresponsibility or a simple lack of support. What was first presented as a fine relationship is now seen as inadequate at best.
But a person who is frequently in the grip of panic is too vulnerable, and feeling too crazy, to confront relationship problems. A woman who can't leave her house without experiencing acute anxiety is unlikely to consider a divorce, no matter how violent her husband becomes. Not until her symptoms are under control will she find the strength to confront the other problems in her life. Clients who return for additional therapy often say things like: "Well, Graham, I'm back and I can't breathe this one away. I faced the panics and now I have to face him."
In these cases, panic was an inner static that prevented reflection and soul-searching. Now that the interference has been reduced, clients are able to face other aspects of their lives. When this happens, I take a much more reflective stance as the therapist. My focus shifts from teaching clients coping skills to helping them explore their values, goals and intentions.
The two endeavors are not entirely dissimilar. In the cognitive-behavioral phase, I am a teacher who listens a great deal. I teach skills that help a person deal with specific symptoms. As a more traditional psychotherapist, I am an empathic listener, but I am still teaching a skill. That skill is inner listening: the ability to hear one's own heart, spirit or soul.
If the issues that bring clients back to therapy are existential, I explain to them that in this phase of their treatment, I will play a different--less directive--role. Sometimes they are disappointed. The previous episode of therapy was so effective that many people come back hoping for more of the same. But this time, there is no ready-made solution to their problems. They have to learn to listen deeply to their own heart and soul.
Fortunately, their disappointment is usually short lived. People who have been faithful to the deep-breathing and relaxation exercises can hear themselves much more clearly than before. Gerald, for instance, originally came to see me for panic attacks. His industry was in the midst of enormous transition. His company was downsizing and his job was in jeopardy. He learned to control his anxieties in the brief cognitive-behavioral therapy and successfully weathered the upheavals at work; however, two years later, he returned to therapy saying, "I survived, but this just isn't what I want to do anymore."
At that point, we entered into a longer, more reflective, therapy exploring what he wanted to do with his life and career. He changed professions and simplified his life. It wasn't easy or always comfortable, but the confidence he gained confronting the anxiety attacks in the early therapy paved the way for deeper work.
The Uses of Anxiety
Over the time I have worked on anxiety disorders, I have arrived at two basic, closely related, conclusions about the nature of these conditions. First, anxiety disorders are a means of keeping the external world at bay.
To understand this idea, it is valuable to contrast this view of anxiety with the perspective of traditional psychoanalytic theory. From a classical psychoanalytic perspective, anxiety is the attempt to repress unacceptable impulses that arise from within the Id. It prevents disorganized thoughts and forbidden urges from invading the consciousness. In this traditional view, anxiety works to keep impulses down within the psyche. Perhaps the best example of this dynamic occurs when a person who experiences homosexual thoughts responds with great anxiety that is expressed through homophobia.
But in my view, anxiety has less to do with repression than deflection. Anxiety keeps new ideas and information out of a person's awareness. It saves overloaded mental and emotional circuits from additional strain. It is a sea wall built against the tide of physical circumstance.
Unfortunately, anxious individuals pay a severe price for this protection. They have trouble accepting feedback or learning from their experiences. They also have a difficult time adapting to new circumstances. Their approach to life may not work very well, but they have difficulty changing it.
As an illustration, consider the dramatic contrast between the way depressed clients and anxious clients respond to a therapist. Most of my depressed clients can take in what I say and consider it. My comment may or may not influence them. It may or may not be accurate. But they take it in. Anxious people usually don't. It is as though feedback and interpretations bounce off them.
With a depressed person, if I say something as basic as, "The opinions of your parents are very important to you," the observation often begins a dialogue about autonomy or dependence or childhood memories. The same comment to an anxious client brings an unproductive evasion: "Oh, yes, they are. I have often thought they mattered too much, but I could never change that."
Depressed people are sometimes helped by supportive comments. They are like a sponge absorbing what is sent their way. But anxious clients wear a Teflon coating and supportive comments just slide off. Depressed people tend to feel guilty and inadequate. Consequently, they feel they must change. Anxious people also feel guilty and inadequate, but they are more likely to feel that something else has to change. They objectify what depressed people personalize.
The handiest object onto which an anxious person can project his internal turmoil is his body. Anxious individuals often view their bodies as failed machines with specific yet undetected flaws that need to be corrected. It never ceases to amaze me that many people with anxiety disorders are somewhat disappointed when tests come back negative. They would rather have a "real" physical problem than a psychological one.
This desire is sometimes fulfilled due to a second trait common to anxious people--their tendency to neglect or even ignore their own needs for the sake of communal tranquility, and compliance with authority figures.
Statements such as "I am a people pleaser," "I come last" and "I have three kids, that doesn't leave much time for me" are very common among anxious people. They are devoted to keeping their environment conflict free, and are more than willing to repress their own desires to do so. Anything that threatens the fragile peace they are trying to maintain is cause for alarm. Since there is little peace in the external world, alarms--in the form of anxiety attacks--go off all the time.
These attacks would be disturbing to anyone, but they are especially disturbing to anxious clients who expect their bodies to be as acquiescent as their emotions. Eventually, however, living in an almost constant state of alert takes a physical toll, and long-ignored needs eventually manifest themselves in physical symptoms. In this way, the desire for a "real" physical problem becomes self-fulfilling.
In therapy I attempt to break this cycle and help clients come to terms with both their internal and external worlds. I try to help them understand that the tranquility they are seeking through repression can only be found by accepting the legitimacy of their own needs. When they grasp this, their Teflon coating begins to dissolve. They can assimilate new information and develop new ways of living. The body can then be seen not so much as something to be controlled but as something to be respected.
Learning to Listen
Once the alarms of the body are silent--once the body component of the mind-body equation has been successfully treated--therapy becomes a reflective process with an emphasis on accepting the importance of subjective experience.
On a concrete level, one of the best strategies for hearing the subjective voice is to continue the practice of diaphragmatic breathing several times a day, until it becomes a natural process: breathing deeply and listening deeply throughout the day. In this way, people can hear their inner voice and weave its wisdom into their responses to the demands of life. In therapy, when people are facing important dilemmas or conflicts, I often encourage them to first be silent and focus on the breath for several minutes. Then, I ask them to listen to what their inner experience says to them about the conflict. I'm often amazed how much more clearly they see their situation after this simple exercise. As they become experts at listening within, they usually discover that the situation is either not as anxiety producing as they feared or that they have the inner strength to handle the problem.
In many clients, the knowledge of diaphragmatic breathing is like a slowly germinating seed. Because it is a physical skill, even those who show little interest in it during therapy can master it later without a therapist's help. A case in point is my former client, Sue.
A year or so after the restaurant incident, I bumped into her on the way into a store. We chatted pleasantly for a while. Things were going very well for her. She had a daughter. The anxiety had receded. She said, "Things are so much better now. It took six months before I took what you or any other therapist said seriously. Then I started doing the breathing and the relaxation tape. I even joined a yoga group last week. I appreciate how kind you were. I didn't listen then, but I do now."
I did not mention the restaurant.
Graham Campbell is a psychologist in private practice with Cedar Associates in Worcester, Massachusetts. His clinical focus is on grieving, terminal illness and the relationship between spirituality and psychotherapy. Address: 9 Cedar St., Worcester, MA 01609; E-mail address: email@example.com. Letters to the Editor about this article may be sent to Letters@psychnetworker.org.
by: Reid Wilson
As I tell this story, you can ask yourself, "What's this have to do with the practice of therapy?" I'll answer, I promise--after the story.
It's Monday morning, and I've set aside several hours to work on this article before my next client comes. I've cleared my desk at my home office, turned off my e-mail, put a sign at the top of the stairs--"Serious Writing in Progress!"--and settled in for the duration. At my first break, I visit the bathroom to discover the toilet is plugged up. I flush to clear it and then . . . filthy brown toilet water is suddenly spilling over onto my white Berber carpet! I rush to turn off the intake faucet and it doesn't help! The water is literally pouring over the side onto my white Berber carpet! I reach for the plunger. Finally, after more mess splashes onto the rug, I get results. But now I'm faced with a monumental clean-up that'll take hours. No more writing! I'm angry, disgusted, anxious, frustrated, and feel somehow betrayed by fate--it's all so unfair! "Why now? Why me?" I grumble. "This is the last thing I need right now!"
But instead of letting myself stew in my own whine, this time, I take a step back and say quietly to myself something that's become my guiding maxim for such situations: "This is exactly what I need right now." Suddenly, all sound quiets in my mind. I'm calm and clear. I continue cleaning up efficiently, but without the mental suffering caused by all the background noise.
This is a trick I now draw on frequently. For all the riches of my life--family and friends who love me, health, satisfying work, a steady income--it never seems like enough. I tend to complain constantly and resist what's happening all the time. At any given moment, I'm complaining that this or that isn't as good, fast, satisfying, exciting, beautiful, or enlightening as it should be. Something is too cold, warm, salty, bright, dark, cheap, or old. I'm not strong, clever, wise, nice, diligent, or happy enough. In short, things are happening to me and feelings are rising in me that I don't want.
The toilet episode says it all. Stuff happens (to bowdlerize the more apposite expression)-- life happens. Instead of fighting it, whatever it is, now I try to welcome it. I don't have to figure out why a stopped-up toilet was "exactly what I needed," I just have to get into that perspective and, once there, it instantly lifts me from my suffering. It doesn't mean I don't recognize how inconvenient, painful, and unpleasant some situations are, but I can acknowledge those experiences and let go of the need to figure them out or fix them. I can embrace the struggle, wrap both arms around the doubts and uncertainties in my life, and shift from being worried to being curious. If I can catch myself saying "I don't like this, I don't want that, I'm unhappy with this outcome, I'm anxious about that, I'm threatened by this," by shifting into a welcoming mode--"This is exactly what I want right now"--I find myself in a much better place psychologically. Then I can peacefully concentrate on cleaning up that rug.
Of course, I don't exactly want my toilet spilling all over my rug. When I tell myself, "This is exactly what I want right now," I'm disciplining myself to stay in the present moment--not to wish for other moments or to wish that my life was different at the moment, but to accept that this moment is all I have at the moment. The only power possible in the moment is to face whatever it demands. When we stop filtering every event through our judgments of what it should or could be like, what we really want, we become alert to our surroundings and curious about how we can interact with them. This is much more fun than complaining that the world isn't following the rules that our little egos generate.
How have these concepts altered my therapeutic practice? As a therapist and as just a person, I'm beginning to learn how important it is for me to embrace bad feelings and discomfort--all those emotions we spend so much of our lives trying to avoid--and then go on right through them to the other side. I'm learning that each time I'm tempted to resist a moment of distress, anxiety, or painful reflection about the past, I invite greater suffering. When I don't accept the present moment, everything bogs down from there. I generate a complaint, I declare there's something wrong, and I try to squirm my way out. At that point, I'm stuck in avoidance and can't move forward to actually solve the problem. But if I can open myself to the painful reality of the moment, I actually suffer less.
I remember the experience of taking my first group therapy course in graduate school, 27 years ago. I still see the syllabus in my mind's eye, listing the dates when each of us would lead a simulated therapy group in class. We all dreaded it--dreaded messing up and looking stupid and incompetent in front of our peers. Perhaps I dreaded it more than most, because I was possessed of the rock-ribbed certainty that it was always my job to fix people, solve problems, do it right and do it fast, with no mistakes allowed. Not surprisingly, on the day when we began (I was in the first round of guinea pigs), I was in a cold sweat, almost panting with anxiety. Now I was faced with a situation that not only could spiral out of my control, but could make me look like a bumbler. What a catastrophe!
Then, as we got ourselves situated in our circle of chairs, our professor, John Gladfelter, introduced the task. "Here's the assignment. I want you to be the worst group therapist you can be. Just be as bad, as incompetent, as you can possibly manage." What?! I was stunned for a minute. When I realized he meant it, I felt my tension draining away like dirty water from a sink as I thought, "I can do that!"
How did it turn out? No one actually tried to be a buffoon. But with the pressure off, and with no need to strictly adhere to vague and ill-defined rules we still hadn't grasped entirely, we all witnessed moments of creativity and intuitive wisdom shining through. More than anything, we relaxed. Even I relaxed, as if given a reprieve from having to do everything perfectly. In relaxing, we could actually meet people on their own terms, see and hear them as they really were, let ourselves connect with them rather than funneling all our energy and attention into squelching or hiding our own fears. We got a taste of the healing power of human contact. And we experienced the freedom of spontaneity--of not being under the gun to predict and control everything that happened in our tiny little worlds. Gladfelter had brought our fears of what might happen into the present, by making it the assignment. In the present, the group had new liberty and power.
Now, as a therapist, I want to help clients discover this same kind of freedom--freedom from the anxieties that imprison them. And I now think that, rather than trying to suppress the symptoms of their anxiety, clients can better free themselves by engaging with their symptoms in a spirit of welcome and open-minded curiosity: "Hello, symptoms. Who are you and what are you trying to tell me?"
What this does is help clients begin to change their own frame of reference about their symptoms, and shift the perspective from which they observe what they're feeling. This shift from "symptoms=bad" to "symptoms=interesting" can utterly transform the way they view themselves and the world. By accepting what the present moment offers, by not resisting, they widen their present possibilities.
Renee looked visibly frightened as she sat down for our first session together.
"Hi, are you nervous?" I asked brightly, realizing perfectly well that she was scared to death.
"I'm extremely nervous," she responded in a quavering voice. I asked her how nervous, on a scale of 0 to 10, and she rated her nervousness as about 8.5.
"Impressive!" I said jovially, "I like people to come in with high anxiety, because it means we have something to work with."
She continued, "I'm really afraid that my symptoms will get so bad--my heart will start pounding so hard and I'll be shaking so much--I won't be able to control them and they'll just overwhelm me."
"Well, you're not in control of them now, are you?" I asked.
"Not really," she responded, "but just talking to you, I'm not thinking about my heart pounding so much."
I leaned back, smiled broadly and said, "Ah. Then, maybe we should get your attention back on your heart again." We both laughed--I heartily, she uneasily, giving me an odd look, as if she were beginning to wonder what she was doing in my office.
A minute or two later, I asked her when the last time was that she'd felt she couldn't even move because her anxiety was so great. "A few years ago," she responded.
I said, almost gleefully, "A few years ago? So you're due for another episode any time now, aren't you?" Now she was looking at me with something approaching alarm, as though wondering, What's this character up to anyhow?
What I was up to doesn't look or sound like the standard, empathic, rapport-building opening moves of a senior therapist. In fact, to Renee, I must have seemed careless, provocative, insensitive, maybe even clueless. She'd entered my consulting room in a state of nearly full panic and I'd said I was pleased. She feared losing control, and I'd reminded her she's wasn't really in control at the moment. She was avoiding panic by not attending to her heart, and I'd suggested we should pay attention to her heart. She hadn't had a full panic attack in a few years, and I'd suggested she was due for one. What kind of therapy is this? What was I doing?
Now, in therapy, I dedicate myself to helping people learn to accept, even welcome, their symptoms. I try to teach them to run toward rather than from what they fear and hate most about their disorders. I insist that instead of trying to evade, stifle, override, or distract themselves from these symptoms, they work as hard as they can to make the symptoms worse. I do all this as a therapist dedicated to helping them genuinely recover from the suffering caused not only by their anxiety but, more to the point, by the endless and often counterproductive tactics they use to escape it. I invite clients--as I invited Renee--to join me in looking directly at their problem with curiosity, humor, and compassion.
My therapeutic premise is that people's worries can be signals warning them about something they need to attend to. But the repetitious, unproductive, obsessive thoughts that accompany anxiety disorders are simply distressing noise. If clients can change the frame of reference from "my obsessive thoughts are in response to a real and dangerous threat" to "my obsessive thoughts are pointless noise unrelated to a real threat," they have a steady platform from which to change their entire world view (and, incidentally, make the symptom go away).
Camille, who was diagnosed with obsessive-compulsive disorder (OCD), had become consumed with worries after her father informed her that he was buying a gun. She thought continually about the possibility of finding the gun and accidentally harming her parents with it. To avoid and neutralize these fears, she compulsively analyzed ways to avoid the danger--she imagined never coming into their house, or searching for the gun and then avoiding the hiding place, or asking her father to get rid of it.
Together, we established that her worry about accidentally shooting her own parents wasn't a reality-based signal or genuine alarm, but a false threat created by her OCD. Thus, her constant analysis of how she should avoid this danger was a chimera built on a falsehood. She experimented with this new frame of reference. She decided to treat her fears about the gun neither as a realistic response to a genuine danger nor as awful symptoms to suppress, but as tiresome noise--those fears were just there, like a mosquito droning in her ear.
The question then became: How best to respond to this pointless background noise? The answer: Camille would purposely try to accept it, even ratchet it up, rather than fight it--feel it, go through it, make it as bad as possible rather than evade it. Once she allowed herself to get into her distress as much as possible, she'd simply tell herself to drop it. In effect, she now had a readymade protocol: "I want to feel uncertain and uncomfortable and worried about the gun. I want to have these fears. That's how I'll get better. So I'm going to fully acknowledge that the worry is here, and then drop the topic as soon as it starts." When the worry popped up, she noticed it, accepted it, and then said quietly to herself, "Drop it!" No thinking, no analysis; she'd just follow the edict. When the topic arises, acknowledge it and then, "Drop it!"
Was this easy for Camille to do? Not at all. Analyzing the problem was her compulsion; it made her feel safe. When she dropped the analysis, she was faced with the dreadful question, "Will I harm my parents?" and had no answer. So she had to hang out with her fear and worry, which put her in considerable doubt and distress. But she was bolstered by her belief in this therapy, by my confident support, and by the success of previous experiments of this kind in the past. Then this experiment worked well, too. She learned that if she let herself feel the worry, while telling herself to drop the compulsive analyzing (which is a kind of tranquilizer), the worry itself gradually faded away--but only if she stayed with her doubt and discomfort. Finally, the entire issue disappeared from her radar screen.
Basically, what I was helping Camille do was to step away from the content of her thoughts, get some distance, and learn to regard it as a kind of game. She looked at her compulsive analyzing and problem-solving and said, "Here I am again, labeling something as dangerous and trying to avoid it." Then she embraced what she'd just been rejecting, "I'm going to act as though this is exactly what needs to be happening."
Ideally, if anxious clients can respond by saying "yes" to the encounter--to accept exactly what they're experiencing in that moment--then they'll be back in control. They can learn to do this if they can endure discomfort. But for many, anxiety has become so dominant that they can't make such a shift directly. To stay on course, they need some sense of safety and a strong faith. In the past, I'd have asked them to be anchored by the skills I taught them. But now, their relationship to me is playing a larger role. I have always felt compassion for their suffering. Now I'm better able to appeal to their courage, knowing the direct benefits that accrue from opening their arms to what they most fear.
In the early stages, when their courage and confidence is still at low ebb, I don't suggest they have to commit to actually trying to change--I only propose that they may want to try experimenting a little. As I suggest homework, I use expressions like, "How about playing with this move?" and "Perhaps you can fool around with these responses." I imply that these strategies are malleable and temporary: "What do you think about trying this move a few times just to see what happens? We can talk about it next time." It's easier for clients to set aside defenses and endure distress if they think the "trial" will only be for a few moments.
The key is helping them alter their frame of reference, which is the entrenched belief that they can't tolerate discomfort and insecurity, even for a moment. To gently challenge them, I turn their struggle with anxiety into a mental game. Anxiety pitches you uncomfortable physical symptoms and uncertainty about the future; it wins if it can get you to avoid threatening activities, fight the symptoms, and hope they go away. But somehow, if you can purposely encourage symptoms, act as if you want them rather than dread them, you trick anxiety and hoist it by its own petard, so to speak. This new frame of reference--treating anxiety as a kind of game--seems to refocus clients' attention away from a pointless fight with their symptoms. Just trying to rev up symptoms makes symptoms seem weaker, more under your control. Clients soon find, in fact, that as they stop resisting symptoms, the symptoms begin to fade and then disappear.
How does this work in practice? Social anxiety disorder gives us shaky hands, a quaking voice, and worry about the critical judgments of others. The anxiety "expects" us to try to avoid it--perhaps by never going to parties or giving a talk in public. So, in this new game, we flip things around. Imagine when feeling anxious before a performance that you ask anxiety to make your hands shake, your voice quake, and the fear worsen. Do your best to get those feelings to last as long as possible. Plead with anxiety to make your hands even shakier, your heart pound even more, your voice become even tighter! That is, refuse to play the game that the anxiety disorder expects. Take charge.
I encourage my clients to push the old game board away and pull up their own game board of seeking out doubt and distress when anxiety wants them to defend against it or run. They then see that the symptom isn't nearly as powerful when they're in charge of it.
Breaking Through to the Present
Let's return now to Renee, the client with panic disorder who was beginning to think she'd ended up with one strange therapist. Halfway through that first session, she was explaining that the lump in her throat was currently causing her the most anxiety. I suggested she ask her anxiety, "Would you please make my lump get stronger?"
Her eyes bulged. She exclaimed, "It sounds scary!"
I asked what she thought would happen.
She said, "I'll either stay the same or get worse. I can hardly imagine getting better by telling it to get worse." After some teasing and persuading, she agreed to try it anyway. What courage! Her first attempt being exceedingly feeble, so I modeled for her: "Anxiety, I beg you to make this knot stronger. I want it to be so large; I want it to be as big as a marble. I want it to be--how about a golf ball? Could you make it a golf ball? I'd like it to be so large that people start to see my neck protrude with this big ball in there. I want to make it so big that to swallow, my saliva has to go all the way around this lump and then down my throat. If you'd do that, it would make me sooo happy. It's so important. All these years I've done so much for you! I'm asking you one simple thing: to make my lump larger, my knot bigger. Please do this one thing for me."
I asked her to try her own version, "as if you're auditioning for a role, and this is your job, and if you don't do this persuasively you don't get the part. Are you willing to try this again?"
Renee nodded and addressed her anxiety in the beseeching voice of a lovelorn swain: "Anxiety, I beg you to make that knot much, much bigger." She laughed, "This just seems so unreal." She laughed again and said with more conviction, "Anxiety, make this knot as big as you possibley can!" Then she paused, looking surprised, and said, "It's not there, anymore."
"Excuse me, Renee?" I said in mock astonishment. "Try harder. Make it as big as you can."
She concentrated for a minute and then looked at me. "It's just not there."
"What do you mean, it's not there?" I asked severely.
"It's just gone," she giggled.
And there it is: Renee accepted her present discomfort and embraced her uncertainty. She set aside her worries about future discomfort and challenged her nemesis. In her anxiety, she wanted to hold back out of fear of her symptoms. Instead, she played her own game of pleading with anxiety to make her more uncomfortable, and the symptoms disappeared. We continued the session in this same provoking style, hyperventilating together until her legs were shaking and hands were tingling and I was sweating and seeing stars. Then she demanded the symptoms worsen and watched as they slowly dissipated.
What's happening here? Instead of experiencing the symptom as interrupting and disturbing the present moment, we invite the symptom into the present moment--at which point, we're in charge, and the symptom is working for us. We prove that we have the ability to achieve a present consciousness that's larger than the symptom.
Then we can move forward with comparatively little resistance, and perhaps some curiosity and interest. When all I have to do is be the worst group therapist in the room, I'm ready to go. When anxious people take on the "challenge" of shaking even more, racing their heart even harder, making the lump in the throat even bigger, they believe they have the skills to meet the challenge. And that changes everything, paradoxically making the heart slow, calming the shakes, and eliminating the lump.
The problems we suffer with anxiety often continue not because we have symptoms, but because we resist the fact that we're experiencing symptoms--doing our utmost to block out the symptoms, rather than getting to know them a little bit. Most of our clients come to us trying to end something unpleasant, seeking both comfort and predictability in their lives. The desire for a life without stress or doubt is perfectly natural. And yet, we compound our clients' problems when we collude in their goal of simply making the unpleasantness go away. Our objective should not simply be to block their discomfort and allay their doubts, but to help reduce their suffering--ultimately, a completely different task.
Discomfort is an inevitable byproduct of interacting with the world and learning what life's rules entail. Doubt arrives as we challenge the status quo and muster the courage to explore our own potential for creativity. Suffering, in contrast, arrives when we insist on playing life's game according to our own private rules, without doubt or discomfort. Not only is this enterprise doomed to fail, when we try to avoid the symptoms of our existential anxiety, we foreclose the possibility of living fully and exuberantly in the present. Instead of saying when adversity strikes, "I want to push this away so as not to experience it," I'm finding that accepting it as it unfolds in the present is the most efficient way around it.
Present tense is what it's all about--even if the present tense isn't always so wonderful. If I can be present, I become powerful--I'll have tossed aside the dominance of my doubts and desires. My mind and body can focus on the task immediately in front of me. I want to engage in the present, not push it away. That'll guide me to my future. I don't want to be experiencing this and wanting that. When I stay with "this" without resistance, whether it's my disappointment, anger, or pain, I have a platform from which I can move forward to something better.
How do we make this shift in consciousness? In the midst of a conflict, to tell yourself, "I'm okay with this experience" places you with the problem in the present. You let go of your rigid goals of how this moment should be and settle into what the moment is, not knowing how it'll turn out or should turn out, but more ready to face what comes.
Reid Wilson, Ph.D., is associate clinical professor of psychiatry at the University of North Carolina School of Medicine and coauthor of Stop Obsessing! How to Overcome Your Obsessions and Compulsions. His newest book is Facing Panic: Self-Help for People with Panic Attacks. Contact: firstname.lastname@example.org. Letters to the Editor about this article may be e-mailed to email@example.com.
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