Getting to the Root of Anxiety
The term “anxiety” covers such a wide range of stress responses that virtually everyone experiences anxiety at some point in life, ranging from worries about calling for a date or addressing an audience to full-fledged panic attacks. Nervousness is essentially a form of anxiety that everyone would agree to. Feeling nervous about talking in front of a large audience of strangers may be considered appropriate anxiety. People generally seek professional help when the level of anxiety increases to the point that it interferes with carrying on their daily lives. Not surprisingly, most people seek relief from the symptoms of anxiety, and the drug industry has produced a veritable pharmacopeia of medications to treat this common complaint, including tranquilizers, beta-blockers and antidepressants.
Cognitive-behavioral therapy has also proven to be effective in addressing the symptoms of anxiety, and insurance companies may actually specify CBT as a course of action for quickly treating a presenting complaint of anxiety. I routinely employ desensitization techniques to deal with clients’ driving phobias. As I tell clients, we essentially get rid of the phobia by boring it to death. First I train the client in belly-breathing to provide a method for continually returning to a baseline of relaxation. (When you tell people to take a deep breath, they usually simply fill their chests. Belly-breathing, by contrast, begins with the diaphragm, as if filling a great barrel from the bottom.) Then the client compiles a list of the six to eight aspects of driving that prove to be scary. We arrange the list in order from scariest to least scary, and begin with the least scary item.
Before starting the actual desensitization process, I elicit examples of the client’s negative self-talk and re-frame one of the phrases into a positive mantra that will be incorporated into the desensitization technique. Such a phrase might be, “I am a skilled driver, constantly aware of my surroundings.”
Suppose that the least scary—but still anxiety-provoking—aspect of driving is pulling out into traffic. I have the client describe and visualize carrying out this activity step by step, monitoring the anxiety level at each step, and reducing the anxiety to zero through repetition before proceeding. The conversation might go something like this:
Client: I check my rear-view mirror and side mirror, turn on my signal indicator, and prepare to pull out into traffic.
Therapist: On a scale of 1 to 10, what is your level of anxiety right now?
Therapist: Okay. Close your eyes, begin belly-breathing, and get very relaxed. What is your anxiety level now?
Client: 2. I don’t think we’re ever going to get it to be less than 2 as long as I’m thinking about driving.
Therapist: All right. That will be our baseline. Now go back to the activity.
Client: I check both my mirrors, turn on the signal indicator and prepare to pull out.
Therapist: Repeat your mantra.
Client: I am a skilled driver, constantly aware of my surroundings.
Therapist: What’s your anxiety level?
Therapist: Okay. Close your eyes, breathe deeply, and continue until you return to baseline.
Client (after breathing): Okay. I’m back to 2.
Therapist: Repeat the description.
This process continues until the client can talk through the entire operation of getting ready to pull out into traffic, inserting the mantra each time, without the anxiety level rising. Then we proceed to the next step, which may be “seeing the speedometer needle go above 100 km/hr [roughly 60 mph].” The client must be able to complete each step without increasing anxiety before going to the next.
It may take an entire session to go through one or two steps. As homework, the client must repeat the exercise, monitoring the anxiety level at every stage and repeating the safe-driver mantra. The technique works by reversing the pattern of constricting concentric circles that characterizes anxiety. As anxiety grows, life shrinks. We have a smaller and smaller circle in which we dare to exist. Frequently clients become so anxious about driving that the first step in the process may be locking the front door of the house and walking toward the car. By addressing and processing each step, starting with the least scary, the client regains control over an ever-widening area of activity. The job of the therapist is to keep enlarging the circle until clients get their lives back.
The desensitization process can, in itself, relieve a client’s phobia, thereby permitting the client to return to normal life activities. (A driving phobia can be particularly debilitating in this regard.)
Sometimes the client wants nothing more, but I open the invitation to investigate the root causes of anxiety, since if unaddressed they may well emerge again in some other form. If the client wishes to proceed, I provide a bit of psycho-education about the nature of anxiety.
All mammals experience fear. If you’re an antelope on the savannah and you spot a tiger, it doesn’t take long for the fight-or-flight mechanism to kick in: respiration increases, blood flows to the extremities, digestive activity ceases, visual acuity heightens, and you race away to safety, after which the fear subsides, adrenaline discharges, and the whole system “stands down.”
Only humans experience anxiety, which one therapist has defined as the fear of a tiger when there’s no tiger present. Humans can visualize the tiger, and may become anxious even thinking about the part of the forest where the tiger dwells. With anxiety, all the emergency responses come into play but the system never stands down: you remain in a constant state of emergency, with all the resulting negative physical and mental effects of sustained stress.
In human beings, that emergency response includes shutting down the neo-cortex, so that in a panic situation you’re essentially leaving your emotionally charged inner four-year-old in charge, hardly a desirable state of affairs. (One might suppose that thoughts travel fast, but even the speed of neural connections is too slow for emergencies; the chemical reactions involving adrenaline are faster than thinking. Our hormonal system is faster than our nervous system!) First-aid for anxiety, in addition to belly-breathing, is asking “Where’s the tiger?” The breathing will help to reverse the physical fight-or-flight response and the question will help reawaken the neo-cortex. Looking around and firmly establishing the absence of a tiger may reduce one’s level of anxiety.
But clients suffering from a mood disorder require more than first-aid. One client, after completing the desensitization process for overcoming a driving phobia, expressed a desire to address the root causes of his anxiety. We went through the usual history-taking for EMDR (Eye Movement Desensitization and Reprocessing), including asking the client to identify his ten worst memories, experiences that brought him down when he recalled them, or experiences that he tried to avoid remembering altogether. These experiences included physical abuse and bullying.
As frequently occurs in EMDR treatment, the failure of a particular memory to be processed in a reasonable amount of time often indicates the presence of an earlier “feeder” memory connected with the same negative self-belief and the same emotional response. The client in question had feeder memories connected with an earlier experience of childhood bullying and also a traumatic experience at preschool. Processing these subsidiary memories allowed us to process the original target memories satisfactorily.
The EMDR protocol calls for using the Future Template technique after processing the individual target memories. The client is asked to imagine coping effectively with some issue in the future. In the case of the driving phobia, the future challenge may be the fear of a panic attack, in other words, a fear of fear. If fears arise as the client contemplates a future scene, the therapist may suggest devising a resource, in the form of a person, an image or a symbol, that the client can call on for assistance. One of my clients imagined an eight-foot-tall bear as a resource. After all, nobody is going to mess with someone walking beside an eight-foot-tall bear.
The client is then asked to play a mental movie, imagining coping effectively with a particular issue in the future, using resources as necessary. If the client can get successfully through the movie, from beginning to end, the therapist “installs” that technique using the bilateral stimulation (usually finger movements) associated with EMDR.
As noted, the prevalence of anxiety has elicited a multitude of medical responses that have now entered the common idiom. At one point in the 1979 film Starting Over, the Burt Reynolds character asks a crowd of strangers if anyone has a Valium and a dozen people extend their hands. But symptomatic relief alone, aside from the negative effects of long-term dependence on medication, fails to address the underlying causes of anxiety. True mental health comes when familiarity with one’s personal demons leads to actively engaging them and learning techniques for keeping them at bay. As with depression, that other most common mood disorder, learning to escape from passivity and helplessness can be a major step in the direction of mental health.
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