WHAT IS RECOVERY?
During my thirty three years as a stress therapist I have treated thousands of clients (both privately and in groups) suffering with acute stress symptoms (physical such as headaches, migraines, gastro-intestinal problems, chronic pain and muscle contraction problems), anxiety disorders including agoraphobia, OCD, depression as well as working with people with bi-polar disorder and post traumatic stress disorder.
I see children as young as 6 years old and my oldest client was 84 years old and had had agoraphobia for 70 years and he made a total recovery. I have worked in counselling couples, teaching anger management to prisoners and have consulted to the Ministry of education working with teachers, psychologists and students.
As you can see my experience is long and wide and, I believe, qualifies me to talk about the recovery process, which I might add can be just as wide and varied as my experience. I have been able to observe first hand the individual differences of clients in recovery and the myriad of factors involved in recovery and relapse.
I hope that my experience and observations, indeed the valuable lessons my clients taught me over the years, will be helpful in some unique way for each of you. There is no one way to recover from anxiety but there are many helpful ways and if I can give you all a little more insight into your own recovery process and a tip or two which may help – then I will be happy for that.
The information which I give you here is my own opinion and does not necessarily reflect the opinion of anyone else – except where I may have borrowed from professional excerpts.
Some time ago, I was speaking with a gentleman who ran a support group for people suffering with anxiety and he was lamenting his frustration that some newcomers to the group only came once, because they were expecting results quickly. I wrote to him to empathise – that as a therapist, I too have been frustrated that some people want a quick fix and, even worse, want me to do all the work and often times to throw in a little magic. I explained to him that the topic of client responsibility in the recovery process is rarely talked about and is often a sensitive one, so we thought it might be a good idea that I speak to his group participants on the subject of recovery. Here is an excerpt of that talk.
So let’s look first at WHAT IS RECOVERY ?
According to the Dictionary of Psychology, “recovery is the period of time between severe symptoms like panic attacks and the cessation of those symptoms for a period of 12 months or more. It is also identified as a period of time that a person is actively pursuing a treatment or support group for their anxiety.”
WHAT IS RELAPSE?
A person is said to have relapsed when symptoms return after a period of time either 12 months after or during recovery. Symptoms of anxiety attacks, avoidance etc. reoccur. Setbacks during the recovery period are a normal part of recovery which is always 2 steps forward and 1 step back with symptoms diminishing over time.
WHAT IS HELPFUL IN THE RECOVERY PROCESS?
Initially when a person experiences prolonged anxiety or panic attacks, the person should see not only a G.P. as soon as possible, but a therapist trained in anxiety treatment. A GP can reassure a person that they aren’t dying and wont go mad, but will usually prescribe a medication which in my opinion often only masks the problem, doesn’t get to the core reasons for the panic, and can cause nasty side effects, often with more anxiety. Once symptoms subside, the person goes back to their frenetic lifestyle only to relapse and then develop a dependency on the medication.
Ideally a therapist trained in anxiety conditions and in Cognitive Behavioural Therapy is preferable to a psychiatrist or other form of counselling. A therapy mode which teaches skills and encourages daily practice appears to work best, as you live your way out of anxiety one day at a time, taking full responsibility for your recovery.
Being around others who have experienced anxiety can be helpful to know you’re not alone and that other normal, intelligent people experience this too and that there is no shame in it. If supports groups are run well, people can be encouraged to explore many different treatment modes but they don’t suit everyone and can often make some people feel worse listening to other people’s symptoms and horror stories. Panic attacks are often so vicious and overwhelming, one usually wants to be rid of them, so treatment is the best option for most people.
It is helpful to have a support person (spouse, friend) to learn the skills to have them encourage and reinforce the skills as well as independence in using them.
PRACTICE – HOMEWORK
Daily practice is vital in the recovery process. One must have total commitment to doing everything suggested by the therapist. Written homework is a crucial factor in recovery as it allows the brain to slow down and expose one’s fears to the cold light of reason. The conscious brain operates at approx. 1200 words per minute – thoughts become too slippery to work things through in your head. We speak approximately 120 words per minute and this is often why therapy feels good – to be able to talk it out, but writing down one’s thoughts slows them down to about 20-30 words per minute which allows the rational, logical and analytical mind to function better and process information more efficiently.
POSITIVE ATTITUDE AND EXPECTATIONS
A positive attitude and an expectation that you will recover are essential ingredients for recovery. Despite agoraphobia’s lengthy history of misnomers, misdiagnoses, mistreatment, lack of understanding in the community and so on, it is possible to recover from the symptoms of acute anxiety. After all, like most cases of depression, the condition only exists as a set of symptoms, which, once the majority have been eliminated, the condition ceases to exist. So it is important to understand this and be willing to work at the problems contributing to anxiety disorders knowing that great progress can be made and indeed being able to live life free of the symptoms again is possible.
A willingness to do everything asked of you in the treatment is vital. When we start a university degree, we give up a big proportion of our social life, t.v., etc. knowing the sacrifice will be worth it in the long run. It is even more important to be willing to give up a few things as well as push ourselves to practice skills knowing that anxiety cannot thrive unless there is a fertile ground for it to grow in and that means dedication to doing it right the first time. We’ll talk more about this shortly.
Dr. Claire Weekes talks a lot about acceptance in her wonderful books on anxiety and agoraphobia. She says that “true acceptance is the keystone to your recovery.” Firstly accepting that you have an anxiety disorder is vital to your recovery. Believing that this is just a short term condition and will go away tomorrow is fooling yourself. Anxiety took a long time to develop and it will take some time in leaving.
Secondly, acceptance that your body will behave in certain ways is important. If you have a virus, you accept a fever, sore throat, aching limbs without too much alarm. I often have to reassure a client who says, “I haven’t had any friends over for dinner for ages.” And I say, “That is normal when you are anxious because your body is trying to heal and it wont feel like entertaining.” You must accept that you have a temporary disability and go with it. Let your body heal rather than trying to put in an extra effort and put more stress on yourself.
When they say, I am so frightened of my heart beating fast – I say, “It’s normal, you have an anxiety condition.” When they say I can’t sleep, I say, “That is normal for anyone feeling anxious. Your brain thinks there is danger out there and is trying to protect you by keeping you on a shallower level of sleep in a state of readiness for flight or fight.” Accept the stomach churning and the phobic thoughts and the tight throat and the crazy thoughts. They are all part of the condition. Relax and focus on what you are doing so that you don’t give in to the fear.
Follow up sessions are essential ingredients for recovery. Follow up sessions once recovery occurs is a good idea to reinforce self-management. Old habits die hard and behaviour modification programs often say that it takes a year as to when one can consider themselves successful in their treatment and recovery. Weight Watchers don’t consider you a success until you have maintained your weight and eating habits for a year. We are the same in my program – that is why regular 3 monthly follow ups are an important part of the program.
Towards the end of my 16 week program, clients are taught goal setting and self management because it is important not to go back to where they were before they began the program. Setting realistic goals, which are able to be accomplished in small manageable steps, gives the client a focus to return to when having a setback or when they are becoming negative. They need to set positive goals for short term medium and long term. Keeping the focus on what is possible and on what is going right. A short term goal might be to remain mindful as often as possible during the day. A medium term goal might include practicing meditation, exercising and going off caffeine. Developing positive scanning techniques to view your progress positively and at the same time learn from mistakes without regret or guilt. Moving toward a different lifestyle takes time and focus and it is also a way of celebrating one’s efforts during recovery, taking on a new identity with improved life skills and beliefs.
WHAT IS COUNTERPRODUCTIVE IN THE RECOVERY PROCESS?
A negative attitude will make you reluctant to try. Self defeating statements such as “I don’t really believe I’ll ever get over this”, or “My friend tried and she relapsed.” are bound to thwart your efforts if you repeat them enough times. Engaging in self sabotaging behaviour will result from doing this, so watch out for the “chattering monkey on your shoulder!
Remember, progress is never linear. It is always 2 steps forward and 1 step back. No quantum leaps are advisable. If someone tells me after two or three weeks that they feel normal again, I am very suspicious and advise them to keep working at it as it is still possible to have a setback. Progress never happens that quickly. Also, one must not compare themselves to others in the recovery process. You all had your different journeys to where you are and so too different ways to cope, different support and so on. Just like school children take different amounts of time to read, so too, you will recover in your own time.
Unfortunately, they do exist. They can come in the form of a spouse, family member or friend. Happily it is not common, but over my many years’ experience, I have witnessed some pretty persistent saboteurs – so much so that we have two sessions dedicated to the support people helping them as well so that this does not happen.
Often people with anxiety disorders have relationships which are delicately balanced with the other person dependent on you being dependent on them. They’ve got used to a role and as you become more independent they can feel usurped, unneeded, and taken for granted and can be unsure of their role.
Sometimes the support person will take out their fears on the therapist. I recall the first time this happened. The husband of a client angrily accused the program of being about destabilizing his marriage. When I asked me why he thought that, he said that now his wife talked back to him and was going to the shops without asking him to take her. Obviously he was afraid she wouldn’t need him any more. Sadly, as she progressed, his efforts to thwart her increased. He would hide the car keys, keep her busy with errands and work around their home and by about the 10th session she pulled out of the program, saying it was easier to be agoraphobic than to have his constant undermining One day she called out of the blue to tell me she was well and no longer having panic attacks. I asked her what had happened and she said her husband had had an accident and was laid up for some time. This meant she had to do all the running around as well as a lot of the work and decision making. Her belief in herself became important as well as her facing her anxiety and moving through it.
Often friends will distance themselves when the agoraphobic becomes well. Accusations that they don’t need them anymore or that they don’t like this new self assured person are common. As a therapist, dealing with saboteurs is frustrating as these same people very often refuse to come along to the program or therapy sessions in order to be reassured that their position is not being undermined.
This is probably the most common reason people do not recover adequately. It never ceases to amaze me that despite my giving very clear guidelines and following up on homework and practice of skills, many clients just will not comply. I must have heard just about every conceivable excuse for not listening to the CD’s, writing homework and practicing the skills. The fact is that some people are not ready to commit and find it easier to avoid practice of the skills or write their homework by visiting a friend or going to their G.P. than to do the work themselves.
Some of the more interesting excuses include: “I didn’t practice my breathing this week because I was too busy.” I assume they were breathing all week, They just had to move their focus to their diaphragm for two minutes a few times a day.”
When informing people they would have to go off caffeine during the program, I am often met with, “I can’t give that up ‘cos I need the kick start in the morning.” Or “I will die without it!” Exercise is not done because, “ It was too cold or I had friends over.” Or the popular one – “I forgot.” Changing behavior is hard for most of us at some time in our life – like losing weight or giving up smoking or becoming more organized in the home. However, it is important to know that what is hard, is to live with chronic anxiety. If an agoraphobic is willing to cook dinner for their family, pay the bills, run the kids to school, entertain friends, turn up for work each day – then that proves they are quite able to meet the demands of others. So why not themselves?
On the bell curve approximately 84% are the majority who will do the homework and achieve good success. A smaller amount of people are very to extremely conscientious and on the other end of the curve, there are those who are not willing to put in the effort, lacking belief in themselves, hoping a miracle will get them well and so they give up. That brings me to the next part of non-compliance which is about pay offs.
Although many clients obtain some secondary gain from their anxiety, such gain is hardly the primary motivation for the anxiety. However, the client does need to be aware of his secondary gains so that he can expect and deal with their loss. The secondary gains for a client vary and a therapist and the client need to work together to see precisely what they are.
When I first started to work with people suffering with anxiety conditions, I could not imagine in my wildest dreams that someone would want to hold on to their anxiety condition for any reason. I refuted such claims by support people, adamantly defending my clients. Then one day a client told me that she believed that part of her problem was that there were certain payoffs which prevented her from seeking help for her condition. She spoke of the relief of not having to take responsibility in the family, not having to make decisions and feeling safe because the family had learned to be protective of her. I was astounded. However, knowing this and seeing it occur more often over the years, has allowed me to structure my program to educate clients about recognising the payoffs and to help them identify which are theirs and to let go of them without fear. Here are just some of the payoffs.
Special treatment. The highly anxious person often has fewer demands made on him. They are excused from public speaking, taking exams, entertaining and so on.
Help. Most people have empathy for a person experiencing anxiety. The help can become an obstacle to getting better. Like my lady who’s husband did everything for her – we can sometimes use a middleman to do things for us such as shopping.
Lack of risk. The payoff may be that with his anxiety as an excuse, he does not have to take a risk and endure the possibility of failure. A client told me he couldn’t teach a new course because of his anxiety. I replied that everyone experiences anxiety around performance, but the difference between those who are successful and those who aren’t’ is that the successful ones keep trying even though they are anxious.
“If only”. An anxious client is able to retain the idea that he is a competent person, and that the anxiety is the only thing holding him back. One client told me he used to fly his small plane down south for work and could go anywhere, any time. He said, “I can’t believe I have this, I am usually a very confident person and I keep thinking it will probably be gone tomorrow.” He justified this as a reason for non-compliance.
Justification. The client may say, “I have to smoke, drink or overeat or cannot do exercise because I am anxious.” The anxiety becomes a rationale for some behaviours he does not want to give up.
Special privileges. The person may use the anxiety to get freedom from those around him. One client who wanted privacy would tell his wife and children that he had to be left alone because he was having an anxiety attack. The client may use anxiety to avoid social duties, (I’m too uptight to be around those people”). Others can often give the anxious person special consideration and let them off their obligations.
Role of victim. An extreme form of secondary gain is found in the clients who take the victim role. This person uses his anxiety to manipulate and control others. The person takes little accountability for his own plight in the world, and instead, blames others and circumstances to an extreme degree. I had a client in the US who wanted to keep me on the phone every day for free therapy. When I used boundaries, she threatened suicide and told me that it would be my fault. The person had well developed skills in getting others to help her. Previous helpers are seen to be persecutors. (Like many other colleagues, I have been accused of being too soft, too hard, not wanting friendship with a client, pushing them on to the next stage too soon, being a home wrecker, not guaranteeing 100% success…). Some people are so invested in their anxiety and see so few other options that they are reluctant to give it up.
My job as a therapist is to point out to a client what payoffs cost in terms of lost effectiveness and human relationships.
Accepting accountability and responsibility is a major part of recovery. Knowing recovery is a self-help process, one must learn to recognise one’s part they play in setbacks and relapse. Believing that the therapist is God and will get them better is counterproductive, though some therapists love to set themselves up as such. Ask questions, challenge ideas that your therapist puts forward. Get fully involved. Some of the best advice I received from my mentors in America in the program was “Don’t expect to cure every person. If you cure one, the program works. Secondly, do not accept bad behaviour and disrespect from someone who uses their condition to do so. There is no reason why good manners and respect cannot prevail.”
Avoidance is probably the most counterproductive behaviour because it is associated with feeling good (relief) and is self reinforcing. Avoidance is an instinctual reflex in times of danger (flight or fight) and helps us to survive when we are physically threatened. However, it is totally inappropriate as a mechanism where perceived threats are concerned. Avoidance brings a feeling of relief, which, when paired over time, becomes habitual. Remember, you only have to think fear to feel fear. The brain does not know the difference between reality and imagination and so the body will react to scary thoughts as though it is happening right here and now. Learning to face the fear using calming techniques is vital so that the association is broken. Systematic desensitisation as well as other techniques like positive visualisation, NLP, EFT, and EMDR can be very helpful to staying in a situation that was once paired with anxiety.
Unbelievably I have had clients who have told me stories of misdiagnosis, cruel treatment, sexual harassment, wrong medications, and over medicating with dreadful side-effects. If you think your doctor is handing out too many drugs, tell him or her or try another doctor. Same with your therapist. You should know if she/he knows much about your condition in your first visit. No wonder people go through the psychological gauntlet with therapists advertising their treatment areas for stress and anxiety with limited training and experience. I would never solely counsel someone for incest or grief or alcoholism as I am not specifically trained in those areas.
There are many different reasons for the onset of anxiety attacks. Some that I have come across over the last 32 years include, a hypoglycaemic condition, lack of vitamin B, poor diet (high in refined carbohydrates), too much caffeine, trauma, (rape, incest, armed holdup), schizophrenia, bi-polar disorder, personality disorders, chronic pain, long term unemployment, medications (pain killers, anti-inflammatories), and drug taking (excessive use of alcohol, nicotine, marijuana and speed.) Treating the symptoms of anxiety should not be taken lightly. A full history of the person’s family history, lifestyle, diet etc. is necessary to know whether to medicate or not and if so, which are more likely to help. There are now many alternatives to medication like St. John’s Wort for mild depression and anxiety as well as natural calmatives which are available over the counter or from naturopaths for anxiety which have been shown to be as effective.
THE IMPORTANCE OF PRACTICE AND HOMEWORK
I am repeating this because there are no short cuts to overcoming anxiety disorders. Anxiety sufferers often have inherited a pre-disposition for having a sensitive nervous system so for you, there are certain things you will react to more readily and strongly than other people will. The same goes for one’s constitution – some can eat anything or never get a cold where others succumb. People who have a sensitive nervous system should not be in stressful jobs, should not take central nervous system stimulants like caffeine or drugs, get plenty of sleep, practice thinking more positively and rationally, exercise regularly, practice time management and learn assertiveness skills. Ideally they should be daily meditators. They should regularly review their goals and learn how to stay in the moment.
They especially need to become more acutely aware of what their stressors are and how to recognise their own stress symptoms. We accept that a person with allergies should modify their house so that they are not exposed to allergens? Diabetics take responsibility for their condition by staying off sugar and sticking to their medications. A lot of previously anxious people believe they should be able to just go back to their frenetic lifestyles, taking responsibility for everyone, not be assertive, drink untold cups of coffee and stay up late and overwork and not have any repercussions.
We all come into this world with individual differences, but surely we must be responsible for our own well-being and that requires that we accept ourselves as we are and at the same time be prepared to put in effort to living as best as we can within our limits – and reaping the rewards of a strong, healthy and happy life.