March-May 2008

The 10 Best-ever Anxiety Management Techniques: Understanding How Your Brain Makes You Anxious and What You Can Do to Change It, Margaret Wehrenberg, Psy.D. (paperback, 224 pages), W.W. Norton, 2008 When you suffer from continued anxiety and worry, you feel as though there is something basically wrong with the biochemistry of your brain.  Not true. Your brain is the world’s most brilliantly complex machine, and it functions impeccably. The problem is that it can learn in a heartbeat how to protect you from threat; but once it learns, it doesn’t unlearn easily.  If you struggle with panic disorder, generalized anxiety or social anxiety, in this book you will find a solid combination to unlock this learning process within the brain, and the good news is: your brain will be an excellent student. Dr. Wehrenberg has done the work to create the right learning environment and to organize your needed tools. If you follow her lead, your body and mind will thank you with the peace and quiet you deserve.

Mindful Solutions for Stress, Anxiety and Depression, Elisha Goldstein, Ph.D. Mindful Solution Series, 2007   Dr. Goldstein is a clinical psychologist and trained teacher of Mindfulness-Based Stress Reduction (MBSR).  His study published in the Journal of Clinical Psychology found that integrating mindful principles into daily life for just 5 minutes a day over 3 weeks resulted in significant reductions in stress and significant increases in life satisfaction, positive relations with others and environmental mastery. This 68-minute CD introduces the listener, in three tracks lasting 28 minutes, to the concept of mindfulness and its benefits for anxiety as well as depression. Then three tracks of guided meditations, of progressing lengths (5 minutes, 17 minutes, 25 minutes), offer different ways to quiet the mind and body, and are there for your repeatedly use. This is a soothing, well-grounded introduction to and demonstration of mindfulness meditation.

Training Event:
Winning the Anxiety Game

Brief Strategic Treatment for the Anxiety Disorders

I'll be offering a 5-day training on Cape Cod this summer. I'll teach from 9 to noon each morning. We'll cover:

• Principles and Goals for Brief Strategic Treatment
• The Anxiety Disorder Game and Second-Order Change
• Provocative Treatment of Panic Disorder and Social Anxiety
• Obsessive-Compulsive Disorder
• Worry and Generalized Anxiety Disorder

Self-Help & Professional Update:
Stand without Crutches

(This is Part 1 or a 2-part article.  The 2nd half will be in the next issue. Professionals: I’ve written this as though the reader is someone with anxiety.)

All of us generate a set of coping strategies to allow us to tolerate events that we would otherwise avoid.  Let’s call these safety crutches because we lean on them for our sense of security. (The research literature calls them safety behaviors.) Crutches are essential when you are first healing a broken leg.  But if you want to walk independently again, you eventually have to put those crutches away.

Your Safety Crutches

And so it is with anxiety: when you are choosing to take a giant step into a new, threatening arena, crutches can be quite handy.

But if you continue to use such crutches from now on, “just in case,” then you can never overcome your fears. The biggest crutch people use is to avoid threatening situations altogether.  The second is to escape the scene.  But there are dozens of subtle ways that people avoid uncertainty and discomfort.  Here are a few:

• Asking a supportive person to accompany you
• Endlessly preparing yourself for an event
• Carrying an anti-anxiety medication
• Distracting yourself
• Repeating reassuring phrases
• Engaging in relaxation exercises
• All OCD rituals

Why Bother?

Why should you reduce your reliance on safety crutches?  There are two ways that crutches interfere: they weaken your sense of control and they decrease your ability to gain control in threatening situations.  You will need to challenge the presumed benefits of those crutches.  Let me summarize what we are learning from research studies.

1. Using safety crutches makes you feel more vulnerable to anxiety.  Facing threat directly makes you feel stronger.

Your solution—to use safety crutches—perpetuates your problem.  Anything that you do with the conscious intent to avoid threat will reconnect you with that threat.  While you are consciously thinking, “I’m so glad the traffic is light,” you will unconsciously think, “because if it were heavy right now, I’d be terrified!”  The natural response to threat is anxiety, so even though you are reassuring yourself, you are simultaneously scaring yourself into believing that driving in traffic is dangerous.

Three studies have been conducted with healthy individuals who have no anxiety-related disorders. The subjects in the experiments were asked to generate uncomfortable physical sensations—for instance, by breathing in oxygen with a mix of carbon dioxide or by hyperventilating. In all three studies, those who were prone to use crutches to distract themselves from their discomfort reported more panic symptoms and felt less in control than those who paid attention to their sensations.

It’s not that people using safety crutches are actually more anxious.  Their heart rate fluctuations during practice tend to be the same as those who face anxiety directly.  But they rate their sensations to be stronger.  That means using crutches may cause you to perceive you are more uncomfortable that you actually are. Who needs that!

1. When you pay attention to your discomfort and doubt, you improve.

Researchers have extensively studied the benefits of staying aware of your discomfort and your fears when you face a threatening situation.  Yes, trying to get your mind off of your discomfort can give you some relief for the moments while you are practicing, but in the long run it keeps you stuck.  In one study, six months after treatment was completed, the group that was willing to focus on their discomfort continued to report greater improvements than those distracting themselves.

In one study, people with claustrophobia (those afraid of closed-in spaces) were instructed to face their threatening situations during treatment.  One group was asked to focus on their perceived threats during their practice.  A second group was given a complicated mental task to keep their minds busy and away from thinking about their fears.  In other words, they were trained to use a safety crutch.  The group facing their threat directly was able to reduce their fear significantly more that the group engaged in distraction.

In another study, people with claustrophobia were asked to enter into a closed-in place alone to practice tolerating the feared situation. One group was instructed that they could use safety crutches any time they needed to during the practice. They were permitted to open a window if they desired fresh air, to stand by the door so they could get out quickly, to check that the door was unlocked whenever they wanted, and they could speak with the experimenter through an intercom. The other group was offered no safety crutches.  The experimenter instructed them on the benefits of focusing on their perceived fears in order to discover whether they were true threats. It was much easier for this second group to overcome their claustrophobic fears.  Using the safety crutches ended up working against the progress of the first group.

Go toward Anxiety & Uncertainty

What does that research mean?  You get better when you are willing to be anxious and uncertain. You have to face short-term discomfort and doubt for long-term improvement. You need to not know how strong your anxiety will become and go forward anyway.  You need to not be sure whether there will be negative consequences.  This is because you must challenge your belief that something intolerable is going to occur.  How? By putting yourself in that circumstance and discovering what happens.

Think carefully about what I am saying.  The research shows that there is an excellent way for you to improve.  Dozens of studies have led us to this conclusion: permitting yourself—even encouraging yourself—to be scared, and feeling that fear instead of blocking it, is healing. These findings have held up in studies of people with panic disorder, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder, claustrophobia, social anxiety and phobias of driving, heights and small animals. It is clear that distracting yourself is not in your best interest.

For example, one study involved thirty-seven women who had been assaulted.  All of them developed PTSD, and the study looked at how well they improved after treatment.  The treatment protocol, called exposure, involved repeatedly imagining the assault while a trained therapist supported their efforts.  While this is an excellent, well-researched form of therapy for PTSD and all the women improved, there was a significant finding.  The women who allowed themselves to feel very scared while they were practicing the exposure and who didn’t block those feelings when they noticed them, were eight times more likely to improve to the highest stage of functioning after.  Eight times more likely to get better—that is a highly significant finding.

So test out your theory that something bad is going to happen, and test it out without any crutches. If you can have faith that such a protocol will help in the long run, you will be more willing to tolerate your anxiety and doubt in the short run.

Get Rid of the Option

Having access to safety crutches, even if you don’t use them, limits your progress just as much as if you use them.  Perceiving that you have the option to lean on a crutch during practice interferes with learning to handle anxiety to the same degree as actually leaning on it. Carrying that anti-anxiety pill in your pocket “just in case” seems like more progress than taking the pill, and that’s true.  But to finish your work, you may need to practice without the option of that pill to bail you out of trouble. Carrying a cell phone or a list of coping skills, preparing excuses for leaving, knowing how to reach a support person, constantly reassuring yourself—these are all just-in-case crutches that cause you to avoid facing your fears directly.  They perpetuate your belief that the threat is real and valid.

Next issue I’ll finish this up.

Resources

Campbell-Sills, L. and D. H. Barlow (2007). Incorporating Emotion Regulation into Conceptualizations and Treatments of Anxiety and Mood Disorders. Handbook of emotion regulation. New York, NY, Guilford Press: 542-559.

Kim, E.-J. (2005). The effect of the decreased safety behaviors on anxiety and negative thoughts in social phobics. Journal of Anxiety Disorders, 19(1), 69-86.

Lohr, J. M., B. O. Olatunji, et al. (2007). "A functional analysis of danger and safety signals in anxiety disorders." Clinical Psychology Review 27(1): 114-126.

Powers, M. B., Smits, J. A., & Telch, M. J. (2004). Disentangling the Effects of Safety-Behavior Utilization and Safety-Behavior Availability During Exposure-Based Treatment: A Placebo-Controlled Trial. Journal of Consulting and Clinical Psychology, 72(3), 448-454.

Rachman, S. (1984). "Agoraphobia: A safety-signal perspective." Behaviour Research and Therapy 22(1): 59-70.
Rachman, S. (1984). "The experimental analysis of agoraphobia." Behaviour Research and Therapy 22(6): 631-640.

Salkovskis, P. M., Clark, D. M., & Gelder, M. G. (1996). Cognition-behaviour links in the persistence of panic. Behaviour Research and Therapy, 34(5-6), 453-458.

Sloan, T., & Telch, M. J. (2002). The effects of safety-seeking behavior and guided threat reappraisal on fear reduction during exposure: An experimental investigation. Behaviour Research and Therapy, 40(3), 235-251.