Positive Matters

Please Note These Articles are meant for information purposes only and are not a substitute for Medical or Psychological treatment.

Jane feels anxious as the aircraft lurches sharply to the left. For four hours into her flight, Jane has been sleeping like a baby. Now she is wide-awake as the aircraft bumps its way though turbulence. In spite of the reassuring message the First Officer has made, Jane has an uneasy, queasy feeling in the pit of her stomach. Perhaps you have been in a similar uncomfortable situation.

If you believe you are a helpless victim – powerless in the face of anxiety – the good news is you are wrong. As we have seen in chapter two, it is not external events that cause emotions such as anxiety but the self-defeating beliefs we have about those events. For instance, overestimating the danger of a situation, while at the same time underestimating your ability to cope with it, can often cause anxiety. Even though the turbulence only lasts a few minutes, Jane continues to experience anxiety for the remainder of her seven-hour flight. The more she tries to stop feeling anxious, the more anxious she becomes.

Let’s join her during a therapy session:

Jane: “I tried my best to stop feeling anxious. I told myself I had no reason to feel anxiety, that it was only a bit of turbulence and that it would pass. The more I told myself to stop being so stupid and weak, the more anxious I became.”

Michael: “Telling yourself it is only a bit of turbulence and that it will pass is good advice. However, I think that to demand that you feel no anxiety is counterproductive because you can never have a guarantee of that.”

Jane: “So does that mean I just have to grin and bear it?”

I explain to Jane the characteristics of irrational beliefs as described in chapter two and how unrealistic demands can feed negative emotions such as anxiety. Jane is able to see that she was demanding herself not to feel anxious. I ask Jane if she is prepared to conduct a little experiment, which she readily agrees to do.

Michael: “I’d like to ask you not to think of a pink elephant.”

Jane: “I can see that’s impossible – the more I am trying not to think of an elephant, the more the image of an elephant stays in my mind.”

Michael: “And the more you demand that you must not feel anxious, the more anxiety you’re likely to feel. It would be highly desirable not to feel anxious but to force that demand on yourself paradoxically feeds your anxiety.”

After identifying more of Jane’s anxiety in relation to flying we fill in a self-help form as follows:

A. Event: Jane’s flight experiences turbulence.

B. Beliefs: I must not feel anxiety.

It’s just awful to feel anxious.

I’m too stupid and weak to stop it.

C. Consequence: Rising anxiety – unable to settle for the rest of the flight.

D. Disputing: Where is the evidence that I must not feel anxiety?

No evidence exists for this – I would highly prefer not to feel anxious but if I do, then I do!

Why is it awful to feel anxious?

Well, it’s very uncomfortable to feel anxious, but I have coped in the past and I can cope again.

How does an inability to stop feeling anxious make me stupid and weak?

It doesn’t. Many people have difficulty with anxiety. Does that make them stupid and weak? Why the double standard?

E. Effective new thinking.

I would really like the anxiety to stop but it doesn’t have to stop. Demanding that I must not feel anxious is probably keeping my anxiety alive and kicking. Labelling myself stupid and weak is not only counterproductive but also factually incorrect. I can distract myself by deep breathing and listening to some music on the headset. I will then probably find that the anxiety passes.

F. New feelings and actions.

Concern, instead of anxiety about becoming anxious.

Better able to concentrate on more important things.

By challenging and changing her beliefs, Jane is now able to accept the fact that anxiety (although very uncomfortable) won’t harm her. During her next flight, Jane again experiences turbulence. However, having prepared herself by using the self-help form, as well as some of the other techniques described in this chapter, Jane is able to cope with her anxiety.

Preparing to leave your comfort zone

Don’t avoid situations

You may believe it’s a good idea to avoid situations that make you anxious. However, nothing could be further from the truth. In many situations, anxiety becomes a learned response. By avoiding those situations you keep that negative and unrealistic learning alive. If you make yourself stay in the feared situation you can unlearn your old ways of thinking and feeling, then the anxiety will reduce until it leaves you completely. However, this needs to be undertaken with some care and in gradual steps.

Beverly avoids social situations. For her, parties seem like a nightmare. Just the thought of engaging in small talk is enough to make Beverly’s heart race. Beverley repeats many of the “what ifs” experienced by sufferers of social anxiety. “What if I say something stupid? What if they think badly of me? What if I shake and spill my drink? What if people walk away from me? What if I get tongue-tied?”

After identifying and challenging Beverly’s irrational ideas, we decide to draw up a hierarchy of the fears Beverly experiences at social gatherings on a scale of 0% to 100%, with 0 representing no anxiety and 100 the most anxious she can feel. It looks like this:

A friend’s house-warming party

Situation Anxiety Level

1. Getting ready to go to the party 10%

2. Walking into the party with a friend 20%

3. Saying hello to the host 35%

4. Being offered a drink 40%

5. Someone asking me to pass him a drink 45%

6. The friend I arrived with walks away to talk

to someone else 50%

7. Being introduced to someone I have never

met before 60%

8. Being asked my opinion in front of several

people 90%

Picture yourself coping

As you can see, Beverly’s list is graded from getting ready to go to the party at just 10% anxiety to being asked her opinion in front of several people at a massive 90% anxiety.

I introduce Beverly to coping imagery. I ask Beverly to anticipate some anxiety but picture herself coping with the situation. Beverly starts by picturing herself getting ready to go to the party. This causes her very little anxiety so we move on to her arriving at the party. Beverly reports feeling a little anxiety but coping relatively well.

Once she starts to picture herself saying hello to the host she starts to feel anxious. In order to reduce Beverly’s anxiety, I ask her to use the breathing exercise explained later in this chapter. She also silently repeats a positive coping statement developed from her self-help form. After some practice Beverley is able to reduce her anxiety from 35% to just 10%. Then Beverly moves on to the next scene in which she imagines someone offering her a drink. This is what she does:

Michael: “Close your eyes, take in three deep breaths and in your mind imagine someone offering you a drink.”

Beverley: “I have the image and my instinct is to say no. If I accept the drink, I am bound to shake and show them all just how anxious I really am. However, I am going to imagine accepting the drink and coping.”

Michael: “That’s good, but before you imagine accepting it, take in three deep breaths and repeat your coping statement, ‘I have been worried about shaking many times before and coped. I will cope again.’ ”

Beverly: “I am picturing myself being a little anxious but accepting the drink – I can see myself coping.”

After practicing this technique a number of times, Beverly reduces her anxiety from the original 40% to just 10%. She is ready to move on to the next level.

During the time we work together, Beverley receives a number of social invitations that give her the opportunity to practice the skills learnt in therapy. Beverly is pleasantly surprised to discover that the coping imagery has given her a newfound confidence. Although she experiences some anxiety it is reduced to the extent that she is able to enjoy herself, something she has not done at a party for many years.

How to use coping imagery

Here, in a nutshell, are the instructions for drawing up your own hierarchy of fears and using coping imagery to overcome them.

1. Decide the issue you wish to work on. It may be a fear of flying, a job interview, a sales presentation or a social event like Beverly’s friend’s house-warming party.

2. Draw up a hierarchy of fears in the same way Beverly did, from 0% (no anxiety) up to 100% (the highest amount of anxiety you can experience).

3. Find a comfortable place to sit, uncross your arms and legs, then close your eyes. Take in three deep breaths and visualize yourself in the situation with the lowest level of anxiety.

4. Get in touch with your anxiety about this situation. You may find that, at the lowest level on the scale, you experience little or no anxiety. If there is no anxiety, move on to the next level. If you do experience anxiety, try the following: Take in slow comfortable deep breaths through your nose, breathing out through your mouth. Feel your body relaxing. . Breathe in slowly and evenly through your nose, exhaling even more slowly through your mouth. As you breathe in, silently say the word calm to yourself. As you breathe out, say the word relax. Try to make the out-breath up to twice as long as your in-breath. The idea is to empty your lungs of old air and make room in your lungs for fresh oxygen-rich air. One way to achieve this is to slow down the speed you repeat the word relax. Calm on the in-breath, R-e-l-a-x on the out-breath.

5. Picture yourself coping. Don’t imagine yourself feeling wonderful, as if nothing is wrong – that would be unrealistic. Instead, see yourself confronting your fear in spite of the anxiety. Paint a picture in your imagination of yourself coping without the usual catastrophic consequences you regularly conjure up.

You may also find it helpful to silently repeat a positive coping statement. You can use or adapt one found at the end of each chapter in this book or you may want to create one of your own, perhaps developed from the effective new thinking (E) in your self-help form.

Practice your coping imagery until you are able to significantly reduce the percentage of anxiety, then move on to the next level using the same technique.

It will take work and practice to reduce the anxiety experienced at every level of your hierarchy – but it will be worth it. I would encourage you to get out into the real world and face your fears even before you have completed this exercise. This will take courage but you can do it. Beverly did just that and is now leading a confident and happy social life.

Whatever can go wrong, will.

David’s relationship with Mel is getting serious. Mel’s parents have invited them both over for dinner. David, being a traditional man, feels the need to ask Mel’s father for permission to marry his daughter. Mel’s father is a professor of physics. David is a plumber, without an academic qualification to his name. David has already made up his mind that the meeting is going to be a disaster. He imagines Mel’s father looking over his spectacles with disapproval, asking what gives him, a plumber, the right to marry his beautiful, educated daughter. Mel tries to reassure David that her parents are kind, accepting people and his job will not be an issue. However, Mel’s reassurance makes no difference and David continues to focus on an extremely negative outcome. This is called Catastrophising and occurs when a person expects the worse to happen, however unlikely that is. It also occurs when people tell themselves a situation is unbearable or awful when it is really just uncomfortable or a nuisance. Blowing things out of proportion can stop a person from taking on new challenges because they only focus on failure.

When David comes to see me, he is thinking of turning down the invitation, feigning illness. It is understandable that David feels apprehensive about meeting his prospective in-laws and asking for permission to marry Mel. However, what makes it awful? Where is the evidence that Mel’s father will disapprove of David? Even if he were to disapprove, can it truly be described as 100% terrible? After all, Mel has pointed out that she will marry David with or without her father’s blessing.

The emotional Richter scale

The seismic activities of earthquakes are measured on the Richter scale. A great way to drastically reduce catastrophic thinking is to measure catastrophising on an emotional Richter scale.

Emotional Richter scale

Not bad The worst an event could be

| |

0%—10——-30—–50—-70——-90—–100%

On a scale of 0 to 100, I ask David to place an X on the spot that indicates how bad he feels it would be if Mel’s father disapproves of their intention to marry.

David puts an X at 95% which is very high.

Mel’s father disapproves of our intention to marry

|

0%—10——-30—–50—-70——-90—X–100%

I then ask David what could happen that would be worse than being rejected by Mel’s parents. David replies that he could be run over on the way to meet Mel’s parents.

I ask him if, in the unlikely event that he was run over, where he would place the X on the scale.

David places the X at 100%. I then ask David what could be worse than this, to which David replies that he could die as a result of being run over. David then tries to add another 10% to the scale to represent the seriousness of dying. When I explain to David that nothing can be higher than 100%, he realises he will have to re-evaluate the seriousness of the previous examples by lowering the other two Xs on the scale.

I continue to ask David for other examples of what could be worse than being rejected by Mel’s parents. We get as far as a nuclear bomb going off in Mel’s parents’ garden. Amid tears of laughter at the thought of a nuclear bomb exploding in a physics professor’s back garden, David is now able to see that he was exaggerating the severity of being refused permission to marry Mel. He also concludes, as Mel had implied, that if her father were to be so unreasonable, he wouldn’t have to take it seriously.

After our work, the emotional Richter scale looks like this:

Mel’s father disapproves of our intention to marry

| Nuclear bomb in garden

|

0%—10—x—-30—–50—-x70——x-90——–x100%

| |

Being run over Being run over and dying

By writing down some examples of worse but unlikely things that could happen, David is able to see how he has been blowing the event out of all proportion. The following summer David and Mel marry and her father gives her away.

If you find yourself exaggerating the terror of a situation, use the emotional Richter scale to put things into perspective. Ask yourself: “Am I overreacting? Would it really be that terrible?” This will lower your anxiety considerably.

Panic attacks

James thinks he is about to go mad – the train has stopped moving and has been between stations for the last five minutes. The train operator has not bothered to make an announcement. James feels his heart pounding. He thinks he is about to have a heart attack. Feelings of terror start to take over. James thinks that at any moment he will be compelled to open the door of the train and run. “What will the other passengers think of me if I make a dash for the door? Perhaps they can see my panic. Why is everyone else so calm?” The train starts moving and James begins to relax.

James suffers from panic attacks, an aspect of anxiety.

If you have ever experienced a panic attack, you will know how terrifying it can seem. James’s symptoms include a pounding, rapid heartbeat with shortness of breath, pains in the chest and a compulsion to flee the place where he is experiencing the attack. James sums it up by stating that he thinks he is about to lose control and go mad. Other typical symptoms of panic include sweating and shaking, tingly or numb fingers, nausea and intense fear. During a panic attack, people often experience feelings of unreality as if they are in a dream-like state. All of these feelings are scary but not unusual. In fact, when experiencing a panic attack these feelings are normal.

What is a panic attack?

A panic attack begins with a false alarm. It is as if your mind tricks you into believing that the situation and the symptoms you are experiencing are dangerous. James really is terrified on that stationary train and truly feels that he is about to die of a heart attack. Of course, in some situations we need to be alerted to impending danger. If you are in a building that is on fire or are confronted by a vicious animal, you need a signal that warns you of the danger. Fortunately, nature has provided this and it is called the fight or flight response.

Faced with a threat, the body reacts immediately with a rush of adrenaline, heightened muscle tension, faster heart rate and raised blood pressure. Blood pumps to the muscles and brain, causing the body to become alert and as strong as possible. This is because, in order to survive, you need to respond by either fighting the threat or running away from it – an appropriate response if your life is being threatened by a real emergency.

Fortunately, we are rarely faced with life-threatening situations. Being stuck on a train is very unpleasant for James but hardly life-threatening.

How a panic attack develops

You may believe that a panic attack comes out of the blue. One minute you feel relatively calm, the next you are overwhelmed with the most intense feelings of anxiety. However, there are several aspects to a panic attack and understanding them is the first step in stopping them.

The first stage involves a physical sensation such as a feeling of unease, pressure in the chest, a heart flutter or a sense of dread. These feelings are followed by thoughts that predict dire consequences such as:

What if I am having a heart attack?

I’m going to die.

If I don’t get out of here, I will go mad.

These beliefs seem very real and lead to a rise in anxiety. This then leads to further catastrophic thinking which notches up the anxiety until a vicious circle of anxiety and catastrophic thinking brings on a full-blown panic attack.

Although you’re only too aware of the feelings of anxiety, you may be unaware of your catastrophic thinking. However, it is there, camouflaged in the feelings of dread.

The Stop technique

Thought-stopping is a technique first introduced by a man named Bain in his 1928 book and further developed by behavioral therapist Joseph Wolpe in the 1950s primarily for the treatment of obsessive thoughts and phobias. It can be adapted to ease anxiety by adding some extra elements and works as follows:

1. As soon as you feel the slightest feeling of unease, say the word stop to yourself — if you’re on your own, you may find it more effective to say it out loud. If you’re in the company of others, say it silently but with passion, as if you are saying it aloud. You can say it with as much aggression as you like. One of my clients also imagines a cannon being fired at the same time. Some people imagine a red traffic light. You can add to the word stop phrases such as “Stop, this is nonsense” or “Stop, I don’t need this”. However, don’t make the mistake of putting yourself down. It is the catastrophic thoughts and feelings you are silencing, not yourself.

2. Next, focus all your attention on external sights and sounds in your immediate vicinity. For instance, James fixes his attention on the train’s route map just above the train door. Jane, our airline passenger, focuses her attention on an attractive man sitting in an adjacent seat. Another of my clients, Alice, experiences panic while working on the computer and so focuses her complete attention on the report she is typing. In this way, you give your mind something external to focus on, instead of your negative thoughts and feelings. Use as many of your senses as you can – sight, sound, smell, even taste – to bring yourself into the present moment.

3. Next, use a breathing technique to calm yourself down. Breathe in slowly and evenly through your nose, exhaling even more slowly through your mouth. As you breathe in, silently say the word calm to yourself. As you breathe out, say the word relax. Try to make the out-breath up to twice as long as your in-breath. The idea is to empty your lungs of old air and make room in your lungs for fresh oxygen-rich air. One way to achieve this is to slow down the speed you repeat the word relax. Calm on the in-breath, R-e-l-a-x on the out-breath. If your mind wanders, bring your attention back to your words as you breathe in calm and out r-e-l-a-x-e-d.

Exercise can help

A powerful form of relaxation, exercise can reduce and relieve symptoms of anxiety and panic. Performed on a regular basis, physical activity helps to reduce excess adrenaline and also increases the morphine-like substances found in the body that have positive effects on mood. Many people report a sense of well-being after they have exercised. If you have not exercised for some time, it is important to start moderately and gradually build up. It’s also advisable to see your doctor before embarking on an exercise programme.

Don’t avoid your emotions

Do you tend to bottle up your true emotions, holding back what you really think and feel? When someone upsets or angers you, do you refrain from saying anything for fear of conflict? Research now suggests that suppressing emotions often leads to anxiety and panic attacks.

Different self-defeating attitudes can cause people to hold back their emotions. This can then lead them to feel anxious. One common belief is: “In order to be accepted, I have to be liked and get along with everyone all the time.” To achieve this unrealistic expectation, a person will try to please others, often ignoring their own feelings and needs. They also avoid conflict at all costs for fear of upsetting other people.

Another related self-defeating belief is: “I must be happy and cheerful all the time.” The person believes that he is not allowed to feel negative emotions. He may believe that feelings such as anger are unacceptable, even dangerous. Rather than express these feelings, he suppresses them. However, powerful emotions such as anger often find a way of being expressed indirectly as anxiety and panic.

Nina has experienced anxiety and panic most of her adult life. She tells me that the previous week she hosted a dinner party for some good friends. Half-way through the dinner she was struck with a panic attack that came right out of the blue. The panic attack was so powerful that her husband had to ask their friends to leave and that was the end of the party.

Nina enjoys hosting dinner parties and doesn’t have a clue what triggered the attack. However, she is now worrying that future parties will bring on further anxiety and panic. I ask Nina if anything had happened before or during the party that may have triggered the attack. At first she insists that nothing had happened. However, after some further questioning, Nina relates that her friend Patricia had asked if she could come over to help her prepare some of the dishes. Patricia was about to start a catering business and needed to build her confidence. She was due to cater for her first client the following week. Patricia spent most of the time criticising Nina’s cooking. This climaxed with the comment, “Never mind, Nina, you do try but you can never come up to my professional standards.”

I ask Nina how she felt about Patricia’s comments.

Nina tells me that Patricia had taken the trouble to come over and help, so she felt she couldn’t make a fuss and upset her. After further discussion, Nina realises that she had, in fact, felt extremely insulted and angry with Patricia and had held back from acknowledging this, even to herself. We discover that whenever Nina feels strong negative emotions such as anger and rage, she holds on to these feelings for fear of upsetting people. Instead, she smiles and is the nice, charming person she thinks others expect her to be.

When emotions are not acknowledged and expressed they can manifest themselves in the form of anxiety and panic. I refer to this as the body speaking its mind. Once Nina has identified, understood and acknowledged the cause of her anxiety, it is time to do something about it.

If anxiety and panic attacks seem to come out of the blue with no apparent explanation, ask yourself:

I. Is there a problem situation or feeling that I am not addressing?

Perhaps someone or something has upset me?

2. Work towards a resolution of the issue. This could be as straightforward as expressing how you feel. It may require you to speak to someone who has upset you to resolve the conflict.

Effective communication

Expressing how you feel is important. You need to get things off your chest. However, like Nina, you may have reservations about speaking up. Some simple but effective communication skills will enable you to be assertive and get your point across while minimising the possibility of conflict.

By standing tall, yet still being open and relaxed, you will literally be making a stand through your posture. You will also be communicating to the other person that you are confident. Don’t smile too much or nod too much. Maintain direct eye contact instead of looking down at the floor.

Because people can react negatively to criticism, it can be helpful to cushion the blow by starting with a positive statement, as the following example illustrates:

“I really appreciate your offering to help but I feel upset by your remark.”

This example also illustrates the use of ‘I’ statements instead of ‘you’ statements.

‘You’ statements are far more likely to cause the other person to become defensive. ‘I’ statements are a way of communicating an issue without accusing the other person of being the problem.

Contrast the following:

‘You’ Statements

You always have to be asked to do the washing-up.

You never think things through.

You never finish your work on time.

‘I’ statements

I would be very grateful if you could help me with the washing-up.

I would really like you to think about that before rushing into anything.

I am really getting held up with my work, as I don’t have that report yet.

Nina resolves her issue with Patricia

During therapy I help Nina face her fear of confrontation. Over a number of sessions, she practises her assertiveness skills by role-playing difficult situations such as the one she faces with Patricia. Nina plays the role of her critical friend and I respond using some of the communication styles listed above. Then the roles are reversed with me being the confrontational friend and Nina responding using the skills she has learned. The following Sunday, Patricia comes over to see how Nina is feeling after her panic attack. After some initial small-talk Nina speaks up. This is what she says:

I really appreciate your coming over to see me today. However, I need to tell you that I felt undermined at my own dinner party by the comment you made about my ability to prepare the dishes. I would really appreciate it if, in the future, you keep such comments to yourself.

Patricia responds by apologising. She says that she has been feeling anxious and a little overwhelmed about starting up her new business. She honestly feels that Nina is a more experienced cook than she is and didn’t mean to upset her. They remain the best of friends.

Learning to confront rather than avoid difficult emotions can take time. Maybe you can enlist the help of family and friends as you practise your new communication skills and assertiveness. You can also practise being assertive in front of a mirror, in your imagination and by recording your new communication style and playing it back to yourself. You will get it wrong sometimes but that is because you are human. With practice you will succeed.

Major points

* Do not avoid situations in which you experience anxiety. Instead, gradually expose yourself to the feared situation. That way you will unlearn your old ways of thinking that feed the negative feelings. Anxiety will then reduce until it leaves you completely. However, this needs to be undertaken with some care and in gradual steps.

* A panic attack begins with a false alarm. It is as if your mind is tricking you into believing that the situation and the symptoms you are experiencing are dangerous when they are not at all.

* Exercising on a regular basis will reduce your anxiety and panic. It is a powerful form of relaxation that increases the morphine-like substances found in the body. These have positive effects on mood.

* Research suggests that suppressing emotions often leads to anxiety and panic attacks. Instead of bottling up your true feelings, learn to become assertive and confront rather than avoid difficult emotions. This may take some time but will be more than worth it.

* Use techniques such as coping imagery to overcome your anxiety. Find a comfortable place to sit, uncross your arms and legs then close your eyes. Take in three deep breaths and visualise yourself coping. Start with the situation you fear least and work towards more challenging situations.

From head to gut

Anxiety is an old habit pattern that I can and will change.

Panic attacks may feel dangerous – but that doesn’t make them dangerous.

I’ve stopped my negative thoughts before and I’m going to stop them again now.

Right now I have feelings I don’t like but they will soon pass.

(C) Michael Cohen From my new book to be published in 2010