Most patients who see me will eventually be introduced to the practice of Cognitive Behavioural Therapy (CBT), the intervention that has the most publications in evidence-based journals for the effective treatment of anxiety disorders.
There are of course other approaches, many of which grew from the original psychoanalytic approaches pioneered by Freud more than a hundred years ago, and since modified by many others. None however have been put to peer review and head-to-head comparisons like CBT.
The task a therapist faces, having chosen to work this way, is how to integrate the approach into the clinical work. Some take a very didactic approach, using a whiteboard such that a session becomes teaching or tutorial-like, with handouts and reading prescribed materials before the next session.
Others weave it into their work, applying a Socratic dialogue, almost Columbo-like, perhaps even spending a whole session gently asking probing questions of the sort:
“What would happen if…
How would that change things…
If you continued to think/behave/feel that way, what would likely happen…
Is there another way to think about this…
How certain are you this is likely to happen…
How did you learn that X is dangerous?
Have there even been any exceptions to the rules you’ve created for yourself?
… and so on…
The idea is that patients themselves begin learning to question their own automatic thoughts, those that come to mind after a certain trigger, or even just randomly, but which elicit a strong physical sensation (e.g., a racing heart, sweating, stomach butterflies, trembling, etc.). These sensations themselves can trigger further thoughts, and thus are often “used” by patients as evidence that the initial automatic thought was true.
This is called emotional reasoning.
And it can be compared to another type of reasoning that is slower, accompanied by much weaker physical sensations, and might often include to-ing and fro-ing between opposing ideas, as one searches for the best response using the available knowledge.
This is sometimes referred to as rational reasoning.
For several years now, I have been introducing my patients to this approach via several videos which may take one or two sessions to go through, stopping at various points to explore their understanding, knowing that if I just gave them a copy to watch on their own, patients would miss a lot of detail relevant to their situation.
In this blog entry, I want to share with you one important section of a video I use.
The video in question comes from a 3-DVD set (each of 2 hours) which explores current ways to think about and measure emotions. It is called “This Emotional Life” from PBS, and is hosted by Harvard psychologist, Dan Gilbert, himself a researcher in the science of happiness and who has previously featured in a number of TED talks.
Notice the talk has almost 12 million views!
The PBS series features cutting edge research (from 2009) from many scientists, but also includes well-known American celebrities such as Alanis Morissette, Katie Couric, Chevy Chase, John McEnroe, Adam Gopnik, all talking about their emotions and experiences, including some who’ve spent time in therapy.
And for each of the emotions it explores, from fear and anxiety, anger, PTSD, to depression and happiness, it features a case study to highlight aspects of the research. The one for fear and anxiety features a young Harvard freshman, Christina Kelly (left), and her fear of flying.
(It took me a while to note we first meet Christina playing Frisbee with a friend on the Harvard lawn; controlling flight, as it were, a counter-phobic, enjoyable behaviour.)
Many of my patients, once the video starts to roll and we meet Christina about 10 minutes in, quite quickly align themselves with her experiences. One thing that is importing to mention is that Christina tells the interviewer that she knows her fear is irrational. But she then goes on to tell him that what really adds to “my overarching fear” is that it’s not one of the usual fears people experience such as “crashing to the ground… or someone’s going to take it over.”
In fact, she tells us that she doesn’t know what it’s about. This is a challenge for any therapist who wishes to use exposure therapies, because it begs the question of what to expose Christina to?
And what makes this aspect of her anxiety worse for her is that she’s likely to be a very good problem solver (at least we can expect so if she’s entered Harvard), yet these skills for which she is likely to have been rewarded throughout her life and come to trust, seem ineffective in helping her solve this problem. For some patients who watch this, I suggest it can see some people saying to themselves, “There must be something seriously wrong with me!”
Yet in other respects, this is like someone who experiences panic episodes which by definition come “out of the blue” rather than before or after a particular triggering situation. And it can be likened to someone experiencing chronic Generalised Anxiety Disorder (GAD) for which there is no past experience or future occurrence being contemplated. It just, is.
Many patients like Christina present having racked their brains for some event which “caused” their fear of flying. I always ask about patients’ own theories of causation but with an open mind that they may or may not be true, may be unverifiable, may be a distortion of memory, may have been told to them by a parent, or perhaps there is no single causal situation but an accumulation of much smaller events.
What I find most important early on is while I acknowledge and seek a patient’s theories, what’s most important in the therapeutic work we will do over a number of sessions, is the act of pursuing what factors are currently maintaining their fears, especially their fearful behaviours. This approach is very much front and centre in CBT done well, but is seen by others practising alternative forms of therapy emphasising past behaviour, learning, and unconscious conflicts, as “superficial”.
Avoidance and safety behaviours
At about 30mins into the DVD (the section about Fear starts about 19mins in), Christina’s therapist, Todd Farchione from Boston University, who has already spent a day with her and will fly with her the next day (yes, a 3-day marathon treatment), challenges Christina forcefully:
It’s at this point – one of many – I stop the video and turn to my patient and ask, “What do you think Todd means by this: no safeties, no avoidances”? (I should point out the expression hasn’t been used prior to this, so a patient watching on their own is likely to miss what this represents.)
Some understand immediately, while others don’t and so it needs some gentle coaxing to elicit the answers I’m looking for, and not have the patient think less of themselves for not understanding immediately.
It’s an opportunity for the patient to learn that one of the hallmarks of anxiety is safety-seeking behaviour.
The evolution of safety behaviours
Over evolutionary time, our brains and bodies have developed automatic responses to perceived threats – an inbuilt threat assessment and response system – which makes the task of rationally thinking how to respond quickly, very difficult.
Over the course of time we have developed at least four immediate response mechanisms having somehow determined a threat is present or imminent. You’ve likely heard of two of them, known as flight or fight.
Psychologists often talk about ancient Man being threatened by a lion or some other marauding animal and these innate behaviours “kicking in”. Flight makes perfect sense, and it’s what causes our hearts to race and we begin to sweat. This is called Sympathetic Arousal.
Fight, in the same context of the marauding animal, is useless. We still do not have the physical ability to deal with such wild animals and would almost certainly perish without extra tools our developing brains could invent, like spears and guns. But this flight and fight system likely evolved way before that, and so a third and fourth defensive set of behaviours also evolved.
The third is Freeze, where we stand rock steady, not breathing, not making a sound, using whatever efforts we can not to be noticed. This too requires a lot of energy and perhaps will only last 30 seconds or so – a minute tops for the untrained – in the hope a marauding animal’s motion detection system is not aroused, and it moves on, ignoring us.
The fourth, which gets scant attention, is Appease.
If you go with your dog to a doggy playground, you will likely notice what happens when a new dog approaches a group of dogs already familiar with each other. They come up to it, sniff and
perhaps offer a play-bow, or a toy to play tug-of-war with.
Or an aggressive dog might lunge.
A small breed, or very young dog might whimper, but under threat, might roll on its back and bear its unprotected tummy.
It’s a doggie way of communicating, “I’m no threat to you and the pack order…and please leave me alone”.
In human terms, it would be like coming to a roundabout in your car when another driver cuts you off, clearly in the wrong. At the next traffic light, you wind your window down to tell them off, but before you can say too much, the other driver gets out of his car and approaches you, revealing himself to be a 6 foot 6 inch Hell’s Angel.
Now would not be a good time necessarily to assert your correct driving behaviour and tell him off. Perhaps it would be better for you to appease the other driver – “Sorry, I didn’t see you…” than stand up for your driving rights.
This behaviour is often seen in work situations where bullies in power abuse their privileges, and subordinates learn ways to appease them until it all gets too much and one blows the whistle (having kept meticulous records) or one simply leaves in search of more satisfying, less stressful work.
Appease is a little different than the others in that it usually takes place using higher centres of the brain in humans, requiring language and an appreciation of the social context. It’s a higher order defensive operation.
What I’ve been describing are all safety behaviours. In animals, it can easily be seen, but in humans things are a little more obscure.
The therapist’s task is to help the patient review their automatic safety behaviours, see them as an effort to appease their own anxiety responses, yet see that over time they actually increase either the intensity of the response, or cause it to occur earlier and to less intense triggers.
Safety behaviours are also known “avoidance” behaviours, the idea being that if I can avoid a situation – including my own unpleasant sensations – I can feel safe. Most patients describe successfully avoiding a dangerous situation (whether real or imagined) as yielding feelings of relief and some form of calmness. Certainly, they’re feelings much preferred over the yucky feelings when in or about to enter their feared situation. It is the most frequent feeling described when patients hear the Captain says the flight’s descent has commenced “and we’ll have you on the ground in 20 minutes…”
So, what was Todd referring to when he spoke of “no safeties, no avoidances” do you think?
Take a moment, then read on…
He actually doesn’t give Christina or the viewer an answer but my experience with fearful flyers suggests it could include:
- Having to visit the restroom multiple times waiting at the Gate before entering the plane to be sure their bladder is empty, minimising the risk of getting out of their seat in flight to use the plane’s restroom
- Boarding as late as possible to minimise time spent on board waiting for the plane’s doors to close (minimises time on board with the door still open, “inviting the patient” to submit to their fears and get off)
- Choosing a “special” seat or location: “I can’t sit in the middle seat; I can only be at the back of the plane”, etc.
- Wearing special clothes, or medallions, or artefacts from a parent, i.e., a talisman of some sort to ward off evil, like a lucky charm.
- Looking at the registration number of the plane to be sure it doesn’t have the “wrong numbers or letters”.
- Only travelling with someone else, never alone
- “Must have” certain items such as an mp3 player, DVD player, headphones, books to read, etc. Most travellers nowadays take such items (I certainly recommend them), but fearful flyers can be known to panic if they have left an item behind, or the battery charge has run down, leaving them with no “safety blanket” to distract them. Or, they are left with the thought the trip will be “a disaster” because they feel unprepared due to missing or non-operational items.
- Checking weather forecasts days in advance in the hope the flight will only occur in fine weather, at least on takeoff or landing.
- Only flying in the afternoon or evening, so the Club bar can accessed for some “self-medication”.
- Overnighting for an early morning meeting to recover from the flight (it’s not a bad idea, but the problem comes when you have to forgo the meeting because the only flight is a morning one)
You perhaps have other “magical” devices or behaviours I haven’t listed, which you might employ in the days leading up to the flight, on the drive to the airport, at the checkin or gate, while boarding, taxiing or some other part of the flight “envelope”.
These could he called “superstitious” behaviours in the sense it can be shown they have no impact on the flight itself. The plane will do what they plane will do whether you cross yourself on pushback, wear green underwear, or have your father’s St. Christopher’s medallion with you (all derived from actual patients’ accounts).
These are all rituals to help us feel safe in the belief we can influence the plane’s behaviour, that of the passengers, and of the crew and indeed the weather.
I have no problems with these at all, and indeed many orthodox religions require the faithful to say prayers for travel before embarking, customs that go back millennia when we got around by foot, on camels, on rafts, etc. When flight was only for the birds!
Here is a portion of Wikipedia’s entry about the Travellers Prayer expected of Jews to say before setting out (click to enlarge):
Islam’s du’a or prayer for travel, can be found here.
Clearly, for millennia, humans setting forth from the (relative) safety of home has been a challenge, hence the need for assurance, via rituals, that one will arrive and return safely.
But it also goes to the idea that, like other warm-blooded mammals, we humans – for all of our intellect and reasoning – are capable of superstitious behaviours, beliefs and rituals*, and sometimes the smarter we are (the more we rely on our intellect) the more easily we can be misled by our thinking systems and emotional systems.
[*There are many ways to understand the meaning of rituals, and I’ll expand upon them in another blog entry soon, one that naturally follows and embellishes this one.]
Recognise your own safety and avoidance behaviours
If you’re to become a better flyer, or overcome your “over the top” anxieties, you need to recognise your own special behaviours you are currently employing. You can use your imagination to recall a recent experience and review your thoughts and behaviours for their truthfulness, or you can watch YouTube videos to help elicit them if imagination does not produce sufficient “oomph”. You can also physically head out to your specific locations in an effort to bring on your anxious feelings, and thus better know your safety behaviours.
Sometimes, your avoidance behaviours might be whatever you can do to “switch off” your yucky sensations, such as a racing heart, dizziness, shortness of breath, and so forth. These are all unpleasant states we can believe are caused by the feared situation, but in fact are a result of us contemplating confronting them without our safeties! They trigger our threat response system which can be very hard to control with thought alone, yielding us to try and control them through ritual, prayer, promises to be a better person, etc. Or via distraction, which is an OK method, as long as it’s not your only tool, because it will sooner or later prove ineffectual.
What to do instead
When confronted with these yucky sensations, most anxious people describe themselves as going from “zero to ten!” when rating their feelings.
In Christina’s case, after telling her that “we’re going on with no safeties”, Todd ups the ante by truly challenging her, as seen in this next screenshot, which also shows Christina’s immediate reaction – zooming from zero to ten, a veritable panic episode, or loss of control scenario.
[Aside: I’ll usually stop the video at this point, and ask patients – but also, supervisees, and workshop attendees (not all mental health professionals are trained to do exposure work) – what they would do if they were Todd. Or if they were Christina, what might they think Todd ought to do while experiencing this “panicky” moment?]
The task I have as a clinical psychologist is to acknowledge patients’ arousal from a resting 1 or 2, and help patients see that their bodies are reacting quite normally under duress (their thoughts, exposure to internal sensations) and are creeping up, rather than jumping straight to a ten. The idea is to help patients modulate these arousal states and keep them within reasonable and manageable levels, where the “yuckiness” is tolerable and not made worse by worrying about it!
Think of it as someone who has been dieting to lose weight or improve their athletic performance, and following a protocol designed by someone else of when to eat, what to eat, how much to eat, etc. Do this for long enough and you will lessen your ability to read your own hunger (how hungry and what foods will satisfy) and “I’m full” signals (satiety).
This is what can happen when you immediately cut yourself off from the uncomfortable signals of arousal and seek safety, comfort and relief. In CBT we call this Low Frustration Tolerance.
Certainly, diaphragmatic breathing will assist as a “Bottom Up approach” to bring focus to what may be a developing sense of chaos and loss of control. But knowing what to do next – in the next minute or so – is also vitally important. Staying in the “here and now” and planning what to do next (having hopefully rehearsed it many times) is a frontal lobe activity, pushing chaos away and bringing focus to the front:
“I know what to do. I’ve rehearsed this many times. Let’s see how I go and keep monitoring. I’ll give myself a rating, and the longer I stay here, and not perform my safety behaviours, the sooner it will come down of its own accord.”
This kind of thinking, and the resulting behaviours, MUST be practised often in order to become automatic, or at the least, available to consider as an alternative to catastrophic thinking, when the proverbial hits the fan. You probably ought to record these thoughts on a 3 x 5 card, or your cellphone (there’s apps for that!) so you don’t forget.
So, if you’re claustrophobic, and feel the sweat start when looking at the plane’s doors about to close, you must have your mantra well-rehearsed: “Doors closed, stay composed.”
In the days before the flight, each time you go through a doorway and close the door behind you, or go into an elevator and the doors close, say this to yourself, with one hand on your belly and practising your breathing. “Doors closed, stay composed…. Doors closed, stay composed.” No one will notice…
If it’s bumps that perturb you (they also literally perturb the plane by the rapidly changing airflow over the wings, but planes love turbulence), then practise your mantra – “Turbulence might be uncomfortable but it’s not unsafe” when you’re out in a car and it starts to get bumpy on the road. Purposefully, take a bumpy bus or train trip for the heck of it and practise on board, perhaps even taking your iPhone with you with takeoffs and other videos to watch (use headphones) via YouTube. This must be practised on a very regular, daily basis for some, and you must keep track of how you perform and when you notice your improvements. You must be able to go into your scary situations, trusting you don’t need your safety behaviours. They’ve been “good to you” for a while now, perhaps helping you get to important places and events, but right now, they are getting in your way.
Thank them, write them down or illustrate them in a journal, and store them as a keepsake on a shelf or digitally. But be ready to say goodbye to them, as a child might a favourite plush toy now that they’ve turned 16 and on their way to independence and adulthood.
Even now, when I think of my favourite childhood toys, I get a sense of nostalgia, a Greek word (-algia) for the pain of remembering those simpler times. If you still have your plush toys, it’s OK to take a favourite on board with you for moments of comfort, especially on a very long journey. Just be sure you can do the flight without it. After all, it’s your senses and memories which bring you moments of serenity, not the toy itself. It’s a cue to remind you of safe times.
[If you like what you’ve read, and would like to follow up with an appointment or some questions, ring me 0413 040 747 in Australia – I’m Melbourne-based – or write to me: firstname.lastname@example.org]