Are there truly helpful non-medication therapies for Anxiety?
My job-related experience reviewing SS disability health records over the years revealed that therapists mostly try to help people with anxiety by coaching them to identify the events that trigger their anxiety episodes. They may then help them cope with these events e.g., teaching them how to detect them in advance of a serious anxiety event and avoid them. They also spend time exploring patients’ childhood, trying to identify other times in life they had anxiety or events that caused “worst periods” of anxiety. I am not sure why therapists believe that a historical review of past anxiety experiences into childhood is helpful, except perhaps in the case of suspected abuse in patients with PTSD. Therapists also spend a lot of time providing emotional support and asking clients about how they “coped” with anxiety since the last appointment (an anxiety coping verbal diary). They almost never use one of the empirically supported treatments that have been developed for anxiety disorders. The goal here is NOT to substitute self-help for formal therapy with a qualified behavioral health professional. However, the following points are things you can do on your own which are known to be helpful, and which a therapist trained in an empirically supported treatment for anxiety will certainly be familiar with. Some of the more common techniques that are supported by empirical research are designed to help the patient develop anxiety management skills:
- Relaxation breathing
- Challenging unhelpful thinking
- Engaging in enjoyable/distracting activity
- Physical exercise
Again, I have found that patients’ compliance with these approaches is surprisingly poor. I spend a lot of time anticipating and then remdying clients problems with adherence and follow-through. For example, nearly every patient reports that when they are having a severe anxiety attack, the “relaxation breathing” technique they were taught is not very helpful i.e., it doesn’t really decrease their anxiety once anxiety has become severe, or during a true panic attack. Also, when I have talked to patients who have been coached to “challenge their unhelpful thinking”, another coping technique, many said that this too, “doesn’t work”, or was very difficult to do during an anxiety episode. One patient told me, “To be honest, I don’t believe that telling myself that my thinking is irrational Is helpful. I feel I have to keep on trying to think about what might happen because if I let my guard down or get distracted by any other ideas, then I will be to blame if something bad happens and I didn’t do enough.” Therefore, it seems that the common, therapy practice of teaching clients to refute or challenge their thinking during an anxiety attack isn’t working out so well for many patients. In the case of this patient, the suggestion to challenge her thinking when she is anxious actually made her feel more “out of control in the moment and increased her anxiety. Therefore, with a technique like this, I have found it is extremely helpful to have clients bring back to therapy sessions 2-3 major anxiety events that happened in the past week so we could practice reviewing, challenging their thinking etc., post hoc. I tell patients that we will do a “psychological autopsy” on their anxiety events, promising them that if they will do this repeatedly with me, they will to gradually gain the ability to impose objective, rational thinking when they first start feeling anxious. The focus is on practice, practice practice with deconstructing recent, past anxiety events, to obtain skills they can start to use with future anxiety episodes.
There are modifications to some of the cognitive (thinking) and anxiety symptom management skills normally taught by most therapists that can improve their effectiveness
First, when I work with most patients with chronic, severe anxiety, I will be told by most that they have already tried many therapies such as cognitive therapy, cognitive-behavioral therapy, ACT, EMDR etc., and the skills they were taught were not very helpful. I generally outline a program that builds skills and activities over time. If you were to study all of the empirically supported treatments for all of the anxiety disorders e.g., EMDR, CBT, prolonged exposure therapy, you will discover that all of them use some form of exposure intervention. By exposure we mean helping clients avoid the experience of anxiety (most attempt to escape, avoid, run away from anxiety situations or symptoms). In my view, all of the effective treatments involve helping people gradually tolerate exposure to anxiety and the situational cues that trigger anxiety, in addition to other skills. This is the case whether we are talking aout empirically supported treatments for anxiety disorders such as OCD, PTSD, generalized anxiety disorder, phobias, etc. Also, a skills deemed by all of these therapies to be helpful in the process of exposure interventions is relaxation training. This is a skill that is known to help patients tolerate various forms of the graduated exposure that is introduced in therapy; and it is a coping skill used in its own right when one is in the midst of an anxiety reaction. Therefore, the first step in treating many cases involving high anxiety should be to help clients master good relaxation training skills. There are many ways of learning learning relaxation and breathing techniques. See “relaxation training” under YouTube, for example, for dozens of examples, video materials to coach you etc.
Relaxation Training With Breathing Exercises
Deep breathing exercise
Choose a comfortable chair or couch to lie down. If you have problems with chronic insomnia at night, I would suggest using your bed to begin learning this exercise. (Learning the technique in your bed can help you more easily add it to your night time sleep regimen i.e., it will help you disrupt your night time thinking-worrying-problem solving associated with insomnia/anxiety at night, prepare you for sleep better, etc).
- Sit in a comfortable position, legs shoulder-width apart, eyes closed, jaw relaxed, and arms loose. Take a minute and consciously check to see if your eye lids are close in a comfortable, “lazy” resting position, or if they feel tight, are jittery, etc. Allow them to become very calm, heavy and rested. Do the same for your jaw and facial muscles, your arms, your legs.
- Place one hand on your chest and one hand on your stomach.
- Check to see how you are breathing. Is your stomach not moving much or not at all, with your chest doing all of the breathing work? If so, start to breath so that only your stomach rises and falls when you breathe in and out.
Inhale: Concentrate on keeping your chest as still as you can (or as possible). Imagine you are trying to use your belly to lift a loaf of bread.
Exhale: Allow your stomach (and the “loaf of bread”) to fall as if you let go of tension and stress inside of your body. Try to picture in your mind the what stress or tension would look like as it leaves your body as your breathe out. It many be helpful to think of a special word as you breathe out as well, such as “peaceful” or “calm”.
Continue lying comfortably and begin breathing naturally, normally. Do not force the breath; When you exhale, let your body tell you when to take the next breath. If you are not able to allow yourself to “just breathe” comfortably, go ahead and take a very deep breath and let it out. The deep breath will really help draw your attention to how your lungs and stomach feel as you move air in and out of your body and especially, how the air feels flowing through your lungs and nose. This is the type of experience we hope to get you concentrating on during this exercise.
Practice 5 to10 minutes daily until the breathing feels comfortable and you notice that: 1) your tension and some anxiety symptoms are reduced a bit; and 2) you can concentrate on just your breathing and how your body feels as it relaxes; your tendency to worry, problem-solve, review events of the day etc., are not interfering with your concentration on the exercise.