Anxiety treatment

What should you expect when you make an appointment to seek help and guidance for your anxiety condition? The reality of 21st century treatment might surprise you.

Almost everyone who comes to this site is seeking help for their fear of flying, or help for someone who is fearful of flying. They want to know how anxiety can be treated effectively. But because I work with a variety of anxieties, people come here because Google or some other search engine, or social media like Twitter brings them here.

At the same time, referrals come to me from people who don’t know this site exists, referred by friends, family, my professional society, doctors, other psychologists and psychiatrists, or from interviews in the media. If it’s a flying situation, I’ll take down details on the telephone, have the prospective patient send me an email, then write a return email with details of appointments times, as well as forms to fill in prior to the first session. (I also include address details, confidentiality arrangements, as well as payment details. I also include requests such as bring a USB memory stick or an iPod to record the session. I also ask them to wander through this site to see if their situation has been discussed.

 A helpful case study – an adult dog phobic patient

Some time back I saw someone for the first time referred by a friend for her lifelong dog phobia. This is quite a common fear, and in this woman’s case, it had become a real intrusion into her quality of life, preventing her from enjoying visiting friends and going for walks.

She came with her doctor’s referral, which allows my fees to be substantially covered by Australia’s national medical health insurance scheme called Medicare, and I took a history including how she believed her fear had commenced then worsened since being a young child and seeing her father mauled.

Now, like fearful flyers, there is no one dog phobic type. One has to understand the triggers that produce anxious sensations, and how the patient interprets those sensations. From there, one needs to understand what the patient does about those sensations and the accompanying thoughts, or cognitions, as well as behaviours that ensue – often avoidance, sometimes freezing on the spot, and for a child, hiding behind a parent.

My dog Shrek in his younger days
My dog Shrek in his younger days

In my new patient’s case, rather than asking her to recount a recent event where she experienced a significant fear, I showed her a selection of pictures of dogs, including me with my German Shepherd Dog, Shrek (left) , which I’d removed from the premises for this first session.

These pictures ranged from small illustrations of little fluffy puppies, through to dogs playing, a collection of cartoon dogs (which brought a smile), through to larger working dogs doing their special jobs with their handlers.

Rather than just asking how she felt watching these pictures, I hooked my patient up to a heart rate monitor, connected to software which measures a parameter called Heart Rate Variability (HRV). The software analyses the change of heart rate over time, and when exposed to various stressors. Unpleasant events produces a characteristic lowering of HRV, suggesting a shift of balance and activity within the body’s Autonomic Nervous System, bringing on the “flight” or “freeze” response.

Please: Forget all the hype about the “flight and fight” phenomenon so beloved of stress management programs. They over-exaggerate the “fight” response, which does occur in animals where the original concept of stress was developed experimentally. But for most humans in real life (not the lab.), it’s the flight or  freeze response that occurs, the latter like a rabbit caught in the headlights, and where our slower, methodical rational thinking seems to get cut off.

In fact this is how my patient described her reactions: If she can she will flee a situation which she predicts will bring on danger (like a dog coming towards her off lead). Or if escape is not possible, or the dog is too close, she will go into a freeze response, closing her eyes, and standing rock still. These were described as automatic behaviours, seemingly without thought.

These responses are evolutionary in nature, serving to save us from our perception of immediate danger, but in modern times, they’re overkill. Almost by definition, when arousal becomes interfering anxiety, it’s either because of a misreading of the situation (it’s dangerous and I don;t know what to do) or the situation does require action (a measure of danger is present) but the response is over the top, causing unthinking fight or freeze.

So, while my new patient watched a list of pictures of dogs resembling more and more her fearful situation (i.e., going from easy to difficult to watch) I was monitoring changes to her HRV which clued me in to what she was really experiencing.By the way, some mental health professionals will only take as their measure what the patient says is their rating. This is a Subjective Measure of distress. It’s useful, but I much prefer to also objectively measure how their body is reacting.

(Think of it as a prospective CEO going to his or her GP for a mandatory examination before taking up a new, highly paid position. The CEO on questioning says, “I feel fine”; the test results come back as elevated blood pressure, cholesterol, blood sugar, etc. What should the GP write in their report back to the insurance company and Board of Directors? “Patient says they’re fine.”

I don’t think so…)

At one point, having pointed out to her her stressful physical responses which could be measured (“yes, it’s like a lie detector!”), we stopped watching pictures, and I showed her in more depth how the HRV measures could be shifted from low (stressed and wanting to flee) to

Cesar Milan discussing "Calm Energy" with the owners of an aggressive chihuahua
Cesar Milan discussing “Calm Energy” with the owners of an aggressive chihuahua

high, a place we could call “calm energy”, a phrase often used by Dog Whisperer, Cesar Milan, when he’s training dog owners (left). By this I meant there was still arousal going on, but it wasn’t to be confused with a state of relaxation or leisure, like chilling out or kicking back, as some describe it. It could be described as focussed attention, or more colloquially, curiosity.

So this is about achieving a better balance between the flight response – the Sympathetic Nervous System’s getting kicked into high gear – and the freeze reaction, where the Parasympathetic System kicks into high gear. Both systems have evolved to be employed for a brief time only – a minute or so until the danger has passed. By the way, the freeze reaction is also known as “tonic immobility”, often seen in animals who have become aware their time is up, like a deer in the headlights, or a mouse caught by a cat. Some animals under extreme threat have evolved to take it one step further, by feigning death (thanatosis), especially around predators who have evolved in parallel to only consume a fresh kill.

What the HRV training does is to help people achieve a healthier balance between these two systems, much like a rally driver “dances” between accelerator and brake to negotiate corners. You don’t want too much of one or the other except in emergencies, but most of the time you want to achieve a more effective combination. If you do weight training, you’ll know you achieve better results by working your muscles in a balanced way – biceps and triceps, quads and hamstrings. Overuse one and not have balance with the other can lead to muscle tissue tears. Our bodies seem to have many balancing systems working in tandem to maintain best performance.

The training in fact starts with changing breathing patterns from unconsciously using the muscles in the throat, chest and back, to more active belly or diaphragmatic breathing. Patients can immediately see the change in heart rate that occurs, with heart rate over time changing from a seemingly random and choppy line, to a more predictable hill-and-dale appearance, like a sine-wave.

Knowing about the physiology of anxiety is very important

For an anxious person, knowing they can control a part of their physiology which is the source of and response to their anxiety, is a major breakthrough. In the first session, this generates much hope and motivation for what’s to come later: eventual exposure in person, hands on, to their feared stimulus. But we take this in small steps, building competence and confidence as we go along. Everyone so often, though, there needs to be a big jump or a randomness built in to the exposure. The data shows this produces a better long term outcome, and less chances of a return to previous levels of anxiety.

Other interventions which generate huge levels of anticipation of change (Ah, if only…)

Now, you will read of one-session miracle phobia cures, and be offered DVDs and CDs containing training for quick results. By all means, read the testimonials and evaluate for yourself the reality of the claims you’ll read and hear about.

By the way, many of the websites that make these promises use really long webpages which build up social proof along the way – the longer you stay scrolling down the page reading to get to the conclusion – an offer of 100% cure or your money back –  the more convinced you may feel about buying the product based on the wrong evidence.

Frankly, I hold major scepticism for the application of these techniques for all people, but probably there is a small cluster who can be helped in just one session. It’s just that in my evaluations I never get to meet such people. It must be my referral system where I’m referred people who’ve tried almost everything then see me as last recourse; or, they’ve read all the miracle cure literature and then come to this site and decided what they’ve read here better appeals to their sense of how change is possible even for long-held and seemingly intractable fears. Caveat Emptor.

If only Medicare in Australia allowed longer extended sessions for Exposure work

Mind you, if Medicare allowed it, for many patients with these sort of phobias I would prefer to do one three hour session rather than several over weeks, but alas, Medicare will not allow that, despite the preponderance of evidence for its effectiveness. Same goes for video conferencing sessions which Medicare doesn’t allow, despite so much evidence for its usefulness especially for rural population. The sad irony is for them to drive hours to see me is a riskier event that the flying we will do as part of their fear of flying treatment.

In the next session for my dog phobic patient, I showed her how a dog developed a phobia*, and how it’s helped to overcome it. Something a little out of the ordinary, but there is method to this apparent “madness”. [*This is part 2, Episode 1, Season 1 of The Dog Whisperer]

Now to the point of this post: At the end of the first session, the patient and her accompanying friend left quite buoyant and hopeful, eager to return the same week to continue the work and watch the dog phobia video. Asked if what occurred in today’s session was what they expected or if they were surprised by today’s session content (a question I often ask new patients), the patient said, “Yes!” Why? Because I thought it would be just talking… I didn’t expect so much activity and learning!”

Behaviours can only be changed by behaving differently

And this is my point. Behaviours can only be changed by behaving differently. Just talking about new behaviours will get you only so far, just like reading a self-help book. What I think is needed is an appropriate plan for any one patient’s presenting situation and history, and then the formation of a good working alliance together with proper measurement to show the patient change is possible, and this is how and why it’s going to happen.

If you’re thinking of seeking help, ask your prospective agent of change how they go about the change process. Is it just talk, do they accompany you into the feared situation, what model of change do they espouse and where can you read up on it before the first session, so you can start the work in a state of expectation and hope for change, as well as knowing what you’re in for in terms of your contribution to the change process?

Bottom line: You don’t have to live with phobia. Change is possible with the right guidance, therapeutic alliance, measures, and planning.

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