How Carol Gradually Improved Her Anxiety Management Skills
It's nice for coaches and therapists like myself to write about cases where they saw dramatic improvements. The truth is most cases aren't like that. I'm glad to say most of my clients experience substantial improvements, but closer to hum-drum than miraculous, and when they move on, life still isn't necessarily a bed of roses. I wanted to write about one such case in the interests of presenting a fair view of what you might expect if you become a client.
Carol, not her real name, described her main issue as panic. In fact she hadn't had a panic attack for over a year before seeing me, but she lived in fear of them. She'd had a few panic attacks in the past – she experienced a sense of overwhelming dread, and physically she felt like her body was in a vice, and she couldn't breathe. She felt like she was going to die, and on occasion had ended up in A&E. Although the panic attacks were connected to stress, Carol felt she didn't fully understand what caused them, and the unpredictable nature of the attacks greatly amplified Carol's fear of them.
When we met, Carol described her life as one of constant anxiety and feeling on edge. Life was very restricted – there were a number of things she just refused to do for fear that she might have a panic attack. Prominent among these was going on holiday – Carol refused to fly. This was a very sore point for her husband and family. Carol had also turned down opportunities for advancement in her career – she felt her current position was well beneath her potential, but among her biggest fears were giving presentations and job interviews.
I knew Carol's case wouldn't be easy because she also reported having chronic fatigue – although you'd have to say a relatively mild case as she was able to hold down a job (part time but five days a week). Although doctors hadn't found anything wrong, Carol believed her anxiety had a its roots in a health problem.
One of my first priorities was to reframe Carol's view of our work together: I wanted her to see that she could gradually develop skills in managing stress and anxiety. Her certainty that she wouldn't ever willingly board an aeroplane meant working directly on that issue was a non-starter. (In fact I agreed with Carol – I could see she first needed some confidence, and that confidence could only gradually develop with experience.
I wanted Carol to see her anxiety was not constant but variable. On a scale of 0 to 10, maybe it never really got to zero but equally it wasn't at 10 all the time. Carol knew about things like flying (which would be 10) but didn't give much thought to everyday minor activities that she didn't like but still was able to do. These were going to be key training grounds. We came up with a few examples, including driving on dual carriage ways and motorways, and standing in queues (e.g. at the supermarket – Carol would start to fear being trapped).
First I wanted Carol to learn the core skills of relaxation, in the setting of my office and without bringing in any triggers or stressors, using biofeedback. Not surprisingly (to me), Carol was a chronic mild over-breather (it's common in cases of fatigue and also of an “avoidant” coping style). Carol was able to make good progress with muscle tension training, and some progress with breathing training, though she didn't feel it would help much in real-life stress.
My aim was to have Carol then practise these skills in mild stress contexts – driving and also queueing. The key thing was to start building a mindset of acceptance and even willingness. Even in these mild cases Carol's response was to refuse to even contemplate feelings of anxiety, and to distract herself by listening to the radio or playing with her phone. While these worked in the easy contexts, they reinforced the deep-rooted belief that Carol couldn't cope and she had to avoid the possibility of panic at all costs.
Gradually Carol was able to learn to pay attention to how her body was feeling, to feel a little apprehension without getting overwhelmed or struggling against it, and to let go of muscle tightness. She gradually built some confidence that she could help herself feel better, that she could respond positively to stress. She even started to see these mild stressors as opportunities (to practise her skills) rather than as threats. I saw that as a major success, as before that, Carol felt pretty powerless in the face of stress.
After several weeks and several sessions Carol moved on. At that time she wasn't really anywhere near ready to book herself a foreign holiday but she was encouraged by what she had achieved and had a much more positive outlook. Perhaps the key thing was Carol now accepted she couldn't avoid feeling stressed, but she had at least some confidence that she could (i) live with some fear and (ii) recover again afterwards. Her new goal was not to avoid fear but to continue to develop her resilience, or her ability to recover.
I like to think we set a bit of a snowball rolling down a hill.
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