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50 Tools for Panic and Anxiety -- page 14
by Monica A. Frank, Ph.D.

Exposure methods are a more intense form of treatment and typically require the aid of a therapist with expertise in treating anxiety to create, modify and implement an effective plan.

Index to 50 Tools

Listen to 50 Tools


Exposure Methods (cont.)

Suggestion 39: Act “As If”

One type of exposure is to act “as if” you did not have the anxiety. In other words, to do what you would do normally if the anxiety was not present. This type of exposure addresses the avoidant behavior and confronts the anxiety. If you have panic attacks while attending meetings, for instance, instead of avoiding the meeting or sitting close to the door you would attend and participate in the meeting in the same way that you would if you didn't have anxiety. In a sense, this is a mindful approach in that instead of focusing on the anxiety thoughts you focus on participating in the meeting. Although this method can be helpful in low level anxiety situations, it may not be very effective when the anxiety is particularly high. However, it can be combined in a step-by-step fashion similar to the systematic desensitization in which you practice it in easier situations and then gradually try it in more and more difficult situations. Read article for more info: Understanding the Act “As If” Concept for Anxiety Treatment

Suggestion 40: Express Yourself Assertively

It may seem odd initially that being assertive can be an exposure. However, as explained previously, exposures involve confronting anxiety. For many people with anxiety disorders, direct and assertive communication can create anxiety. In particular, for some people the unwillingness to be assertive can trigger or worsen panic attacks. For instance, if a person is experiencing internal conflict about a situation such as being pressured to stay at work when her daughter is participating in a special event, the inability to say “No, I can't” can lead to increased anxiety or even a panic attack. So, as you may see in this example, although being assertive may cause anxiety, not being assertive may lead to even more anxiety. This is an example where many people may avoid the short-term discomfort of being assertive only to have the consequence of increased anxiety because of the internal conflict. Many people already know how to be assertive but avoid it due to the discomfort. However, others do not know how to assertively communicate. If that is the case for you, the first step with assertive communication is to learn and practice the skills. Many times I've seen clients balk at being assertive when they think about it in general terms but when we practice the specific method they feel less anxious. For instance, in the above example of being pressured to stay at work, they might be thinking “I can't tell my boss 'no.' It will look bad on my review.” However, if we develop and practice a specific statement such as “My daughter has an important event tonight. Is it possible for me to do this tomorrow?” they are more likely to think “Oh, I can do THAT!” Oftentimes, just planning how to respond specifically can make it seem possible to do.

Suggestion 41: Tolerate the Anxiety

Panic Disorder has often been referred to as the “fear of fear.” In other words, the person is anxious about feeling the symptoms of anxiety such as the increased heart rate, breathing rate, dizziness, etc. As a result, more anxiety is experienced affirming the person's belief that the feelings of anxiety will only lead to a worsening of the condition.

This cycle of anxiety needs to be broken to gain control over the Panic Disorder. The fear of anxiety only creates more anxiety. The fear of having a panic attack creates more panic attacks. By reducing the fear of anxiety, the anxiety itself is more likely to reduce. Panic attacks may even disappear when you are no longer fearful of them.

How can the fear of the anxiety symptoms be reduced? All the exposure methods have as the goal the reduction of the fear. However, this particular method of tolerating the anxiety specifically is focused on feeling the anxiety symptoms.

The process for this method is to gradually increase the time that you can tolerate the anxiety without using the anxiety management tools to reduce it. When you use this advanced method you should already have some mastery with using the anxiety management methods to reduce anxiety. However, instead of immediately using these tools you allow yourself to experience the anxiety symptoms.

You may notice the connection between this technique and the advanced mindfulness practice. Instead of getting rid of the unpleasant sensations of anxiety you allow yourself to “be” with the sensations for longer and longer periods of time. In this way you learn that the anxiety may be unpleasant but it is not harmful.

Initially, start with very short periods of time such as a minute or so. Increase the time gradually until you are confident that you could tolerate the anxiety indefinitely. At that point you are no longer fearful of the symptoms and are unlikely to create additional symptoms due to your fear of the anxiety symptoms.

This method can be paired with other methods such as systematic desensitization. If you are doing systematic exposures, you can combine tolerating the anxiety with the exposure rather than immediately trying to reduce the anxiety. For example, if you are doing exposures to driving you can allow yourself to feel the anxiety while driving before you use your skills to reduce the anxiety. Over time you can gradually increase the length of tolerating the anxiety while driving.

Suggestion 42: Structured Worry Time

The method of having a scheduled time to worry is for those who are worrying all the time and can't stop even though they know the worry is unproductive. This is considered an exposure because the gradual process of reducing worry time may increase anxiety. In particular, although this may not be obvious at first, worrying is often a distraction from anxiety. I understand that most people who worry are likely to disagree with this statement “No, it is the worrying that causes my anxiety!”

However, I would suggest that for chronic worriers, the anxiety is already present and that the worrying provides a focus for the anxiety. Even though worrying is unpleasant it is more comfortable than experiencing diffuse anxiety without an explanation. Therefore, when a person attempts to stop or reduce worrying they are more likely to experience more anxiety initially rather than less. Which is why the structured worry time method is an exposure.

The method is quite simple on the surface. Instead of worrying throughout the day you establish a certain time that you will engage in worrying. The amount of time may vary for each individual but the point is to have a time where you completely focus on your worries. Then, throughout the day when a worry occurs you tell yourself, “I will save that worry for my worry time but I don't need to focus on it now.” If just telling yourself isn't effective enough you may need to write it down. The Worry Box app provides a simple method for doing this. Although the method is simple, initially it may cause increased anxiety. Therefore, you need to have a plan to cope with the anxiety. You need methods throughout the day when you put the worries away as well as anxiety management after your worry time. Throughout the day the mindfulness methods or short stress management techniques are helpful. After your worry time it may be good to do some cognitive restructuring related to the worries and some deeper relaxation.

The idea with structured worry time is to increasingly shorten the time and eventually to eliminate it. This may need to be done in a stepwise fashion similar to the gradual desensitization described previously.

Some people may find the structured worry time is paradoxical. In other words, when they try to worry during their worry time they may have trouble worrying. This may be due to finding that the worries are no longer important or that the structured worrying is not very satisfying. It is okay if this occurs but continue with the worry time until you no longer engage in the worries throughout the day. READ MORE: page 15

Kindle Books by
Dr. Monica Frank

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