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Hi once more – Here is the next article from my book “Freedom From Agoraphobia.” Here, we identify the traps causing your panic attacks and begin the process of changing them. (!) It’s an exciting and rewarding process. One note: If the Sample Life Chart does not come out on the Website, I will post it on mine – Agoraphobia-Treatment.com. Again, 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. So here we go:
Insight-oriented Therapy: Part I Or Why??
So, what is it? Psychodynamic psychiatry is the knowledge of human psychology that started with Freud and has been developed and added to for most of the 20th Century. I think Freud’s greatest contribution to Western culture was his asking the question: “Why?” Specifically, “Why do people act and feel as they do?” Big deal, you say? Well, actually, it is a big deal. Because when he asked the question “Why?” he made an obvious but crucial assumption – the assumption that there was an answer. In other words, he somehow developed the idea that human feelings and behavior had reasons behind them – that there was some kind of logic to them – a psycho-logic. This is such a vital and basic idea that nowadays we just take it for granted. We talk in terms of being in denial or projecting feelings or suppressing our anger or having low self-esteem or being traumatized. We have no doubt at all that there are reasons for our suffering. Can you imagine a time when people had little or no idea that there were reasons (internal reasons) behind what they went through? They must have felt like they were living in a whole different world. Freud’s purpose in identifying what went on behind the scenes was to find out what was causing things to go wrong so they could be set right. It also turned out that just by understanding why we feel as we do often makes the correction obvious or even automatic. One small example of this is the “anniversary reaction”: Have you ever had a day when everything was just going wrong? And even the things that were going right somehow were all wrong, too? You just seemed to have gotten up on the wrong side of the bed? Well, you could have been having an anniversary reaction. And if you were, you’d instantly know that that was the problem if someone reminded you that this was the anniversary of the day someone you cared about died. You would know it because the moment this fact came to your attention, everything would change. You’d feel sad and perhaps miss the person, but your irritability and sense that all was not right with the world would vanish. Perhaps you have experienced this. If not, the next time you are feeling all out of sorts, ask yourself if today is the anniversary of a loss. If it is, you will be surprised at how just the conscious realization of that fact causes everything to change. And that is the point: becoming consciously aware of what’s going on beneath the surface can automatically change things. This brings us to the definition of the word “insight.” “Insight” means becoming consciously aware of what’s going on inside yourself. So insight-oriented therapy works just that way - it produces change by providing insight. Perhaps you’ve already experienced this by reading about traps. You might have said: “Hey – that’s what’s going on with me.” If so, you had some insight. And the change in your life resulting from this insight follows right along automatically. For example, you might have realized that you need to say “no” to something you’ve been making yourself go along with. If so, you will soon experience how this realization changes what you feel and do. Usually, insight-oriented therapy takes place in a therapist’s office. (If you decide you need this help, see Article 7 on selecting a therapist.) But insight occurs by your looking within yourself. And there’s only one person required for that. So it is also quite possible for you to get your own insight - if you know where to look. So here’s where to look: Anxiety Chart and Diary First, you need to become aware of what you are actually dealing with. This is why you have been diligently keeping your Anxiety Diary and Anxiety Chart. If you have been writing down what caused your anxiety to go up, you have made a good start on figuring out the “why” of it. Periodically, by reviewing them, the Anxiety Chart and Diary will begin to reveal what the various times you became more anxious had in common. You have probably already done this to some extent. Instead of simply knowing that you get more anxious in the supermarket, dental offices, church, movies and airplanes, you have probably realized what all of these situations have in common – that you cannot leave them without calling attention to yourself or making an embarrassing scene. See if you can find the common denominator among other situations that increased your anxiety.
Just like that, huh? Well, ‘yes’ for some people and ‘no’ for others. But even if it’s the biggest thing you’ve ever taken on, it’s got to be done. So gird your loins and let’s go for it. If you decide that now is not the time for you to get out of your overall “Life Trap”, that’s O.K. It will still help in major ways to identify it. Many people know without any effort what is the overall trap going on in their lives. Just this week as I am writing this, a brand new patient asked: “So why does this happen?” I’m sure she did not expect a real answer because she was certainly surprised when I gave her one. I told her about traps. And as I described how people go into periods of having more panic attacks or fewer panic attacks depending upon whether they are in traps in their lives, she just kept nodding and saying stuff like: “Uh huh. Uh huh. That’s right. I see that!” It was at the end of the appointment, so I have to wait until next week to hear what her traps actually are. But it was clear that she knows. So if you know what your Life Trap is, you can skip ahead to “How To Get Out Of Your Trap” in the next article. If not, read on. A lot of what an insight-oriented therapist does is to show you where to look to find the answers you are seeking. Here’s a pointer for where and how to look for your Life Trap: It’s a phrase I just can’t resist putting in: “Subsequence often implies Consequence”. These are $10 words saying that something that happens after something else (subsequently) is often because of it (a consequence). For instance: you got sick to your stomach after going out to eat so you conclude that it must have been because (a consequence) of something you ate. Subsequence implies consequence. Cool, huh? (Not the sick stomach, however.) Yes, it’s relevant.
An excellent question to ask in order to figure out your Life Trap is:
“What did the panic attacks start after”? And an excellent
way to figure this out is to do a Life Chart. In fact, this is very
worthwhile even if you do know what your trap is. Your Life Chart A little further on is a sample Life Chart. For this imaginary person, it roughly shows the frequency and intensity of panic attacks by the height of the boxes and it shows the ages at which they occurred. There are notations as to major events going on in her life at these ages. Can you discover the common factor among the various periods during which she had panic attacks - what they happened after? Skip ahead, study the chart now and think about it before you read the answer. Here is what the chart shows: From 5 to 6 years old, she had a number of panic attacks related to starting school (a common occurrence in pre-agoraphobic children). From 15 to 19 years old, the panic attacks came back fairly severely and frequently. This period was kicked off by her father’s death. At age 24, they came back with similar severity when her first husband began drinking. This continued until age 28 when her doctor gave her Paxil to take. This cut the panic attacks approximately in half until she was 36. At that time, she quit the Paxil and there followed 2 years of even worse panic attacks than before she started it. At 38, she got divorced and the panic attacks tapered off to the level they had been when her husband started the drinking. At age 41, she met and later married Sam. The panic attacks stopped altogether. However, when she was 44, Sam was diagnosed with an enlarged prostate and the panic attacks returned with moderate severity. Have you figured out the common factor? The (all too common) answer is… loss. Our subject first got panic attacks (in itself a very good clue) when having to start school – i.e., loss of home and parents each day. Then she got them again when her father died. Her husband’s drinking was like not having the guy she married anymore. And Sam’s prostate condition now threatens the loss of him. By the way, this does not mean that she is doomed to always have panic attacks (since life always has its losses). Her problem is not that there are losses but that these represent a (guess what?) trap for her. For reasons such as having learned that she must always be “the strong one” who never cries or falls apart, she does not allow herself to grieve her losses. This means that she is stuck with some very strong feelings and no outlet for them. So what happens? Panic attacks, of course. But there is a way out. She needs to grieve. How can she get help with this? See for yourself: Type the words “Grief Group” in the “Search” box on the Internet computer at the library or in your home. See what happens.
When Ken was 6, his father died in an accident at work. His two sisters are 14 and 16. He was the product of an unplanned pregnancy. With his father gone, the family has too little money to get by. His mother just can’t manage raising the kids and working as well. She decides to accept her sister’s offer to care for one of the children. She picks Ken for this since the girls will be out on their own in a few years anyhow. Not surprisingly, Ken had his first of a series of panic attacks the day he is supposed to go live at his aunt’s house. The panic attacks eventually tapered off until an incident in high school: The tough boys hung around together. They taunted smaller boys like Ken – calling him names like “fag”. When he tried to hit one of them, several boys grabbed him and held him helpless while they pulled off his pants. He ran after them but some girls saw him running in his underpants and laughed at him. Ken finally made it to the Boys’ Room. His next series of panic attacks began then and there. Ken’s next spate of panic attacks occurred as an adult when he was laid off from work. The company was doing poorly and someone had to go. They picked on Ken even though he had more seniority than some of the other workers because they had to keep up their quotas of minority employees. At this time, Ken had undertaken an expensive series of orthodontic treatments for his little daughter. If he did not have the job, he did not have the dental insurance to cover the treatments. What could he do? Jobs weren’t easy to get. He couldn’t just have the dentist pull the braces off her teeth. They were already partway straightened. If only it weren’t for those quotas. It just wasn’t fair. He resumed having panic attacks. Here’s a one-question quiz: Ken is a person who is likely to develop a panic attack if: a) His daughter was the only kid to forget her lines in the Christmas pageant and the other parents teased him about it afterwards. b) His wife told him she wanted a divorce because she just did not love him any more. c) His auto insurance was unfairly raised after an accident that was the fault of the other person but who lied about what happened and was believed. The answer is… whatever would make Ken feel unfairly but helplessly angry. That is the common denominator in the situations that brought on panic attacks before – being picked as the kid to lose his home, being bullied because he was smaller than the other kids and being laid off because he wasn’t a minority. So, in the quiz, the third choice would certainly do it. The others could do it also if you took them as making Ken feel helpless anger. Thus, if he felt angry because there was something unfair that caused his daughter to forget her lines (like the lines were changed at the last minute), the first choice could give him a panic attack. The second one also could if there was something about his wife wanting a divorce that made him feel helplessly angry. An example would be if she wanted a divorce because she had turned to someone else as a result of Ken being away from home a lot, working. On the other hand, if Ken just felt embarrassed about his daughter forgetting her lines or just hurt and rejected by his wife wanting a divorce, these situations would not result in panic attacks. Ken would get some useful insight if he drew up a life chart showing his periods of panic attacks and what situations had preceded each period. He should then look for the common denominator that was present in each situation. When he finds the correct one, he’ll quickly know it because it will apply to the little, daily situations as well as to the large events of his life. For example, we have already figured out that the common denominator for Ken is anger – especially anger over something that was unfairly done to him and which he is helpless to do anything about. So, just as we did with our quiz, we can predict the situations that will cause him to panic. We know that if Ken is the thirtieth car stuck while the drawbridge is going up, he probably won’t have a panic attack. But if they let a long line of cars through and pick on Ken as the first car to stop to wait for the bridge, we’ve got a pretty good guess that he’s in for trouble. Here’s a list of frequent common denominators. As you go over the significant events in your life chart, if your common denominator does not leap out at you, try looking for one of these: Sadness Grief Anger Frustration Embarrassment Humiliation Fear of Death Fear of Injury Fear of Loss Fear of Failure Longing To Be Loved Helplessness Being Smothered Being Abandoned Feeling Overwhelmed with Responsibilities Not Having Control Addiction In fact, all suffering can be boiled down to: 1. Being without someone
or something you want to be 2. Being with someone or
something you want to be So, another approach to figuring out your Life Trap is to ask yourself: “What am I with that I want to be without; or what am I without that I want to be with?” As you look over the list above, everything on it is included in this question. Thus, we can be without people we love, we can be without security, we can be without power to do something, we can be without health, success and so on. Also, we can be with people we dislike, we can be with too many responsibilities, we can be with the knowledge that we made fools of ourselves and so on in this vein. Remember, too, that traps involve I-Can’t-But-I-Must double binds. So you could also ask yourself: “What do I feel I must do but can’t?” Again, the answer will be your trap. If you ask: “What do I feel I must do in my life but can’t?,” the answer will be your current Life Trap. If you ask: “What do I feel I must do today but can’t?,” the answer will be your immediate, Day-to-Day Trap. This trap could be the same one as your Life Trap, or it might be a small version of your Life Trap. Ken getting stuck as the first car made to wait for the bridge would be an example of a small version Day-to-Day Trap. If you have done all this and asked yourself all these questions and still can’t figure out what your Life Trap is, you could ask someone who truly cares about you. Tell them not to hold anything back because you really need to know: “In what way do you see me as being trapped in my life?” Especially if you explain why you are asking, the two of you should be able to come up with it. (Unless your friend is rolling on the floor laughing that you could seriously ask something so obvious.) Finally, the last resort: You’ve made a life chart and no pattern of subsequence and consequence is visible. You’ve gone through the list of possible common factors among trapping situations and none of them seem to apply to you. You’ve asked yourself who or what you are without and want to be with and vice versa. You feel you’ve got everything you strongly want. You consider the double bind and feel that you can do everything that you must without undue stress. And your friends and loved ones agree that there is no major problem in your life or how you are taking things. You are really stuck – no traps. What this means is that your unconscious mind is hiding something from you. And from the people who know you as well. (Yep, it can do that.) So, at this point, you need the assistance of someone who is trained in unearthing what goes on in people unconsciously – namely, a therapist. An insight-oriented therapist. When you go to a therapist, you can make it clear where you are coming from – that you are not looking for a prolonged revamping of your character. Instead, you can explain that you are looking to understand how you are trapped in your life because you are working your way out of Agoraphobia and need to know this. So (you explain), what you are after is a good, thorough evaluation to be followed by a frank and open discussion of the therapist’s conclusions. You should ask if the therapist is agreeable to this. Because you do not want a long therapy that attempts to gradually bring you to those same conclusions for yourself. And you do not want the therapist to hold things back to spare your feelings. You are paying for the straight scoop and want to know that that’s what you will get. If the therapist is not agreeable to this, then you will need to look further for one who will give you what you are paying for. Such an evaluation should only take a few hours – I’d say six at the outside including giving you the results. You can also ask for the therapist’s written report of the evaluation. There should always be one. So there you have it – how to identify the cause of your panic attacks. (!) Once you have done so, keep your eyes open. Things are likely to begin to change all by themselves. And that is the basis for the most mainstream and widely-practiced form of psychotherapy: making what is unconscious conscious. (Incidentally, this was Freud’s great discovery.)
Wishing you well until next month, Mark Eisenstadt, M.D. You can find Article twelve Here
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