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What is it about anxiety that's so horrific that otherwise high-functioning people are frantic to escape it? The sensations of doom or dread or panic felt by sufferers are truly overwhelming—the very same sensations, in fact, that a person would feel if the worst really were happening. Too often, these, literally, dread-full, sickening sensations drive clients to the instant relief of medication, which is readily available and considered by many insurance companies to be the first line of treatment. And what good doctor would suggest skipping the meds when a suffering patient can get symptomatic relief quickly?
But what clients don't know when they start taking meds is the unacknowledged cost of relying solely on pills: they'll never learn some basic methods that can control or eliminate their symptoms without meds. They never develop the tools for managing the anxiety that, in all likelihood, will turn up again whenever they feel undue stress or go through significant life changes. What they should be told is that the right psychotherapy, which teaches them to control their own anxiety, will offer relief from anxiety in a matter of weeks—about the same amount of time it takes for an SSRI to become effective.
A therapist armed with methods for addressing these clusters can offer their anxious client the promise of relief for a lifetime, if they know which of these techniques work for which symptoms, and how to use them.
Cluster One: Distressing Physical Arousal
Panic is the physical arousal that sends many clients running for Xanax. Sympathetic arousal causes the heart-thumping, pulse-racing, dizzy, tingly, shortness-of-breath physical symptoms that can come from out of the blue, and are intolerable when not understood. Even high levels of acute anxiety that aren't as intense as outright panic attacks can constitute very painful states of arousal. Physical symptoms of anxiety include constant heightened physical tension in the jaw, neck, and back, as well as an emotional-somatic feeling of doom or dread in the pit of the stomach. The feeling of doom will always set off a mental search for what might be causing it.
Bad as these symptoms are, there are methods that, when followed regularly as lifelong habits, offer tremendous relief.
Method 1: Manage the Body. Telling anxiety-prone clients to take care of their bodies by eating right, avoiding alcohol, nicotine, sugar, and caffeine, and exercising is a strikingly ordinary "prescription," but not doing these things can undermine the effectiveness of other antianxiety techniques. During the summer before Ellie went off to college, for example, she'd almost eliminated her anxiety by practicing deep, calm breathing and learning to stop her catastrophic thinking. She'd even been able to stop taking the antianxiety medication she'd used for years. But two months after starting college, her panic attacks came roaring back with a vengeance. She came back to see me, but quickly let me know that she was going to call her psychiatrist for another Xanax prescription. I suggested that, before she made the call, she spend a couple of weeks keeping a "panic profile"—a journal recording when and under what circumstances she suffered from panic attacks.
A couple of weeks later, she came to my office smiling broadly. "I figured it out," she said, grinning as she showed me her panic profile. She'd traced her panic attacks to days after she drank heavily and smoked cigarettes—neither of which had she done over the summer while living in her parents' house. Also, her caffeine use had risen dramatically while at school—to help her wake up for classes after partying at night—and her diet had devolved to pizza and doughnuts. She really didn't want to give up these habits, but keeping the journal had reminded her that her anxiety symptoms are physical, and that calming her body had defused her panic triggers once before. Taking care again to eliminate CATS (caffeine, alcohol, tobacco, sugar + Nutrasweet), Ellie got back on track without returning to meds. The simple rule--manage the body—must remain a first priority throughout treatment for anxiety. Ellie had a major relapse when she let go of routine self-care.
Method 2: Breathe. Ellie and I next reviewed her use of diaphragmatic breathing to ward off the panic. As it turned out, she'd forgotten how helpful breathing had been when we first started working together, and had quit doing it. Now, not only did she suffer again from panic, but she thought it was too powerful to be relieved merely by breathing deeply. She'd begun to panic just thinking about feeling panic. I've often found that when clients say that breathing "doesn't work," it's because they haven't learned to do it correctly. Or once having learned it, they've given it up when they felt better, believing that they no longer needed to do it. By the time they feel anxiety returning, they're convinced that something so simple can't possibly be really effective. Therefore, it's important for therapists to emphasize and reemphasize that breathing will slow down or stop the stress response, if the client will just do it.
The biggest block to making breathing truly helpful is the time it takes to practice it until it becomes an ingrained habit. Most relaxation books teach clients to practice breathing once a day for 10 minutes, but I've never found a client who actually learned how to do it from this one, daily, concentrated dose. I don't teach clients to breathe for lengthy periods until they've practiced it for very short periods many times a day. I ask them to do the conscious, deep breathing for about one minute at a time, 10 to 15 times per day, every time they find themselves waiting for something—the water to boil, the phone to ring, their doctor's appointment, the line to move at the bank. This will eventually help them associate breathing with all of their surroundings and activities. This way, they're more likely to actually remember to breathe when anxiety spikes.
Cluster Two: Tension, Stress, and Dread
Many clients with generalized anxiety disorder (GAD) experience high levels of tension that are physically uncomfortable and compel them to search frantically for the reasons behind their anxiety. They hope they can "solve" whatever problem seems to be causing anxiety and thus relieve its symptoms. But since much of their heightened tension isn't about a real problem, they simply waste time running around their inner maze of self-perpetuating worry. And even if their tension does stem from psychological or neurobiological causes, there are ways to eliminate the symptoms of chronic worry before addressing those dimensions. The following methods are most helpful for diminishing chronic tension.
Method 3: Don't Listen When Worry Calls Your Name. Colleen feared I'd think she was crazy when she said, "It's as if my anxiety has a voice. It calls to me, 'Worry now,' even when there's nothing on my mind. Then I have to go looking for what's wrong." And she was very good at finding something wrong to worry about. An executive who had a lot of irons in the fire, she had no shortage of projects that needed her supervision. On any day, she could worry about whether a report had been correct, or projected figures were accurate, or a contract would generate income for her firm. In describing the voice of worry, she was describing that physical, pit-of-the-stomach sense of doom that comes on for no reason, and then compels an explanation for why it's there.
Few realize that the feeling of dread is just the emotional manifestation of physical tension. This "Don't Listen" method decreases this tension by combining a decision to ignore the voice of worry with a cue for the relaxation state. Early in treatment, GAD clients learn progressive muscle relaxation to get relief. I always teach them how to cue up relaxation several times throughout the day by drawing a breath and remembering how they feel at the end of the relaxation exercise. We usually pair that deeply relaxed state with a color, image, and word to strengthen associations with muscle relaxation and make it easier to cue the sensation at will.
To stop listening to that command to worry, I suggested that she say to herself, "It's just my anxious brain firing wrong." This would be the cue for her to begin relaxation breathing, which would stop the physical sensations of dread that trigger the radar.
Method 4: Have a Little Fun. Laughing is a great way to increase good feelings and discharge tension. The problem for anxious clients is that they take life so seriously that they stop creating fun in their lives, and they stop experiencing life's humorous moments. Everything becomes a potential problem, rather than a way to feel joy or delight.
Margaret was a witty woman, whose humor was self-deprecating. A high-level executive who typically worked 12- to 14-hour days, she'd stopped laughing or planning fun weekends about two promotions back. Her husband rarely saw her on weeknights, and on Saturday and Sunday, she typically told him she was just "going to run over to the office for a little while"—anywhere from 3 to 7 hours. When I asked her to make a list of what she did for fun, she was stymied. Other than having a drink with friends after work, her list of enjoyable activities was almost nonexistent.
Getting in touch with fun and play isn't easy for the serious, tense worrier. I've often found, however, that playing with a child will get a person laughing, so I asked her to spend some time with her young nieces. She agreed, and noticed that she felt more relaxed after being with them for an afternoon. Then I asked her to watch for any impulse to do something "just because," without any particular agenda in mind. When I saw her next, she seemed transformed. She said, "I had an impulse to stop for an ice-cream cone, so I just went out and got it. I don't know when the last time was that I felt like doing something and just did it—no worries about whether everyone else had a cone or whether I should wait till later. It was fun!" Over time, listening to her inner wishes helped Margaret feel that there was a reservoir of pleasure in life that she'd been denying herself, and she began to experiment with giving herself the time to find it.
While these techniques aren't complicated or technically difficult to teach, they do require patience and determination from both therapist and client. For best results, they also demand clinical knowledge of how and why they work, and with what sorts of issues; they can't simply be used as all-purpose applications, good for anybody in any circumstance.
But the rewards of teaching people how to use these deceptively simple, undramatic, and ungimmicky methods are great. While clients in this culture have been indoctrinated to want and expect instantaneous relief from their discomfort at the pop of a pill, we can show them we have something better to offer. We can give people a lasting sense of their own power and competence by helping them learn to work actively with their own symptoms, to conquer anxiety through their own efforts—and do this in a nonmanipulative, respectful, engaging way. What medication can make that claim?
This blog is excerpted from "Turning 'I Can't' Into 'I Will,'" by Margaret Wehrenberg. The full version is available in the July/August 2004 issue, The Body in Psychotherapy: How Far Do We Want to Go?
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