Q: My approach to helping clients deal with panic attacks and phobias focuses initially on teaching them breathing and relaxation exercises, and then encouraging them to gradually face the feared situation without getting so panicky. I often find it a very slow process. Is there any way to speed it up?
A: Yes. My clinical experience indicates that clients who can be persuaded to provoke and endure their symptoms without resorting to relaxation exercises quickly become habituated to their fears. Symptoms sometimes disappear in as little as two or three weeks.
This may sound counterintuitive—I'll stop being anxious if I make myself anxious?!—but treatment centered on provoking anxiety is based on the same theory as the treatment you currently employ. Both approaches assume that the best way for clients to overcome their anxieties is through exposure to the situations that they fear. Your approach aims to overcome clients' natural reluctance to this strategy by teaching them skills that will make the feelings that they experience in these situations more tolerable. Thus equipped, the theory goes, they'll be willing to place themselves in anxiety-provoking situations frequently enough to learn that the catastrophe they fear won't overtake them. At that point, their fear of such situations either dissipates or remains at a manageable level.
I liken this approach to persuading a reluctant swimmer to get wet by wading gradually into the water. What I'm suggesting is that you'll get better results and get them more quickly if you can persuade that swimmer to jump.
Here's why. For people to become habituated to their fears, they must be exposed to those fears with sufficient frequency, duration, and intensity. The drawback of a method based on relaxation techniques is that these skills may keep the client from experiencing the panic intensely enough to fully habituate themselves to anxiety provoking circumstances. This leaves the client dependent upon the techniques, and still vulnerable to an attack that's strong enough to overcome them.
My primary goal with panic clients is to change their most basic orientation toward the situation they're in. I want them not just to try to get anxious, but to want to get anxious, not just to tolerate the discomfort, but to desire that the discomfort stay. While I utilize a variety of behavioral techniques, my primary approach is cognitive. I want them not just to look for opportunities to be uncertain, but to be excited when they notice they feel apprehensive and uncertain in a fearful situation. This strategy forces them to confront their cognitive set that anxiety is bad and to be avoided or stopped as soon as possible.
I've developed an alternative five-step treatment based on the work of the top clinicians and researchers in the anxiety field. The five steps are: (1) Encourage clients to get anxious on purpose. (2) Once clients are anxious, persuade them to remain anxious for as long as possible. (3) While clients are anxious, teach them to support themselves through positive self-talk and away from catastrophic thinking. (4) Help clients gradually forego the use of relaxation exercises or other "safety crutches." (5) Introduce them to this routine in safe places such as the therapist's office, and then have them apply it in progressively more threatening situations.
This approach may not be for everyone. I've had clients whose symptoms were too strong for them to endure for any length of time. With these clients, I fall back to an approach based on "safety crutches," and work toward the day that those crutches no longer are necessary. For the majority of my clients, this new method has worked quickly and completely.
In working with clients prone to panic attacks, I'm less interested in what external situations they're afraid of than what physical and psychological symptoms threaten them. Clients typically experience at least one of four symptoms: a quickened or irregular heartbeat, difficulty breathing, dizziness, or disorientation. Once I know how the client experiences anxiety, we induce those symptoms in a number of ways, through the process that David Barlow calls "interroceptive exposure." If, for instance, a client experiences shortness of breath, I ask them to breathe through several cocktail straws for several minutes. Brisk exercise can produce an accelerated heartbeat. Staring at a fixed point on a blank wall provokes feelings of disorientation. And as any child knows, spinning in a swivel chair makes you dizzy. Some practices, such as hyperventilating, can be used to bring on several symptoms at once.
When the symptoms dissipate, we induce them again. I often recommend that when clients practice these exercises at home, the practice session should last from 45 to 90 minutes.
Throwing away their "safety crutches" is frequently the most difficult step for clients with anxiety disorders. These practices have helped them navigate the menacing waters of their everyday lives, and they are loath to give them up. We've identified over 70 behaviors that help clients avoid, mute, or shorten symptoms of anxiety or panic. These include carrying an antianxiety medication in their pocket, practicing breathing skills, monitoring their pulse rate, sitting close to an exit, leaning against a wall, staying somewhere only briefly, turning the radio up, never passing a car, and always avoiding crowds. I help clients identify their safety crutches and gradually reduce their reliance on them. As they realize that they can manage the sensations of panic without these restrictions, they're willing to take more risks in the provoking situations.
From this point on, one gets to Carnegie Hall by practice, practice, practice. People need to provoke and endure their symptoms again and again, in as many different locations and circumstance as possible. Clients have several options on how to proceed. After listing the situations that provoke anxiety, they can choose to induce their symptoms in the easiest situations first. This way, they can gradually build their skills. But there may be some situations that they want to master immediately, even though these situations are more frightening. (For example, they may want to start driving alone.) If they're sufficiently motivated, they should go ahead. Or there may be threatening events that are a necessary part of the week, like grocery shopping or an office meeting. They'll be facing these anyway, so they might as well practice their skills while they're there.
These suggestions may seem threatening. Clients must commit voluntarily and purposely to being scared and uncomfortable for a while. The good news is that this approach not only works fast, but greatly reduces clients' fears, rather than simply teaching them to manage those fears.
Reid Wilson, PhD, is associate clinical professor of psychiatry at the UNC School of Medicine. He’s the author of Don’t Panic: Taking Control of Anxiety Attacks and Facing Panic: Self-Help for People with Panic Attacks.
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