Ten Steps to Relieve Anxiety. H. Michael Zal

she became anxious as she tried to control her negative emotions. Sometimes she failed and, in her own words, she became like her father, “the monster.” When all else failed, she used avoidance to stay in control. She took time off from work, didn’t see her boyfriend for long periods of time and retreated to her apartment as she had to her room as a child. Henry David Thoreau said, “Things do not change; we change.”⁴ It took a while for Penny to understand her behavior through therapy and start to change.

      Penny suffered from a major depressive disorder as well as GAD. I was reluctant to prescribe an antianxiety agent because of her history of polysubstance dependency. I took a history of all the psychiatric medications that she had been given through the years. The one that seemed to work the best was an antidepressant that also had a calming effect. For sleep, she occasionally took a sedating antidepressant often used for insomnia.

      I taught Penny behavioral relaxation techniques, including progressive muscle relaxation and deep breathing, which she found helpful. I also encouraged lifestyle changes such as caffeine reduction and good sleep habits. She began to keep a diary, which helped drain off some of her negative energy and angry feelings. I pushed her to broaden her world and reconnect with friends and family. One of the best things that happened was that out of the blue, her old boyfriend called her. He wanted to see her. In therapy, she reported: “When he called, I felt cornered and trapped like I always did with dad. With dad, I used to have to take a (pill) before I saw him. I felt hurt and inadequate. In the past, when Ben called and asked me out, I used to have to drink two margaritas to calm down before I saw him.” I had her make a list of how Ben and her dad were the same and how they were different. Apparently, they both had “anger against the world and were judgmental.” However, with Ben, she admitted that she felt safe around him and “he wasn’t a drunk.”

      “I want it to work this time [with Ben]. I want to work on the things that make me irritable about him,” she said. He often overstayed his welcome and didn’t allow her enough privacy. He wasn’t always attentive to her and liked to go off and talk to other people when they went on vacation together. He was obsessed with politics and would talk passionately at length on the topic. We discussed ways that she could make the relationship better. She came up with the idea that she could set limits on his behavior, change the subject when he went on a rant about politics and tell him what she needed from him. Most of all, she had to keep focused on the fact that although he had some of her father’s behaviors, he was different from her father. I told her to look Ben right in the eye and say to herself, You are not my father. If she felt tense prior to seeing Ben, she promised that she would engage in twenty minutes of relaxation exercises rather than having a drink. When her mind drifted back to childhood, perhaps she could refocus and really enjoy being with Ben in the present.

      When she started to feel better she stopped coming to therapy, so I called her after nine months. She picked up the phone on the first ring, sounding pleasant and glad to hear from me. “I’m working a lot,” Penny said. “Things are the same with the family and the anxiety. Not much has changed for me. I talked to Ben when he was in the hospital but I am not seeing him. He calls me from time to time. Too much time has gone by. I can’t go back to seeing him again. I don’t have the energy.

      “Therapy did help but I got to the point where I felt that I wasn’t going any further,” she continued. “I was disgusted with myself and I felt that I was dragging you through the mud of my life with me. So I just stopped coming. You tried very hard. I knew that you were trying to tell me things and connect the dots for me. I would get it and then when I left, I couldn’t always make it work.”

      I told her that I thought she was being too hard on herself, that perhaps her expectations were too high and that change takes time. I told her that I thought that she had made some progress. I asked her how her temper was. She answered, “Oh, my temper has been better. I don’t let myself get drawn into the chaos at work anymore and I’m not acting out. I guess I did make some progress.” I encouraged her, when she felt ready, to return to therapy and continue to takes steps in a positive direction. We wished each other well and hung up.

       Susan’s Story

       “My anxiety is a life-long problem. When I began therapy at age seventeen, I learned that I had been having anxiety attacks going back to when I was five. When I was young, it presented itself as a fear that something horrible would happen to my mother, who is an alcoholic. I could not sleep anywhere but at home. She’d have to come to my classroom and stay until they could pry me off of her.

       “As I got older [high school], it took a toll on my physical being. I was diagnosed with irritable bowel syndrome. I barely ate because my stomach was in knots all the time. By my senior year, I was having anxiety attacks. I’d be in class and start thinking that I had to get out of there. I’d feel out of breath, my heart would beat fast and my palms would sweat. These attacks increased three years ago when my mom became ill. I’d feel out of control and my limbs would tingle.”

      Susan was in her thirties when I first met her. She was a petite woman with green eyes who had been married for thirteen years, with two children and five dogs. Her husband was a salesman who traveled and was away at least one week a month. She described him as “a sarcastic, total hothead,” but she felt that they had a good marriage. Susan suffered at times from Temporomandibular Joint Disease (TMJ), irritable bowel syndrome, headaches and a balance disorder. “These physical things are frightening. I’m afraid I’m going to die,” she said. Susan had an inconsistent work history and had had multiple part-time jobs.