Treatment

Part III

Component #4: RELAXATION, IMAGERY & BREATHING: (RIB)

Relaxation: Research I have done over the years suggests that many practitioners who treat anxiety disorders (especially panic disorder), consider relaxation techniques to be an important component of treatment (Bourne, Edmond J., 1995, The Anxiety and Phobia Workbook; see chapter 5 in Psychological Treatment of Panic by Barlow, David H. and Cerny, Jerome A., 1988).

This is why: The unpleasant effects of anxiety can be better tolerated and more easily managed by teaching people how to relax. Therefore, they feel it is essential that clients learn at least one of a number of structured relaxation techniques. The methods most often used by psychologists and other therapists are:

• Progressive Muscle Relaxation (PMR);
• Visualization (e.g., of peaceful scenes);
• Guided imagery;
• Meditation;
• Autogenic Training.

It is common sense that learning how to relax would be helpful to those who experience undue anxiety. I am certainly not denying this point. However, I believe several problems arise when structured relaxation methods become a necessary part of the formal treatment protocol. These problems shall now be briefly addressed:

First, by including structured relaxation techniques (e.g., PMR) as part of the treatment paradigm, I believe an implicit suggestion is being made – namely, that the anxiety clients experience is not tolerable. Or, perhaps worse, that learning relaxation technique(s) is essential to the management of anxiety.

As a therapist – if you were my client – I would not intentionally give you these messages. On the contrary, I would emphatically give you the opposite message: that your anxiety is tolerable, and that, with the attainment of greater mastery and control, it will become increasingly manageable and less problematic for you.

Perhaps most important, by learning to better tolerate anxiety you will realize that it won’t matter if you experience an anxiety episode at some time in the future. Why not? Because it will be clear to you that anxiety doesn’t have to be incapacitating or highly disruptive to your life. In effect, you’ll know that you can handle it! This realization will help you cope with anxiety more effectively, and generates several corresponding psychological benefits of immeasurable importance.

As your ability to manage anxiety increases you will gain a sense of increased internal security; this means that gradually, you will feel more self-reliant and less dependent on others for emotional stability. Another benefit of achieving greater mastery and control over your anxiety is increased psychological strength; having greater psychological strength will enable you to cope with stress more effectively, resolve problems more easily and better manage the responsibilities and pressures of daily living. Finally, as your confidence and ability to deal with anxiety increases, you will attain greater freedom from the fear and apprehension that sometimes occurs prior to an anxiety episode (especially panic attacks). Put another way, the likelihood of your experiencing the unpleasantness of “anticipatory anxiety,” will also decrease dramatically. Importantly, this conclusion is based on both personal and clinical experience. It also is, in my view, irrefutable proof that anxiety can be effectively managed and controlled without the necessity of having to learn and apply structured relaxation methods. I’m sure you’ll agree that the psychological benefits mentioned above are significant and well worth striving for.

Second, in order to derive any actual benefit from relaxation methods (e.g., meditation), one must devote both time and effort to learn and practice the techniques. This is not an easy thing to do. It is especially difficult in today’s “hustle-bustle” world, where time is a precious commodity.

Lastly, assuming one has learned a particular method of relaxation, one must then be able to apply it in each instance where anxiety becomes problematic. Sometimes this is simply not feasible. Imagine, for example, that you are in a church or restaurant and suddenly, without warning – as sometimes happens – an anxiety episode occurs. What do you do? Realistically, could you rely on relaxation techniques to cope with the situation? I think you’ll agree that the answer is no. In these situations (and countless others), it is simply not practical – nor even possible – to immediately self-induce a state of relaxation in order to cope with anxiety.

With this in mind, perhaps now you better understand why structured relaxation techniques are not typically a part of my treatment protocol. Most importantly, it is why I urge my clients to adopt the mantra (yes I’ve said it before): “MASTERY AND CONTROL IS THE GOAL!”

Before we move on to the topic of imagery, allow me to offer an important clarification concerning the subject of relaxation. I understand, of course, that relaxation can promote certain healthful benefits. Knowing this, I encourage my clients to invest time learning how to become more relaxed. In some instances I recommend the practice of meditation. I am an ardent proponent of meditation because most people who meditate regularly report substantial benefits from this practice. With time and dedicated effort, daily meditating helps reduce overall stress levels while promoting an enhanced ability to feel more relaxed and “centered.” So, if you can incorporate mediation into your health regimen, I heartily endorse it. If you cannot, however, an alternative would be to focus on three important goals:

1. Find ways to reduce stress, such as exercise.
2. Work toward easing tension; don’t allow conflicts to linger and remain unresolved.
3. Become more self-nourishing; take better care of yourself, physically, mentally and emotionally, while increasing the time spent engaged in recreational activities.

It should be apparent that these are highly important mental-health-related goals worth striving for. In my work with clients, we discuss various ways they can modify their current routines and incorporate these vital practices into their daily lives and regimens. When they are successful in doing so, they usually report feeling less anxious and more in control overall. This is not surprising, considering the relationship between stress, tension, and anxiety. As stress and tension levels decrease, very often so does anxiety!

Imagery: The great physicist, Albert Einstein, once said that “imagination is more important than knowledge.” As if to prove the point, although it is perhaps little known, Einstein relied on his vivid imagination – as well as mathematics – to discover some of the fundamental laws of the universe. Not surprisingly, he realized that imagination is a powerful mental tool.

This is especially true if, like Einstein, you spend time imagining elevators (or trains) hurtling through space at the speed of light. In a similar sense, I encourage my clients to use imagery in order to help them better manage their anxiety. Like imagination, imagery can also be a powerful instrument of the mind.

Simply put, imagery can be defined as: a mental process of creating or generating pictures in the mind. Because it can be very helpful to clients at times, I use imagery fairly regularly with them. I refer to one technique in particular as my roots metaphor. Here’s how it works: During one of the didactic sessions, I take a piece of blank paper and, from the center, draw a series of long straight lines next to one another. The picture resembles the below ground roots of a tree.
I then show the drawing to the client. As he/she studies it, I usually say something like, “This drawing illustrates, in a simplified manner, the basic process involved in the transmission of neural impulses. The lines represent the pathway of these impulses as they travel deep inside the brain. Now, try to imagine that these lines are like roots of a tree. The roots start small, but as they grow, they thicken and lengthen, implanting themselves deep into the soil. And once this happens the tree becomes very strong and firmly set in the ground.”

Usually clients have little difficulty grasping this. I then go on to say, “now imagine that the anxiety you experience occurs in the brain as a series of neural impulses. These impulses travel slowly at first, but then accelerate, reaching deeper parts of the brain as they journey.

Now the most important thing for you to understand is this: “Just as the roots of a tree grow stronger and deeper with time, so it is with anxiety. As the neural impulses travel faster, reaching deeper levels of the brain, your anxiety also gets stronger and harder to exert mental control over.” I then ask my client if this makes complete sense to him.
Invariably it does. Finally, I introduce the notion that he can use this technique to gain some control over his anxiety. I usually put it in the following way: “Okay, now that you understand the metaphor, the final step is to apply it at the right time.” At this juncture I ask the client the all important question: “At what point in an anxiety episode (or panic attack) do you think you’re likely to have the best chance of controlling it?” Without hesitation, the response I get is: “In the very beginning.” I then make the suggestion that the technique should ideally be applied as soon as the client recognizes the signs or sensations associated with an anxiety episode. Once they learn how to do this (i.e., become aware of an impending episode), the next step is to implement the technique.

I tell the client that the moment he or she senses that an anxiety surge is imminent, he or she is to imagine the roots as being very thin and short. I go on to say, “Alright, now that you can see the roots in your mind’s eye, I want you to try to interrupt the growth process. With a minimum of mental effort, try very gently to visualize the roots being drawn back toward their center. Remember though, the idea is not to resist or struggle. Simply focus your attention on the image of the roots. Gradually, you will be able to visualize the roots receding toward their center, and, as this happens, your anxiety will diminish proportionately.”

After reading about this visualization exercise, you may be wondering whether the technique really works. I am pleased to tell you that YES, it really does! And best of all, there are other techniques that are equally effective. But we’ll save that for another time........

Breathing: Have you ever been on an airplane and seen a passenger crying or nearly hysterical, while breathing rapidly into a paper bag? I have. As a matter of fact, at the time I viewed this very event, I immediately approached the passenger (a young woman in her late twenties), in order to assist her. What do you imagine she was experiencing? If you guessed a panic attack, you were right!

The timing of the episode, however, was a little unusual because the plane had been in flight for some time. Normally, panic episodes occur nearer to take-off, rather than in mid-flight. Let me share with you what I did to help her.

First, I sat down next to her and told her to look directly at the point between my eyes (in order to facilitate what is called one pointed attention). Then, while keeping her attention focused on this spot, I suggested she try to decrease her rate of breathing by taking slow, deep breaths. I softly instructed her to breathe from her abdomen, and to notice the sensation of her stomach gently rising and falling. Finally, I gave her the suggestion that with each breath, she would experience increasingly greater relief from the intensity of her anxiety symptoms. Over the next ten minutes or so, she did feel better. She had calmed down considerably and was relatively OK – though certainly quite shaken and confused – during the remainder of the flight.

Importantly, this actual incident illustrates that deep, abdominal breathing is often an effective means to temper the highly unpleasant symptoms of an anxiety episode (e.g., rapid heart beat, hyperventilating, sweating, etc.).
If done correctly, it can offer almost immediate relief. Additionally, and perhaps best of all, abdominal breathing requires little effort. It can also be performed in virtually any setting, at any time.

It is for this specific reason that I encourage my clients to learn how to do it, and to actively practice the technique on a regular basis (especially those persons who have weak coping skills or are susceptible to severe panic episodes).

Finally, if you’re wondering why deep breathing helps, the reason is this: When people hyperventilate, or breathe in short rapid bursts, the amount of oxygen in the bloodstream increases. This creates an imbalance between the levels of O2 and CO2.

Abdominal breathing actually adds more carbon dioxide to the bloodstream, thus restoring the proper balance. This is why breathing into a paper bag can be helpful (i.e., increases intake of CO2). So, the next time you find yourself in a situation where an anxiety episode seems imminent, remember about deep abdominal breathing. It can help!