How Anxiety works:
I like my anxiety how I like my spice.
Not too little, not too much.
Anxiety is a signal in our bodies telling us to pay attention--either to something happening in our environment, or something shifting within ourselves. It guides us toward information that--at its best--is adaptive and helpful in our daily functioning.
Anxiety is a normal human emotion. We need anxiety. We should feel anxious about that test. We should feel anxious about that date. We should feel anxious about that job interview. In each of these areas, a moderate amount of anxiety can enhance our performance--we think on our feet, we're alert, we're able to be responsive to the moment. Feeling no anxiety at all would be detrimental to our survival as a species. Consider Exhibit A:
At the same time, however, we know that past a certain threshold--defined by a complex interaction of environmental and genetic factors--anxiety can become toxic. It has a detrimental effect on our performance, and our functioning. The anxiety becomes so "hot," so loud, that we are not able to hear the information it contains. We become overwhelmed, dizzy, frantic, and panic, with our bodies at times feeling as if they are on fire. As the anxiety continues to rise, we are so uncomfortable and in such distress that we do whatever we can to either leave the situation, or change our bodies and internal state. This usually happens when we enter what I affectionately like to call the "Hell to the no" zone.
In order to down regulate or turn down our anxiety, we avoid social situations, places, people, objects, thoughts, even other feelings (such as anger, for example) that we learn to associate with this toxic state. Or, perhaps we turn to a substance or other behavior that "takes away" the anxiety. And the thing is, it works... for the moment. The anxiety goes down, sometimes rapidly, depending on what we do. But the next time we have that worrisome thought, or find ourselves in certain social situations, or encounter the object of our fear, the anxiety comes back. It's like the Star Wars series--our intrepid heroes blow up the Death Star only to face, what, a couple of movies later? Another Death Star. The Empire Strikes Back. Again, and again...
What happens when we depend on avoidance as our go-to coping mechanism, is that we do not give our bodies an opportunity to figure out that anxiety has an--ahem--built in structural weakness: it can go down naturally.
Anxiety is an emotional state that is biologically self-limiting. If you allow yourself to tolerate this state, despite how painful it can be, it would reach a natural apex or arc, after which point it would start to go down by itself (Figure 1, click to enlarge). The irony is that you engage in avoidance precisely at the point where it might begin to self-regulate. Tolerating anxiety for prolonged periods of time not only teaches your body that you can survive those moments. This also allows us to build tolerance to anxiety so that the next time you become anxious the arc, duration, and intensity of the anxiety will be smaller (Figure 2, click to enlarge).
How can you deal with anxiety effectively?
There are different kinds of tools that are effective for reducing or managing anxiety. We can group them under three different headings:
- Coping skills: These are behaviors, exercises, or activities you can engage in to manage or momentarily reduce your anxiety. Practicing a breathing exercise, for example, might help you feel more relaxed, but it may not necessarily prevent you from having anxiety again in the long-term.
- Exposure: This involves literally placing yourself in the anxiety producing situation, and bearing the anxiety directly without avoidance, so that your body (and mind!) will acclimate and learn that it is safe. Exposure is the tool which is the most difficult for people to engage in, whether in psychotherapy or in their everyday lives. It can be very uncomfortable, but it is the most effective tool at reducing anxiety over the long-term.
- Acceptance: This one's tricky. Acceptance involves a mindset of openness to the situation at hand, without trying to rigidly forcing it to change, and without attachment to the outcome. For example, if you are delayed on a train in getting to your destination, instead of saying "I wish this train would move faster!", being able to acknowledge, "It looks like I'll likely be late. That sucks, but it's ok." Acceptance means letting go. It may involve accepting that you are in a situation where you are vulnerable and will likely become anxious--and that the situation will pass. It means facing reality instead of trying to will it to change.
These three have a dynamic relationship with one another. While it is true that coping skills may attenuate, but not eliminate anxiety over the long term, it is also the case that using coping skills may help manage anxiety so that you can tolerate an exposure.
This analogous to using swimming floats on your arms when you first learn how to swim. Using swimming floats will help keep you above water, but they won't by themselves help you learn to swim. However, using them may make it easier for you to stay afloat long enough to properly learn how to swim, until you take the risk of removing them and discovering you can still float. And hence swim.
At the same time, more and more clinicians and scholars argue that it is more effective to forgo breathing techniques and other coping skills to reduce anxiety, and engage in exposure directly for better long-term improvement. You might need to skip the floaties and do a cannonball right into the middle of your anxiety.
This is where acceptance comes in. Being open to reality means accepting it as it is--bare and with no frosting. The reality might be that at this moment the current situation may be too overwhelming, and yes, you may need to avoid and leave it in order to cope for now. Reality might also be that at this moment you need to face that situation headfirst in order for things to get better. Acceptance means letting go, with compassion for yourself. It means balancing your options, then deciding how you want to tackle your anxiety in this present moment.
Professional treatment for anxiety: the place of psychotherapy
This is where psychotherapy comes in. Psychotherapy is an intervention that works right on the edge of your comfort zone, by helping you learn skills, tools, and new experiences that limit avoidance and ultimately help reduce anxiety over time for the long-term. Some forms of cognitive therapy do this by targeting the thoughts and stories you tell yourself about anxiety. Other forms of psychotherapy--such as exposure therapy--focus on helping you sit with and overcome those situations, objects, people, or things that make you anxious.
Not because those things are necessarily anxiety provoking in and of themselves, but because therapy exposes you to the internal states and feelings associated with those objects that feel intolerable. Other acceptance-based and psychodynamic therapies emphasize coming to know yourself, and in turn, understand and accept those parts of you that feel scary, unknown, shameful, unpredictable, or that make us fear that others will reject us. By expanding the range of your comfort zone, and increasing the window of tolerance, psychotherapy expands your range of freedom.
Different therapists and therapy approaches move and operate at different speeds. Different interventions seem to be helpful, sometimes even in combination. In looking for help, you need to find a therapist and a therapy that works for you.
It's important to find a therapist you feel comfortable with, but more importantly, one that you are comfortable with helping you be uncomfortable. As with spicy food, so too with change--it needs to be within your own window of tolerance. Not too little.
Not too much.
Think that you struggle with anxiety? Want to get a sense of how much it affects you? Try this free evidence-based measure of anxiety. Although initially developed to assess for Generalized Anxiety Disorder, the GAD-7 has also been useful in tracking changes in Panic Disorder, Social Anxiety Disorder, and Post-Traumatic Stress Disorder. You can also read my review of a neat app which translates the GAD-7 into an easy to use tool on your phone.