A New Way of Looking at Anxiety
Since I first began working with anxiety-related problems in 1981, there has been an explosion of knowledge in the causes of and treatments for them. Today there's a flood of books and audio and video cassettes that describe programs for overcoming anxiety-related problems, as well as an increasing number of centers and therapists who specialize in treating them. Amid all this good news there is a sour note that is often not heard: Research has shown that the approaches currently being used to treat anxiety-related problems do work and provide relief, but they often fail as long-term solutions.
A tremendous number of people with anxiety-related problems go to a specialist or work through a self-help program and experience good results. However, after a period of time that can range from a few weeks to many years, the symptoms return. For some, the symptoms return in full force with debilitating anxiety and panic attacks and the redevelopment of avoidance behaviors or rituals. For others, the symptoms return at a level that is lower than originally experienced, or take a somewhat different form,which might include excessive worry or nervousness. It might also include avoidance behavior or nervous rituals that are different from those that accompanied the original onset of severe anxiety.
There are also many people who go through programs or read books and never find the relief they are seeking. Their initial intense symptoms may be greatly reduced, but they continue to experience a significant level of anxiety-related symptoms in spite of treatment. When anxiety symptoms return, or are never fully resolved, the sense of failure, anger, confusion, and depression that occurs can be overwhelming.
This book takes the next step in the evolution of solutions for anxiety and shows you how to move beyond what have been found to be short-term fixes to achieve long-term recovery. As you work your way through the chapters, you'll meet three people who have taken this next step, battled the crippling effects of severe anxiety, and won. Their battle was not an easy one nor was it over quickly. However, all three did eventually achieve long-term recovery. As you read about how they accomplished this, you will learn many new things about yourself, gain many new skills, and develop a new way of looking at anxiety.
One of the central themes of this book is that anxiety is simply a "messenger" that is telling you that you have one or more important life issues to address. Sometimes symptoms develop because a person is overwhelmed by too many things going on at the same time, such as problems with health, money, children, or work. However, anxiety can also be connected with problems in relationships (your ability to connect and be intimate with others) as well as with what are often called "existential" issues (how we answer the questions "What is the meaning of life?" and "How do I find happiness?").
The purpose of this book is to help you understand the message your symptoms are sending you. All too often, it is easy to become so focused on the symptoms of anxiety (the messenger) that youfail to understand the message. Learning to identify the message lifts the feeling of shame and demoralization that develops when you're focused on the elimination of symptoms. It's also the key to achieving what I call long-term recovery.
Once this idea is accepted, the goal shifts from the absence of anxiety to the management of anxiety. This is a more reasonable goal. Once the focus becomes the message (the underlying issues generating the anxiety) rather than the messenger (the symptoms), long-term recovery is possible.
What Is Long-Term Recovery?
Long-term recovery is really the final stage of the process that people recovering from anxiety go through. As people move through this process, they achieve progressively higher levels of recovery. For the sake of simplicity, I've divided these into the following three basic levels:
Level One: Basic Symptom Control
At this stage of recovery a person is focused on controlling symptoms. Indeed, this is always my initial focus with new clients.
When they're experiencing intense symptoms, people simply aren't interested in long-term answers. They want relief and they want it now!
By the end of this stage, however, a person has made much improvement. Anxiety symptoms are greatly reduced with only occasional episodes of intense anxiety or panic, and there is usually the ability to function comfortably in at least half of the everyday situations that were formerly uncomfortable.
A person at the end of this stage also has a good understandingof the mechanisms of anxiety, along with a broad range of coping skills for managing symptoms. While no longer hypervigilant (always on guard, watching for symptoms), this person is still moderately on guard. For many, medication continues to play a major role in symptom management.
Level Two: Advanced Symptom Control
A person in this stage of recovery is gaining greater confidence in his skills due to the absence of most, if not all, avoidance behavior. Intense episodes of anxiety are now infrequent. To at least a moderate degree, he has come to terms with those aspects of his personality that can cause problems and, when present, the genetic predisposition that makes him prone to anxiety. He has gotten to the point where he will not let symptoms interfere with his behavior. He knows how to avoid the anxiety-panic cycle and use his various skills effectively. There is some understanding that symptoms are messengers.
A person at this stage who relied heavily on medication while at level one is now no longer using medication, using it at a reduced level, or reserving its use for situations that are especially anxiety provoking.
Although anxiety is still a fearful thing, there is now more awareness of the issues that trigger anxiety. The focus has shifted, at least in part, away from the symptoms to the causes of anxiety. However, because this understanding is incomplete, periodic flare-ups of moderate to intense symptoms still mysteriously occur. When this happens there is a tendency to move back to level one and again become preoccupied with symptoms and develop avoidance behaviors.
Level Three: Long-Term Recovery
A person at this level perceives anxiety in a completely different way from a person at the first two levels. Anxiety is seen as a natural part of life rather than as something to be avoided. A person at this level can easily identify her core issues and understand clearly and fully the various messages anxiety sends. When anxiety is experienced, she realizes that high levels of anxiety are supposed to occur when real-life issues are present, so she focuses on the issues generating her anxiety rather than on the symptoms. This, in turn, allows her to experience high levels of anxiety without the distress or escalating symptoms she experienced when her anxiety-related problems began. A person at this stage who formerly relied on medication for symptom control finds it is no longer needed.
Before proceeding, take a moment to decide which of the above levels best describes you at the moment. If this is the first book you've read on anxiety, you may still be caught in the initial intense symptoms and have yet to experience any relief. If you've been battling anxiety for years, you've probably read many books, been through one or more programs, or seen several therapists in your quest for recovery. In this case, you may have cycled back and forth between levels one and two. In either case, my goal is to give you the tools and the knowledge you need to achieve long-term recovery.
How to Get the Most out of This Program
This book is designed to be used as a workbook. In order to get the most out of it, you need to read through it slowly; I suggest you spend at least one week on each chapter and do as many of the recommended activities as possible. While it's best to work through the book systematically, some people just can't wait to learn what each chapter contains. If you are one of these, go ahead and read through the entire book to get a general idea of what it covers. Once you've done this, read the book all the way through, slowly.
In order to achieve the long-term recovery described in this chapter, you need more than just a general understanding of ideas. Your goal is to internalize the information and skills presented in each chapter, to make them a natural and automatic part of your behavior. The recommended activities play a key role in this process. The more time and energy you spend on them, the more successful you will be.
Beginning with the next chapter, plan to spend at least one week on each chapter before you move on to the next one. Start by reading the headings to get an overview of the material. Then read the whole chapter at your usual reading rate. It is best to read each chapter at least three times, more if you find the information difficult. The second and third readings will increase your understanding of the material and reveal ideas that were missed during the first reading.
There may be times when you could spend more than one week on a chapter. While it is important to be thorough, it is also important to maintain your momentum. Therefore, spend nomore than two weeks on a chapter, and do as many of the recommended activities as possible. After completing the program, you can spend additional time on those areas where you feel more work is needed.
This may sound like a lot of work; it is. But keep in mind that it took you all your life to develop the behaviors and thinking patterns that produced your condition. It will take you time, energy, and a strong commitment to learn new and effective ways of thinking and acting. If you work through the material in the manner outlined, chances are excellent that you will succeed.
Summary of Key Ideas
1. Anxiety is a normal part of life. It is a "messenger" that indicates the presence of a problem or issue that needs to be resolved. The more intense the anxiety, the more important the issue. People with severe anxiety often have important life issues they are not dealing with effectively.
2. Long-term recovery focuses on the management of anxiety rather than on the absence of anxiety.
3. There are three different levels of recovery possible. Many people become stuck at the first or second level, or cycle back and forth between the first two levels.
4. People who achieve long-term recovery perceive anxiety differently from those at the first two levels of recovery. When anxiety occurs, they understand the message and respond to it in an effective way. Because of this, they can experience high levels of anxiety without the distress or escalating symptoms they experienced when their anxiety-related problems began.
5. In order to achieve long-term recovery, you need to work through the program presented in this book in a slow and systematic manner.
Getting the Most out of the Recommended Activities
At the end of each chapter is a set of activities many people have found valuable in achieving long-term recovery. You may find that some of the activities involve information or skills that are already a part of how you usually think and act. Or you may find that the material seems awkward, uncomfortable, or difficult. This is to be expected since this program is designed to meet the needs of many people and you are unique, with your own personal requirements and abilities. Spend less time with activities you find easy and more time with those that seem difficult.
The easy activities probably involve skills you have already practiced and ideas you have already internalized. The difficult ones probably involve skills and ideas that are new to you or that you've never really mastered. These are the ones that are the most important for you. However, if a particular activity causes undue stress or anxiety, it means you are not ready for it. Skip it and work on exercises that are less difficult. Then return to the stressful exercise later. You may find that it is not as stressful as when you first tried it.
One of the keys to achieving long-term recovery is developing the ability to hear the message that your symptoms are sending.
Often this can be difficult. So, even though a particular exercise may not seem like it applies to you, do it anyway. You may be surprised by the results.
No one can say exactly how long it will take you to achieve long-term recovery. It depends on the genetic makeup of your body,your personality, and the complexity and difficulty of the issues from both your childhood and your present circumstances. It should also be noted that when you do achieve long-term recovery, you probably won't know it until you've been there for quite some time. This is the way personal growth takes place. However, if you have a strong commitment to use the book as it is designed--to do the reading and apply as many of the suggestions to your life as possible (even though you may think they are silly or may not fully understand why they are suggested)--it is very likely you will succeed.
Establish a Regular Study Time
As you work through this book, keep in mind that it is a self-directed study program. Establish a regular time to work with the activities at the end of the chapters, and make this scheduled study time as important as your regular meals. If you use a calendar or appointment book, record your study times in it. Having a regular study time helps you avoid the common mistake of working only when you are experiencing high levels of anxiety. Remember the "good day rule": You can make the most progress when you are feeling good and your life seems to be running smoothly. It is during these times that it is easiest to look at yourself objectively and do the activities listed in the chapters. It is also when you are least motivated to do them. Do them anyway. It is during your good days that you will be most able to develop the skills and understanding you need to achieve long-term recovery.
Write a Brief Explanation of Your Condition
Before you go on to the next chapter, write a brief explanation of why you think your symptoms developed and why they continue to be a problem. This explanation can range from one paragraph to a page in length. Keep this explanation so you can refer to it later.
Consider Using Supplemental Materials
This book can be used by itself, however, you may find supplemental materials helpful, especially if you are having trouble understanding or sticking with the written material. Helpful materials are described in the "Supplemental Materials" section at the end of the book.
Although many people have used the approach in this book to achieve long-term recovery without the help of a psychotherapist, others have found it best to use it in conjunction with professional psychotherapy. If you are experiencing extreme difficulty coping with life, find a therapist experienced in working with anxiety-related problems. Guidelines on how to select a therapist are given in appendix 2.
Find a Study Partner
Although it is possible to work through this book on your own, many find it helpful to have a friend or relative read and workthrough the material with them. Your study partner does not need to be a person with anxiety-related problems, but he or she does need to be someone you trust and with whom you are comfortable. Discussing the chapters with a study partner deepens your understanding. This partner will also be able to help you discover things in the material you may not see on your own.
Consider Joining a Self-Help Group
Many people find that a self-help group is tremendously useful in helping them to achieve long-term recovery. A well-run support group offers the advantages of a study partner multiplied by the number of people in the group. Appendix 3 describes how to find a local self-help group.
A Word about Medication
Most clients come to therapy seeking a quick and easy solution that will return them to where they were before their distressing symptoms began. This is a normal reaction and explains the heavy reliance on medication so common among anxiety sufferers. In response to this demand, a wide variety of medications has been developed that can reduce anxiety symptoms. While they can be very useful in stabilizing a person who is feeling out of control, they are usually not a long-term solution. About half the people I see are put on medication prior to coming to me. The other half either have taken no medication or are using medication "as needed." Of the three case studies in this book, Mary was taking a tranquilizer as needed, Robert was on a regular dose of medication, and Kimberly had taken medication but did not like the side effects and had discontinued using it.
In each case I told them what I usually tell my clients: If you're taking medication, continue taking it as it has been prescribed.Most of my clients do not like being on medication, but it is important to stay on any prescribed medication until you feel you've mastered the basic skills and are ready to begin reducing the dosage. When you feel you wish to go off your medication, be sure to consult the physician who prescribed it, and go off it gradually. If you've been taking medication regularly, the sudden withdrawal from it may cause an increase in your symptoms or produce other adverse effects.
If you are not taking medication and are able to function adequately, I encourage you to see what you can accomplish through the skills taught in this book. If your symptoms are making it difficult for you to function, then medication may help to reduce those symptoms enough so that you can cope with life while you work through this book. If you decide to try medication, I would recommend that you see a psychiatrist rather than a family physician. Psychiatrists specialize in psychoactive medications (medications that affect emotions and mental processes) and are better able to mix and adjust those medications when side effects occur. As with all physicians, seek a psychiatrist who listens carefully to you. The guidelines for selecting a therapist listed in appendix 2 also apply to psychiatrists.
One key exception to the above general guidelines is obsessive-compulsive disorder. Since this condition has a large biological component, medication is often helpful when used in conjunction with a cognitive behavioral approach, such as the one described in this book.
A Word to the Spouse or Significant Other of a Person with Anxiety-Related Problems
I strongly recommend that the spouse or significant other of a person with anxiety-related problems become educated about what his or her loved one is experiencing. Unfortunately, the spouse or significant other is often very fearful about or scornful toward his or her loved one's anxiety-related problems. Sometimes this is due to a secret fear that if the loved one gets better and becomes more independent, the relationship will end. Other times, it is because the spouse or significant other is dealing with issues that are similar to those of the loved one. Sometimes simple ignorance as to the nature and causes of anxiety-related problems leads a spouse or significant other to view the loved one as being "silly" or "childish." The result is that the spouse or significant other withdraws and ignores the problem or tries to "fix" the loved one by giving simplistic solutions that do not help. Both of these approaches weaken the relationship and cause anger and bitterness in the person who is suffering from the anxiety-related problems.
As you educate yourself, you may find that you are dealing with many issues similar to those of your loved one. When this is the case, sharing such a discovery can be very beneficial. It can also help you become more effective in your own life. One of the best ways to educate yourself is to become a study partner. If your personality or your relationship with your loved one makes this difficult, you can at least read this book and discuss what you have learned.
I encourage you to do the exercises yourself and discuss those sections of the book that describe issues with which you struggle.For example, you can construct your own genogram as you work through chapter 2, and identify core beliefs and associations that interfere with your life as you work through chapter 4. Since much of what is written in this book applies to everyone, you may find that you and your loved one share many struggles of which you were unaware. Working through the book in this manner is a wonderful way to support your loved one, and will probably deepen the bond between you.
Copyright © 1997 by Reneau Z. Peurifoy