I’ve now finished the CBT self-help classes I have been taking this summer. I wasn’t sure how to write this post as it isn’t such a personal perspective as the last, and I’m reluctant to turn this into a mental health blog in general; my aim is just to keep sharing where I’m at. But I felt I wanted to follow up my previous article on techniques for managing depression by sharing the treatment techniques we learnt on the remainder of the course, as I feel the more this information is shared about, the more we can help each other overcome our illnesses.
The second half of the course looked more at ways to overcome anxiety – first a session about understanding and handling panic attacks, then a session looking at worry and how to manage it healthily, and finally a short session on recovery and avoiding relapse*. I’ve been experiencing more anxiety than is normal for me since being ill, but not to the extent of being diagnosable, hence this being much less of a personal perspective than part 1; I haven’t had to deal with the symptoms to know how effective these treatments are. But here they are; they’ve helped me to understand anxiety more, and I hope they will help us to overcome any anxiety of our own, and to help others experiencing it:
Panic attacks – ‘Panic’ is one of those words that is in everyday use, and yet has a very specific meaning when talking about mental illness. We all ‘panic’ at times. But not everyone experiences panic attacks. Panic attacks are very common, affecting maybe 1 in 20 of us; they are extreme anxiety attacks, usually lasting just 10-20 minutes, that cause physical symptoms such as a pounding or skipping heart, breathlessness and/or hyperventilating, sweating, shaking, feeling like you will be sick or need the loo urgently, or feeling dizzy or faint, and feel terrifying. When a person is having a panic attack, they often feel like something awful is happening to them, for example that they are choking or having a heart attack. They feel so bad, people become anxious about having another.
The course leaders described what is going on here as being like a household smoke alarm, which goes off if there is a fire, but also reacts to burnt toast! Basically our brains interpret something as a threat, even if it may be a non-physical threat such as a deadline or a crowd, and release adrenaline, which would prepare our bodies for ‘fight or flight’ responses. The physical symptoms experienced in a panic attack are the direct result of this adrenaline, which increases heart rate, breathing, sweating etc to prepare our bodies for action in response to this ‘threat’; the symptoms may be scary but they are not dangerous, and the worst is not going to happen. Knowing this can in itself help break the fear cycle.
The anxiety the onset of a panic attack causes can cause a vicious cycle of panicking thoughts and symptoms, and afterwards, the fear of a repeat can mean that consciously or even unconsciously a person can begin monitoring their body for small changes – which can trigger the ‘smoke alarm’, and mean a panic attack can seem to come on out of the blue. And so, we start to avoid certain situations we fear may bring on an attack or be hard to cope in if it happened, and develop ‘safety behaviours’ to cope, things like staying near to exits, having something to distract us like a phone or music, or seeking reassurance. In the short term, they help us feel less anxious; but in the long term they reinforce the problem. What if these things were not available to you? Could you cope? If not, it is a safety behaviour. Using it is training your brain to be dependent on it and that without it you would be unable to cope, whilst never giving yourself a chance to prove that you can cope.
To regain your independence from safety behaviour and feel able to cope in situations that made you anxious, the treatment is again going to involve hard work and perseverance, but apparently really does help people overcome crippling anxiety. It involves facing your fears in a very careful way. The aim is to retrain your brain not to be afraid of fear, but to accept that anxiety subsides with time and doesn’t need to be run from. Anxiety symptoms are caused by adrenaline, and adrenaline wears off; this treatment teaches you to feel the adrenaline wearing off and become used to that as a normal follow-on to the feeling of it increasing.
Firstly, grade the situations that make you anxious – give them a score out of 100 for how anxious they make you feel and rank them. Find one thing that ranks about 40-50, and work with that until it stops causing you anxiety before moving on to something tougher. Identify any safety behaviour you use, and perhaps incorporate that into your scores; maybe something is easier to face with a friend than alone for example, so would score lower. Taking that situation that scores about 40, work on putting yourself in that situation regularly, at least four times per week, scheduling it specifically into your diary to make sure you do it. Do not allow yourself to do anything to lessen the anxiety of the experience or distract yourself; you need to be able to feel that initial anxiety to feel it coming down with time. Stay in the situation long enough each time to experience the anxiety levels reducing to about half what they were initially. This way you teach yourself by experience that if you expose yourself to this situation, the anxiety will reduce.
We discussed reasons it may not work, and they mostly came down to not staying in the situation long enough, masking the anxious feelings, or incorrectly grading our anxiety, which obviously takes some practise (if you pick something you think will be a ‘40’ and it turns out to be much more anxiety-causing than that, you may not be able to handle sitting it out long enough to let the adrenaline come down and feel that effect, whereas if you go for something that turns out not to make you very anxious you won’t feel much either). Basically this aims to retrain our brains out of triggering the ‘smoke alarm’ over situations that are actually not dangerous, and get used to the physical sensations of increasing and decreasing adrenaline, whilst increasing our self-confidence.
This obviously only works for situations that we can experience regularly; for one-off situations such as a job interview or party for example, we were taught to try behavioural experiments. The first step in this case is to identify the anxious thought (perhaps ‘I won’t know what to say if I’m asked a question and will look stupid’ or ‘no-one will talk to me’). Then identify any safety behaviours you might use (maybe taking in notes to read from, or taking your phone to hide behind). Then plan an experiment (Can I do this thing without my safety behaviour?). Plan out how you will do it, then predict exactly what you think would happen if your anxious thought turned out to be true. Write it all down to keep a record of to refer back to. After the event has happened, come back to your experiment, and note down the actual, honest outcome, and exactly how it worked without your safety behaviour. How does it compare to your prediction, and what does that say about your initial anxious thought?
Finally, when we came to discuss this as a group, several people said that the controlled breathing techniques we learnt previously really helped overcome panic, firstly by shifting the attention onto the action of breathing, and secondly, physically working with the adrenaline by increasing oxygen intake whilst slowing breathing down, which helps the heart rate to come down and stop hyperventilation.
Worry – When we’re ill, our worrying can feel out of control. There are basically three types of ‘worry’: Practical worries (about something we are able to do something about); Hypothetical worry (‘what ifs’, which we can’t do anything about), and ‘Rumination’ (going over past events and thinking what you ‘should’ or ‘shouldn’t’ have done or wishing it had been different – which again we can’t do anything about). We handle worry differently because of differing basic beliefs about it – some negative (for example ‘I shouldn’t worry’, or that it will get out of control), some positive (for example thinking it helps motivate or prepare us for things).
We all worry, and that’s ok, but we can’t deal with worry by simply trying not to worry; that just makes us worry more. To deal with excessive worry healthily, try keeping a diary for a short while to identify your worries. Are they practical or hypothetical worries, rumination, or negative thoughts? Negative thoughts are better dealt with by thought challenging.
Set aside a short period 15 minutes of the day as a worry time – a time when you won’t be busy with other things and not too late in the day so you go to sleep with anxiety; you need time to relax afterwards. Through the day, write down all your worries as you go, maybe on post it notes so they can be discarded once dealt with, and put them aside to look at in that planned worry time – that way you acknowledge them rather than trying not to think about them but can shelve them for later; you can think about them but don’t have to think about it right now. Practise drawing your attention back to the here and now after writing down a worry, perhaps by focussing on your breath or on your physical senses (what can you physically hear right now for example). In the worry time, allow yourself to think about the things you’ve written down, but discard them at the end of the allotted time.
Any that turn out to be practical worries, you can think through a strategy for how you will deal with them. When you do this, think as creatively and even outrageously as possible to list all the possible ways you can think of to solve the problem: For example, if the problem is having no money for the bills, solutions could be to change jobs, cancel a subscription to something you don’t use… or rob a bank! Then go through the advantages or disadvantages of each, make a plan, schedule it, and once you’ve done it, review how it went.
I’ve found a massive difference in my own excessive worrying simply from categorising my worries; once I’ve noticed what I’m thinking it seems to have interrupted the worry process enough for me to bring me out of the worry. The techniques we’ve already learnt for motivating ourselves and challenging negative thoughts have also really helped me with worries too, meaning I get on with addressing practical stuff rather than getting into a cycle of letting tasks become overwhelming. As for rumination… I’m going to need counselling for some of that.
Recovery – It is normal to experience both good days and bad days during the recovery process. Keep a diary and monitor how you’re doing to see if the bad days are increasing or decreasing, and to keep a record of the symptoms you experience. If they’re increasing, you may be able to troubleshoot by looking to see if there’s a technique you’ve forgotten that could help, or maybe you need further help – in which case, do seek it out. The treatment techniques require a lot of practise so keep trying, and monitor how they are going alongside how you feel. Keep practicing them until they become second nature again.
So, how am I?
As I write, I am doing really well! For the past three weeks I’ve been feeling far more myself than I have for maybe a year or more. Maybe all my self-care efforts are paying off; maybe prayers are being answered; maybe the CBT is having an effect; maybe these are good days, interspersed with bad days on the road to recovery, or the end of the first wave of illness before the next hits. Maybe it’s the season – I find it hard to feel down when the autumn is coming in, although it’s also a season when vulnerable feelings make more sense. Maybe it’s a combination of things. But I’m feeling good just now. That said, I’m taking one day at a time; I can feel the depression-monster lurking somewhere behind my back, and I’m having to keep checking over my shoulder the whole time to stop it sneaking up on me again. I can still hear it feeding me lies, and it’s still taking deliberate effort to put these things I’ve learnt into practise and stay healthy. I’ve now started seeing a counsellor. CBT treats the symptoms of mental illness really effectively, but many of us need more than that to fully recover; counselling aims to address the underlying causes. I definitely feel in need of both tackling the symptoms and the causes. I feel now like I have strategies for coping and re-developing my resilience to pain. But I am still carrying that pain around, and I really want to address that, to dig underneath and understand what’s really going on. I’m hoping counselling will help with this. Another step towards kicking this thing!
*We also had a quick look at medication; I’m absolutely unqualified to talk about this medically, so if you want to know more about it, please speak to a doctor or pharmacist for advice. I can’t tell you about all the different types of drug, how they work and what they do, except that it’s to do with healing the way chemical messages are passed within the brain, which gets disrupted when you are ill. But the main points I’ve learnt are that there are many different drugs out there, which work in different ways and have different associated side effects. Most take a few weeks to take effect, during which time they may make you feel worse before you get better, so you may need to persevere to get the benefits. Most of the side effects subside in that time too. Different people’s anxiety and depression illnesses respond differently to different medications, so you may need to try more than one before you find one that works, and that may mean finding a good doctor to work with you and be understanding of you. They are not addictive. Most people are able to start coming off medication after six months or so, some need longer. Those I know who do or have used medication are really keen to tell me the difference it has made to their lives, that they are able to feel like themselves again and live a normal life. As for the stigma attached – if you had cancer, and were recommended medication to treat it, you would take it and no-one would criticise you for it. If you had a condition, diabetes for example, that meant you needed to take medication daily to be able to lead a normal life, you would take it and no-one would criticise you for it. Mental illness is illness. Mental health medication is medication. Let’s not treat it any differently.