courage

August 13, 2009

“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.

August 6, 2009

Social Anxiety Disorder and Its Treatment

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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.

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

June 11, 2009

What “Fidelio” Tells Us About Life

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I’m not much of an opera lover. The stories are mostly preposterous, and I prefer instrumental music to vocal music most of the time. But, every so often opera puts words to music in a way that is immensely touching and wise. For me, the best example of this comes in the vocal quartet “Mir ist so wunderbar,” from Beethoven’s only opera “Fidelio.

Beethoven sets the drama up quickly. Florestan, housed in a dungeon, is the political prisoner of an evil and corrupt Governor named Pizarro. Florestan’s wife, Leonore, doesn’t know whether Florestan is living or dead. But, ever faithful, she disguises herself as a man using the name “Fidelio” (so much for the preposterous part) and gets a job at the prison. Her boss, the jailer Rocco, has a beautiful adult daughter named Marzelline, who is being pursued by a prison guard called Jacquino. But as soon as Marzelline gets a look at her dad’s new assistant, she pushes Jaquino away and has eyes only for Fidelio. Fidelio can’t exactly reject his boss’s daughter, and he lets her and her father assume that a marriage will be near at hand.

At this point, Fidelio (“faithful one”), Marzelline, Rocco, and Jaquino sing a vocal quartet that is touching because of its gorgeous music, but even more, because it describes the poignancy of the human dilemma in which these four decent people find themselves.

As the musical lines of the four voices weave in and out, Fidelio expresses her worries over her husband, the possibility that she will not find him,  and the anguish she feels at Marzelline’s affection for her;  Jaquino articulates his heartbreak at having been jilted by Marzelline for Fidelio; Marzelline sings as a young woman in love; and her father, Rocco, looks forward to the happiness of these two good young people — his daughter and Fidelio — and their domestic life together.

The music touches us because of what we know that they do not. Marzelline will have her heart broken, as she must very soon, when she discovers that her future husband is a woman. Rocco, too, will have his future hopes for this daughter dashed. Fidelio faces danger if Florestan lives and she attempts to rescue him, and her own unhappiness if she has arrived too late to save him. And there is no certainty that Jaquino will ever win over Marzelline, even as a “rebound romance,” once Fidelio’s identity and true gender as Leonore are revealed.

But there is more, and it is what Beethoven’s opera tells us about life by way of this music. It is that even decent and good people such as these four will sometimes be at cross purposes that frustrate them and hurt them. The disappointment will not happen because any one of them wanted to harm any other one of them. It will occur simply because that is the nature of human existence. And Beethoven made art of this fact of life. We feel for the characters, however absurd the opera’s premise, because we’ve been there too, been in difficult relationships where pain was inevitable despite our best efforts to avoid it for ourselves and avoid inflicting it on others.

The disappointments that are bound up with living, the tragedy that touches virtually every life before its end (and, often, because of its end), is the stuff of opera, life, and of psychotherapy, too. Fidelio moves us because it is a story of self sacrificing love and courage. And the irony of great art that comments on human suffering, such is this vocal quartet, is that just as Beethoven moves us to tears, he touches our heart in a way that enlivens us, and makes life worth living in the moment that we share the beauty and wisdom of his vision.

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The above image is a poster for an April 12, 1904 performance of Fidelio, sourced from Wikimedia Commons.