Two Approaches to Anxiety

When it comes to anxiety disorders, particularly panic and phobias, cognitive-behavioral therapy is well-established as the treatment of choice. More specifically, research evidence strongly supports the value of exposure to feared stimuli in decreasing or eliminating anxiety. 

The general idea is that experiencing the stimuli without (1) a feared outcome occurring, and/or (2) responding fearfully through fight/flight or safety behaviors diminishes the cognitive/neurological link between the stimuli and danger. Over time, the fear progressively decreases until it is minimal or even eliminated.

The problem with this scenario is that it requires the client to actually feel all of their fear and anxiety...and they have probably come to therapy hoping not to feel these feelings! It requires significant courage, trust in the therapist, and belief that the end result will be worth the discomfort. It also requires that the costs of living with the anxiety outweigh the discomfort of treatment.

However, given that these conditions are met, and the client agrees to exposure, the therapist has to decide between two competing protocols:

1) Flooding 

In flooding, the client is exposed to the object of intense fear, while preventing avoidance or other safety behaviors (hence the technical name, Exposure and Response Prevention), until the fear subsides. Since a discrete episode of anxiety is time-limited, the fear does in fact dissipate over time, which in turn provides new experience as a foundation for cognitive and behavioral change. 

2) Systematic Desensitization

While flooding dives right in with exposure to intensely feared stimuli, systematic desensitization eases clients in more gradually. Therapist and client work together to create a hierarchy (gradated list) of anxiety-provoking stimuli. Then, treatment starts with exposure to something that produces mild anxiety. Once the stimuli no longer produces anxiety, treatment progresses one step up the hierarchy to something slightly more fear-producing.

Flooding produces more dramatic results in a shorter period of time, but is also more distressing than systematic desensitization. In contrast, systematic desensitization takes much longer to get to the source of anxiety that is causing the client the most distress. However, it also gives the client the opportunity to gain confidence and mastery as they overcome less intense fears, and demonstrates that the approach is effective before asking them to confront more intense fears. 

Given these relative strengths and weaknesses, which do you prefer? Are there situations in which one is preferable to the other? How do your clients respond?

Fear of the Unknown

A theme that has been coming up among my clients this week is fear of the unknown. Specifically, several of them who are "stuck," immobilized by their ambivalence about recovery, have identified the fact that they don't know and can't imagine what recovery might be like as the strongest force pulling them away from recovery efforts.

While everyone may experience different versions of it, I think we all share this kind of fear of the unknown. The whole fortune telling industry banks on this anxiety, and our willingness to spend money to make life more predictable. The thing is, life is inherently unpredictable, and seems to delight in proving that to us.

And here is the other thing: even when we have every reason to expect a positive outcome, we still experience the fear. For example, one of the ways I have tried to assuage my clients' fear of recovery is to remind them of other people's stories of what recovery is like - both the stories of people they may know, and stories that have been published in popular recovery books. However, while such stories may temporarily raise overall sense of hope that recovery might be possible and positive, they don't erase the fear.

The fact that fear continues regardless of efforts to cognitively talk oneself out of it suggests that this kind of anxiety is not cognitive at all. In fact, although I rarely subscribe to Freudian theory, I think he may have been onto something when it comes to anxiety. Freud identifies five types of anxiety, associated with stages of development:

1. The first kind of anxiety which infants experience Freud called automatic anxiety. It is a reaction to stimuli that are perceived as threats beyond the infant's control - things that cannot be escaped or regulated. Ego psychologists have renamed this kind of anxiety annihilation anxiety. They argue that "infants experience these terrifying moments at the level of excruciating organic distress, accompanied by inchoate fears that overwhelm them" (Berzoff et al., p. 81), in large part because they have not yet developed a structure of defense mechanisms to assuage their anxiety.
2. The next form of anxiety that develops, in early childhood, is separation anxiety, or fear of abandonment. It is less intense than annihilation anxiety, but still quite intense, since young children depend upon adults for their very survival.
3. The next level of anxiety involves fear of loss of a caregiver's love and esteem (fear of rejection). It shapes children's behavior by motivating them to adhere to rules and limits set by caregivers.
4. The fourth level of anxiety Freud termed "castration anxiety," but modern theorists have renamed fear of bodily harm, or loss of valued physical or mental capacities. It is understood as "projected fear of retribution for hostile wishes against a parent" (p. 82).
5. Finally, the fifth stage recaps the four earlier stages, this time triggered not by interactions with the caregiver, but by internal interactions between the superego and ego.

While I have some skepticism about the latter two stages, I have observed the first three to be common ongoing concerns for people at various ages and stages of development; therefore, I can easily believe that they might be universal.

I also suspect that they have something to do with our fear of the unknown. My theory is that the unknown becomes a projective test of our deep-seated anxieties. In the absence of evidence or data about the nature of what will come (which is, after all, the definition of the unknown), our psyche runs through its repertoire of worst fears. Thus, when clients are able to explore their fear of the unknown, common themes that come up include abandonment, rejection, loss of capacity, and even annihilation.

So, where does that leave us - clients and therapists alike? Recognizing these core fears and their developmental basis does not necessarily make the fear go away. And when it comes to fear of the unknown, the only true antidote is to turn the unknown into the known. That means "feeling the fear and doing it anyway" - accepting the experience of fear, exposing oneself to fear without avoidance, and guiding our choices and actions by our values and goals rather than our emotions or worry thoughts (sounds a lot like ACT, right?).

How do you think about the fear of the unknown? How do you respond to clients' fear of the unknown?

The Sky is Falling!

Do you remember the story of Chicken Little? (You probably heard it as a child, but if you don't remember that, you might remember the...adapted version...made into an animated movie in 2005). It begins when an acorn drops on an unsuspecting Chicken Little as he's walking through the woods, hitting him on the head. Not seeing the acorn, Chicken Little concludes that a chunk of the sky has fallen on him. He panics, and runs off to alert the King - and everyone else he meets! - that "the sky is falling!"

It is easy for even children to recognize how silly Chicken Little's conclusion is - the sky isn't made up of something hard, and chunks can't fall out of it. However, at some point or other, most of us have "sky is falling" moments. You know what I mean: We jump to conclusions based on very little evidence. We catastrophize, imagining all the possible worst-case scenarios. We work ourselves - and sometimes the people around us - up into a panic, completely unnecessarily. We can all relate to Chicken Little.

So, why do we do this? Why do these thoughts, which CBT labels cognitive distortions, seem so ubiquitous? I think of it as something brains do, trying to be helpful. The brain's job is to think, after all, and it's pretty darn good at problem solving, so it figures that we'll be ok as long as it can identify and plan for all possible outcomes. And, if it can plan for the worse possible outcomes, better outcomes should be a piece of cake, right?

Unfortunately, the brain's strategy doesn't actually help that much - in part, because the brain is very creative and keeps coming up with additional strategies or details, and in part because the process of thinking all of these things tends to spike our anxiety.

There are a few different strategies for these "sky is falling" moments (depending on the person and situation). 

1) Worry control - as the brain spits out all of its possible scenarios, you can try to make them less anxiety-provoking by asking two questions: how likely is this, really? and could I handle it? Usually the answer to the first one is low, and the second one is some version of yes (or sort of, probably, etc). Therefore, even if the thoughts continue, the panic subsides.

2) Reframe - classic CBT, this involves catching the thoughts and replacing them with more balanced thoughts. (While this may sound similar to worry control, the difference is that worry control allows the catastrophizing thoughts to continue, it just frames the catastrophe as unlikely and/or manageable; reframing tries to stop the distorted thoughts altogether). 

3) Relaxation - instead of approaching it through the thoughts themselves, you can also try to approach it through the body. Just as thoughts can produce physical anxiety, physical relaxation can restore balanced thinking. Progressive muscle relaxation may be the easiest strategy, since it focuses on the body rather than requiring more mental concentration, such as meditation or mindfulness does. 

Do you find one of these strategies more (or less) helpful than the others? Are there other strategies you use to combat catastrophizing?

The Relaxation Response

Just about everyone has heard of the "Fight-or-Flight Response," the body's physiological response to a perceived threat. Basically, the perceived threat triggers the release of stress hormones (such as adrenaline and cortisol) that activate the sympathetic branch of the autonomic nervous system (which controls involuntary body functions). The sympathetic branch responds with increased heart rate, faster and shallower breathing, dilated pupils, increased blood flow to the muscles, muscle tension (sometimes leading to shaking/tremor), sweating, flushing or paling, decreased or interrupted digestion, and reduced immune functioning, among other things. All of these changes prime the body to respond to the threat by either fighting it or fleeing from it.

The fight-or-flight response was quite useful in the distant past, when most of the threats humans faced were threats to their physical safety - dangerous animals, or warring tribes, for example. Fighting or fleeing were the best ways to ensure survival. In contrast, the vast majority of the threats we face now are not threats to our physical safety. Instead, we experience anxiety about things like money, obligations, being judged or evaluated, etc. Neither fighting nor fleeing is very productive for these modern-day threats! 

Indeed, the physiological responses designed to prepare our bodies to fight or flee can actual interfere with adaptive responses to today's threats. For one thing, it's very hard to think rationally when the sympathetic branch is activated, making it difficult to navigate the complex social and logistical challenges we perceive as threats. Additionally, our common threats tend to last longer than a physical threat - for days, weeks, months, or even years, rather than moments. Chronic exposure to stress hormones, and activation of the sympathetic branch can result in serious health problems: high blood pressure and other cardiovascular problems, reduced immunity to illness, inflammatory problems (e.g., irritable bowel syndrome, asthma, psoriasis, lupus), pain, sleep disturbance, reduced memory and concentration.

Fortunately, we can increase the efficacy of our immediate response to threats, and reduce the health risks of long-term stress by activating the body's opposite process: what Benson and Klipper dubbed the "Relaxation Response." This response is based on the second branch of the autonomic nervous system, the parasympathetic branch, which triggers effects opposite to the sympathetic branch. It reduces heart rate, makes breathing slower and deeper, increases digestion, reducing muscle tension, restoring body temperature and immune functioning, etc. Since both branches cannot be active at the same time, activating the parasympathetic branch deactivates the sympathetic branch, short-circuiting the fight-or-flight response. 

That sounds good, of course, but how do we activate something that is involuntary, and therefore not in our conscious control? While we can't intentionally alter our heart rate, for example, we can begin to influence the autonomous nervous system through body functions we have some control over. Take breathing, for example: while it (thankfully) happens automatically, we can alter the rate and depth of breathing. Intentionally taking slow, deep breaths is one way to activate the relaxation response. We can't directly affect our body temperature, but we can use hot or cold compresses to affect temperature indirectly. We also have control over most muscles. Using strategies like progressive muscle relaxation, we can reduce muscle tension and related pain. Any and all of these strategies can counteract fight-or-flight, trigger the full relaxation response, and therefore lessen distress and improve the effectiveness of our reactions. 

It's obviously much easier to activate the relaxation response from a neutral state than in the midst of fight-or-flight. Since it gets easier with practice, it's a good idea to practice relaxation in the absence of a threat, so that it's available as a coping strategy when threats occur. (Of course, should you find yourself facing a bear, or other physical threat, let your fight-or-flight response protect you!)

Fear of The Unknown

Clients often tell me that they are afraid of "recovery." Regardless of what they're recovering from, and how painful it's been, the idea of recovery is still scary. Why? Because recovery represents something that triggers some innate fear in all of us - Fear of The Unknown.

It is true that most (but not all) of my clients had some period of their lives before their problem began - a period, we might presume, of relative "health." If recovery is a return to health, how is it The Unknown?

One possibility is that people have forgotten what health was actually like - how they felt and acted when "healthy." We might suppose that the longer the problem has lasted, and the shorter the preceding period of health, the harder it is to remember to remember. Greater intensity of problems may also pose more of an obstacle to remembering. Either way, forgetting renders "health" an Unknown.

Another possible explanation is that the problems that bring people to therapy also have a way of skewing their perspectives - memories, beliefs, ideas, etc. Sometimes problems become part of their identities, or seems like an inevitable part of their futures. Because of how the human brain is structured, it is much easier for someone to recall all of their past experiences that are similar to their current experience, and imagine a future that is also similar, than it is to call up competing examples. As a result, "recovery" can be a fleeting concept in the mind, hard to pin down and easily overwhelmed by problem-thinking.

Whatever the reason that "recovery" is experienced as an Unknown, it is undeniably that Unknowns inspire a fear like no other. Even those who are facing a serious medical diagnosis usually say that waiting for results of diagnostic tests is the hardest part, because the waiting is a period of sitting with The Unknown. So, what's so scary about The Unknown?

All of our natural fear responses - fighting, fleeing, worrying, etc. - are designed to be responses to an actual threat. Our instincts are helpful when we're being chased by a bear...or navigating a dangerous intersection, or to a lesser extent, when we need to figure out how to get our work done or pay our bills. If there is an identifiable problem, we can apply our worry and excess energy to finding a solution.

When there is not an identifiable problem, problem-solving falls flat. We don't know what to do about The Unknown. We don't know what will help, or where to begin to get a desirable outcome, because we don't know where we're starting, or where we're going. Whatever we think or do just adds to our anxiety, because we always end up back at the same place: with our hands tied by the inscrutability of The Unknown.

And there is no quick fix, no easy solution. We can't give our clients the kind of lived experience of recovery that would ease their minds and making it somehow a Known quantity. We can help them imagine, put up metaphorical signposts and point the way. But, each person has to feel their own way into recovery, into knowing and believing in it. In the wise words of Rainer Maria Rilke (1903):

"...have patience with everything unresolved in your heart and to try to love the questions themselves as if they were locked rooms or books written in a very foreign language. Don’t search for the answers, which could not be given to you now, because you would not be able to live them. And the point is to live everything. Live the questions now. Perhaps then, someday far in the future, you will gradually, without even noticing it, live your way into the answer."