On day 5 of the Problogger challenge, a post to answer one of the questions that came up a lot when I askied for things you’ve always wanted to ask a psychologist: how to overcome anxiety.

First, you are not alone

I wasn’t surprised that anxiety was a common theme. Anxious feelings are extraordinarily common and takes a lot of forms. If I asked, 90% of you would say that you sometimes feel anxious, and the rest of you either didn’t understand the question or you’d just be wrong.

Anxiety disorders – that is, a clinical condition based on anxiety that is severe enough to often get in the way of daily life – are less common, but still happen a lot. About a third of the US population experiences a diagnoseable anxiety disorder in their lifetime, and about a quarter of those would be considered severe (for those of you who like all the geeky details, go here at the NIMH). I’ll put the numbers in perspective: if you’re hanging out with 2 friends, one of you is likely to have an anxiety disorder sometime in your lifetime. That should make those of you convinced you’re the only one feel a little better.

But it might not, since you are, after all, anxious.

Here’s what doesn’t work

The thing about severe anxiety is that, if you knew how to make it better, you almost certainly would. Here are four “helpful” things people say, that won’t work:

  • “There’s nothing to worry about”
    Great, thanks, now I feel so much better. 
  • “Get over it”
    Thanks, I wish I would have thought of that sooner.
  • “Well, you just need to get to the bottom of it!”
    If only I knew.
  • “Don’t think about it.”
    Try this: don’t think of a blue monkey.

Two steps to overcome anxiety

What does work is always – and you hardly ever hear a shrink say anything in the absolute – always some form of exposure and response prevention (ERP). That’s a fancy way of saying that you need to do the things that make you anxious (exposure), and you have to do something different than you’ve always done (response prevention).

Step 1: Exposure.

Every time you avoid the thing that makes you anxious, your brain says, “See, I told you that was bad. I feel better not doing it, so it’s better to avoid it.” You simply cannot get over what makes you anxious without being exposed to it, because avoidance is self-reinforcing and self-perpetuating.

Then again, simply being exposed to something doesn’t make you less anxious. If you’re afraid of spiders and I put a spider on your desk, you’re more likely to burn the house down than to magically feel better. So you can’t get better without exposure, but the exposure needs to be graduated enough to allow you to learn new ways to cope.

Step 2: Response Prevention.

There are different ways to do this, but the goal is always the same: you need to learn some new way of responding. It might be that you learn to become physically relaxed, instead of tense, when you think about what makes you anxious. Simpler to say than to do, but with practice and some coaching you can learn it.

Sometimes you get creative and see things from a new perspective. I once had a client who was terrified to get on an elevator because she was afraid of enclosed spaces. The problem was that she worked on the 50th floor of her building. I taught her relaxation, and we worked our way through a personalized hierarchy of steps, a method called systematic desensitization. The hierarchy is unique to the individual, and runs from least anxiety provoking to most. For her, step 1 was mentally imagining walking into the building, and step 10 was physically being on the elevator with the doors closed. She worked through the steps beautifully, until we got to step 8, which was stepping on the elevator.

Nothing seemed to work to help her stay relaxed through that step – no matter what, she just couldn’t stand the sight of the open elevator (we were practicing with the elevator in the 3-story building where I worked). In a moment of inspiration/desperation, I had her turn around and get on the elevator backward. Since she didn’t have to see it, she felt less afraid – no one said this was a rational process – and we were able to work through the rest of the steps.

If at first you don’t succeed, try something else

There are other things that work similarly. For one man who was afraid of speaking in public, I suggested they imagine everyone in the audience being in their underwear (I stole that from somewhere, but it’s a little like the Boggart cure in Harry Potter). Afraid of driving over a bridge? Whistle Y.M.C.A. or some equally dumb song while you drive.

You get the idea: to overcome anxiety, work your way up to doing the thing that makes you anxious, but do it in a new way. That’s the heart of ERP.

Finally, a couple of caveats

  • This is a blog post. It’s accurate, but simplified, and not a substitute for hard work and/or professional help.
  • When you need help, find a competent therapist, one who understands the point of ERP. I’ll write about picking a therapist another time.
  • Sometimes medicine helps, at least temporarily.
  • Some forms of anxiety disorder are complex enough that it takes some time to sort out; for example, Generalized Anxiety Disorder and PTSD.  In both of these, the process of working through ERP is different, but the principles remain the same.
  • Last, but not least, “stress” is not an anxiety disorder, and sometimes worry is realistic. If you are deeply worried about money because you lost your job, it doesn’t mean you need treatment: you need income, assistance, and ideas about how to manage limited resources. If you live in a high-crime area and worry for the safety of you children, you need ways to cope with actual threat. Social ills don’t require psychotherapy, they require societal solutions.

Dr Les Kertay

Have a question you’ve always wanted to ask a shrink but were afraid to ask? I won’t do virtual therapy, but I’ll do my best to answer. Leave me a note or send me an email. Have you been able to resolve a psychological problem in a creative way? I’d love to hear about it, and I bet others would too.

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