Ask Dan’s Mom, Pt. 4

Every Friday I ask my mother, Marilyn Smith — psychotherapist, anxiety expert, and genetic wellspring of my neuroses — some questions about anxiety, anxiety disorders, and anxiety treatments.

The series “Ask Dan’s Mom” will soon be opened to questions from readers. If you have a question about anxiety you’d like me to share with my mother, please email me at [email protected].

Part 1 of “Ask Dan’s Mom” here. Part 2 here. Part 3 here.

Hi, Mom. How was your week? How’s Bennie [her dog; see Pt. 3]? Has he stopped throwing up?

Good morning! Thanks for checking up on Bennie. He’s been fine, although for some reason he still gets carsick. Luckily this doesn’t make him throw up, just drool … a lot. I gave him some Dramamine but it didn’t help. The vet said I could try Xanax next. Maybe I should teach him the breathing techniques we’ve been talking about, because now I think he has anticipatory anxiety about feeling nauseated!

Wow, yet another child on Xanax, huh? If you’re not careful you’re going to get a reputation. I suspect you won’t have much luck getting Bennie to stop panting uncontrollable, but maybe we can continue to work on me. I took your advice and spent the past week working on Step One of the breathing technique. I admit that I didn’t do it religiously, but I did it as often as I could — and I think I got the hang of it. So I’m ready for Step Two. Educate me!

OK! This is fun. You’re finally following my advice!  So Step Two is not that different from Step One. Again, no distractions, and you should still pick a time to practice when you’re relatively relaxed: usually at bedtime or early in the morning before my granddaughter wakes up and starts demanding your attention. Now that you’ve practiced getting the breath lower into your lungs we can add in a meditational component. Start counting your inhales and exhales to help you focus on the breath (and not, for example, on what work you have to accomplish that day). As I said last week, I like to breathe in through my nose for a count of four and exhale through pursed lips to a count of six — but do whatever combination works best for you. What’s important is that the exhale is longer than the inhale. When your thoughts start to wander (and trust me, they will), accept them but gently return yourself to your breath. I know how hard this is, especially for someone like you whose mind jumps around like a meshugana monkey! (Mea culpa. I know my genes are to blame.) Work on this for another week and then we’ll move on to Step 3.

OK, Mom. I’ll try. In the meantime, I want to pick up a thread that we let drop last week. You mentioned that you tend to favor cognitive-behavior therapy for people who are very anxious. I know this is true of a lot of clinicians these days. Could you explain why this is?

I thought I already answered this question. But since you obviously don’t remember, I’ll try again. (Sometimes we have to hear the same thing repeatedly before it resonates and makes sense.) Interestingly, to get the full benefit from CBT you have to practice continuously, just like you do with the breathing (and in fact better breathing techniques can be an integral part of CBT). Or like going to the gym to build up muscles and stamina. It takes time and patience. Essentially, with CBT treatment bad habits of mind get replaced over time by new and healthier habits of mind. By this I mean that what CBT practitioners call “automatic thoughts” gradually get chipped away at by a conscious, careful questioning of those thoughts and the premises behind them.

You totally did not answer this question last week.  We only touched on the subject and said we’d get back to it. In fact I’d still like more information. Let’s try a hypothetical, if you’re game. Say a person comes in with a relationship anxiety: she’s concerned that her husband may not love her anymore. How would a CBT practitioner handle the situation?

OK, I’ll try to give you a very quick (I’ve got to run out to talk to your grandmother’s nurse) run-down of how this hypothetical might be addressed using CBT. I’m actually visiting your brother right now, and he’s lying on the couch like a slug, so I’ll use him as inspiration.

Wife: I don’t think my husband loves me anymore. 

Therapist: Why do you think that?

W: He comes home from work, sits right down on the couch, and zones out.

T: What do mean he “zones out”?

W: He turns on the TV and doesn’t talk to me except for the occasional muttering.

T: Does he do this on weekends also?

W: No. He’s entirely different on weekends and holidays.

T: What is he like on those days?

W: He’s funny. He’s engaged.

T: So what’s another possible explanation for why he’s so out of it during the week?

W: Maybe he’s tired?

T: Yes. What else?

W: He’s stressed and needs to unwind?

T: OK. Right. So maybe his behavior has little or nothing to do with his feelings for you …

This example is pretty rudimentary, but you get the idea. You can apply the questioning process — call it the “reasoning-about-your-assumptions-and-beliefs” process — to almost any other hypothetical. The basic premise is that the thoughts about a situation precede the feelings about a situation — so you want to focus on the “automatic” and scary thoughts and examine them to determine if they’re in fact rational.

And does the breathing help this process along, in your experience?

Absolutely it does. For most people the breathing helps to calm down the mind, which makes it all that much easier to scrutinize the negative and often irrational thoughts.

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