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Hi –
Here is the next article from my book “Freedom From Agoraphobia.” In it, I am trying to give you principles of how to work a program for overcoming Agoraphobia or Panic Disorder. Also, choosing a therapist (if you want one) can be very tricky. So, I am hoping to help you avoid the pitfalls in doing this.
Since I am an M.D., I cannot express my point of view without being concerned about liability. So please note this disclaimer before reading further: Any medical information in this article is not intended as a substitute for informed medical advice and you should not take any action before consulting with a health care professional.
As always, I hope you learn from and enjoy this (at times irreverent) article.
Mark Eisenstadt. M.D. Article 7 For the next several articles, we will first look at the use of medications and then go into methods from three major forms of therapy that work to overcome Agoraphobia. How do I know they work? Easy. Because I have seen them do so over and over. (There is also a convincing body of medical research proving that they work.) No single therapy seems to do it all for most people. So when working with someone, I combine the therapies to fit the needs of that person. When one works better for someone, I use that kind the most. And I add in some of what I have learned from some less common forms of therapy as fits the situation. Most often, I also teach people how to do meditation. So this will be covered, too. I believe that people can go quite far with applying these methods for themselves. They are not complicated. Mostly, making them work takes sticking with it. In this article, we’ll start by going over some general principles about therapies and how to use them. Principle 1: “Each person must work out her own salvation diligently.” In other words, by using the methods I will be describing, you can get past your Agoraphobia. But, there’s a “but.” And the “but” is that you must adapt the techniques to your own self and your own ways of making changes. In order to quit smoking, I had read all sorts of methods and helpful ways of going about it. But, in the end, I found that I had to work out my own way of using those methods and even invent some new variations to make it work. Some methods were not for me at all. Others were crucial. Principle 2 You have to do it. Just reading about how to make changes will be as effective as reading about how to play the piano. I had one very bright college student in one of my treatment groups. She dealt with what she was taught in exactly the same way that she treated her courses in school: She quickly learned all the principles and could quote them back to me without a moment’s hesitation. In fact, her understanding was so good that she could tell other members of the group how to apply the techniques to their own situations and how to get over obstacles when these arose. And she did so quite correctly. Of course, she never actually did the techniques herself. What was the need? She understood what had been presented perfectly. Naturally, the moral of the story is that she completed the program with the ability to get an A+ on any exam on the subject but having no fewer panic attacks than she had to begin with. And the poor, dumb, average person who hadn’t caught on nearly as quickly but who went out and actually used what she learned, had achieved all sorts of successes. We had nagged and warned and predicted that this was going to happen if she did not put the techniques into practice, but that was one lesson she somehow did not get. Or, maybe did not want to get. And she went off telling herself that the fault was in the treatment methods, still not having learned the one lesson that would have served her so well in this and many other areas of her life. I mentioned before the saying that the only experiences that are failures are those we do not learn from. That was certainly true for my college student. There was a lesson in her having failed to overcome her Agoraphobia. And if she had learned that one, it might have turned out to be even more valuable than having succeeded in overcoming Agoraphobia. So, try out all the methods. Understanding them won’t get rid of panic attacks. Doing them will. Then, work out your own salvation by adapting them to your needs and creating variations that work for you. Experiment! This is vital! Once you start treating your panics and reactions in an experimental way (“Gee, I wonder what will happen if I try this…”), you have the attitude that makes things change. Principle 3 Keep at it. Do not discard a method just because it does not seem to produce results right away. This is work! (Although it is also fun, at times, too.) Do not take one or two piano lessons and give up because you are not able to give concerts. Each of the methods works. If one is not working for you, you are just not yet skilled enough in using it. But you will become that skilled with practice. Anyone can learn and use these methods. After you have learned how to make a particular one work, you can decide whether this is one you want to use more or less than others. Principle 4 Master each technique the way it is given. Once you get it to work, then modify it to your own style. Some of the methods may be unpleasant for you. Do them anyway. They will work. And they may become your best friends. Later on, you can emphasize some other techniques if you want. Do not try to invent your own therapy as you go. It would be too easy to indulge in just skipping the hard parts and getting nowhere as a result. Principle 5 As was mentioned in previous articles, other people with similar problems can be a great help. Especially if you get stuck. Lots of people have been through this or are working their ways out of it. There are many groups for agoraphobics – self-help groups, groups led by trained therapists and others. It is very useful to share your experiences with other people, hear about their similar struggles and successes and get tips for getting over humps in the road. When you do the assignments for getting out in the world, it is much more fun to have someone (or ones) to do them with. Other members of your group would be ideal for this. If a therapist runs the group, her approach may or may not be compatible with the program you are following here. Since these are mainstream methods, they will fit quite well with most therapy groups. However, if you encounter a conflict, you will need to decide which way you want to go. Most places, there are lots of other options of groups if you decide to continue with this rather than switch horses. Also, as you doubtless know, the Internet is full of resources for finding groups or others with whom to talk such as this one. One caveat: I have known groups in which the members are not working to overcome their Agoraphobia. They never learned that one could. These are usually leaderless support groups and the aim of the people who run them is mutual misery sharing. The members are going nowhere with their Agoraphobia nor are they seeking to. They have given up. There is an underlying belief in these groups that Agoraphobia is incurable. So the members’ goal is simply to hold each others’ hands while living their unhappy lives. As if this were not bad enough, people in these groups are often getting worse by the process of “symptom-swapping.” This phenomenon occurs in all groups but especially in these going-nowhere groups. It is exactly what the name implies – people pick up each others’ symptoms. Somebody in the group talks about seeing flashing lights during a panic attack and pretty soon, you are having flashing lights in yours. (Stop it! I used that example on purpose. Flashing lights is not a symptom of panic attacks so don’t adopt it if you were starting to!) Support groups in which people are just helping each other make the best of a bad thing are fine for diabetes, schizophrenia and having one leg. When it comes to Agoraphobia, however, they are simply well intentioned barriers to recovery. Principle 6 – Getting Help Besides working this program with help and supervision by an appropriately trained professional, if you get stuck or simply wish to work that way, you can enter individual therapy. But there’s a difficulty: How do you find a good therapist? Here are some suggestions: 1. Get a recommendation from someone you know and trust. Preferably from a number of people. And preferably, people with problems like yours. If you attend a group, you may get good leads there. 2. Ask the therapist what her credentials are. I know this can take assertiveness and that may be a problem area for you, but it’s good practice and can have important results. Therapists come with all kinds and amounts of training. In fact, guess what is often required of you in order to call yourself a therapist or to offer “counseling”? Nothing! That’s right – nothing. And guess what a bunch of high-faluting sounding initials after your name can mean? Again, nothing. Or they can mean that you attended a two-day workshop from God-knows-who and received a certificate when you woke up at the end because you paid the fee. Giving workshops and certificates of attendance is big business. Do you know what a Certified Agoraphobia Counseling Associate is? It’s a C.A.C.A. The point is that different states and countries regulate the use of some words and not others. In some, you will have to have certain training and/or take an exam to call yourself a “psychotherapist”, and in others, you won’t. Initials can mean a lot or nothing at all. The only way to know is to call up the licensing board and ask (unless you are able to ask the therapist, herself). Certain degrees and titles are always regulated in the United States. M.S.W. always means that the person has a Masters of Social Work degree. To get this degree, the individual has to have graduated from a Masters program in Social Work. Usually, such programs are 2-year post-graduate degree programs that one enters after getting a 4-year Bachelor’s degree. The amount of training and experience doing therapy is quite variable in such programs. Some schools of social work are known for their excellent training in doing therapy. Psychiatrists must have a M.D. degree plus 3 years of specialty training in Psychiatry. This is a legal requirement for someone to call herself a Psychiatrist. Again, training programs differ but all Psychiatrists are trained in prescribing medications and in some forms of psychotherapy. They are permitted to call themselves “Doctor.” They are physicians – namely, Doctors of Medicine. People who have majored in Psychology in college or graduate school can call themselves “Psychologists.” Thus, they may have 4 years of post-high school education, 6 years, 9 years or more. They may have Bachelor’s degrees, Master’s or Ph.D.’s. Ph.D. Psychologists may also call themselves “Doctor.” They may have as many or more years of specialty training in Psychology as a Psychiatrist has in Psychiatry. Their title of “Doctor” refers to being a “Doctor of Philosophy.” One is not necessarily better than the other. But they are different. Only Psychologists are permitted to administer psychological testing. In most states, only M.D.’s can prescribe medications. (Although many states are increasingly licensing Psychologists and others with special training to prescribe also – such as Psychiatric Nurse Practitioners.) Some Psychologists have more training in doing therapy than the average Psychiatrist. Some have much less. You need to ask a Psychologist what her degree is and what is her experience in doing therapy. For professionals who are not newly graduated, the most important factor will be the kind of work they have been doing since school. If they have been primarily doing therapy and come well recommended, they likely are a good choice. If a Psychiatrist or Psychologist has mostly been doing other work than therapy – such as research or evaluations – she may not have the skills you are after. People with other degrees than these can be excellent therapists. But so can your hairdresser. Their training just will not give you that information. 3. Find out where the therapist “is coming from.” Some Psychiatrists believe that medication is crucial (see “The Infamous Chemical Imbalance” in the next article). So, you also need to ask what is the “orientation” of the therapist. This means what is the major kind of treatment she offers. Although the asking may be difficult, it can also be quite revealing. If you are made to feel stupid for asking, that tells you one of the ways that person is going to make you feel in therapy. Do you want to hire someone who makes you feel stupid and pay them a lot of money to help with your problems? Better than just going away is to tell her that she made you feel stupid for asking. Now you will get to the real nitty gritty! If she tells you that that was not her intention and reassures you that you asked a legitimate question and gives you a useful answer, then you will know you can talk with her. If she acts “huffy” and makes you feel that feeling stupid is one of your problems, then you also know what to expect in the future. If the therapist tells you her orientation is towards some kind of therapy you do not really know about, ask what that is. Again, you will learn a lot. For instance, many therapists I know seem to feel it is a good idea to answer questions by giving out the least possible amount of specific information. They seem to have really practiced saying words that leave you thinking: “Huh?? What did she say?” Are you up against one of these? Do you mind getting “put off” answers? Or, you may find out that this therapist has a very specific orientation. Like the approach that says your Agoraphobia is really a problem with your relationship with God. Maybe that’s right down your alley. Maybe not. But now you know. 4. Finally, use your own common sense. You are the consumer. In fact, many mental health centers now refer to the people who come for treatment as “consumers”, not patients or clients. So, if you feel that you are not getting what you are after, tell your therapist. If things cannot be worked out so that you feel satisfied, switch to another therapist. Do not “throw good money after bad”, as the saying goes. I know someone who went through four years of psychoanalysis, going five days a week. The cost was enormous. He was unhappy with what he was getting, but always figured it was his fault. After all, his psychoanalyst was one of the most high-ranking in the country. Finally, he quit. He used the excuse that he was moving. Years later, another analyst who had been one of his teachers said: “I wondered how long it was going to take you to find out about him.” This does not mean that you should quit as soon as you and your therapist disagree about something. There are always rough spots in any relationship. In therapy, these can be the best opportunities to learn something valuable. And you do not want to be switching from therapist to therapist, always leaving just when you could have gotten something you really wanted. But if you have given it a good try with a therapist and it’s not getting you anywhere, then shake the dust from your feet and move on. Perhaps some kind of rule of thumb would be helpful: If pressed, I would say that if you felt good enough about a therapist to try it with her and you still felt you were getting nowhere after 8 sessions (or 2 months of weekly meetings), it’s time to seriously consider changing. So much for therapists. Next month we will look at medications. And then we will get to the heart of changing. Have a good month. Peace and Progress, Mark Eisenstadt, M.D. You can find Article Eight Here
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