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Anxiety! Why We're Anxious and the Secret to Getting Better

Here is what I discovered about how to treat anxiety.

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Anxiety and its next of kin, fear, are arguably the oldest, most basic human emotions, bequeathed to us by a vast history of prehominid ancestors. We owe our survival as Homo sapiens to these emotions, which were literally built into our nervous systems as an evolutionary hedge against extinction. Yet today, while still protecting us from genuine danger, they’ve morphed into a multitude of extraneous and dysfunctional afflictions—panic disorder, obsessive-compulsive disorder, phobias, and all-purpose generalized anxiety disorder (summoning up anxieties on any and all occasions)—the only effect of which seems to be to torment us pointlessly.

When I began my practice, psychotherapists still knew precious little about anxiety, even though it was probably the commonest form of suffering among the clients we saw. By and large, it was considered a symptom of some deeper psychodynamic process, and analysts helped clients find the deep-seated meaning behind their fears. The working Freudian hypothesis of agoraphobia in women, for instance, was that they withdrew to their homes out of an unconscious fear that they’d become prostitutes.

It wasn’t until the 1960s, when behavioral psychologist Joseph Wolpe’s experimental research perfected relaxation techniques and systematic desensitization, that anxiety began to be treated as a separate problem. To treat a fear of dogs, for instance, Wolpe taught the patient how to become deeply relaxed. He then introduced imagery that evoked a weak anxiety response, such as seeing a dog from a great distance and chained behind a fence. Relaxation procedures counteracted the anxiety produced by that image until it no longer distressed the patient. Wolpe would then introduce a slightly stronger anxiety-provoking image, such as being 20 feet away from a fenced-in dog, until it, too, ceased to arouse anxiety. Progressing up the hierarchy of fears about dogs led to recovery.

When it came to working with anxious clients, my own biggest asset was my experience, early in my career, of treating chronic pain patients in a hospital setting. I discovered that there were a number of similarities between the way people handle chronic pain and the way they handle anxiety symptoms. Those in chronic pain will anticipate their next pain episode with dread, so even though an episode might last only 10 minutes twice a day, it can dominate a pain patient’s waking hours.

Once I realized that I could substitute “panic attack” for “pain episode,” I began to get my bearings on treating the panic in agoraphobics, who’d started getting referred to me after a series of stories in the national media gave the condition a label for the first time. At first, I’d been hesitant to accept these referrals, but soon changed my mind. “Wait a minute,” I thought, “I know something about this.” Soon I’d cobbled together a treatment procedure.

I started by teaching agoraphobic clients formal relaxation, although I knew from my struggles with pain patients that, while relaxation could help some, it would never be enough. Additionally, I expected to use systematic desensitization, because it had worked well for the few clients I’d seen who’d had specific phobias. But with clients who feared panic, the method failed me. Since a panic attack arrives so unexpectedly, the client instantly becomes aroused to the highest degree and feels out of control. I couldn’t seem to undo that reflexive response by pairing relaxation with anxiety-provoking imagery of the event. Clients felt too scared to trust that these relaxation and desensitization skills would protect them.

I had to shift my thinking. I couldn’t help my clients undercut the intensity of their fear through some formal procedure in my office. Instead of progressing up a list of anxiety-provoking situations, I needed to focus on the on-off switch of panic. These clients either avoided their anxiety and felt comfortable or faced the threat and zoomed up to peak anxiety. I had to address the moment of panic. When you anticipate an anxiety attack, you desperately want something you can do that will bring immediate relief. I figured my primary strategy needed to focus on skills for responding to the actual feeling of panic.

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