One of the most frequent questions I hear from people considering CBT is: “Can you help me get rid of my anxiety?”
I wish I could answer with an unqualified “Yes!” But I’m a psychologist, not a purveyor of snake oil, and professional ethics require me to set reasonable expectations for treatment.
Wiping out anxiety completely isn’t a realistic therapeutic goal. It’s also not in anyone’s best interest to aim for total mental control. Like it or not, anxiety—whether a hard-wired physical response to an objective threat or the product of an over-active imagination—plays an important role in everyone’s emotional repertoire. So we all need to negotiate a peaceful coexistence with it.
A few weeks ago I had the chance to test out my own advice about meeting fears head on. I was at the highest point in LA’s Runyon Canyon enjoying the vista of the city spread out beneath me and the Hollywood sign in the distance on a perfect Southern California day. I sat on a rock soaking up the warmth of the sun and giving the experience my full, mindful attention. Then I started on the descent.
That’s when the panic gripped me.
Heights have always made me nervous, and I’ve never liked hiking downhill. But this time I wasn’t just cautiously inching my way down the slope in my typical fashion. I froze completely. My heart pounded. My mouth dried up. I felt dizzy. I couldn’t figure out how to put one foot in front of the other.
The steep dirt path littered with jagged rocks made my anxious brain conjure up images of slipping and plunging forward and cracking open my head and lying in a pool of blood. Not likely. But it could happen.
Oh, wait! It had happened —just a few months earlier, on a perfectly flat walk only two blocks from my house when I tripped on an uneven patch of sidewalk and landed in the emergency room.
OK, so my fears weren’t entirely irrational (an argument I hear frequently from people with anxiety reluctant to approach triggering situations). But, still, I had to make my way down the mountain.
So I decided to recruit the mindfulness skills I’d just been practicing. I didn’t try to relax. I didn’t tell myself I had nothing to worry about (because, really, how could I possibly reassure myself given the evidence to the contrary?). I didn’t try to push away the gory images. I didn’t attempt to slide down on my butt crab-style, a technique I’ve employed in the past to navigate precipices. I didn’t try to take a calming breath or grab onto my husband’s arm for support (not a viable option anyway because he was focused on his own worries about slipping and dropping his camera).
What did I do? I gave myself permission to be scared. I decided not to care about how slowly I was going and made room for the faster hikers to pass me. I looked down at the path in front of me. I concentrated on finding a place to plant my foot and took a step. Then another. And another. Until I finally reached the bottom.
And the next day, I went back and climbed to the top again. The view was breathtaking
OCD is a formidable opponent. It’s the sharpest prosecutor, the meanest bully, the dirtiest thug. Arguing, appeasing, or getting into a fight with it won’t work. You’ll lose.
If you suffer from repugnant mental intrusions, you may believe your thoughts are the problem. You’ve probably spent hours, days, or, quite possibly, years trying to reason with them or push them away. One obsession may resolve only to have another one surface. It’s exhausting and demoralizing.
Surprising as it may seem, your thoughts are not the problem. Everyone has thoughts, even bad ones. In a seminal 1978 experiment, psychologists Stanley Rachman and Padmal de Silva found that nearly 90% of the “ordinary” people (that is, a non-clinical population) they sampled admitted to having had occasional thoughts about committing violent crimes, engaging in taboo sexual acts (with children, family members, or animals), blurting out obscenities or racial slurs in public, harming themselves or loved ones, or doing something inappropriate (such as laughing at a funeral). The main differences between these so-called “non-clinical” obsessions and the “clinical” ones of someone with OCD are the frequency of the thoughts, the distress they cause, and the efforts expended (ie, the compulsions) to get rid of them.
British writer David Adam has recently published an excellent memoir, interspersed with fascinating historical accounts of the disorder, about his struggles with OCD, The Man Who Couldn’t Stop: OCD and the True Story of a Life Lost in Thought.
Here is some cutting-edge advice in Adam’s book on how to cope with obsessional thoughts:
“Grit your teeth in the face of your thoughts and for God’s sake be more obstinate, head strong and wilful [sic] than the most stubborn peasant or shrew. Indeed, be harder than an anvil . . .If necessary speak coarsely and disrespectfully like this: Dear devil, if you can’t do better than that, kiss my toe.”
The statement embodies all we’ve learned from evidence-based treatment. It’s exactly the type of approach psychologist Reid Wilson advocates when he talks about “chasing the bogeyman” (I attended a workshop he gave on this treatment method just a few weeks ago).
An up-to-the-minute strategy for dealing with intrusive thoughts. From the 16th century, courtesy of the theologian–and OCD sufferer–Martin Luther.
I discuss this question so often in my practice—and have so frequently considered blogging about it—I had to scroll through my archives to see if I’d already written a post on the topic. But, apparently, it only existed in my mind.
I’m prompted finally to address the issue of medication because I attended an interesting discussion the other day about a book titled Does My Dog Need Prozac? Everyone in the group, including me, has a fearful dog (my Australian Shepherd Freddie, as I’ve mentioned before, is tightly wound and “reactive” to other dogs, people unknown to him, and the television). We talked about how to help our sensitive pets be more comfortable in the world while at the same time learning to accept them as they are rather than being disappointed when they don’t behave like TV dogs. Come to think of it, this attitude of acceptance would make it a lot easier to be content with children, spouses, friends, and colleagues who don’t quite meet our expectations, either.
Given the title of the book, the conversation eventually turned to the use of medication to help ease reactive animals’ fears. According to the animal behaviorist who moderated the discussion, people are as reluctant to medicate their anxious canines as they are to consider pharmacological treatments for themselves—although she encounters, as I do, less resistance to so-called “natural” remedies, such as herbal compounds and vitamin supplements. (I’m always puzzled when someone who is adamant about not taking medication will ingest an uncontrolled, unregulated substance, however natural it may be. After all, poisonous mushrooms and hemlock are natural, too. But lethal.)
My position on medication is flexible. I’m more than happy to try a course of CBT sans meds if someone comes to me with that preference. The research suggests that CBT alone can be as effective as a combination of medication and CBT together in treating anxiety. and I’ve certainly seen many people benefit from CBT interventions without the help of a prescription. Medication alone, on the other hand, is not as effective. It may lessen discomfort, but it won’t resolve the patterns of avoidance people develop—and often become consumed by– to cope with their distress.
Here’s the rub. If anxiety is off the charts, a person (or dog) won’t be able to think clearly enough or stay in a triggering situation long enough for tolerance and habituation to take place. So medication can be very helpful in dialing down the arousal enough to facilitate the behavioral practice crucial for success.
I doubt animals feel stigmatized if they need to take Prozac (though their owners certainly might). But many humans I’ve worked with are ashamed, or see themselves as weak, if they can’t white-knuckle it through without the aid of a pill. Despite advances in modern neuroscience, culturally we’re still stuck in the last century when it comes to psychiatry, seeing mental disorders as failures of will or character flaws rather than disturbances of brain chemistry.
I personally have nothing to gain from recommending a course of medication. I can’t even prescribe it. But I believe in doing what works best—for people and for pets. And sometimes that means using all the tools we have at our disposal, including pharmacology, to make the process of coping more manageable.
[For the record, we did try Prozac with my late Golden Retriever Calvin, who suffered from separation anxiety and compulsive licking. Freddie hasn’t been on any medication because we’ve taken great pains to work with him behaviorally, and he’s responded to the training. In the interest of full disclosure, I confess to having been one of those owners who gravitated towards holistic remedies, such as DAP (dog-appeasing pheromone) and lavender spray. Sadly, none of them worked, so we’re back to plain old desensitization. And lots of dog treats.]
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