We sometimes use mini-exposures to demonstrate the fallacy of these beliefs. One woman, who was afraid of heights and suffered from panic disorder, was asked to accompany the therapist to a floor that was above her comfort zone. She expressed high anticipatory anxiety about going to a higher floor, and worried that the anxiety she felt on the higher floor would remain high for the entire day and interfere with her demanding job. Despite her concerns, she accompanied the therapist to the higher floor (she chose the floor once entering the elevator), she experienced only a fraction of the anxiety she had anticipated, and her anxiety for the remainder of the day was unaffected by this experience. In fact, all her beliefs about this experience turned out to be unsupported by the information provided by our exposure experiment. She was certainly not recovered, but began to question some of her long-held beliefs about her anxiety. We are frequently able to create these types of “corrective learning experiences.”
It is a wonder that anxious patients get things so wrong, and continue to hold onto erroneous beliefs that make their life so miserable. The culprit is the nature of anxiety and its ability to spread the false message that it needs to be avoided, and that resistance is the best way to deal with it. Resisting anxiety discourages observation of the processes that are generating anxiety, and keeps patients ignorant of what they need to know.
Approaching Anxiety Mindfully
Mindfulness is an essential aspect to treating anxiety. Mindfulness is a state of open and active attention to the present, moment by moment (Kabat-Zinn, 1994). It involves the experience of observing one’s thoughts, feelings, and sensations from a distance, without judgment or evaluation. A mindful attitude implies that there is an observer that can stand back and look at present experiences with perspective, so there is a “self” and an “observer” at the same time. Mindfulness allows patients to gain an increased awareness of inner experience, and has some similarities to introspection. Both involve attending to inner life, but introspection aims to further explore causes or unconscious meanings. Mindfulness, on the other hand, aims to observe the details of the process apart from content. A mindful approach can help patients observe that much of their distress comes from avoidance of anxious thoughts and sensations, rather than the thoughts and sensations themselves.
Mindfulness can be difficult for anxious people, since they try to avoid unpleasant sensations, and mindfulness asks to attend to all experiences. Anxious people also have an ingrained tendency to become triggered by certain mental images and bodily sensations, while mindfulness asks to focus without judgment or elaboration. But patients are sensitized, and their reaction makes certain thoughts seem loud and sticky, crowding out the rest. They are constantly checking their thoughts and bodily sensations in order to avoid them, making it harder to stay in the present. There is also the added challenge that anxious people can be extraordinarily hard on themselves, filling their mind with critical self-recriminations, while a mindful approach encourages one to attend to inner life non-judgmentally.
Patients might feel perplexed and frustrated after explaining the importance of mindful awareness. They tend to beat themselves up for failing to stay focused on the present, which usually means getting lost in “what if?” thoughts of the future. This makes it even harder to remain non-judgmental, and this negative cycle can wreak havoc on mindful practices. We often paraphrase Jon Kabat-Zinn’s gentle guidance and say to patients something like, “And when—not if—your mind wanders away into the future or the past, as it is likely to do, each time you notice that it has, gently and non-judgmentally escort your mind back to the present moment” (Kabat-Zinn, 1990). Change “what if?” to “what is.”
Change “what if?” to “what is.”
Appreciate how hard it is for patients to stay mindful of anxious feelings, and that it is unrealistic to think they won’t fall off the wagon. When this does happen, ask them to follow two basic principles: the principle of discipline and the principle of gentleness. The principle of discipline addresses the difficulty of staying connected to anxious thoughts and feelings, and our inborn desire to avoid, suppress, and run away from the task. After all, this is hard work for patients! They are staying with a painfully distressing experience in the hopes that things will improve in the future. It is not unlike the discipline that is necessary for successful dieting, exercise routines, or smoking cessation. The principle of gentleness recognizes fallibility and the near certainty that people get frustrated, curse themselves out, make mistakes, want to give up, feel sorry for themselves, and bemoan their bad luck. We do best by getting back onto the path with a gentle voice and self-forgiveness. Internal compassion does not condone or suggest giving up or being lazy, but it also does not condemn. It gives an understanding internal hug—and a gentle escort back to the task at hand.
As patients learn to become more comfortable with mindfulness, they will alternate between self-discipline and self-gentleness. Both are necessary; neither is sufficient.
Embracing Anxiety
Anxiety gets worse as patients try to push anxious feelings away. Accepting anxiety is therefore the paradoxical ability to leave it alone. Techniques to relax and calm oneself will often increase anxiety if the goal of these techniques is to turn off the anxious feelings. And distractions—which can sometimes provide temporary relief—can empower the anxiety in the long term if they are utilized improperly. So right from the start, it is important to educate your patients that anxiety is paradoxical, and that taking an entirely different approach—that of accepting and actively allowing what they previously fought and rejected—will ultimately lead to less suffering. Most patients have already discovered that trying to relax does not work for them, but they rarely understand why.
Virtually any response to anxious symptoms undertaken with the express intention of controlling or eliminating these symptoms is subject to what has been called the ironic process (Wegner, Broome, and Blumberg, 1997). This describes the mechanism by which our patient’s attempt to relax is accompanied at the same time by a heightened vigilance designed to check and monitor whether the technique is working. This is a very general process that is responsible for many failed anxiety management techniques, including the fact that attempts to banish anxious thoughts tends to bring them back stronger. Forcefully attempting to use breathing as a relaxation tool tends to result in more anxious breathing, and trying to relax often does the opposite.
This truism about anxiety’s paradoxical nature is one of the most difficult lessons for our patients to learn. Most patients are asking for methods to rid themselves of anxiety. They want the anxiety to go away. Many wonder why they can’t reason themselves out of it, or why they can’t just figure out what caused it so their fear will then disappear. Some are disheartened to hear that there is no magic cure, and this can easily lead to additional anxiety and disillusionment. Present this with compassion, sensitivity, and at a manageable pace that does not frighten patients away. As with every other aspect of therapy, timing is essential. Our experience is that this attitude of acceptance has to be very carefully articulated or it will simply be understood as depressing and hopeless. Patients respond initially with “You mean I am stuck like this and I had better get used to it and stop complaining?” This is not at all what acceptance means and this theme will likely need repetition and clarification throughout the therapy.
Acceptance means knowing what is modifiable and what is not, what is important to modify and what can be left alone, so that emotional and physical energy is not wasted on the wrong targets. This is where the notion of what is automatic—thoughts, feelings, and sensations—enters the discussion. Not only is one not able to jump in and change what is automatic, but one is not responsible for what happens automatically. That helps us determine what to change. Thus, for example, the initial rush of physical symptoms that occurs when the amygdala sounds the alarm bell (the first fear) is not the target for change. This whoosh of arousal occurs before our conscious awareness, and ca
nnot be intentionally suppressed. And—if we are brutally honest with ourselves (and believe contemporary research)—we all have a tendency to make initial snap evaluative judgments of virtually everything and everyone we see, some of them extraordinarily unflattering! This tendency is also not amenable to change or suppression. Our anxious patients need to know that we all have sudden automatic intrusions of upsetting thoughts that seemingly come out of nowhere (“I could jump off this balcony,” “What if I suddenly yanked the steering wheel into traffic?”, “What if I start to giggle in church?”).
These initial reactions are automatic, unmodifiable by intentional means, and occur prior to and outside of conscious awareness. However, all is not lost, because what is modifiable is our reaction to these automatic events (the second fear)—we have the capacity to take them seriously or not, to differentiate between arousal as real danger or a false message of such, to determine whether our thoughts contain useful informa tion, or just plain noise, and—even if they do contain information—what to do with it. Most importantly, we have the capacity to then disengage from these events so they do not produce misery and do not continue to persist.
Anxiety symptoms become less terrifying when the patient learns to view them as automatic, conditioned, natural, and part of the human experience.
Anxiety symptoms become less terrifying and more tolerable when the patient learns to view them as automatic, conditioned, natural, and part of the human experience, as opposed to signaling danger, pathology, or weakness of character. Everyone has these experiences from time to time. People who don’t have an anxiety disorder tend to notice them and then let them go. It is resistance—the frightened and sometimes desperate need to fight back the anxiety symptoms—that produces the greatest discomfort and disability. If these automatic experiences signal danger, it is natural to fight them, or—at the very least—do everything one can to keep them happening. On the other hand, if we understand them as benign—perhaps uncomfortable or even weird—but not dangerous, then acceptance is achievable.
Here is an example that illustrates the central importance of valid information to help us understand arousal: In 1938, there was a dramatized radio production of HG Wells’ War of the Worlds (Koch, 1970). It was a realistic portrayal of a fictional alien invasion, complete with reporters describing the invasion and government spokesmen recommending evacuation. For those who tuned in from the beginning of the show and heard the introduction, it was entertaining, suspenseful, and engaging. However, for those who missed the introduction, they had no idea it was a fiction (the show was broadcast without commercials). Many panicked, resulting in traffic jams, overwhelmed phone lines, and real trauma. The trauma was real, but the information was false! In an analogous manner, our nervous system feeds us fiction on a regular basis. Once we understand these signals as fiction, we can tolerate false alarm signals in our bodies and we can even enjoy the creativity and silliness our minds can come up with. Our job is to help our patients believe that these are truly false alarms. The very same physiological state that occurs in a panic attack—acute pumping adrenalin—is present on a roller coaster, and some people happily seek out and pay for this experience! What is different is not the biology; it is the understanding and the attitude that accompanies the experience.
Anxiety symptoms are thus false alarms. A rapid heartbeat does not signal an impending heart attack. A feeling of being off balance or light-headed is not a precursor to fainting or syncope. The derealization and depersonalization that accompanies hyperventilation are not signs of psychosis or impending loss of control. Tingling in the fingertips and toes and face does not imply a brain tumor. A wave of nausea does not mean vomiting is on the way, nor that the body has ingested a poison or an allergen. Blurry vision is not going to lead to blindness. In addition—and deeply important to know—bizarre intrusive thoughts are thoughts. They are not calls to action, uncontrollable impulses, or evidence of perversion, suicidality, or of being a loser. They do not mean what they may seem to mean.
Patients keep the anxiety process going because they are trying to get away from the rush of arousal, and the assessment that something is very wrong. We are addressing now the nexus of a number of processes central to anxiety disorders: The ironic process (checking frequently to make sure it isn’t there, thus making it more intrusive and alarming), the misleading message that anxious arousal is synonymous with being in danger, the stickiness of the alarming thoughts, the experience that thoughts and actions feel fused (thought–action fusion), the sensitivity to anxious arousal that is central to all people with anxiety disorders (anxiety sensitivity)—all these combine to keep anxiety going and increase its intensity. These processes underlie the functional autonomy of anxiety disorders, and account for why they continue to exist separately from any historical context or conflictual issue, and why they can go on indefinitely unless directly addressed. This is the attitude we aim to change.
The Role of the Therapist
Since it is natural for patients to misinterpret these experiences as requiring avoidance and resistance, a straightforward discussion of the biological pathways of these false alarms can be an excellent way to start. Some patients find a discussion of the role of the amygdala and the tendency for certain people to inherit the capacity to become afraid of fear (anxiety sensitivity) particularly helpful. This can go a long way, but it is not the complete story. Accepting anxious arousal is difficult because it triggers the biological drive for survival. The misleading messages from anxiety are saying, “You are in danger if you ignore my message—and the thoughts, feelings, and memories that are associated with it. You are putting your health, your existence, and that of others at risk if you don’t put energy into avoiding, fleeing, and fighting the feelings.” Embracing anxiety therefore takes courage and effort.
A straightforward discussion of the biological pathways of fear and false fear alarms can be an excellent way to start.
The anxiety-generating process is especially rapid and complicated when patients are experiencing high levels of anxiety. If they are telling you about episodes of high anxiety, or—better yet—actually experiencing those feelings in the midst of their therapist session, patients will tell you that they feel overwhelmed, they will complain of a variety of physical and mental symptoms, and they might use terms like panicking, losing their mind, freaking out, cracking up, or going insane. Some patients might cling to you and beg for reassurance, while others feel like they are on a tightrope, trying to avoid a disastrous fall, and view your input as a dangerous distraction. Most will be somewhere in between.
Some patients may beg for reassurance and others may avoid the therapist’s input.
When patients are feeling such high anxiety, it is best to stay with basics. Let them know that anxiety is uncomfortable but not dangerous. What they are experiencing is temporary—they aren’t losing their mind, they aren’t going to do the things that run through their minds. Stay with them. Pay attention to your own fear of their anxiety—the less afraid we are of the patient’s anxiety, the more helpful we can be. Praise them for their courage. Anxious arousal is a product of the amygdala, a primitive part of our brain that is sometimes likened to our inner infant. And, like an infant, anxiety is comforted more by a soothing attitude than by soothing words. Anxious patients can sense our own anxiety, and respond with more distress if we communicate pressure or irritation.
Patients need to know that anxiety is uncomfortable, temporary, and that they are not “losing control.”
It is important to make a very clear distinction between encouraging exposure and pressuring the patient to do it. Essential for patients feeling safe in your presence is their explicit belief that they will never be forced—or put under undue pressure—to endure anxiety when they want to stop. Patients always have the option to stop the exposure, because there might be times when words don’t make contact and they are experiencing more distress than they chose to endure. Let them know this is an honorable choi
ce. Patients also need to know that they will never be tricked or surprised. It is not the therapist’s responsibility to take away the patient’s anxiety. That only clouds the issue and turns the experience into an irrelevant test. This is practicing a new attitude, not testing the patient’s skill. Each experience of anxiety can become a learning experience. Patients should expect anxiety to return, and it is your mutual task to help them cope more effectively the next time. Even while delivering this message about anxiety, it is possible to be comforting and compassionate, as with any patient who is having a difficult time.
Never trick, surprise, or insist. It is not your responsibility to take away your patient’s anxiety.
The serenity prayer of the 12-step movement may be the single most influential bit of wisdom ever: peace comes from accepting what one cannot change and changing what one can—and most importantly discerning the difference between the two. That is the attitude we hope to instill.
God grant me the serenity
to accept the things I cannot change;
courage to change the things I can;
and wisdom to know the difference.
Living one day at a time;
Enjoying one moment at a time;
Accepting hardships as the pathway to peace;
Taking, as He did, this sinful world
as it is, not as I would have it;
Reinhold Niebuhr (1943)
Once again, here is where a mindful attitude is extremely helpful. At first, the idea of observing their own thoughts and sensations may feel almost alien to patients. They may not have a notion that there is an “I,” an observer that can stand back and look at thoughts and sensations. They may not yet grasp the idea that it is not the thoughts and sensations that cause the ongoing anguish, but their reaction to, judgment of, and avoidance of these thoughts and sensations that is the ultimate source of the suffering. In the beginning of treatment, they may benefit from simple mindfulness exercises aimed at observing their inner experience. Here is a simple exercise to demonstrate the act of observing (speaking very slowly):
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