What Every Therapist Needs to Know About Anxiety Disorders

by Martin N Seif

  Again invoking the tranquilizer analogy, here is a patient telling his therapist why he was unable to drive over the bridge.

  PATIENT: I was on the highway and I realized I forgot my Xanax.

  THERAPIST: You forgot to take your pill?

  PATIENT: No, I never take any Xanax. But I carry it with me, and I’m fine. I was on the highway and checked my briefcase and realized I had left them home. I got really frightened and got off at the next exit.

  THERAPIST: So can you explain to me how not taking a pill keeps your anxiety low, and not having the pill spikes it higher.

  PATIENT: It’s for just in case.

  THERAPIST: Yes, just in case. So here is what you are saying. If you know that you have easy access to your Xanax, then your anxiety stays low and you have no need for it. But just knowing that it’s not available, that triggers your anxiety. Our job is to figure out what is different about you when you have your Xanax and when you don’t.

  Similarly, the therapeutic goal is to determine what is different about our patients while using a coping technique, as opposed to when they aren’t. A patient related high anxiety during a business meeting while trying to use breathing techniques to keep it low:

  PATIENT: I was using the breathing techniques to keep my anxiety down, but I started to get anxious anyway. I thought to myself, “Oh no! What if it doesn’t work anymore? What if I’m back to where I started? Maybe I’ll never get over this problem.” I was totally panicked by then.

  THERAPIST: The problem is that you are thinking that breathing should take away anxiety. Breathing can help you stay focused in the present. It can reduce some of your hyperventilation symptoms, and it can make it easier for you to keep with the best therapeutic attitude. But tools don’t take away anxiety. Tools can help you pass time while your symptoms subside on their own, but as soon as you check to see if they are working, you actually provoke more anxiety. And I’m truly sorry you felt so upset. But at the same time, by now you know me well enough to realize that I’m also pleased you were able to have such a great learning experience.

  PATIENT: Yes, I know. In fact, as I was coming here I had the thought, “Well, the doctor is really going to be happy about this!”

  When anxiety returns despite techniques—as it always does—patients begin the anxiety producing process once again. They lose hope. They drop the feather. They don’t realize that they are able to do it on their own. So, people who believe it is the technique (and not their thoughts and beliefs about the techniques) that is helping, are more vulnerable to relapse when they have a setback or unexpected return of anxiety.

  There is a second important overarching problem with techniques and coping skills: they often serve as neutralization or safety behaviors which inadvertently fuel the fear cycle illustrated in Chapter 3. What patients call coping techniques can negatively reinforce anxious arousal. That is, they may immediately reduce anxiety, but anxiety returns even more intensely, and so increases the need for more anxiety reduction. In this way, misapplied coping techniques very easily become addictive, like any instant soother, such as a support person or a magic feather. By helping the anxious person avoid going through the storm of arousal to emerge on the other side, coping skills can rob him of the chance to experience the natural resilience of body and mind. They may provide instant relief but, like a drug, they are not easy to give up, and they reinforce a fear cycle with an escalating and often generalizing course. Thus, having a phobic companion come along with a patient may indeed make him less scared that one time. But the downside is that the companion acts as a negative reinforcer, and this may result in the patient experiencing anxiety in more places and situations when unaccompanied—requiring the presence of the comfort person even more. This pattern undermines the development of a patient’s confidence in his ability to tolerate distress and does nothing to teach him the difference between danger and discomfort. Instead, he is more likely to experience an escalating reliance on the external support. This in turn is demoralizing.

  Another example of a coping technique that is subtle avoidance behavior and will ultimately backfire is often taught by well-meaning family, friends, and even therapists. It is the “think positive thoughts”—and all its variations, including affirmations, ritualized prayer, ritualized behaviors, little positive reassurances, and mental gymnastics designed to banish anxiety by suppressing, diverting, and avoiding what are automatic conditioned negative thoughts. As will be discussed in some detail in Chapter 9, these are actually mental compulsions and have almost no value in the ultimate goal of reducing the suffering caused by anxiety.

  How Techniques Can Be Helpful

  Coping skills are most effective when helping patients “while” they feel anxiety, not “in order to” take it away. The anxious patient might say to herself, “While my mind is handing me crazy thoughts, or while my body is acting like there’s some emergency, I am going to try to breathe in a natural way or I’m going to get my shoulders out of my ears.” This is very different from the approach that says “I have to breathe right or relax in order to stop my mind from handing me anxious thoughts or to keep my body from feeling weird or having symptoms.”

  Coping skills are most effective for helping patients “while” they feel anxious, not “in order to” take the anxiety away.

  Techniques Are Temporary Help, Not Goals

  Coping skills or anxiety management techniques often place too much importance on the content of anxious thoughts, suggesting that they need to be stopped, avoided, or fixed. This is a misunderstanding of the goal of modern anxiety treatment. As stated in the introduction, it is not true that “changing the thought will change the feeling.” Paradoxically, patients often trigger the ironic process by trying to change a thought and thereby making it more intrusive. But even more importantly, it ignores that anxious thoughts are identified not so much by their content, but by how dangerous they feel, and by the accompanying urge to respond as if they warn of a real and present danger. That is why we view coping skills as temporary bridges as opposed to goals.

  Coping skills can also inadvertently block the new learning needed for recovery. If someone has learned to cope with cleaning the bathroom by using a new pair of rubber gloves each time, it may seem to take care of the problem. But the real problem is not about cleaning the bathroom, it is the patient’s belief that bathroom germs are dangerous and it is intolerable not to know for sure that you have avoided exposure to them. This kind of coping skill breaks down when inevitably there arise doubts about the certainty of keeping germs away—a possible hole in the gloves, or the realization that one is allowing one’s children to use the bathroom without wearing gloves.

  This is why some patients repeatedly use coping techniques to get through anxious experiences without a reduction in anxiety. Here is an example:

  PATIENT: I hate the Bay Bridge and I have to drive on it every weekend. I can do it, but I have to count in my mind the whole time, to keep myself distracted until I get over it. I check in with my husband before I start and ask him to say a prayer for me. One way I try to cope is to tell myself over and over that it is just like any piece of road.

  THERAPIST: So you are on the bridge while trying to pretend you are not on the bridge? It sounds like you believe you are practicing the bridge and it is not getting any easier, so it seems practice doesn’t seem to work. All you seem to be learning is that going over the bridge is miserable.

  PATIENT: Yes exactly. Practice does not help. I am using coping skills and it never gets better.

  THERAPIST: Well, you are actually practicing avoiding anxiety by pretending not to be on the bridge, so it is no surprise that you are not actually learning anything new. This way of “talking to yourself” is actually you giving yourself a message that it is dangerous to be anxious while driving on a bridge.

  Sometimes coping skills are more subtle, but they unfortunately serve the same purpose of negatively reinforcing anxiety.

  PATIENT: I
’m claustrophobic. When I fly, always sit in seat 1A. It gives me the most amount of room. And I don’t have to look at the rest of the plane. So I can tell myself I’m just all by myself in this little space. Oh, and I always step into the plane with my right foot.

  PATIENT: I always take the upper level when I go across the George Washington Bridge. That way, I tell myself if there is a disaster and the bridge starts to collapse, there is still the lower level to hold me up.

  PATIENT: I used to worry about germs, so I absolutely love these antimicrobial wipes. Whenever I think that I might have gotten some germs on my hand, I just pull them out and wipe myself up. They are fantastic!

  PATIENT: Thank God for cell phones. Now I can text my husband and he can text me so that I don’t have to worry about his safety.

  Emergency Coping

  There are places—and important ones—for coping skills in the successful treatment of anxiety disorders. Anxiety management techniques can be extremely helpful as temporary emergency measures, when a strategy is needed to cope with a highly anxious situation, because avoidance would have significantly negative consequences. In these cases, it is better to have the patient get through the anxious experience, rather than suffer the negative consequences.

  Here is an example. A patient with both panic disorder and social anxiety disorder (SAD) is starting a new job. He realizes with terror that people in this job go out for lunch in groups, which is the specific set of triggers that he finds intolerable. He can tolerate—just barely—the anxiety of elevator, hallway, lobby, and restaurant, but the addition of his peers (whom he fears will notice his anxiety) sends him into panic. In this case, he worked out a series of coping mechanisms that included reasonable excuses for a later lunch, methods of reducing the visual space of his lobby, leading his colleagues on a path that he found less triggering, methods for distracting himself when he felt too anxious, and a non-intrusive way to lead a small group of walkers closer to a wall—which he felt as comforting. Every single one of these coping mechanisms included some aspect of avoidance, and none of them helped to embrace the therapeutic attitude. But they did help him hold on to his job, and the patient was highly cognizant that this was not a long-term solution. It was an emergency fix. He kept his job, but understood these temporary measures needed to be abandoned so that the sustainable work on his anxiety disorder could begin.

  The same sort of temporary emergency intervention may be needed to provide for the safety and care of children when a parent is disabled by fears and has not yet grasped the basics of treatment. Here is an example: a mother was having health anxiety fears and spending every day in the emergency room with her toddler “in case” one of them needed emergency medical care. She was aware this was not an ideal way to spend her time. Before she was able to learn a new attitude to her fearful thoughts, she was able to bring her child to her mother’s house and spend the day there. Her plan was to have her mother reassure her or babysit “in case.” This was a temporary way to better care for her child until treatment progressed to where the patient was able to do without her mother’s reassuring presence.

  Similarly, it might be reasonable to take a PRN benzodiazepine in order to be able to keep a promise to join a group school outing on a bus instead of disappointing the child by avoiding it. These actions allow parents to consistently place their children’s welfare front and center. These coping techniques allow “getting through” experiences, until such time as there is enough distress tolerance to undertake new learning. They should be undertaken with a conscious awareness that they are “crutches” that will be set down when the leg is stronger.

  Here is another example. A patient was having panic attacks and her doctor needed her to have an MRI to rule out a serious medical condition. She asked to be sedated and to have a friend come into the room with the MRI and hold her ankle and talk to her so she could have the procedure. She was simply not ready to do it on her own, and it was not reasonable to expect her to be convinced that her panic was not dangerous until the test was done.

  Similarly, when someone early in treatment calls in the middle of the night in a state of acute hyperventilation and panic, they will not be able to reason because of their terror, no matter what wisdom you have to impart. Yelling “Accept!” over their gasping breath will not be helpful. A soothing tone with instructions to lie down on the floor on the tummy, to stop trying to “fix” the breathing, that this is not a true emergency, and to put a pillow under the chest and simply let mechanics work and time pass will be a more effective intervention. Ultimately, lying on the floor is not an option for managing hyperventilation but in the immediate moment that may be the best thing to do. (Another version of this technique is to direct the patient to get onto his hands and knees—remaining on the mattress is fine—and continue to breathe in that position. The pressure on the arms keeps the chest in place, and gravity helps pull the diaphragm down, so that hyperventilation is temporarily allayed.)

  Techniques That Can Be Helpful: “What Is,” Not “What If?”

  There is a general rule for the use of coping skills or anxiety management techniques: they are most effective when helping patients attain the proper therapeutic attitude. Chapter 3 stresses that patients do best when they embrace the experience of anxiety in order to disengage from it. Any coping mechanism, skill, or technique that encourages this attitude is doing its job.

  Mindful Sensory Awareness: Staying in the Present

  Staying grounded in the present moment, sensing instead of thinking, tends to help anxious people add less second fear. When attention focuses on what can be seen, heard, felt, and experienced in the moment, there is less judgment, catastrophizing, and worrying—all of which adds up to less elaboration on the meaning of anxious arousal or intrusive anxious thoughts. The purpose is not to lower anxiety, for that will engage the paradoxical nature of the symptom, but reduced anxiety is a valued side effect. An example of such a technique would be to pay attention to sounds or smells or particular colors while walking through a mall, and being aware, at the same time, that one’s heart is beating fast and one feels off balance. It is easy to make a mistake here and instead of staying grounded, substitute unhelpful distraction: the goal of staying “in the now” is to be present while anxiety is present, not in order to make it go away.

  Another aspect of staying grounded in the moment is to let go of formulating an escape plan. Planning one’s escape propels patients into future thinking, trying to solve the issues created by imagined catastrophes, retriggering the fight, flight, or freeze response, and further elaborating on anxious arousal.

  When anxious, patients have the tendency to think they know what others are thinking, how they are perceived by others, and to look at themselves through the eyes of people around them. This is a sign of getting outside themselves, an indication that they are losing touch with groundedness in the present. Suggest that patients pay attention to how others look to them, what colors they are wearing, and what style of dress they are wearing. Ask them to focus on what they think of others, and less on what others might be thinking of them.

  Expecting and Allowing

  Hoping not to be anxious is counter-productive. It is helpful to remind oneself that symptoms are conditioned phenomena with well-worn neurological circuits, and that the discomforts of mind and body will occur. An example might be illustrated this way:

  PATIENT: I know I should go to the gym but I am so self-conscious and anxious in front of all those cute athletes in little bodies. I feel like a hippo. I am trying to tell myself that I don’t really look as bad as I think, so I will have the courage to walk in. Maybe I should try to buy an outfit that camouflages me better.

  THERAPIST: Actually what I would like to suggest is that you walk in the door saying to yourself “I feel like a hippo. There is nothing I can do about feeling this way. But I can use the treadmill while I feel this way.”

  PATIENT: How will that take away my anxiety? I have been doing that a
lready.

  THERAPIST: My guess is you have been feeling like a hippo all the while telling yourself that you shouldn’t feel that way, that you should stop feeling that way, that there is something wrong with you that you feel that way. I am suggesting that you go ahead and think it on purpose. It won’t take away the feeling or the initial anxiety, but it will take away the internal battle that is keeping the anxiety going. You would at least have a chance to get used to the place.

  Mindful Labeling

  Anxiety management techniques that encourage a more mindful approach are also helpful. Anxious people often need to be taught how to uncritically and simply observe and label their inner experiences. The vignette above illustrates another important principle. Patients routinely confuse thoughts, images, sensations, and feelings. Getting these sorted out can be of enormous value. In the example above, the statement “I feel like a hippo” is a thought, not a feeling. The feeling that accompanies the thought is shame. The sensations that arrive with the shame are flushing in the face and rapid heart rate.

  It is also helpful for a patient to understand the story of “I feel like I am having a heart attack.” It actually begins with the sensation of shortness of breath or tachycardia. Then comes the associated thought “heart attack” and then the feeling of panic or terror close behind. These distinctions help patients separate those experiences that are automatic and not modifiable, from those that can be modified.

  And it helps them to distinguish the facts (“my heart is beating fast”) from the thoughts (“I am having a heart attack”). Similarly, “I can’t stand it anymore” is a thought. Despair is a feeling. Nausea is a sensation. And so on.

  Mindful labeling includes encouraging patients to rate their level of discomfort on a fear scale and become adept at watching it go up and down. They will notice the ways in which intrusive thoughts, the attempt to rid themselves of anxious feelings, and the effects of judging and evaluating instead of simply observing send anxiety up automatically. An example: