What Every Therapist Needs to Know About Anxiety Disorders

by Martin N Seif

  At first, the idea of observing their own thoughts and sensations may feel almost alien to patients.

  Sit comfortably in the chair and close your eyes, or if you prefer, just find a spot on the carpet and lightly rest your eyes there. Now try to notice how your body feels. See if you can take a little tour of your body and see where you find muscle tension. Not to change it, just to notice. Your scalp? Your forehead? Around your eyes? Your cheeks? Chin? Notice the tension in your neck. Front. Back. When you are ready, move to your shoulders and arms. Now your chest. Your belly (and so on …). Perhaps now you can focus your attention on your breath, notice in … and out … in … and out. Mostly your chest? Your belly? Is the air you breathe out warm? Perhaps you can notice now the places where your body touches the chair. Your thighs, the backs of your arms. Now perhaps you can turn your attention to the sounds in the room. What can you hear? (wait 30 seconds) … Did you hear your own heart or breath? … As you turn your attention to your breath—just following it—notice your mind and what it is doing. Notice your thoughts. Just notice what they are. Rest lightly there. Notice how your mind jumps from one thing to another. Notice when you stray from your breath and go forward and backward in time. Notice judgments. Liking and not liking. Self-critical thoughts. Impatient thoughts. Come back to the present moment each time you notice you are not here in time. Just watch.

  The point of this exercise is not to become relaxed—although many people will spontaneously report feeling more relaxed. The point is to learn to observe in a nonjudgmental way, the contents of the mind and the sensations of the body: to learn how to be an observer as well as a participant in the experience of the senses and the mind. Be sure to clarify that this is not a technique to ward off or cope with anxiety; it is an exercise in simply turning one’s attention to inner experience and embracing it.

  It is worthwhile to note that there are some patients who experience increased anxiety—sometimes to the point of panic—in response to relaxation (Wells, 1990). Most of these patients are chronically anxious and interpret sensations associated with letting go of muscular tension as weird or out of control. They report they don’t feel sufficiently vigilant, and are frightened by the lack of tension in their body. They are so used to tension in their body that it can feel scary to be without those feelings. These patients are generally vigilant, need to place strict controls on the sensations they allow, and often shun drink or medicines, because of the anxiety that can be triggered by alteration in bodily sensations. This is called panicogenic relaxation, and it is understandable when relaxation is viewed as a threat to ongoing vigilance. With patients like this, we suggest that you precede any mindfulness exercises with a message about accepting, observing, and even welcoming whatever “strange” sensations appear, and then to proceed gently, allowing your patient to set a manageable pace.

  As patients become more skilled at standing back and observing their own reactions to anxiety, they begin to see and understand the ways in which they struggle to avoid it, and the distressing emotions maintained by that struggle. So the aim is to teach patients how to embrace anxiety, because this is the path that alters the fear maintaining cycle. Embracing anxiety means refusing to engage with its frightening messages and, instead, allowing the feelings to remain: not fighting back, not pushing back, not getting in a tug of war with them, not running away, not looking for reassurance, not checking to see whether the feelings are going up or down, not trying to stop the catastrophic “what if” thoughts, not analyzing the meaning of the anxiety, and not trying to suppress them. Embracing and disengaging from anxiety is doing what is perhaps the most difficult thing of all—observing and leaving it alone, while doing nothing to directly change it.

  Teaching Metaphors

  Metaphors are frequently used as a means of communicating the therapeutic attitudes of paradox and disengagement. Here is a partial list of metaphors that communicate similar ideas. Metaphors and stories can illustrate the path to a richer, more psychologically flexible life. Many patients spontaneously create their own meaningful metaphors as they begin to grasp the basic ideas.

  Bug on a Windshield

  Imagine you are driving on the highway and a big, fat bug smashes into your windshield. You immediately put on your windshield washer, but discover to your annoyance that you are out of washer fluid, and all you have done is to smear the remains of the bug all over the windshield. You are on an interstate and the next exit is 28 miles down the road. How do you cope with this situation?

  On one hand, you can do everything you can to try to get the bug off the windshield, but each additional effort only makes the smear larger and more intrusive. You can put yourself in some danger by opening up your window, leaning forward, and trying to wipe the windshield with an old cloth you happen to have in the back seat. You can continue to use the wiper without any washer fluid.

  On the other hand, you could also accept the unfortunate annoyance, and acknowledge that your task at the moment is to drive the car as safely as possible. You realize that you have a fairly clear—but annoyingly obscured—view of the road, and that you are able to safely drive the car despite that intrusion. As you drive, the wind dries up the smear and on its own, with no intervention from you, the mud begins to flake off and fly away.

  Headache

  Think of times you have a splitting headache. Then some emergency occurs, and you cope with it. It is as if the headache becomes less intense—it goes into the background. It makes no sense to say that you pushed your headache away, but the pain became much more bearable as you disengaged from the pain and engaged with the task at hand. In the same sense, anxiety can’t be pushed away, but it becomes more bearable as you disengage from the distress and become more engaged with manageable tasks in the present.

  Float

  The best thing to do when feeling anxiety is also the hardest thing to do—do nothing. If you imagine anxiety as a huge wave that builds up intensity to a crescendo and then starts to recede, the best way to cope with that is to simply float on the wave. You don’t have to fight the wave or stop the wave or modify it in any way. Instead, simply allow the wave the pick you up and then allow it to gently place you back where you were when it passes.

  Watching Anxiety Pass

  Lie on the ground and imagine that your anxiety is in the clouds floating in the sky. You wouldn’t think of changing the course of clouds as they float by, and, in the same manner, imagine that you have no control at all over the anxious arousal that you have placed into the sky. Your job is just to observe the clouds and your anxiety as you let time pass.

  Picture in a Picture

  There are televisions with the capacity to embed a small picture of one channel while the large screen is tuned to a different channel. People often use these to follow a sports event while also watching a favorite show, and allow their attention to move from the big screen to the little square in the corner and back. Think about intrusive thoughts or unwanted sensations or anxious narratives as appearing on the “Anxiety channel” in the small picture in the corner. Imagine that the “Real life channel” is showing on the big screen. There is actually no way to turn off the little picture. It is just there. Imagine watching the big screen, and when you notice your attention has been pulled to the Anxiety channel, simply redirect your attention without judgment back to the real show.

  Pop-ups on a Computer

  Many people can identify with this metaphor. You are working on your computer and unfortunately you keep getting pop-up ads intruding. You quickly hit the delete X and they disappear. However, one shows up with no obvious X in the corner. You try to right-click. You try to move all over the text to find a hidden delete button. There is none. You keep accidentally opening up the ad and have to endure a 15-second promo for something annoying. Then the pop-up shows up again. No X for delete. All you can do is reduce it slightly and drag it to the side. Your job is to keep on working on whatever you were working on—and stop trying to find a sol
ution to the annoying intrusion and accidentally wasting even more time and energy. Eventually the pop-up will leave, but you just can’t know when.

  Kids Fighting in the Rear Seat

  You are driving on the highway. There are no exits for miles and the traffic is moving fast. In the back seat are two children, safely strapped in but tired and crabby and screaming at each other and at you. There is nothing you can safely do except keep driving. You can’t turn around. They don’t listen to you trying to quiet them. You are helpless to calm them. Eventually they will probably fall asleep, but, until then, all you can do is keep on driving.

  The Anxiety Channel

  You wake up one morning and a weird event has occurred. Your house has grown an extra room. The only thing in it is a massive wall mounted flat screen TV. It is tuned to the Anxiety channel. There is no remote. There are no controls on the TV. The plug is apparently behind it. There is no way to turn it off. Your job is to carry on your life without continuous checking to see if it is off yet—it isn’t. Sometimes you can hear it clearly—especially if you are resting or quiet. Other times it just sounds like a mumble. You have to figure out how to give up on getting it to turn off and still lead a good life.

  Anxious Arousal as a Gust of Wind

  When anxiety comes, try to go with it. Don’t flee it. Turn your sail into the anxious wind. There will be less resistance. Anxiety will have less effect on you.

  Allow the Ant

  Imagine an ant crawling up your arm. Don’t brush it off. Observe. Notice discomfort. Notice thoughts. Notice sensations and urges. Let it happen. Do nothing.

  We present additional metaphors in Appendix 1.

  Essential Elements to the Therapeutic Attitude of Acceptance

  We have distilled what we find to be the most important aspects of the therapeutic attitude into five basic elements: expecting, labeling, surrendering, actively allowing, and tolerating uncertainty. We include tolerance of uncertainty to underscore that along with each of the first four elements is an accompanying task: to tolerate the possibility of being mistaken—that there is at least some uncertainty inherent in each element—and that there is a leap of faith involved in acceptance.

  Expect Anxiety

  Expecting anxiety is in direct opposition to hoping anxiety won’t happen. Such hopes, while natural, greatly undermine the attitude of acceptance. They set up a fight with symptoms. Dashed hopes bring shame, disappointment, and anger when conditioned responses are triggered. And surprise itself is an arousing response which sets up a struggle.

  Expecting anxiety acknowledges the impact of the anxiety disorder. The goal is never to be surprised or blindsided by the emergence of high anxiety. An analogy is the model of Alcoholics Anonymous: members always introduce themselves as “alcoholics,” even after decades without a drink. A member once explained why: he said that—despite 23 years of sobriety—he never again wanted to be blindsided by a sudden urge to drink. In his distant past, walking by a bar, he might notice the smell of whiskey and the next thing he knew was waking up under a bar-stool, dead drunk. He was now always ready to take action if an urge to drink should emerge.

  In the same way, expecting anxiety acknowledges the possibility—or more accurately, the inevitability—of anxious arousal in the future. This allows patients to assume the most therapeutic way to react to it. Addressing the therapeutic attitude that allows patients to accept the things they can’t change is an essential part of recovery. Anxious people have anxious bodies and conditioned anxious reactions that will re-emerge in the future. Hoping that anxiety will not happen is counter-productive.

  Expecting anxiety also suggests that patients remain mindful about times when they might be more sensitized. Anxiety tends to flare during stressful times, among stages of the menstrual cycle, during times of fatigue, illness, hunger, anger, and any strongly arousing emotion. (This is the aspect of anxiety sensitivity that was addressed in Chapter 2.) Patients can become better predictors of when arousal might occur, and be more accepting when symptoms do arise. There is inherent uncertainty in predicting symptoms: anticipatory anxiety gives false messages (see Chapter 13) and confidence that a task is mastered is a set up for great distress when unexpected symptoms occur.

  Label Fearful Distress as Anxiety

  Anxious thinking distorts the view of the world, makes it feel unsafe, and outsmarts common sense. So it is essential to make a clear distinction between two very different types of fearful distress: distress generated by danger, and distress triggered by anxiety. They require opposite attitudes to respond well. A mindful approach helps to make this distinction because it encourages patients to observe—as it is happening—their internal fear producing process. When confronted with danger, our goal is to protect ourselves. We want to distance ourselves from the danger or neutralize the source. Here is where the “fight, flight, freeze” arousal mechanism is protective.

  But if one feels terror based on anxiety, attempts to avoid the source will only serve to reinforce the anxiety. The “fight, flight, freeze” arousal mechanism has been tricked, and points patients in the wrong direction. So the first job is to put the label of anxiety on all fearful distress that is not caused by an objective danger. Feeling frightened is not the same as being unsafe. Labeling anxiety is the first step towards breaking this connection.

  Here is an example of someone successfully labeling terror as anxiety.

  This terror that I feel is my anxiety. I am not in danger. I do not have to avoid whatever is making me feel this way. There is no danger to confront. I just have to stay with the idea that my terror is anxiety. My anxiety makes the scary thoughts going through my mind feel like they can really happen. I therefore can’t trust my feelings when dealing with anxiety. This is an example of anxiety trying to bluff me.

  This can be difficult to remember when patients are trying to cope with high anxiety. We sometimes suggest they write their own version of what they want to say to themselves, and put them on a card that is easily available during these times. This is a difficult point for your patients. Since the feelings of fear triggered by real danger are the same as the feelings of fear that accompany anxious arousal, the physiology is identical. So feelings are useless in helping make the distinction between danger and anxious arousal. This means that there is a need to rely on facts and not feelings. Labeling distress as anxiety and labeling thinking as anxious thinking requires that patients need to know the facts about anxiety.

  Labeling anxiety is the first step towards disabling anxiety.

  Part and parcel of labeling is coping with its inherent uncertainty. Here is an example: A 28-year-old man came into therapy because he was told by his doctor that he had panic disorder. He had several episodes of tachycardia and tightness and pains in his chest that resulted in three emergency room visits. He had been worked up by a cardiologist and told that his heart was entirely healthy, and his symptoms were a result of panic attacks. He was not still not certain what he was experiencing was anxiety, and not a dangerous medical condition.

  PATIENT: It seems unbelievable that there’s nothing wrong with my heart. But that’s what the doctor says. I get such pains and I feel my heart thumping.

  THERAPIST: It sounds like it really terrifies you.

  PATIENT: Yeah, I’m hoping you can give me some techniques to make these go away.

  THERAPIST: Well, it sounds like you aren’t sure about what the doctor told you. I suspect you wonder that maybe there is something dangerous about your heart, and you are having trouble dealing with that uncertainty. Your doctor is saying one thing, but your body is still reacting with such intensity and such pain.

  PATIENT: That’s exactly right. I keep thinking that the doctor must have missed something.

  THERAPIST: So at this point you are having difficulty labeling your experience as anxiety. You are uncertain whether it is anxiety—as the doctor told you—or perhaps your life is in danger because there is something wrong with your heart. You have t
he opinion of one highly respected expert. You probably pretty much believe him, but you aren’t sure. So we have to figure out what will allow you to accept the fact that no one is correct 100 percent of the time, and to grapple with the risk that you can’t be completely certain it is anxiety as opposed to a heart problem.

  Here is another example: A 52-year-old man with obsessive-compulsive disorder (OCD) is terrified that he might send out a wildly inappropriate email to a business contact. His work-day has become a hell of continually checking and rechecking all the emails he sends out. He is struggling to label his distress as anxiety when in the midst of his checking ritual.

  PATIENT: I know it’s crazy, but I can’t stop worrying that maybe I’ll curse out a client, or send some sexually offensive comments on my emails.