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
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.]
When people come to me for help with anxiety, I explain to them why relaxation won’t be part of the treatment plan. The typical response is often less than enthusiastic: “I don’t like feeling this way. Aren’t there techniques you can teach me so I can feel better?”
It’s understandable why someone with anxiety would want to alleviate the symptoms, which can be extremely uncomfortable–debilitating, even. But when avoidance is used to cope with the distressing feelings, the solution becomes the problem.
Avoidance is a natural response to a threatening situation, even if the threat is only a figment of a hyper-vigilant imagination. So if you’re given to worry or panic, you’re likely to steer clear of the places or events that set you off. Maybe you’ve stopped riding the Metro or declined career-advancing opportunities requiring public speaking or travel. Maybe you’ve stopped meeting friends for happy hour, taking vacations, or exercising (because you don’t want to risk elevating your heart rate). Maybe you’ve even put major life events–changing jobs, committing to a serious relationship, getting married, starting a family–on hold until you feel better.
You know you need to get your life back. But how?
The answer doesn’t involve a technique like relaxation. It requires a seismic mental shift: instead of moving away from anxiety, seek it out.
Scary, I know. And hard to execute, especially when you’ve gotten accustomed to organizing your actions around avoidance. But reclaiming all the activities you’ve relinquished in order not to rock the boat can be exhilarating.
I’m not suggesting you go full-tilt at first like the hapless character depicted in this classic Far Side cartoon, using “Professor Gallagher’s controversial technique” to overcome his fear of heights, snakes, and the dark by hanging from a high window in an enclosed chamber crawling with vipers. No need for total immersion (or “flooding,” as it’s called in behavior-therapy parlance). A gentler approach will work just as well–better, even–as long as you allow yourself to feel some discomfort.
If it’s too hard for you to execute such a plan on your own, consider enlisting the help of a cognitive-behavior therapist to help you bolster your resolve.
You have nothing to lose but your fear.
This blog is intended solely for the purpose of entertainment and education. All remarks are meant as general information and should not be taken as personal diagnostic or therapeutic advice. If you choose to comment on a post, please do not include any information that could identify you as a patient or potential patient. Also, please refrain from making any testimonials about me or my practice, as my professional code of ethics does not permit me to publish such statements. Comments that I deem inappropriate for this forum will not be published.