DEALING WITH ANXIETY:THE TRAP OF REINFORCING THE SYMPTOMJOSEPH A. TRONCALE, MD FASAMRETREAT PREMIERE ADDICTION TREATMENT CENTERS

ANXIETY AS THE MOST COMMON COMPLAINT IN MY PRACTICE• If you could be a fly on the wall in my office, by

far the phrase that I hear the most is: “Doctor, I need help with this anxiety.”

• People are suffering a great deal.• Let us look today at what causes this great

suffering and what we can do about it.• Also let us look at what we should avoid in our

attempts to help.

PATIENTS THAT I SEE HAVE ALREADY BEEN CONDITIONED TO LOOK FOR MEDICATIONS• I work in drug and alcohol treatment, so people

with addictions look for a “fix” in or out of their addiction.

• (This is no different than non-addicts, however. Non-addicts can “get away” with more drug use because they suffer fewer consequences, so it is less of an issue generally.)

• So what should our approach be to anxious people who come for advice, counsel and treatment?

THE OUTLINE FOR TODAY

• What is anxiety?• Do we, as therapists, have a approach that we

feel confident is helpful?• I would like to discuss some pitfalls in the

treatment of anxiety.• I plan to share my experience with the use of

Acceptance-Commitment Therapy (ACT). What it is and how I use it.

WHAT PERCENT OF YOUR PATIENTS PRESENT PRIMARILY WITH ANXIETY?

• 0-25%• 26-50%• 51-75%• 76-100%

HOW IS ANXIETY DEFINED?

• “It is helpful to think of anxiety as a reaction to stress.” Thomas Fogarty, MD

• “a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome”

Oxford Dictionary

HOWEVER…

• We know that anxiety may have nothing to do with an “imminent event”

• It may be just sitting there with no known association or be paired with a past event

• It may be associated with something that will never happen.

• It may be associated with something that would otherwise be considered wonderful by an outside observer.

WHAT IS PANIC?

• Panic is the extreme anxiety of actually worrying about being anxious.

• Anxiety likes to feed on itself and intensifies as one attempts to suppress it.

• It is the “Chinese finger trap” of psychological process. The harder you try to escape, the more surely you are caught and stuck.

SO…

• Can we conclude that anxiety has a timeless quality? That is, anxiety knows no time frame?

• If so, we basically put the parameters on our own anxiety…

• But anxiety is not something that we are able to consciously deal with once it gets past a certain point. Where is “THAT” point?

“THE POINT OF NO RETURN!”

• Think about your own “anxiety breaking point.” • How much can you tolerate before “losing it?”• What situations can you think about in your own life

that have taken you from feeling in control to feeling the inner chaos to feeling fear and reactivity?

• How quickly does it happen? What is necessary for the point of true anxiety to appear?

HOW MANY TIMES HAVE YOU BEEN TOLD: “DON’T WORRY ABOUT IT!”

• “Stop worrying!”• It is like asking the passenger in the back seat

of the car to stop the vehicle.

• More helpful perhaps: “What are your possible actions given the current circumstances?”

CONTROL

• Control is the great illusion of anxiety.• There is no brake, there is no button to push,

there is no computer mouse, no fire extinguisher, no nothing.

• In the end, there is nothing to control anxiety.• But our brain can’t easily accept the fact that

circumstances cannot be manipulated to do what we want all of the time.

SO WHAT DO WE SEE IN THE ANXIOUS PERSON?• Fight or Flight• The common denominators are rigidity,

autonomic overdrive, and fear in some form(s).• It may be physical rigidity or hyperkinesia• It may be psychological rigidity or distraction• It may be relationship rigidity (doing the same thing all

of the time or doing nothing the same all of the time)• It may be communication rigidity (not listening, rapid

speech, too much verbiage)

THE FIVE LAYERS OF ANXIETY ACCORDING TO FOGARTY• Masked anxiety• Anxiety• Depression• Emptiness• Inner Death

• Inner death is the hopelessness associated with the idea that there is only anhedonia from here on out.

CLINICALLY, IT IS IMPORTANT TO RECOGNIZE THESE LAYERS…• To move people out of whatever layer they are

in is not up to us as therapists or doctors, but it is important to support the person where she/he finds him/herself emotionally. If people are paralyzed with fear or anxiety, then medications or hospitalization is indicated. If, however, the person is not to a point of paralysis, then there is the opportunity to work outside of critical care parameters.

“WHY” IS NOT A GOOD QUESTION IN THE TREATMENT OF ANXIETY

• Treating anxiety is generally about diffusing the laser-like concentration of emotion and going two or three feedback loops back in the person’s psychological timeline.

• The psychological timeline should be differentiated from the person’s actual life.

• You may be thinking about something in the future or far distant past which may be the last thing on your psychological timeline.

THE MYTH OF “THE ANXIETY-FREE LIFE”• Anxiety is a part of life, not an aberration.• It is an adaptive mechanism, not a fault• Perfectionism is an escape mechanism, not an

achievable goal.• Catastrophic thinking is not a cushion to keep

bad things from happening, it is another escape mechanism so that defeat is incorporated into what would otherwise be normal life.

TRADITIONAL WAYS OF TREATING ANXIETY• Medicate (either by prescription or by not.)

Something of a quick and dirty solution…• Gets rid of the feeling temporarily• Generally reinforces not dealing with causality

• “Talk it through” (Mostly a temporary fix)• Distract (Escape)

MEDICATION

• Self-medication with alcohol or drugs• Prescription medications such as benzodiazepines can

lead to addiction, but more importantly have a rebound effect of increasing the symptom over time and resetting neurochemical receptors.

• The more gamma amino butyric acid (GABA) receptors you fill, the more you make. The more alcohol or benzodiazepines you use, the more anxious you become when you run out of alcohol or drugs.

WHEN MEDICATION IS ESSENTIAL• For individuals who are suffering with anxiety

secondary to severe trauma, there may be no way of helping the individual until the limbic system is brought down to a “fight or flight” level that is acceptable.

• This can be done with non-addictive medications that calm deep limbic structures so that the individual can begin to work on what will make changes in the anxiety symptoms.

TALKING IT THROUGH

• Talk therapy of various forms can be helpful if it does not reinforce the idea that “talk without change” is useful.

• A good therapist will know how to avoid circular thinking of this sort, but a lot of people talk to non-professionals with their anxiety and it only serves to harden the anxiety.

ENTER ACCEPTANCE-COMMITMENT THERAPY (ACT):• Developed by Steven Hayes and Russ Harris• Third Wave of Cognitive Behavioral Therapy• Basically states that an individual can accept

feelings and move toward values or the individual can escape feelings and move toward suffering.

MOVING FROM SUFFERING TO LIVING• Simple concept, but anxiety ruins it for people.

THE ACT “TRIFLEX”

• There are three behaviors that lead to what is called “Psychological Flexibility”

• These are:• The ability to “open up”• The ability to “be present”• The willingness to “do what matters.”

OPEN UP

• ACT discusses the concept of “fusion”• “Fusion” in the ACT model is, as Russ Harris

says, “Getting entangled with our thoughts and getting pushed around by them.”

• In my opinion, anxiety, without clear and present danger, is the manifestation of fusion. That is, anxiety is the inability to recognize thoughts as constructs rather than as reality.

EXPERIENTIAL AVOIDANCE

• When individuals have uncomfortable feelings, they tend to avoid them rather than face them.

• Who wants to face pain? Yet, if we do not, we store up emotions that will eventually “come out sideways.”

• The “beach ball” analogy.

DEALING WITH FUSION

• Creating awareness of experiential avoidance:• What are your thoughts when you are anxious?• If you kept a diary, what percent of the time would you

be anxious?• What do you struggle with in your thoughts?• What do you do to resolve the issues?• What negative talk to you hold on to?

NEW THOUGHTSNEW MANTRAS• The Three-Chair Exercise in Emotion-Focused

Therapy• Set up three chairs• Have the patient (Jim) sit in chair #1• “Jim #1, talk to Jim #2 and tell Jim #2 all the negative

things you tell yourself about yourself. Now move to chair #2 and Jim #2 defend yourself to Jim #1.

• Move client to chair #3 and have Jim #3 speak compassion to Jim #1 and Jim #2.

• What will you get?

ANXIETY BRED FROM SELF HATRED AND NEGATIVE SELF TALK• Trying to keep people out of chair #1 and chair

#2.• Putting oneself down and defending oneself in

an exercise in futility, anxiety and primitive thinking.

• Only by sitting in chair #3 and practicing self-compassion can one achieve an anxiety free state.

BE PRESENT

• We all know about mindfulness.• It is important that we help train our patients/clients

in the discipline of staying in the present moment.• There are 4 states of being in this paradigm.

• Past (associated with shame and guilt)• Future (associated with anxiety)• Nowhere (associated with escape into numbing,

perfectionism, overwork, catastrophic thinking)• The Present (what is at the moment)

DO WHAT MATTERS

• What is a value-driven life?• How do you identify what you value?• Are you escaping your feelings and moving

away from your values or are you actually doing what YOU want to do?

• The “bus-driver” analogy

WILLINGNESS IS NOT THE SAME AS TRYING• “Trying is Dying.”• Many of my patients tell me that they are going

to “try” to make the changes we have suggested.

• Saying “I’ll try” is a socially acceptable response to suggestions, but it does not cut the mustard with regard to ACT. Willingness is the key whether we are talking about changing addictive behaviors or anxiety-associated behaviors.

IN CONCLUSION

• Anxiety is suffering• Suffering is a part of life• Some forms of anxiety require medication• Most forms of anxiety require a willingness to

“unhook” from feelings, move toward values, and stay in the present.

• It takes practice and discipline as well as the belief that change is possible.

THANK YOU VERY MUCH

• Joseph A.Troncale, MD FASAM• Retreat Premiere Addiction Treatment Centers• josepht@retreatmail.com