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Some years ago, a young woman in her
late twenties (we’ll call her Sarah), came in for therapy
because she had developed a driving phobia. Interestingly, the onset
of the phobia coincided with the death of Sarah’s father.
Almost immediately following his death, Sarah discovered that she
was not able to drive her car without a relative seated next to
her at all times. This became both impractical and inconvenient.
It was also her main reason for seeking help.
During the course of her therapy, Sarah made a most important discovery.
She realized that: “my father was my anchor and losing him
left me feeling lost, insecure and unstable.” Soon after grasping
this important connection (i.e., between driving and her father’s
death), Sarah began to drive on her own. Gradually, she increased
the distances she drove. She also began driving on a variety of
different roadways (e.g., expressways, interstates). After about
six months Sarah was virtually symptom free and could drive anywhere
she wanted.
There can be no denying that severe and/or unrelenting anxiety is
difficult to live with. As this example demonstrates, abnormal anxiety
– and sometimes phobias – usually sends a message to
us. Often, these messages–which typically manifest in the
form of physical and mental symptoms–contain
important personal meaning.
In Sarah’s case, the meaning associated with her anxiety symptoms
appears to be fairly obvious: she had lost her most important anchor,
her father. This loss destabilized her psychologically, because
her father was a major part of her support system.
But once she understood – at a deep emotional level –
that losing her father had significant personal meaning for her,
the effect was quite liberating. Thereafter, the progress she made
in therapy accelerated. Not only was she able to drive without undue
fear or anxiety, but she became emotionally stronger and more independent.
Thus, the central point to bear in mind is this: If we ignore these
messages and their associated meanings, we do so at our own risk.
So, though it may be difficult for you, try to not wish for your
anxiety to “go away.” Instead, do yourself a favor –
think about what happened to Sarah. Yes, I’ve said this before,
but it is so important, it bears repeating. Remember, your true
first task is not to “get rid of anxiety.”
Rather, your initial and proper goal should be to
discover the underlying reason(s) that buttress your anxiety; to
understand why it has intruded into your life and become unmanageable.
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CASE STUDY #2: Social Anxiety
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About a year ago, a young man in his
early twenties (whom we’ll call Adam), came in for treatment
of severe social anxiety. Adam was 6’2” tall, had “movie
star” looks, and an IQ in the 140-150 range. Despite his considerable
assets, however, Adam was highly uncomfortable around people. He
could not engage in conversation or interact with virtually anyone
other than family or friends. In fact, Adam was so nervous during
his first and subsequent meetings with me, that his left leg would
shake uncontrollably throughout most of the sessions.
Not surprisingly, it took some time for Adam to feel comfortable
just being with me. Therefore, in the initial stages of treatment
we simply got to know each other. Gradually, Adam’s level
of comfort increased. He became more relaxed (his leg stopped shaking
so much), and his optimism concerning treatment also increased.
Noting this, I encouraged Adam to explore the “meaning”
of his anxiety. Why was it so strong? What was it trying to tell
him? What purpose did it serve? He took up my suggestion and gave
serious thought to the matter. After about four months, Adam made
a most important discovery: He realized, by examining instances
that preceded his anxiety, that he found it extremely difficult
to make requests of people – other than friends or family
– to oblige him. Even the thought of making requests of others
unnerved him.
Some examples that Adam cited were: asking a stranger the time of
day; asking for directions; taking up an interviewer’s time,
or even “chit-chatting” with people (which to Adam meant
that he might be taking up their time by subjecting them to boring
conversation). In each of these cases, Adam felt he was, in some
manner, obligating the other person; In other words, by asking of
others – what he considered to be “favors” –
he was, in effect, imposing on them.
The reason he felt this way was because Adam considered himself
to be a highly moral person, and to him, obligating or imposing
on others is wrong.
This realization was unmistakably a breakthrough for Adam. Why?
Because he now understood the reason for his anxiety – it
arose each time he felt he might be obligating or imposing on others.
The most important point is this: Adam had obtained empirical evidence
concerning why he became anxious in social situations. By the process
of empirical validation, he discovered
the source of his anxiety; his belief that by imposing on or obligating
others, he was violating his moral code. To his considerable delight,
once Adam confirmed that the basis for his anxiety was for the most
part irrational, his anxiety dissipated almost entirely. Following
this, he felt both relieved and greatly liberated. Importantly,
Adam also improved in other ways: his self esteem increased; he
felt more confident, he became more assertive, and finally, he even
completed several medical school applications, and got a part-time
job at a nearby hospital.
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CASE STUDY #3: Public Speaking Anxiety
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Several years ago, an attractive married
female (whom we’ll call Melissa) in her late 20’s came
in for counseling because she was having extreme difficulty giving
oral presentations at work.
Despite her best efforts at being composed, she experienced considerable
anxiety – sometimes days before – and during these presentations.
This situation was causing her a lot of stress and had reached the
point of becoming intolerable to her. During the first session,
Melissa admitted that she needed help. She was also highly motivated
to overcome her problem. As is my custom, my first step was to do
some “depth” (psychodynamic psychotherapy – which
focuses on developmental, personality and other relevant issues),
work with Melissa. As therapy progressed, I explained to her about
EP and then implemented this procedure: First, I suggested that
Melissa set aside several hours each week in order to give “at-
home” oral presentations. During the initial practice sessions
her goal was simple: I instructed her to just complete the presentation
– from start to finish – without judging her performance.
Because she had made some
progress, at the beginning of the fourth week I suggested that Melissa
rate her level of anxiety immediately after giving both the at-home
and at-work presentations. This would allow her to better monitor
her progress. Next, I recommended that Melissa conduct her at-home
practice sessions in front of others. (She did so, in the company
of her husband and several of her friends).
By the end of the sixth
week, Melissa reported that she had made substantial progress. Her
anxiety – which she initially rated at level #9 – dropped
to about level #5. After another six weeks or so, she was almost
anxiety free. Because her anxiety level had dropped so dramatically,
it appeared that she had become virtually desensitized
to it. Importantly, Melissa also found that she no longer worried
or thought about having to give oral presentations (over the weekend)
as had been her tendency. She had ceased ruminating about them,
and was rewarded by not experiencing virtually any anticipatory
anxiety, as a result. I should mention here that, although Melissa
still felt a bit anxious prior to giving the presentations, she
characterized this feeling as “nervousness” rather than
anxiety. Unlike the anxiety she experienced previously, being nervous,
much to her delight, did not interfere with her performance.
It is important to note here that I generally use
the EP procedure in conjunction with other forms of intervention
(e.g., desensitization, “depth-work”). As is the case
with most clients, I did spend some time exploring with Melissa
the meaning of her anxiety symptoms. Hence, I believe that the combination
of depth-work together with EP (which incorporated desensitization)
were both instrumental in helping Melissa overcome her public speaking
anxiety difficulties.
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CASE STUDY #4: Test Anxiety
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During my one year internship I was
most fortunate to be able to work at the Georgia State University
Counseling Center. This setting was ideal because it allowed me
to complete my dissertation work on the subject of test anxiety.
Based on my research, I designed a treatment protocol for test anxious
students.
Although the treatment was administered in a group format, I should
mention that it could also be carried out individually. The treatment
program consisted essentially of two components.
- A didactic
part, in which I reviewed the tenets of my dissertation research
and explained what I believed to be the root cause of test anxiety;
and,
- An experiential
component, which focused on each student’s personal
experience related to test anxiety (i.e., a process of phenomenological
reduction that allowed each participant to systematically examine
the nature and process of his/her anxiety experience).
After about five weeks,
I had presented all of the didactic material to the students. I
had also given each participant the chance to share his/her experience
with the group. The final step then, was to review the data (i.e.,
the written record I had compiled and condensed, to reflect the
common elements of each participant’s experience).
The results provided a fascinating, if not surprising, conclusion.
Every student in the group, without exception, expressed almost
the exact feeling (paraphrased), with regard to why they became
anxious while taking important tests: “If I don’t pass
the Regent’s test – a requirement for all Georgia college
students – my life will be over!” In other words, they
had put all their eggs in the “academic basket.” Talk
about pressure!
Fortunately, once they realized
this most important fact, their experience changed dramatically.
Each student again took the Georgia Regent’s test. Not only
did each one of them pass – after having failed the test previously
– but they also reported feeling much less anxious during
the test. Needless to say, the students were most pleased. In addition,
one of the group members, a delightful elderly woman who hadn’t
been to college in over forty years – told me after taking
her first exam: “If I had had your telephone number, I would
not have hesitated to call you at two o’clock in the morning
to tell you that I got an A on my test!” That was some news.
Hearing it was truly gratifying and convinced me that the treatment
program had been a success.
Finally, I would like to
emphasize one additional important point: If you’ve read the
section entitled WHAT IS ANXIETY, you may recall that I articulated
what I believe represents the core of the anxiety experience:
a sense of trepidation that things are not going to turn
out OK.
Now, let’s briefly consider the psychological message each
student gave to himself/herself (prior to participating in the group).
By thinking and believing that passing the Regent’s test was
absolutely critical to their success, they left themselves no viable
alterative concerning their future. Put another way, if they failed
this test they had no “back-up” plan, and thus were
not able to feel secure about their future.
As I reflect on the experience these students shared, it brings
to mind the old adage, timeworn though it is, “Don’t
put all your eggs in one basket!” – For if you do, things
may not turn out the way you would like.
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CASE STUDY #5: Panic Attack
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Recently, I had the pleasure of treating an
Hispanic male, in his early forties (whom we’ll call Ricardo),
who had sought help for frequent and often intense, panic attacks.
Ricardo was a highly intelligent, soft-spoken, married man with
four children.
He was also very articulate,
well dressed, and well-mannered, in short, a true gentleman. It
was a pleasure treating him, because Ricardo was simply the type
of person you could not help liking. Despite his considerable personal
assets and financial success, however, Ricardo had struggled with
episodes of panic, for over twenty years. Therefore, when he came
in for treatment he was highly motivated. Of course, this made it
easier for me to help him. Why? Because the more motivated a client
is, the more effort he/she normally puts forth. Not surprisingly,
motivation tends to correlate highly with the results achieved in
therapy.
Ordinarily my protocol for
treating panic disorder is fairly extensive, requiring some twelve
to fifteen weeks of therapy. Ricardo’s case was no exception.
He remained in therapy for about four months and during that time
we focused on the specific factors that I felt were critical to
the success of treatment.
First, we explored whether
the source of Ricardo’s panic episodes was internal or external.
Were the attacks due to situations and circumstances or to internal
mental processes that Ricardo was not aware of? As is invariably
the case, Ricardo acknowledged that the source was indeed internal.
What’s more, he made a most important discovery that proved
to be of enormous benefit to him.
Ricardo realized that without meaning to, he was generating panic
episodes by the way he thought about and reacted to certain bodily
sensations.
In brief, he was interpreting a sudden increase in his heart rate
as a sure sign of heart trouble. At times, whenever his heart rate
would unexpectedly accelerate, he became convinced that he was having
a heart attack. In view of this, it is no wonder that he tended
to react to these episodes with panic.
Second, once Ricardo empirically
validated that the source of his panic episodes was internal, his
optimism about therapy increased dramatically. He had, of course,
heard me emphasize the importance of “mastery and control”
numerous times.
But now the difference was
that he himself believed he could acquire it. And from this point
forward, Ricardo assumed a more proactive role – rather than
depending too much on me – in the treatment process. Some
of the more important aspects of his behavior that he paid closer
attention to were:
- His anxiety “triggers;”
(i.e., the situations/circumstances that occasioned his anxiety);
- His tendency to misinterpret
and exaggerate the meaning of certain bodily sensations (e.g.,
increase in heart rate);
- his negative self talk
(e.g., “I’m a basket case”), and
- Finally, his marked propensity
to become extremely passive and helpless after experiencing an
anxiety episode.
Needless to say, Ricardo’s
hard work in therapy paid off. He made considerable progress after
some four months, and now believes he is all but immune to future
episodes of panic. Now, if his heart rate were to suddenly increase
during a business meeting, he would react differently than in the
past. Unlike previous instances, the probability of his experiencing
symptoms of panic would be low. Instead, he would more likely conclude
that his heart is probably OK and, that the true problem concerns
anxiety rather than cardiac malfunction.
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