People who are hit with panic attacks have a common response. They feel compelled to fight the symptoms with all their available resources. They brace for the fight as they approach any feared situation. And if they predict this on-guard approach will fail, they avoid entering the scene as the only way they can guarantee their safety. But this resistance and avoidance comes with a price: a restricted lifestyle, anxious hypervigilance and often depression.
Over the past three decades, specialists in the treatment of panic disorder have helped their clients move from a commitment to resist their symptoms to one of acceptance. By allowing the racing heart and spinning head and wobbly legs to continue in a permissive mental environment, clients discover that they don’t actually have a heart attack, go crazy or faint. As they adopt this new permissive attitude – “It’s OK to be anxious here.” “I can handle these symptoms.” “I’m willing for people to notice my nervousness.” – then each panic attack runs a more limited course with far less intensity.
While this permissive approach has been standard, there also has been a secondary approach to treatment: to voluntarily, purposely seek to increase the uncomfortable physical symptoms. This paradoxical approach, dating back at least to Dr. Victor Frankl’s logotherapy, is now set to take center stage. The chief reason is a pragmatic one: the more provocative treatment is the briefest of treatments.
This winter, the Anxiety Disorders Association of America will release Facing Panic: Self-help for People with Panic Attacks. This guide is a synthesis of the work of this field’s foremost clinician-researchers. Here is the central therapeutic strategy, expressed as five instructions to the reader:
Get anxious on purpose. Once you are anxious, encourage the symptoms to continue for a long time. During this time, stop worrying and start supporting yourself. Let go of your safety crutches. Do this over and over again, in all your fearful situations.
Let’s look at each of the five directives:
Get anxious on purpose. The key here is not just to become anxious, but to purposely choose to get anxious. It is the seeking of the anxiety state that distinguishes this step from the more common approach of tolerating or putting up with the symptoms. It is a shift in one’s relationship toward anxiety, and it is a critical distinction. “Having” anxiety is insufficient; “wanting” anxiety is the central goal.
Once you are anxious, encourage the symptoms to continue for a long time. Here is an extension of the first step: invite your distress to stay around as long as possible. Try to keep it. If it subsides, feel disappointed, and look for ways to bring it back. We know from our studies of flooding that prolonged exposure leads to habituation. But this only occurs if the person drops his guard and allows the anxiety to exist during that time. I am proposing that we challenge the foundation of this flooding protocol. We can greatly shorten the required length of exposure if we emphasize the person’s therapeutic stance: first, to seek out the uncomfortable symptoms, and then, to consciously desire for them to remain for as long as possible.
During this time, stop worrying and start supporting yourself. While we encourage clients to feel scared and to feel the uncomfortable physical sensation of panic, we discourage worried thoughts (there is an appropriate therapeutic time to encourage worried thoughts, too, but I won’t cover that in this brief article.). We are battling two fronts here. First, panic sufferers will worry about just how uncomfortable the symptoms will feel. But, more importantly, they will worry about the catastrophic outcomes: fainting, having a heart attack, making a fool of themselves. We want them to learn, through specific exercises, that the panic attack will be uncomfortable but not horrible. Once they can downgrade their interpretation of the symptoms, then they can accept their symptoms instead of fear them. This stance is reflected in such supportive statements as, “I’m scared, and I’m safe.”
Let go of your safety crutches. Safety crutches are actions that help prevent or mute the symptoms of panic. We have identified over seventy behaviors, such as carrying an anti-anxiety medication in their pocket, practicing breathing skills, monitoring their pulse rate, sitting close to an exit, leaning against a wall, staying somewhere only briefly, turning the radio up, never passing a car, and always avoiding crowds. While these are understandable, protective strategies, they all are based on the fundamental misperception that panic symptoms result in catastrophe. We help clients identify their safety crutches and gradually reduce their reliance on them. As they realize that they can manage the sensations of panic without these restrictions, they are willing to take more risks in the provoking situations.
Do this over and over, in all your fearful situations. To overcome panic, people need to practice their skills again and again, in as many different locations and circumstance as possible. Primary in this effort is to want to feel anxious and to desire to remain uncomfortable for as long as possible. As they change their attitude in this manner, they discover that going face-to-face with panic eventually reduces their symptoms and gives them back their freedom.
When asked about James Braid, Ernest Rossi said, “Braid is the true father of hypnosis (personal communication, Dec. 7, 2001). His work forms the basis of what I’m doing today.” This praise becomes understandable after a quick look at Braid’s contributions. He not only popularized the terms hypnosis and hypnotist; he first explained trance states as the interplay of physiology and psychology.
Historians credit Braid (1795-1860) as both the first researcher of psychosomatic medicine and the father of modern theories of hypnotherapy.
Braid’s work marked the end of Mesmerism, which held that a hypnotist emanated magnetic fluids to invoke trance. Mesmer believed he could ‘mesmerize’ trees in order to hypnotize passersby, reasoning that the magnetic fluid would pass from the trees to the subjects.
Braid debunked Mesmer’s theory by utilizing a simple ocular fix as an induction technique. He had subjects stare at common, household objects and within minutes, they entered a trance state. His studies proved that hypnosis occurs naturalistically within the subject and wasn’t dependent on the showmanship of the hypnotist. He wrote, “The whole (of the induction) depended on the physical and psychical condition of the patient… and not at all on the volition, or passes of the operator” (Braid, as cited in Tinterow, 1970, p. 283).
Erickson often echoed this theme, “Once you really know…that you don’t do it, your subject does it, you can have unlimited confidence…that your patient is going to go into a trance” (Argast, Landis & Ruelas, 2000, p. 55).
Braid asserted that everyone can be hypnotized, assuring his contemporaries that, “success is almost certain.” (Braid, as cited in Tinterow, 1970, p. 287). Braid described trance as a “universal phenomenon” and “a law of our species” (p.288). Erickson was later to concur, stating, “As long as your subject is alive, you can expect some developed trance state” (Argast et al., 2000, p. 55).
In 1843, Braid conceptualized trance as a, “shift of the nervous system into a new condition,” (Braid, as cited in Tinterow, 1970, p. 271) marked by excitement and the mind’s fascination with a single idea. “It is this very principle, of over-exciting the attention, by keeping it riveted to one subject or idea which is not of itself of an exciting nature… and (a) general repose which excites in the brain and whole nervous system that peculiar state which I call Hypnotism” (p. 301).
Similarly, Braid characterized psychopathology as a mind fascinated with a single, negative idea.
“Abnormal phenomenon are due entirely to this influence of dominant ideas over physical action, and point to the importance of combining the study of psychology with that of physiology, and vice versa” (p. 369). He added that, “all the natural functions may be either excited or depressed… according to the dominant idea existing in the mind of man… whether that has arisen spontaneously, had been the result of previous associations, or the suggestion of others” (p. 369).
Braid regarded hypnotism as a “valuable addition to our curative means,” describing it as “a powerful and extraordinary agent in the healing art,” while cautioning that it wasn’t a “universal remedy” (p. 272). About hypnotherapy, he believed that “the imagination has never been so much under our control or capable of being made to act in the same beneficial and uniform manner by any other mode of management hitherto known” (p. 272).
Braid also detailed the first list of naturally occurring, hypnotic phenomenon: eye movements, pulse and respiratory changes, and catalepsy. He stated that, “All the (hypnotic) phenomena are consecutive” (p. 307). He reported an “extreme acuteness of hearing during the first stage of hypnotism” and advised “allow(ing) the hearing to disappear, by which time all of the other senses will have gone to rest…I allow all of the senses to become dormant and then rouse only the one I wish to exhibit in the state of exalted function, when operating carefully” (p. 312).Braid wrote poetically about how subjects find a somatic balance so they do not topple over. “They acquire (a) center of gravity, as if by instinct, in the most natural and therefore in the most graceful manner ” (p. 305). He added that because of this “faculty of retaining any position with so much ease, I have hazarded the opinion that the Greeks may have been indebted to hypnotism for the perfection of the sculpture” (p. 305)References:
Argast, T., Landis, R. & Ruelas, G. (2000) Now You Wanted A Trance Demonstrated Today. Laguna Nigel, CA: SCSEPH
Tinterow, Maurice M. (1970) Foundations of Hypnosis: From Mesmer to Freud. Springfield, IL: Charles C. Thomas
Tom, a young adult, has had bipolar mental illness with episodes involving complex paranoid delusions. He had been hospitalized four times during the eight year interval since his diagnosis and the time I saw him. Tom’s latest admission followed a trip, with his parents, in December, 1991. Tom’s delusions intensified, on that trip, and he believed the name of a town where they had stopped (Winslow, Arizona) held a special message for him. He walked the streets through the nights, “circling around a U-turn exit and ending back at the hotel.” Tom said he could “…WIN the battle if he went SLOW.”
After his admission, I met with Tom to discuss that experience. He spoke frankly and with a look of fear in his eyes. I remembered an example in which Erickson discussed the choice of not confronting a patient (1) and decided not to confront Tom’s delusions at that time. After his improvement and release, Tom was tapered to monthly sessions. Two years later, he continued to have thoughts about returning to Winslow despite his overall absence of symptoms. I gave him an assignment of writing the Chamber of Commerce of Winslow, utilizing the reality of Winslow to confront his delusional memory. The following month, he reported he had not done this homework assignment, and that he “had not thought much about Winslow. Reality catches up with you. I guess I’m enjoying reality. Why should I take a trip down memory lane when I could take a real trip to Key West?” Currently, Tom is stuck in a new dilemma which is more reality-based and more congruent with post-adolescent searching. “I’m living a mundane existence. I’m living in the present and not in the future. However, I have started going out with my friends after work. I have accomplished one of my major goals which was to move out of my parents’ home and live independently.” I concluded this session by waving my hand towards the end of the couch and asking him if he could imagine a little baby learning to walk, leaning against the arm of that couch right there.
He nodded affirmatively. I carefully helped him visualize that child learning to take his first step. I emphasized that the adult knows what the child will do in the future, but the child doesn’t. At first the child tries to stand, ever so cautiously, staggering and falling on his bottom. Learning occurs through trial and error. I told him, “I know you soon will be able to walk. You try to take a step and falter, but you try over and over again. And then you learn to walk. As you continue growing and changing, more self-confidence is gained.”
The next month, Tom returned to my office saying he needed to return to Winslow in order to go ”full circle and bring closure to that episode.” He added that he always returned to the sites of his psychotic episodes. At this time he held a job as a waiter, but had been thinking about leaving the position stating: “I can’t be a waiter all my life.”
I inquired how long he wanted to be a “wait-er?” He didn’t know so I asked again. “How long are you going to be a WAIT-er?” Returning the emphasis, he replied “I guess I’ll have to be a WAIT-er until I make the trip and go full circle.” At the conclusion of the session, he reflected “I feel like I was in a tribulation stage for several years. I have now been in a waiting stage for nearly three years. I’m not sure when this waiting period will be over, but the next stage will be a moving-on phase. Maybe I’ll move to another city and settle down. Maybe it’ll be Winslow.”
(1) Erickson,M. (Rossi, E., Ed.). Innovative Hypnotherapy: The Collected Papers of Milton H. Erickson on Hypnosis, Vol. 4 1980. New York. Wiley & Sons. pp 70-74.Comment on the Case of Tom
by Harriet E. Hollander, Ph.D. The Milton H. Erickson Institute of N.J.
Tom has been diagnosed with a Bipolar Mental Disorder and exhibits its classic features. His illness began in late adolescence, and he has short-term psychotic episodes following psychosocial stress. Trips to strange cities and disruption of significant relationships with family are characteristic symptoms. Delusions may persist in remission and are seldom treatable by direct confrontation.
Medication, along with psychotherapy,i s the current treatment of Bipolar Disorder. Many of Erickson’s colleagues and students believed that Erickson had little use for medication even in the treatment of major mental illness. In her speech to the Ericksonian International Congress, 1994, Mrs. Erickson clarified Erickson’s view on psychopharmacological interventions to mental illness. She told the audience that Erickson, whose strategic interventions with psychotic patients were deservedly famous, placed little faith in the use of medication, mostly because the medications then available didn’t work. Certainly, she indicated, he would have prescribed medications which were effective and could help the patient.
Many individuals who might benefit from psychopharmacological treatment refuse it for a variety of personal reasons, leaving the therapist to rely on behavioral strategies. This history does not state whether or not Tom was on medication for his disorder. The psychotherapeutic approach taken by the therapist stands on its own as a thoughtful and empathic strategy to stabilize the psychosocial stresses that might have triggered further manic episodes.
The therapist gives his attention to the patient’s age-appropriate effort to individuate and separate from his parents and become an autonomous adult. He makes use of a metaphor with many levels of meaning when he suggests hypnotically to Tom that he imagine a little baby learning to walk, imagine the little baby learning to fall, and succeeding through trial and error. He draws the analogy with Tom’s courage to take the natural steps in his development even if he can’t anticipate where his steps will lead in the future. Tom had the delusion that the town name “Winslow” has a special message for him-“win slow”. Doke did not deal with this directly. The homework assignment of writing the Chamber of Commerce was designed to allow Tom to understand, on his own, and willingly, that ”Winslow” was merely the name of a town.
Doke kept “win slow” in his mind. When Tom began talking about returning to Winslow, Doke used Tom’s play on words which had created the “special message” as a base for an intervention. As Tom talked about his job and his future, Doke asked, “How long do you want to be a ‘WAITer’?” Meaning was created on both the rational and irrational levels in Tom’s own style of communication. The question, which Doke wisely did not explain furlher, was loaded with a directive for action. The patient’s response testifies to the efficacy of Doke’s intervention. Erickson’s rationale for not confronting a patient’s delusions directly and aggressively is set out in an article coauthored with Jeffrey Zeig in the Volume referred to by Doke: (pp 34-35).
Man is characterized … by cognition and emotion, and man defends his intellect emotionally. … All people defend their ideas whether they are psychotically based, culturally based, or nationally based or personally based… the first thing in psychotherapy is not to try to compel him to change his ideation; rather, you go along with it and change it in a gradual fashion and create situations wherein he himself willingly changes his thinking.
The case presented above shows a thorough grasp of this principle and is part of the therapist’s respectful approach to his client and his willingness to protect the patient’s personality while also making change inducing treatment interventions. The patient begins to conceptualize his journey through life as stages in which he moves forward.
Editor’s Note: Tom had been under the ongoing care of physicians since his initial hospitalization. He had received a variety of medications, none of which was entirely successful in controlling his symptoms. Following this case report, Mr. Doke reported that Tom drove through Winslow and talked about the event, as if it was unremarkable. Even though Tom remains seriously ill, his psychotic episodes have become less frequent and his social development has continued.