There is evidence that patients who can better understand the meaning of their signs and symptoms of anxiety do better, and this is called the psycho-education phase of treatment. It can be done poorly (“Here’s some handouts – read them before the next session”) or it can be done using multimedia and involving the patient in their own understanding. This is the approach I take, using whatever stories and metaphors which can best help patients come to terms with the presence of anxiety in their lives, and then learn to better manage it through evidence-based means (as compared to wishing, and “chronic” medication).
Don’t get me wrong about medication – for some people it’s a real boon. Yet it concerns me when I hear stories of patients being on anti-anxiety meds for years with no psychotherapy. Yes, symptoms can be managed and reduced. But don’t confuse this with meaning that anxiety is some kind of chemical disorder or imbalance. If your doctor says it is, ask for the evidence they are relying upon – is it a Cochrane-based meta-analysis or a pharmaceutical company talking points PR memo?
One of the best models of brain function I have seen comes in a video I use (US iTunes link) about how the US Navy Seals deal with panic on the battlefield. Rather than simply training physically harder, they – like those in aviation and surgery – now employ techniques heavily influenced by neuroscience and sports performance psychology to assist soldiers to stay focussed on task, read situations “early” and practise, practise, practise their contingency plans.
This approach also has benefits for anxious patients preparing to enter their feared situations. While it might be helpful to know how a situation came to be feared (especially one that may have been previously pleasing and enjoyable, like flying), it rarely makes much difference to just know that. What’s more important is to appreciate the factors currently maintaining and reinforcing the fear, especially the behaviours, thoughts, and feelings that now seem to occur automatically.
This is where knowing how the brain is organised and its evolutionary history which still affects how it operates can be very useful in designing an anti-anxiety program. At that program’s heart will be exposure – to the physical triggers, and to the accompanying or predisposing thoughts and feelings.
I’m sorry – but I know of no other way that can comprehensively help modulate one’s fear responses for the long haul other than such a program.
If someone says to you there’s a really easy way, ask if they have taken their approach to professional football or netball teams, to Defense Force personnel, to Wall Street bankers, to University research departments and demonstrated then sold their wares. The techniques I use – evidence-based ones – meet these criteria.
So, what do we need to know about the brain at the outset that will ultimately come to be the backbone of our anxiety work? Well, the most commonly accepted ideas currently in neuroscience are about the brain’s top to bottom organisation. At the bottom part are the earliest parts of brain development which we share with many other creatures, both cold and hot blooded. These are areas of the brain which control basic functioning, such as blood pressure and heart rate, digestion, sleep and so on. Areas commonly referred to as “set and forget” and which seem to be outside of our immediate ability to control with thought alone. Sever the connection to the rest of the brain and body at this point (the brainstem) and death immediately follows – as in execution by guillotine.
In more evolved species, another level further up in the mid-brain has evolved, and it’s generally thought that this is where our emotional responses to the worlds outside and inside of us is processed. This is where we “make sense” of the world through our senses rather than through language. It has many circuits which can be said to offer “quick and dirty” responses to threats, and in different animal species these responses can appear to be quite innate, reflexive and instinctual. Circuits kick in when a threat is perceived and “standard” behaviours to thwart the threat follow. Some animals never learn to adjust while some – such as dogs – are very social and have learnt to live with humans and so have evolved some very interesting new learnt behaviours around us. Things that are not necessarily in their repertoire if left to their own devices (e.g. offering “high fives” or “shake hands”)
The problem with the quick and dirty systems is that they’re susceptible to errors in order not to make the mistake of not acting on a potential threat. So they tend to activate the circuits of “run or fight or freeze or appease” first and ask questions later, so to speak.
In other words, as humans, we have evolved to better survive in a world of potential threats and live another day (even if you later discover you were initially wrongly informed) than be wrong about a threat (a threat is present but inaccurately perceived or ignored) and thus be someone’s lunch. Hence, the frequency of “What if…” self-talk questioning in anxiety presentations.
At this point in explaining such things to patients, many will nod their heads and tell me, “Yes, that makes a lot of sense… that somehow, even though I know flying is essentially safe, I am giving myself false alarms months or weeks away from my flight. So, knowing this, now what?”
And here is the rub. Showing patients these explanatory ideas accompanied by excellent multimedia, very much appeals to the newest areas of the brain, which we don’t share with many of our animal friends, and this is the top-most cerebral cortex. In particular, the area of the brain that has most recently evolved “which makes us most human” (as one of the iTunes videos says) is the area at the very front of the skull, called the prefrontal cortex. It is a slower, decision making, problem-solving, story-telling interpreter and synchroniser of all that happens in the brain. It also happens to reach full maturity well past our teens, in terms of the extent of its connectedness with other regions of the brain it “supervises” and co-ordinates.
Having it take better control of the older, “quicker and dirtier” parts of the brain is the objective of therapy, in my view. It’s called taking a “top down” approach. I like to think of anxiety as a more bottom up brain activity, where the older centres pounce on threats, assess quickly and cause old, well-established circuitry to kick in. Because of its speed and connectivity, many anxious patients describe how all rational thought seems to fly out the window when confronted by either their external triggers (“ the engines seemed to slow down on take off”) or their internal sensations (“I’m breaking out in a sweat even with all the air on me”).
This is why just sitting in your therapist’s office practising thought stopping or challenging certain thoughts, while a good thing in principle, will only get you so far. You’re retraining only one part of your brain – perhaps the part that affords you a living via the work you do – but it is only a small element of the whole fear response/threat activation story. You need to be able to practise and consolidate a more topdown approach so your changes in thinking clearly change your behaviours, and feelings.
In order to assist patients with what actually works beyond their learning cognitive reappraisal or restructuring techniques – and I’ll include the new wave of mindfulness training in here as well – patients (and their therapists for that matter) need to learn how to actively bring the top down approach into greater effect.
Back to a useful model
Because I’m going to ask patients to do things, not merely listen, watch and read, I need patients to prepare themselves for the work ahead. So having a really practical model for how to conceive of the work is vitally important. Without really understanding the learning principles and behaviours on which I am relying for change to occur, patients are less likely to practise, nor take their homework (in between session tasks) seriously. I might as well just dole out pills – if I was licensed to do so.
The model I’m going to use makes use of the YouTube video below, of the orchestra conductor Sir Simon Rattle. It’s based on one of my videos where a sports and performance psychologist explains the functioning of the pre-frontal cortex as “acting like the conductor of an orchestra”, synchronising brain activity, like a conductor does for the various sections of the orchestra.
This model is quite useful, if a little simple, so in my work with patients I extend it somewhat for educational purposes. The introduction of music is also vitally important, as we will explore its use for various flight phases, especially turbulence. The relationship between music and brain activity is quite fascinating.
First, take a look at this 2013 YouTube video of Sir Simon Rattle conducting a collective of German school orchestras in Germany, in German! (With subtitles). It shows 21 minutes of rehearsal, but please, just watch a few minutes at its beginning to get a feel for what’s happening, then pause it, and read on:
You’ll note firstly how Sir Simon simply asks the young musicians to play a very well known piece without much instruction at all – they’re going from the notation and past experience.
Watch a few minutes then advance to 8minutes 45secs, and watch a few minutes more as he demonstrates how a conductor earns his or her money – not from the Saturday evening performance an audience witnesses, but from the days of rehearsal leading up to the performance.
After listening to the combined student groups play without his instruction, he then proceeds to guide them through his interpretation of this famous classical piece. As I point out to my patients when I show them this video, while it may be the case that the orchestra members have in front of them copies of the musical notation score as composed by Grieg, there is more to playing the piece than simply playing the notes.
We don’t have recordings of classical pieces in their original interpretations by the composers themselves, so we must in 2015 rely on conductors’ interpretations of the music notation. Which is why there are so many recordings of some very famous pieces by different orchestras with different conductors. While some music critics may say “X’s rendition of Beethoven’s Piano Concerto in A minor is the definite work by which all others can be compared” that doesn’t stop more renditions being produced!
So while a B note is a B note is a B note, as you will see in the video with Sir Simon Rattle there is plenty of room for interpretation. Notice the words he uses to instruct the fledgling orchestra and how he mouths the rhythm and attack he wants them to emulate. This is because the musical score contains more than just the notes to be played, but how they’re to be played – soft, slow, with brio – all of which is up to the conductor to interpret.
So, the task of the conductor is to understand the musical piece, know what each section of the orchestra should sound like, and then corral them into a unified wall of sound which is as close to the composer’s intentions (as per the conductor’s interpretation) as can be. This is what the audience has paid to come to hear. Indeed, some sit in their theatre row following the score note by note.
If the conductor is the pre-frontal cortex, what is the limbic system which seems to run away with the show so often in those who experience intrusive anxiety? In my view it’s probably the percussion section – boom! boom! – which can really rattle (ahem!) the concert hall purely by how many decibels of sound it can unleash compared to the sweet sounding but much quieter string section.
The task of the pre-frontal lobes is to exert influence on the rest of the brain so that dealing with a threat is done in a purposeful, planned way, taking into account past successes (“if it ain’t broke, don’t fix it”) yet prepared for possible eventualities. In the case of an orchestra on tour, it might be that some delicate rebalancing might be needed for an unfamiliar concert hall which has different acoustics than the home base.
So, in few of flying terms, while taking a flight between familiar cities, say Melbourne to Sydney or LAX to San Francisco has a certain familiar rhythm to it, it can vary by several minutes due to air traffic control, the runways in use, the weather on the day, etc. Pilots and cabin crew of course are aware of these daily and expected variations, and plan for them. As a passenger who experiences fear of flying, one must board knowing certain things happen in certain sequences but never to an exact timetable – commercial aviation is simply not that precise, yet its safety is not threatened by these daily perturbations.
The fearful flyer’s task is to exert a top down approach where possible by planning and decision making and being mindful of appraising the situation accurately and accepting that flying occasionally triggers unpleasant sensations, including just thinking about it!
You can help your own inner conductor by having at your disposal bottom up skills too: adjusting where and how to breathe to maximise heart rate variability, making sure you keep your core temperature well regulated by your appropriate choice of clothing and keeping hydrated; having music, books, games and videos to watch to enchant and engage you so as to push back against the “yucky thoughts and feelings” you have come to expect on flights; and in terms of long flights, having plans to chunk the time on board into smaller chunks.
The more direct way to use your “inner conductor” is to practise shifting thoughts from all or nothing or catastrophic styles of thinking (“Once inside the plane and the door closes, I’m trapped… trapped I tell you!”) to ones which better describe what’s happening and reduce your threat response (“the doors must be closed for a safe flight – I choose to be here… while it’s true I can’t leave when I choose to mid-flight, it’s really just the thought that I can’t leave at my own bidding that causes my distress, not that I am in the plane. Some people relish the 12 hours across the Pacific as time for themselves, away from work and family demands, where they can catch up on reading, writing or even just sleep. My plan is to plan how to do that…”)
Now that long sentence is what you can write down as a reappraisal in the cool light of day… but you need a short cut when on board, and push comes to shove. You need a mantra or “alias” to help, like “doors closed… remain composed” or similar phrases. And you need to expose yourself by visualising or using YouTube videos to bring on your triggers each day in the lead up to your flight. You must practise hard at pushing back against your automatic thoughts. Don’t be afraid of them if you feel they trigger unpleasant sensations. That’s a sign your pre-frontal cortex is reaching out to the rest of your brain, especially its threat assessment centres. You need to practise better thinking – a less fearful mindset – to better prepare yourself for your imminent flight. This applies for anxiety-laden scenarios other than flying of course.
If you want, grab a set of 3 x 5 index cards. On one side identify your automatic thoughts which in the cool light of day are threat triggers; on the other side, reappraise the thought with more useful and evidence-based ideas which challenge and push back and thus help recalibrate the threat assessment centres. Knowing what else to do other than panic will go a long way in this recalibration process.
This is the sort of work I do with patients. It’s not appealing to the “subconscious” like hypnosis is alleged to do. It’s bloody effortful work and should be undertaken only if you’re willing to put the time and effort into it.
If not, seek out those who practise other treatment forms. But in the meantime, ask yourself if those young German students of music working with Sir Simon Rattle got there by training their “subconscious” brain, or sheer hard work and practise, practise, practise.
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This article first appeared (with additional images and video clips) on Les Posen’s blog ‘FLIGHTWISE’