Читать книгу Ten Steps to Relieve Anxiety - H. Michael Zal - Страница 13
ОглавлениеStop the world and the anxiety process for a moment. Give yourself time to recoup. Slow down and gain perspective. There is no danger. You don’t have to race so fast. Perhaps you are putting yourself under time pressure. Give yourself permission to relax. Don’t let the symptoms of anxiety control you. You can take charge of them.
People who are anxious move too fast physically and mentally. They always seem to be busy. Some experience physical symptoms such as heart palpitations and shortness of breath. Sometimes they are not even aware that they are feeling anxious and just feel pressured, tense and irritable. They may act restless and fidget if sitting too long. Often they feel compelled to do things like they were a wound-up clock. Overly perfectionist, they have a determination to get it right and have an exaggerated sense of what they and you “should be doing” and the specific way that tasks “should be done.” They have to do them all on their own, in their own way, and often do not like how others complete a task, yet they complain that they have to do everything themselves. They often have a strong need to please others and therefore have trouble saying no. This puts them under further time pressure and increases their tension. They have difficulty unwinding and relaxing when they should be relaxing. Their to-do list grows longer and longer. By the end of the day they are tired, wiped out and unable to sleep. These behaviors make them more prone to burnout. Judy, one of my clients, has these problems.
Judy’s Story
“My anxiety is my best friend. I guess my anxiety has been with me so long I became inexplicably comfortable with it. I was described as a ‘hyper’ child (although I did well in school), who never wanted to sleep. I think I must have thought that if I relaxed I would lose my energy level. My mother was the same way. She would clean, clean, clean and work, work, work. At one point, I was working full time, dating and going to graduate school. I had so many people I didn’t want to disappoint. I was under stress and the anxiety returned big time. My coworkers described me as a ‘hyper nut.’ (In a good way!) I think that my anxiety worked for me. I could pull all-nighters and study and then go to work the next day. The anxiety or the ‘hyper personality’ became part of me. I lived with it, accepting that ‘this is me.’ I seemed to thrive on pressure but hated it at the same time. Although I did very well, I couldn’t calm down when I wanted to. There were ebbs and flows; some years were worse than others. I am my mother’s daughter.”
Judy bounded into the office and onto a chair. She was forty-three years old. She carried a large red purse that caused her to be somewhat off balance. She talked with her whole body and threw herself into different positions like a rag doll. Judy complained of anxiety, palpitations, sweating, tension headaches, shortness of breath and feeling hot or cold. “Everything is overkill with me. I’m over the top,” she said. Indeed, she did not seem to relax for a minute. My first thought was, Where do I start with this lady?
During the opening session, I took a psychiatric and medical history (a habit I always practice), asked Judy about her family, her education and her job history. I did a mental status examination which confirmed my initial impression that she was suffering from generalized anxiety disorder (GAD). At the end of the hour I said to her, “Judy, I had a job to do today. I had to make a diagnosis and formulate a treatment plan. Now, I have to ask you two things. Did you feel comfortable talking to me today? Did everything that I said to you seem to be relevant to you as a person or did you feel that I was trying to put you into a square hole in which you did not belong?” She answered that she had felt comfortable and that she felt that everything that I had said to her was about her and resonated with her. I stood up, smiled and shook her hand. “Then we have made a start.”
Judy was not wrong in her assumption that she had inherited her anxiety from her mother. Research studies on twins have long hinted that anxiety-related personality traits such as worry, harm avoidance, tension, fear of uncertainty, fatigability and pessimism are 40 to 60 percent inherited. Human genetic studies have proven this premise to be true.1 In 1996, Science Magazine reported evidence of a gene (the functional unit of inheritance) linked to individuals prone to these anxiety traits.2 According to Gregor Mendel’s genetic model of inheritance, two alternative forms of a gene, which carry a delivery system for the brain chemical serotonin, influence human “neuroticism” (anxiety and associated traits). One form results in more protein, more serotonin uptake and more neurotic behavior. The second form results in less protein, less serotonin uptake and fewer neurotic symptoms. An offspring exhibits one or the other of the genes but not a mixture of the two.3
It soon became apparent that Judy definitely also had issues concerning time pressure that added to her tension and stress. She told me that her father was in a long-term care facility and frequently needed to be hospitalized due to falls. In spite of having two sisters, she was the designated caregiver and took care of most of his needs. Her son had dropped out of college, lived at home and was not working. Her live-in boyfriend, although she said that he was emotionally supportive, didn’t seem to do much around the house and was not always there physically or emotionally. She demanded an intense level of performance from herself, at work and everywhere else. These demands meant that she had no time for herself to unwind and relax. She constantly had too much to do and too little control over the time and manner in which things were done. This was aggravated by her inability to establish boundaries between her work and personal life.
Many times during our sessions, I said to myself, I wish that I could just get Judy to learn to relax for a moment. I tried to teach her a breathing exercise to slow her down and allow her to calm down. I illustrated the exercise myself. I took in a deep breath through my nose and let it out very slowly. I placed my hands flat on the top of my chest and moved them down slowly as I exhaled through pursed lips. This took me about fifteen seconds. I asked Judy to try it. She did it in two seconds flat as if she was blowing out birthday candles. I said, “Try it again and do it more slowly.” By the fourth try, she had it up to eight seconds.
Judy often complained of feeling that she was going from one pressure cooker at work into another pressure cooker at home. I asked her to pause for a moment and allow her rational brain to seek a solution rather than responding with anxiety and irritability while under stress. I suggested that she try to think of a way that she could unwind and reduce her tension between the time that she left work and returned home. She answered, “Another therapist taught me a trick to help me stop bringing my job home. He suggested that when I leave work that I stand outside for at least ten seconds and tell my mind, ‘work is over, no more thinking about it.’ This is harder than it sounds. However, with practice, it works.” I suggested she do the same thing before she entered her home, which she agreed was a good idea.
As I have gotten to know people who are anxious, I have noticed that there are certain themes that continually crop up in our conversations during therapy. Like many anxiety-prone people, Judy was also a perfectionist with high expectations of herself and others. Anything less than 100 percent was seen as failure. This is one reason that she hesitated to delegate some of her father’s care to her sisters, because “They don’t do it right.”
She valued control and predictability. Any loss or threatened loss of control made her feel helpless and subsequently anxious. She had a need for too much control to feel secure and calm. Like other anxious people, she was overly concerned with what “should be.” She felt that there was only one “correct” way to do things. She tended to see things as either black or white. This also made her more prone to anxiety. She would often say, “They should have done it this way.” I would counter by saying “According to whom?” She would laugh because she saw my point. The word “should” reflected her need to do things according to her rule book. These rules allowed her to feel more in control but restricted her flexibility and spontaneity.
During one session, Judy went on and on about her mother. She spoke about how her mother had been hard on her and was big on guilt: “She was the disciplinarian in the family and beat the crap out of me. She was very hard to please. She felt that her increased anxious energy was productive but she felt that mine was non-productive. Mom worked all the time and was not there for me. She had a high-pressure job. Like me, she thrived under the pressure but hated it at the same time. I remember saying to her, ‘This is a new generation, mom. I will never do all you do.’”
At this point, I asked her, “Did you like it when your mom acted that way?”
She answered with a loud and emphatic, “No!”
“Then why do you act that way toward your family members?” I asked. I could see the light bulb go on in her head.
She went on to talk about her sisters: “My twin sisters were born when I was two. When my parents brought the baby girls home from the hospital and I saw them for the first time, they told me that I took a bag of oranges and threw them one at a time at the two of them. I don’t know how mom did it. She had to learn to cook, find a babysitter for my two younger sisters and me in the summer and maintain the house. Mom pushed me off to my grandmother, who died when I was twelve years old. My aunts were there for me, but basically I was alone. My father worked full time and belonged to a lot of organizations. He came home at six and expected dinner on the table. He spent time with us only on the weekends.”
Judy’s Opinion of What Helped Her Anxiety
“My mother dropped dead at sixty-eight years old (burst an artery in her brainstem). Stress kills! That’s when I went to therapy for the first time. The rug had been yanked from beneath me. My rock was gone. Dr. Zal is the third therapist I have had. He does ‘talk therapy.’ Sometimes you just can’t see yourself and need that outside professional opinion to point things out to you. He can zero in on what I call my ‘bad behaviors’ in dealing with anxiety. He is honest and direct. He calls me on my crap, as I call it. We are getting to the root of my anxiety. He is helping me deal with the stress caused by taking care of my dad, who is in a long-term care facility. He is teaching me how to say no! I have trouble saying no to anyone who asks me to do something for them (even people I don’t consider close to me) and it just adds to my stress. I get upset if people don’t like me. He helps me by asking easy questions such as, ‘Do you like everyone?’ I answer, ‘Of course not.’ He adds, ‘Then why does everyone have to like you?’ His query stops me dead in my tracks.
“I used to handle stress by eating poorly, drinking too much coffee, smoking more. It didn’t work. I still felt increased pressure, felt overwhelmed and couldn’t get things done. I had trouble concentrating and making decisions. I worried constantly. I had ‘stress eczema,’ headaches, insomnia and muscle tension and spasms. In therapy, we have discussed better ways to handle stress. I have learned new coping skills. I am exercising more, have decreased my caffeine and take time to sit down and eat right. I do meditation and yoga. If I can’t sleep, I get up and do something constructive until I feel tired again. I try to not define my value in life only through my job. I try to enrich my life outside of work by spending more time with my friends, family and boyfriend. (We have a ‘date night’ now every month, for just the two of us.) I try to do things that I like, even if I have to schedule time for fun. I like politics and writing. In fact, I’m a political junkie. I am trying to stop being ‘superwoman.’ I try to pace myself, organize my time and prioritize important activities. I try to be real about what I can and can’t do. I have decided that I will not do any more overtime at work without being paid for it. I am letting my twin sisters help more with my dad. I am trying to stop worrying about the future so much! I am trying to enjoy today.
“Dr. Zal also gave me several anxiety-decreasing exercises, one of which is called ‘deep breathing.’ When he asked me in the office to take a slow, deep breath, he said, ‘That was it? Not even close.’ As simple as it sounds, it takes practice to do this exercise. I have to be constantly reminded that the push that I feel I receive from my anxiety is often a false assumption. I am so used to doing it the old way. So I practice every day. Every night, when I leave work and before I enter the house, I take time to ‘de-stress.’ Visualization techniques that I use are also helpful. I am soon to join Maum Meditation to further help my relaxation. I have a lot of work to do, but with Dr. Zal’s guidance and some relief from the medication that he prescribed, I’ll get there. I’m calmer, but I still freak out a little. I’m a work in progress but I am getting better.”
My Opinion of What Helped Judy’s Anxiety
Treatment for Judy included many aspects. Some of our goals were to help her relax, reduce her time pressures and allow her to feel better about herself. I educated her about her anxiety and gave her reassurance that she was not crazy. From the beginning, the positive therapeutic relationship between us allowed her to feel more secure and calmer. Initially, I fulfilled her unconscious need for an older therapist who was accepting and whom she felt would not hurt or punish her. Judy grew more tolerant of her anxiety as she understood her genetic propensity and realized that it wasn’t her fault.
As you see above, we sometimes used modified cognitive therapy techniques to test out some of her assumptions, challenge her inaccurate thinking and give her perspective. Laughter helped. I often joked with her, which allowed her to relax. She was taught relaxation techniques including deep breathing and visualization. We discussed lifestyle changes, such as exercise, diet and reducing her caffeine intake. She brought yoga and meditation into the equation.
When Judy came to me, she was taking an antianxiety medication twice a day. I switched her to a different medication, because her original prescription only lasted four hours whereas my prescription lasted about eight hours.
In therapy, Judy mentioned that her mom was hard to please and was big on guilt. She worked all the time and was often not home. Judy grew up feeling that she was “bad” and thought that this behavior had caused her mom’s actions. She felt that any female authority figure and sometimes the world would “beat the shit out of her.” This made her feel fearful, angry and inadequate. She was also an “injustice collector” who always fought for the underdog. However, in spite of her childhood, Judy saw her mom as “her rock” and wanted to please her. She became tearful when I first pointed out this dynamic to her and why her verbally abusive female supervisor at work made her so angry and was such a problem for her. Unconsciously, she hoped that her next interaction with her supervisor would be better and that if she could just do her job more efficiently that it would help the process and finally get her the approval and positive feedback that she craved.
Judy described her father as “the best daddy ever. He was calm. He was not a disciplinarian and was always there for us. He took good care of us.” He also made her feel safe in spite of a mother who “beat the crap out of me.” This helps explain why she was so intense in trying to do everything she could to keep her father alive. It also explains why she chose three different older male therapists. I tried to instill in Judy a sense of self-worth, even if she didn’t please everyone. She was smart, had a solid work ethic, was a good friend and really cared about people. I tried to help her to see that she was a capable, strong woman who had been standing on her own two feet since age twelve and had done well on her own. Perhaps she didn’t need a constant safety net. Perhaps she didn’t need a therapist cum father figure in her life to constantly support and protect her. As she gained these new perspectives, she started to realize that there was no danger in her life any longer. She started to give herself credit for being capable and realized that she was not the problem.
Judy’s annoyance with her two sisters went back further than when her father entered the long term care facility. She realized that she was angry at her siblings, not only because they didn’t do things her way, but also because she resented their intrusion into her life when she was a young child. When they were born, she lost her prime position in the household and she was given increased responsibility before she was ready. At first she was afraid to tell them that she was angry that they didn’t do their share for their father. She reluctantly took on the role of designated caregiver. Although she complained a lot, in some ways it fulfilled her needs, particularly to feel in control and therefore safe. As she started to understand these issues, she was better able to insist that her sisters share the workload.
After her twin sisters were born and her grandmother died, she noted, “I was alone.” Judy felt that she needed outside support or she would be helpless, vulnerable and isolated. In her present life, she felt that she could not rely on her son. She was angry at his behavior and had no respect for him because he had dropped out of school and was not working. She could not rely on her boyfriend because, although he was emotionally supportive, he was not always around and “didn’t always get it.” Judy had grown up trying to please people so that they wouldn’t leave her and would be there to protect her so she wouldn’t feel bad or guilty. She had been in therapy with several different counselors for a long time because she felt that she needed this constant support.
Judy felt guilty about her son’s life performance. He didn’t fit the mold that she envisioned and was not a reflection of her way of dealing with the world. He was a child of divorce and she blamed herself for his adolescent behavior. During her therapy, he started working in the same facility where she was employed. He did well and she got positive feedback from her coworkers. This helped Judy feel better about herself as a mother and allowed her to understand that perhaps he did have some potential to be emotionally supportive to her in the future.
I encouraged Judy to spend more quality time with her boyfriend, which helped her feel loved, appreciated and more supported. He had not offered on his own before, because he felt that she did not have the time and was not interested. By being more proactive, she was starting to take charge of her anxiety by saying “Stop” to the anxiety process.
