Sam, 32, appeared in my office in time for the session immediately before lunch. He was wearing a grey suit, pale pink shirt, tie, and black oxford shoes. He was clearly nervous and flipped a pen continuously back and forth through the fingers of his right hand while he sat waiting for me. When I called him, he jumped up like he’d been ejected from the seat. After getting settled in my office, I asked Sam what brought him in to see me.
“I’ve never been to a therapist before, but I have to do something. I can’t live like this. I have a big presentation coming up at work, and I know I can’t do it. If I can’t do it, I’ll be fired, or at the very least demoted, and that would suck. I love my job and I was killing it until last month. Then it all went to hell and I can’t seem to get myself together.” He rubbed his face with both hands and then looked around. I pointed to the fidget gadgets on the table next to him and he looked relieved. He chose a large onyx marble and began rolling it in his hands.
“Tell me about last month. What changed?”
“I don’t know. I was giving a presentation in front of my boss and some potential customers. I’d prepared well, I was confident, and I figured I could kill it easy. I was talking about technical stuff that’s a part of my responsibilities, and I thought ‘This is going great.’ All of a sudden, I couldn’t breathe, my heart was racing, I started sweating, and I fell onto a chair. I didn’t sit in it. I fell on it. I couldn’t talk, and my boss and one of my colleagues kept asking me, “What’s wrong?” When I couldn’t answer, someone called an ambulance. I was starting to feel like I could breathe again, but I was so shaky I couldn’t stand up, when the paramedics came. I almost wish I’d had something terrible because it was so embarrassing. They checked me over in the ambulance and then told me I probably didn’t need to go to the hospital. “It looks like you’ve had a panic attack,” one of them said. I thought, ‘Panic attack? What the hell is that?’ They advised me to see my doctor about anxiety and let me go back to work.”
“That sounds rough. What’s happened since then?”
“That’s the problem. It’s like something broke in me. I’m having panic attacks every day, and some of them are just massive. I feel like I’m dying. If I’m not actually panicking, I’m worried about panicking. These attacks feel terrible and I need to get rid of them. I can’t live like this.”
“It feels as if panic is consuming your life.”
“Yes! It’s not just consuming my life it’s totally wrecking it! I can’t even think about doing a presentation, I have to psych myself up to order coffee from the barista at my favourite coffee place, and I don’t want to go anywhere in case I have one of these stupid attacks and it absolutely sucks.”
“I bet it does. What happened when you went to see your doctor?”
“He said I am having panic attacks and I should see a mental health counsellor. He said if I work with a counsellor and it doesn’t get better, I should come back and he’ll prescribe something to help. I have never been to a counsellor, but I really don’t want to take medication for this, so here I am.”
“How do you feel about being here?”
“I’m struggling. I have couple of friends who have seen therapists in the past and to be honest, even though I never said it, I thought to myself that it meant they couldn’t ‘man up’ and deal with life. I feel stupid just saying that out loud. I don’t know what you can do to help, but I do know that my doctor certainly thought counselling was the best solution.”
“What kind of things are you saying to yourself about being here?”
Sam looked pained. “I’ve been pretty hard on myself all month and sitting here waiting I just kept thinking, ‘This is so stupid. You just need to grit your teeth and get over it.’ The thing is, I have been trying to do that and it isn’t working.” He shrugged and tossed the marble back and forth.
“What kind of a relationship did you have with anxiety before that panic attack?”
“Relationship? I don’t think I had one. I wouldn’t ever have said I felt anxious about anything.”
“How about worrying? Or catastrophizing?”
Sam looked surprised. “Catastrophizing? That’s part of anxiety? My friends tease me about always thinking that the worst will happen and planning as if that might happen. I just always thought it was contingency planning. If I figured it out and planned for it, then I didn’t…” Sam fell silent.
“…worry about it?” I offered, and grinned.
Sam offered feeble grin. “I never thought about that as anxiety.” He paused, “I just thought of it as good planning.”
“It is good planning. It can also be an observable manifestation of underlying anxiety. What do you know about anxiety?” I asked Sam.
“Not a lot. I heard my dad refer to anyone who seemed to be worrying as ‘a Nervous Nellie,’ and he was quite scornful…” he paused suddenly. “My mom planned for everything. We carried so much crap with us whenever we did anything, because ‘just in case,’ something bad happened. I always wondered if something was going to go wrong when we went to do anything. I never thought about that being part of anxiety. It actually makes me wonder about some of the conflict between my parents over what my father called, ‘Your mother’s Chicken Little habit.’” Sam looked pensive.
“It’s possible,” I agreed, “that your mother’s contingency planning was evidence of anxiety which your father appears to diss. What matters to you in this conversation is that anxiety tends to run in families for a couple of reasons, like genetics and modeling. There are two basic types of anxiety with the myriad manifestations. State Anxiety is the type of anxiety that one would experience before doing something like an exam, or presentation, or riding a rollercoaster. It usually has a physical component such as ‘butterflies’ in the stomach, a dry mouth, sweaty hands, and cognitive noise.” I paused. “When have you experienced this type of anxiety?” I queried.
He laughed. “I actually prided myself on not having any of those symptoms before a presentation. My colleagues called me, “Iceman,” and I kind of liked that. I don’t remember having any issues before exams in school, or before any my presentations. And I don’t do rollercoasters,” he said with a grin. “Something might go wrong and I can’t plan for it.”
“That’s telling, actually. The difference between the presentations and the rollercoaster is control. You have almost complete control over the presentation process, and almost none over the rollercoaster.”
Sam looked surprised. “Oh,” he said thoughtfully. “that makes sense. But why would I suddenly fall apart doing a presentation? Something I’ve done many times before without an issue?”
“Well, that’s where the other type of anxiety comes into play. Trait Anxiety is a type of anxiety that actually lives in your nervous system. A nervous system always on guard is the result of genes that have been switched on. That switch could be flipped for a number of reasons, but the end result is the same. Your Sympathetic Nervous System (SNS) is dominant, likely from birth, and its job is to keep you safe. When you grow up with this system in control, anxiety is your normal. Make sense?”
“It does,” Sam said sounding thoughtful. “But what does that mean for me and suddenly freaking out over every little thing? He suddenly looked uncomfortable.
"I was really nervous about coming here," he said quietly. "I just figured out that I probably use a lot of of words that actually mean 'anxious.'" He paused. "How do I deal with this?”
“Part of the therapy process is understanding how State and Trait anxiety work together. When the underlying anxiety is never acknowledged or curated, eventually, the nervous system is strained to its limit and the next anxiety-provoking event causes a what we call a ‘hysterical’ response. That means the response is way out of proportion to the actual event. Fortunately, there’s a whack of research that provides strategies and techniques that help you not only to manage your nervous system, but also to learn how to calm the SNS so that a panic attack isn’t your first response to life events. You’ll do some work with your counsellor unraveling the history of anxiety in your family, and at the same time, we’ll provide you with strategies to practice that will allow you to calm your nervous system at will.”
Sam looked relieved. “I’m prepared to do whatever I need to do to make this better. I don’t want to take medication, and I do want my life back. Where do we start?”
“Living like this is definitely not great so we start with some practical strategies. I call them ‘self-rescue skills.’ I’ll give you some suggestions to practice this week between sessions. The second thing we’ll do in nearly every session is provide you with accurate information. Knowledge is power. When you know more, you have more options. As you work with your counsellor, you’ll identify the way anxiety is embedded in your genes, and the way it was modeled as you grew up. To put it another way, you’ll identify your ‘normal’ for measuring anxiety, and dismantle it so you can mindfully build a better measuring stick for anxiety. How does that sound to you?”
“You think that I can get past this just by talking?” Sam asked skeptically. “That would be great, but I’m having a hard time making that work in my head.”
“Oh…you’re not just going to talk.” I grinned. “You’re not the first to wonder how counselling deals with something that can be so physically and mentally disabling. The good news is that the research says it’s possible, and I know from 30+ years of professional experience that you can recover your equilibrium and live without this monkey on your back. The wild card is always the individual. You’ll talk in therapy but there’s things you actually need to do to get better. We counsellors bring the skill and proven strategies to the process and the client brings a determination to do the work in between sessions. Or not.” I shrugged.
“If what happens in counselling is going to give me my life back, then I’m all over that,” he said adamantly.
“Sounds like a plan. Earlier, I mentioned mindfulness. Have you ever practiced any form of mindfulness?”
Sam rolled his eyes. “Do you mean sitting on my butt, eyes closed, doing something funky with my fingers while I hum an unpronounceable mantra? No.”
“No, I mean mindfulness. Being present in the moment rather than regretting the past or anticipating the future. Most people are not mindful. They live on ‘autopilot’.”
Looking thoughtful, Sam said slowly, “I don’t think I’m ever present in the moment. I’m always anticipating that something bad might happen and I need to be prepared. Either that, or I’m beating myself up about something that happened that I could have anticipated.” He suddenly paused, looking stunned. “Is that anxiety?”
“Yes. That’s anxiety.”
“Holy sh*t. Oops. Sorry. I swear a lot.” Sam said ruefully.