Read Free Yourself from Anxiety Online
Authors: Emma Fletcher
Free Yourself from Anxiety (12 page)
‘The thing that helped me the most was taking the time to visualise the exposure before I did it. I used to rehearse it mentally, taking it step by step and always visualising a successful outcome.’
J
ULIE
‘What he
[the therapist]
did recommend was that it was imperative to keep to a maintenance programme by practising the exercises I had been taught.’
N
ORMAN
For someone with OCD, exposure work focuses on the element of compulsion and its companion, avoidance. (Obsessions are dealt with in the cognitive part of CBT – see Part Three.)
It can seem as if OCD recovery requires the opposite of other Anxiety disorders. A person with, say, social phobia, has to find a way to stay in social situations – they have to do something they
don’t
want to do. A person with OCD has to find a way to stop doing their compulsions – they have to stop doing something they
do
want to do.
In fact the underlying problem is the same – learning to tolerate Anxiety until it dies down and eventually goes away. The person with social phobia will feel anxious if they are in a social situation. The person with OCD will feel anxious if they don’t do their compulsions. Both can gradually learn to put up with the anxious feelings until they start to go down.
There are often two elements to compulsions:
1. Having to do the compulsion a certain number of times, or until it feels like enough times.
2. Having to do the compulsion in a certain way – if a mistake is made, you have to go back to the beginning, and the one with the mistake doesn’t count.
Both elements can be tackled with exposure work. Start by asking yourself two questions:
1. What do I do because of my fears?
2. What have I stopped doing as a consequence of my fears?
Answering both questions might produce two quite long lists, for instance:
1. Because of my fears of contamination I wash myself several times a day all over, I clean my kitchen and bathroom every day, I wipe over all shopping that comes into the house with disinfectant and I have to decontaminate myself if I’ve been out of the house.
2. As a consequence I’ve stopped growing my hair because short hair is easier to wash, stopped cooking meals from scratch because of having to keep my kitchen clean, stopped buying fresh fruit and vegetables because they can’t be disinfected and stopped going out much as it takes so long to decontaminate myself afterwards.
Put the lists in order of difficulty and choose whichever item seems easiest for your first goal. Remember that your goals need to combine two elements:
1. doing something you have been avoiding (exposure); and
2. stopping yourself from doing the compulsive rituals (response prevention).
‘Response prevention’ is a technical term used in clinical treatment for OCD but it doesn’t mean you have to stop completely all at once. Like all exposure work, you are more likely to succeed by approaching it gradually, step by step. You can start by cutting down on the number of times you repeat a compulsion, or by increasing the time between exposure and starting the ritual. See the examples below.
Reduce the number of washes by one, maintain that until comfortable, then reduce by one more and so on.
OR
Delay time of starting to wash by one minute, delay time of starting to wash by two minutes, and so on.
If your OCD makes you very slow at everyday tasks try setting a time limit – start with a generous time and reduce it day by day. It can help to have someone else show you how they complete the task within a normal timescale, but don’t ask them to show you every time, just once.
If your OCD includes asking for reassurance, then the people you ask will need to be involved in your exposure work. Ask them to limit the number of times they give reassurance to you.
Everyone knows you can’t stop yourself thinking just like that. If someone says to you ‘don’t think about a yellow car with red spots’ you will immediately get an image of a car like that in your mind. So don’t waste energy trying to simply stop yourself from having compulsive thoughts. Instead look for ways of reducing the amount of time you spend with them, or reducing the number of times you need to do them. You can look at ways of resisting the compulsion for instance:
•
Thought stopping: say, or think, the word STOP.
•
Thought switching: deliberately start to think about something else – choose this in advance, and choose something you find pleasant.
•
Distraction techniques. These are explained in Chapter 26.
If you consider that this kind of technique makes matters worse because it gives the thought too much importance, then try ways of reducing the importance:
•
Expose yourself to the trigger for the thought until you are tired of it.
•
Exaggerate the thought until it becomes ridiculous.
•
Practise letting go of the importance of the obsession – see it as background noise that can be ignored.
Examine your behaviour while you are busy with your thoughts (this is known as ruminating). Do you stop what you are doing so that you can sink into your ruminations? Simple tasks, or distractions such as listening to the radio, might help you come out of yourself. Or set aside a fixed time each day when you are allowed to brood.
Choose a behaviour that you can train yourself to associate with letting go of the thoughts – something as simple as standing up and leaving the room every time they start.
If your OCD includes strong mental images you can take control by pretending you are filming the image – you can reduce the size of the worrying part (dog faeces for instance) or you can zoom in on something harmless at the edge of the picture such as a patch of grass.
‘Without warning a voice, seemingly from nowhere, said “Kill him.” … I became very hot and waves of panic washed over me. I could not get the words out of my mind. I was frantic with fear at this terrible thought … I thought I must be losing my sanity, what other explanation was there?’
M
ARGARET
‘I had to kneel at one of the graves and rub my hands in the dirt amongst the gravestone, … I have since learnt that this type of treatment is called exposure therapy where your fears are faced head on. I had already mentioned to the staff that I had this fear of anything related to death, and that afternoon was certainly spent facing this problem head on. My anxiety level was able to be kept under control for most of that time, and on arrival back at the hospital I was prevented from washing my hands which I feel did me some good.’
N
ORMAN
It can be a good idea to enlist the help of someone you trust while you’re doing exposure work – the return-to-the-supermarket ladder in Chapter 23 included using a helper. Of course it isn’t essential and many people complete their recovery with very little help.
If you are going to ask someone to help you with your exposure, you both need to understand certain things.
•
You are in control of your recovery. If you are attempting a goal, you will explain it to them, and explain how you would like them to help. You can also decide how you want them to behave if you decide to abandon the goal. We suggest that you ask them to talk to you calmly, to ask you if you feel you can go on just a little longer, and if you can’t, then they accept that the goal will stop there.
•
They must never trick you, because you have to be able to trust them absolutely. So no promising you that it will only be a short drive, and then taking you further, or coaxing you out of the bathroom and then refusing to let you back in.
•
They need to be able to stay calm when you are anxious. It won’t help you if they become panicky in response to your distress.
•
They don’t need to understand the nature of Anxiety disorders, as long as they can accept that you need to do exposure in a certain way.
•
They must never belittle your difficulties.
•
They must give you their time and attention – it’s no use at all if the helper on the supermarket ladder thinks they are going to do their own shopping at the same time.
•
You must understand that your helper isn’t a saint – just someone who is trying to do their best for you.
•
And finally, don’t feel guilty about asking for help. When you are better, you’ll find a way to repay them for their kindness.
Talk to your helper before you start the exposure session. Explain exactly what you hope to achieve with the goal and what you want the helper to do. Their overall function is to help you feel safe in a frightening situation. They will do this just by being there, and also there are things they can say to help:
•
Grounding – remarks that remind you what to do such as ‘just breathe out slowly’.
•
Reassurance – simple phrases such as ‘you can do this’ or ‘take your time’.
•
Distraction – helping you to focus on something outside your fear, to remind you that the outside world is still there, for instance ‘that girl’s got nice hair’ or ‘did I tell you we’re going to paint the kitchen?’.
•
Perspective – remarks that remind you this won’t last for ever such as ‘we’ll have a cup of tea when we get home’ or ‘mustn’t miss EastEnders tonight’.
•
Praise – sharing in your jubilation when you achieve a goal, however small it may be.
Explain to them that you might not give very coherent answers to their remarks, and that this doesn’t matter.
If you haven’t involved anybody else in your OCD you can still choose to ask for help with exposure. Explain to the helper what your goal is, and what they can do to help you.
Your helper can use the same techniques described above for helping with panic and phobias:
•
Grounding – remarks that remind you what to do such as ‘just breathe out slowly’ or ‘you were going to stop after ten minutes.’
•
Reassurance – simple phrases such as ‘you can do this’.
•
Distraction – taking your mind away from your obsession, remarks such as ‘Did you see that goal on Match of the Day?’ or ‘I really must get some new shoes.’
•
Perspective – remarks that remind you this won’t last for ever such as ‘let’s have a hot drink in a while’ or ‘pizza for dinner tonight, can’t wait.’
•
Praise – sharing in your jubilation when you achieve a goal, however small it may be.
Your helper needs a special technique if you tend to ask repeatedly for reassurance that something is alright, or is done. Agree with them beforehand that they will only reply once, and that after that they will say something like ‘we agreed that I wouldn’t give you any more reassurance.’ It’s best if they stick with just one answer, whatever you say. If you become distressed, they can comfort you, but they can’t give reassurance. It’s important that they stay calm, and keep their voice calm.
‘The trigger for my recovery was when I suddenly had to fly to get to an important family occasion. I had been comfortable with my agoraphobia and had made friends with it, so when I realised I had to travel and go on a plane, outside my comfort zone, my anxiety went through the roof. I did manage to get there, with a lot of help, and afterwards I started on recovery work.’
J
ULIE
‘You no longer need to keep asking for reassurance. However, how will loved ones cope with this change when they’ve developed the habit of constantly giving in to your demands for reassurance? This is one of the things you may wish to discuss with them, and remind them that it’s not particularly helpful to keep giving this reassurance.’
N
ORMAN
‘I did some one-to-one work with a co-worker at first, then a couple of us would go out together and we would talk to take the focus away from feeling scared. I began walking round the car park, then gradually built up over 6 months until I could go into town. I can go out now on my own, … I still feel anxious but now I am no longer enormously afraid.’
S
ARAH
‘I’ve done exposure. I asked the doctor and he organised a carer to take me out twice a week for 3 hours at a time. I’ve been places I never thought I’d go – I went to Old Trafford to see the flowers for the Munich memorial.’
W
ENDY
When you first start on exposure work it can be helpful to adopt a range of coping skills. These are little crutches that help you through the challenges, and that you know you will eventually do without. They are very similar to safety behaviours (Chapter 18) but they are aimed at helping you get through your goals and you will drop them as soon as you can.
We have some suggestions for coping skills that have worked well for other people over the years, but anything that works for you is fine. There are only two considerations:
1. It mustn’t be damaging (such as using alcohol to get through).
2. It mustn’t feed into your Anxiety (such as saying a prayer if you have compulsive thoughts around prayer).
Read through the list and pick out anything that appeals to you. If you think that panic will cause the skills to fly out of your head, write your chosen ones on a little card to carry with you.
•
Breathing
– if you’ve been practising slow calm breathing you’ll now reap the benefit as you’ll be able to use it to keep yourself calm during your exposure sessions.
•
Paper bag
– people who suffer from panic sometimes find it helpful to carry a paper bag (never a plastic one and not too small or too
large). At the onset of panic, breathe out into the bag, then breathe in from the bag. Do this for a few breaths. It calms you because you are breathing back in your old air, instead of sucking in fresh air that will give you too much oxygen. Breathing into and out of your cupped hands has a similar effect.
•
Exercise
– if your exercise programme is going well you can remind yourself how fit you now are, and that your body can clearly cope with Anxiety. This is specially useful if panic makes your legs turn to jelly – if you are fit, you can be sure that they will carry you, however shaky they feel.
If your helper has read Chapter 25 they already understand what they can do to help you. In addition they can remind you to use your coping skills.
•
Counting
– choose something to count – red cars, lampposts, people with hats on – to take your mind off the anxious feelings.
•
Mental arithmetic
– start from 100 and count backwards in 7s, or multiply numbers together.
•
Reciting
– repeat your favourite poem, hymn or prayer in your head. Or try the words of a song, and walk along to the rhythm of it.
Carry something that will distract you, and help you stay focused on the goal rather than the Anxiety, e.g.:
•
Something interesting
in your pocket that you can touch for reassurance: a pebble or coin, your keys.
•
Sweets
– many people find it helpful to suck a strong mint.
If you’ve been faithfully doing relaxation at least once a day, you’ll now find that your mind and body will be conditioned to relax when you hear the words on the recording. You can:
•
Play
the recording through a headset while you’re doing exposure.
•
Repeat
to yourself your favourite phrase from the recording.
•
Picture
your favourite scene from a visualisation recording.
•
Anger
– surprisingly, anger is helpful for some people. Anger gives us energy, and you can use that energy to drive yourself through a difficult exposure session. It’s best if it comes naturally though, arising from the frustration you feel. Don’t deliberately wind yourself up to anger.
•
Delight
– think of the joy you’ll feel when you manage your goal, or focus on the pleasure your success will bring to the people who care about you.
Imagine feeding your anxious thoughts into a shredder, or tie them to a balloon and let them float away.
When you’re planning your exposure, it’s okay to work out how you’ll escape if you need to. There is so much embarrassment surrounding Anxiety, and so many people dread humiliating themselves in public, that it’s worth working out what you’ll do if you need to get out. Something as simple as patting your pocket, or looking in your bag, tells any onlooker that you’ve forgotten something and explains why you’ve turned back.
Finally, create a reward system for yourself. When you’re planning an exposure session always think about how you will reward yourself when it’s all over. Because you need to do exposure every day, most rewards will be small treats that are easy to arrange and not too expensive. Every now and then you can give yourself something bigger, or more costly. Having something to look forward to will help keep you motivated, and improve the quality of your life.
Just like coping skills, rewards can be anything as long as they are not:
1. harmful to you
2. part of your Anxiety.
Rewards can also be incorporated into the exposure work, so that you may set yourself the task of going out to buy your favourite magazine, or use the time freed up by not doing rituals to watch TV.
Here are some suggestions:
•
Take a hot relaxing bath.
•
Watch your favourite TV programme, video or DVD.
•
Eat a cream cake or chocolate – yes, you can break the diet rules occasionally!
•
Cook your favourite meal.
•
Read a book or your favourite magazine.
•
Phone someone you rarely talk to.
•
Enjoy the garden, if you have one.