“The Only Thing We Have to Fear is…”

Franklin D. Roosevelt’s 1933 inaugural address, given in the terrifying midst of the Great Depression, is quite well-known for the line: “The only thing we have to fear is, fear itself.” With 25% of the work force unemployed, there was much of which to be afraid.

Less well known, but no less eloquent and telling a comment on fear came from his widow, Eleanor Roosevelt, when she was asked late in her life to give a radio audience some guidance based on her own life experience. Recall that Mrs. Roosevelt was a timid, unattractive, and lonely child, afraid of many things; left by her widowed father to be raised largely by her severe grandmother. She eventually became world famous, not only because of her husband, but because she became a champion of the rights of disadvantaged groups and a spokesperson for the United States. Eleanor Roosevelt was a public woman known for her actions and her voice when most women stood in the shadow of a husband.

The quote? “You must do the thing you think you cannot do.”

Good advice for just about everybody.

Social Anxiety Disorder and Its Treatment

http://upload.wikimedia.org/wikipedia/commons/4/43/VER_model.gif

Social anxiety isn’t unusual. Since you are reading this, you might well be wondering whether your own experience of anxiety (or that of someone you love) constitutes a Social Anxiety Disorder.

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), such a condition exists when someone experiences a “marked and persistent fear of one or more social and performances situations in which the person is exposed to unfamiliar people or possible scrutiny by others. The person fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing.”

The essence of this condition is a preoccupation with what others might think of you.

Now, we all are concerned with this some of the time.

Think of hoping to get a job promotion or wanting to impress a potential romantic partner. But consider the language of the diagnostic manual carefully, especially the words “marked and persistent fear.” One hallmark of this disorder is avoidance. When the anxiety is so great that you do your best to get out of doing something (e.g. asking someone on a date, giving a speech, attending a party, returning an item to the store, etc.) then you very well may have a clinically significant condition that can benefit from treatment. In effect, you are trying to avoid both the uncomfortable situation and the feelings that you believe will come with it.

In addition to avoidance, the individual will commonly be aware that his fear is greater than that which would be experienced by most people in a similar set of circumstances, and that the condition is very distressing and/or interferes with his life in significant ways. In fact, one of the ways that Social Anxiety Disorder complicates one’s life is by making it difficult to do the things and have the relationships that would make that life interesting, enjoyable, and fulfilling.

Is it hard to take a compliment, be the center of attention, or talk to a stranger? Do you worry what others will think of how you look and sound? Is it hard to be spontaneous in a conversation and are you too distracted by your own worries to fully concentrate on what the other person is saying? Do you get tongue-tied when trying to make an impression or have the sense that your voice is quivering or that you are perspiring too much?

Do you hesitate to state a strong opinion for fear of sounding stupid or being rejected for your ideas? Do you try to prevent others from getting to know you very well because you believe they will eventually conclude that you are inadequate and reject you? These kinds of preoccupations are typical of Social Anxiety Disorder.

The good news is that with persistence, an accomplished therapist, and the right program of treatment, you have an excellent chance of significant improvement. On the order of 80% of those who receive a systematic cognitive-behavioral (CBT) program will likely experience such change.

A good CBT counselor first makes sure that social anxiety is your major problem. For example, its not unusual for people with a Social Anxiety Disorder to have had one or more panic attacks. If those episodes occur outside of social or performance situations and lead the person to focus on their physical health, they likely indicate that a Panic Disorder is present and that the panic itself should be the focus of treatment.

However, about 50% of people who have clinically significant social anxiety also have had panic attacks. Therefore, if your preoccupation is more about how you look to others and what they think of you than it is about the symptoms of panic, treatment is likely to target your social issues.

CBT assumes that bodily sensations (such as shakiness, blushing, or a lump in your throat), behavior (such as having difficulty making eye contact or avoidance), and thoughts (such as the belief that others will reject you or that you will lose your job) all interact to fuel your social anxiety problems.

Thus, for example, the more your thoughts focus on the belief that you need to be perfect or the likelihood that you will fail, the more you are likely to experience physical manifestations of your anxiety and behave in a way that betrays your insecurity. As a result, CBT attempts to help you change physical symptoms, behavior, and cognitions.

A good cognitive behavior therapy program for social anxiety will help you learn to counter irrational thoughts that tend to be self defeating (this is called cognitive restructuring), and gradually practice with the therapist (this is called role playing) those situations that are difficult for you, beginning only with those that produce a relatively small amount of anxiety, and then try out your new skills in the real world, again beginning with relatively easy kinds of social interactions and working toward the ones that are harder for you.

And, you will discover that if you can tolerate small amounts of anxiety rather than flee them, you will “habituate” to the anxiety in much they way that your nose adapts to a foul odor by adjusting so that after a short amount of time the smell is not nearly so strong; similarly, your anxiety will weaken if you stay in the uncomfortable situation, usually within 45 minutes.

Treatment typically takes somewhere in the neighborhood of three to four months, although it can take longer if other issues also need attention. When it is successful, the patient usually finds himself less troubled by physical symptoms, more assertive, less preoccupied with other people’s opinions, more optimistic, less awkward, able to receive compliments without discomfort, able to look people in the eyes, and less avoidant.

It can feel enormously freeing and lead to much better things in life, including more and better friendships, greater vocational success, and a more satisfying romantic life.

Persistence is essential and the program takes some courage. But if you want to change your life and be less encumbered by social anxiety, CBT for Social Anxiety Disorder has much to offer.

The image above is described as Template: VER model created by Braintest. It is sourced from Wikimedia Commons.

What to Expect in Your First Therapy Session

http://upload.wikimedia.org/wikipedia/commons/thumb/6/6c/Freuds_House.jpg/256px-Freuds_House.jpg

Going to therapy for the first time takes some courage. You are about to talk about some very personal things to someone who is a complete stranger. What can you expect?

1. First of all, expect to be at least a little bit nervous at the beginning. But even before you get inside the therapist’s office, you will have to fill out some paper work. You will also receive a written description of the therapist’s practice, including such details as whether the therapist accepts your medical insurance and how he handles that. Additionally, he will give you information about how your medical records are safe-guarded and the extent to which those records are confidential.

2. The therapist should greet you, bring you into his consulting room, and sit face-to-face with you. Therapists generally want to convey “openness.” It is therefore rare for a therapist sit behind a desk, with you on the other side.

3. After a few “ice breaking” words, the counselor will ask you why you have sought treatment. If you already told him some of this on the telephone, he will want you to fill in the details.

4. Don’t feel that there is a particular “correct” order in which to tell your story. Simply tell it. Initial sessions should generally allow enough time for you not to be rushed. The therapist has probably scheduled at least 75 to 90 minutes to spend with you.

5. If it makes you feel better, it is entirely appropriate to bring an outline of the topics about which you wish to talk, and to consult this outline or read directly from it whenever you need to.

6. The counselor is likely to have some questions for you. He should want to know about your background, not only about the concerns that exist in your life at the moment. Unless he knows that history, he won’t be able to fully understand how you came to have the current difficulties and whether they represent a repetitive pattern in your life.

7. Among the topics you might be asked about are such things as a description of your parents and their approach to rearing you, relationships with siblings, the educational and social history of your school years, whether you changed residences with any frequency as a child, past and current health concerns for you and your family, the presence of any traumatic events in your life, your dating experience, the type of friendships you have or have lost, work background, alcohol or drug use, current medications, present family relationships (spouse/children), financial concerns, and past or current depression or anxiety issues.

Additionally, expect to be questioned regarding any evidence of mood fluctuations, sleep, digestive problems, headaches, caffeine use, suicidal or homicidal thoughts or actions, difficulties in maintaining attention, hyperactivity, hallucinations, delusions, hobbies, religion, how you feel about yourself, whether you can be assertive in your life (say “no” or ask for things), diet and eating/weight problems, obsessive thoughts, compulsive actions, and what you hope to get out of therapy.

Of course, the first session won’t have time to touch on all these areas in the initial session. A counselor will proceed gently.

8. You should not feel that you must discuss topics that are too uncomfortable for you. A sensitive therapist will give you permission to cover only the ground you wish to and a sense of control over the session’s progress so that you don’t become overwhelmed.

9. The therapist might well ask you what challenges you’ve had in life and how you have managed to overcome them. This kind of question helps you to know what strengths you have and to help you remember that you have surmounted past difficulties and therefore can rely on those strengths to help you surmount the current problems.

10. By the end of the session, the therapist should provide feedback about what you have said. This is, in part, to help you and the therapist know if he has heard and understood you and whether his initial impression of you seems appropriate.

11. The counselor, to the extent that he offers interpretations of the material you have presented, should let you know that this is a first impression and therefore not necessarily perfectly accurate. An expert therapist needs to hear your concerns about him personally, his ideas, the therapy approach he is recommending, and his effect on you. Such a person will not be offended by your concerns and wants to hear from you what feels right and what doesn’t feel right about the therapy process.

12. The counselor will normally allow a good deal of time to answer any questions that you have about him and his approach. Although most people usually do, it is not essential that you make another appointment at that time. If you already believe that this therapist is not the right one for you, it is perfectly appropriate to say so and ask him for a referral to another professional.

13. By the end of the session you ought to have a sense of direction and at least an initial treatment plan as articulated by the counselor. The therapist is likely to remind you of the importance of regular attendance and that your dedication to your own healing is essential to obtaining the results you want. Therapy, unlike medical intervention such as brain surgery, requires effort and activity on your part. It is also essential that you have the courage to look at yourself honestly, recognizing that in order for your life to be better you will have to be willing to change some things about yourself.

14. At the end of the first session you might feel exhausted, in part because talking about big emotions is hard work! You are likely to be less anxious than you were when you came into the session. You may feel some amount of relief at having talked about things that you have rarely if ever discussed before. If the therapist has done his job, you should have a sense of hope.

15. In the days following the first psychotherapy encounter, you might well find yourself still processing the material you discussed. This can be unsettling, but it is quite normal. Additionally, a person new to therapy can feel that he has said too much and made himself too vulnerable to the therapist, especially if he (the patient) is a private person. Some people will therefore not return to therapy after the first session. If you have this hesitation, however, remember that it is in your interest to persist despite your discomfort if you sincerely wish to change your life. Good luck!

The above image is the entry to Sigmund Freud’s office at Berggasse 19 in Vienna, Austria. It originally was posted to Flickr by James Grimmelmann and was sourced through Wikimedia Commons.

The Importance of “Showing Up”

http://upload.wikimedia.org/wikipedia/commons/thumb/6/68/Reporter_raising_hand_at_US_Army_press_conference.jpg/500px-Reporter_raising_hand_at_US_Army_press_conference.jpg

Woody Allen denies he ever said, “Ninety percent of life is showing up.” Still, someone did.

Regardless of the author, what does it mean?

It refers to taking chances and working hard; if not welcoming challenges, at least not shying away from them. They often come without an announcement for those who listen for their call.

In and out of my clinical practice, I’ve met people who don’t “show up,” sometimes literally. Such individuals fail to put time and effort into therapy or whatever they “claim” is important to them.

How many people say their family is the essential thing in life but allocate their hours as if loved ones were second, third, or even lower on the list?

“Showing up” means stating you value something or someone and striving for consistency between your words and deeds. Of course, when acknowledging a person or thing has worth, you are taking the risk that a failure to search for it, discover it, or maintain it will disappoint you.

Other self-deceptions can also motivate the failure to be “present.” The parent who claims his children are Number #1 might substitute “quality time” for inadequate quantity. Where money is not an issue, providing gifts does not offer a worthy excuse for the lack of a benign and caring adult presence. Worse still is when the parent blames the young one or the spouse for his absence.

Teens are not free of their own self-willed ignorance about what they do. I treated some teenagers who denied school mattered and didn’t try hard. In this way, they protected themselves against possible frustration.

Better to be thought indifferent than unable to “do the thing you think you cannot do,” as Eleanor Roosevelt said. The adolescents in question armored their egos from the hurt that comes with the awareness of inability.

Ironically, some of these kids might have succeeded with sufficient dedication, persistence, and a little assistance. The decision not to “show up” became a self-fulfilling prophecy, guaranteeing the result they feared.

“Showing up” often brings unexpected benefits, as well. If people observe your face and your diligence, they may give you the benefit of the doubt. Your efforts and identity stamp you as someone reliable and conscientious.

The memory of those qualities attached to your name increases your chance of being called upon. Someone comes to believe in what you can do, sometimes even an unknown authority who has heard about you.

Is this luck? Perhaps. But by living this way, you will find yourself more often in the right place at an opportune moment. Or, as Branch Rickey said, “Luck is the residue of design.”

Determination pays off in unexpected ways. Countless stories tell us how bright and attractive women come to fall in love with men who, at first, make no impression.

Ultimately, these ladies admired the man who seemed dedicated and sincere in his pursuit (I’m not talking about stalkers). The strength of the man’s personality and the sheer amount of contact allowed her to see him in a fresh light.

Contrast this with gentlemen afraid to ask the woman out, unable to imagine she might reciprocate interest. The most successful suitors are those who don’t worry much about rejection, or if they do, refuse to let the potential pain stop them. They think more about the goal than future disappointment.

There is much to behold when the sun is ablaze, but what you focus on sometimes makes a transformative difference in where you land. Too many of us become as sightless as those who are blind.

A woman I talked with at a high school reunion said all the attractive girls wondered what they’d done wrong when the boys didn’t ask them out. Most of the young men were terrified! The ones who walked the high wire of romance had the field to themselves.

Fear doesn’t get you anywhere in life. We tend to regret missed opportunities more than those we reach for but fail to grab. On one’s deathbed, no one says, “Gee, I should have done less with my life.” The only exception to this rule of regret is spending more time with your children, a late sadness that trumps much else.

Many tell themselves they won’t act until the moment is right, as if waiting for their feelings to catch up to their desires is a recipe for accomplishment.

Instead, events often turn out the other way around: your hesitation changes over time because of repeated actions. And nearly as frequently, your emotions can be modified by what you tell yourself about them.

One can decatastrophize the situation by looking at it through an objective lens of reality and the lessons imparted by history rather than through the telescopic magnifying effect of emotion and imagination.

If fear prevents you from translating your values into action, their alleged importance might as well not exist. If your anxiety leads to avoidance, perhaps you will also miss what psychotherapy can do to put you on the right path in small steps.

Cognitive Behavioral Therapy (CBT) is often beneficial in dealing with social anxieties and other fears, producing empirically verified results otherwise unavailable. There is no shame in having fear; everyone experiences it, and some amount of anxiety is useful. However, allowing paralyzing worry to capture all your days must be escaped.

For those who dare to face their troubling anticipations (with a bit of help), life can provide rewards thought unavailable.

Don’t be afraid to change. “Show up” for life.

Remember, “This isn’t the rehearsal; this is the performance.”

The image at the top of the post is a reporter raising his hand to ask a question of U.S. Army General Ray Odierno at the Pentagon Press Conference on Iraq, June 4, 2010. It is a U.S. Army photo taken by Cherie Cullen.

The second image is a Poster for the Federal Theatre Project presentation of “Help Yourself” at the Musart Theatre, 1320 S. Figueroa, Los Angeles, Calif., showing a bank teller and a woman with bags and stacks of money, 1937, Library of Congress.

Finally, “The Bravery” is an album cover of a release by Kirill Fandeev. All three are sourced from Wikimedia Commons.