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.Breathing Lessons
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.
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