For anonymity’s sake let’s call my student Sean. For years his anxiety was debilitating! He has struggled with it for about 30 years and sought help in many different ways, including counselling and medication treatment. After a course of individual psychotherapy with me, as well as intense involvement in the practice of mindfulness meditation, he eventually got to the point of being able to live without medication, most of the time symptom-free. Maybe once or twice a year he experiences a very manageable recurrence of the anxiety, which he meets with his mindfulness skills.
This article is not about the successful treatment of anxiety disorders through mindfulness meditation. Instead, I want to show how a mindfulness practitioner with quite considerable long-term meditation experience deals with the occasional recurrence of symptoms, particularly when they are extreme. I also want to highlight the mindfulness principles involved in this process.
Sean came to see me recently, because at the beginning of September his anxiety started to reemerge after having been anxiety-free for some time. Nothing unusual had happened and there was no external reason for the recurrence of his anxiety. His anxiety was very bad this time around; it worsened to the point of being almost intolerable and lasted an unusually long time of approximately two months. At its worst, he couldn’t stand it anymore and two things happened: He began to consider the possibility of going back on Cipralex, an antidepressant with a strong anti-anxiety component he is familiar with, which worked well for him in the past. At approximately the same time, he called my office to make an appointment, with the intention of exploring with me anything he might possibly overlook in his psychological approach to his anxiety. Unexpectedly, these two actions of booking an appointment and intending to go back on Cipralex caused the symptoms to vanish. By the time I recently saw him, he almost wondered why he was there with me.
We first talked a bit about how he was managing his anxiety and what mindfulness principles he was applying to deal with it. What he told me was very revealing of quite a skilled mind working with the adversity of an affliction. With many of the principles of meditation that he had learned, such as the recognition that thoughts are not facts, giving emotions a wide spaciousness through allowing and letting be, and sheer tenacity and perseverance, he maintained a deep curiosity about how far this ‘internal catastrophe’ can go. As if he was watching a storm pass by, he simply allowed the inner storm to unfold with as little resistance and as much awareness as possible. Over the years of meeting these symptoms in this fashion, he discovered that nothing more catastrophic happens than an enormous feeling of unpleasantness washing over him, including at times the very unpleasant experience of feeling he is going to die. He discovered a sense of pride and strength in his ability to look the monster directly into the eyes, realizing that the only thing he had to fear is fear itself. Unlike years ago, when such anxiety would have caused him to be out of commission and unable to function normally, he can now continue to go about his life’s business as usual.
He also has access to Ativan, a minor tranquilizer with specific anti-anxiety properties. This is not the kind of medication that would be wise to take on any regular basis, which is why he uses it only very rarely if there’s really no other option, at most maybe one minimal dose tablet once a month if he is really very anxious. He explained to me that he always waits until the storm is over and the anxiety subsides, because it helps him disidentify from the experience, find strength in not allowing the anxiety to control him and significantly decrease the impact the anxiety has on his life. After the worst of the storm is over, he sometimes feels quite exhausted, at which point he may take an Ativan tablet to give himself a good rest. This approach to his anxiety is wise, because while he prevents himself from backing down when the anxiety is at its worst, and instead continues to hone his mindfulness skills to change his relationship to the anxiety, he effectively engages the brain cells in a massive rewiring process that leads to greater integration of his organism, a decrease of symptom strength and the hold it has on him, and therefore longer periods of symptom-free health.
Anyone with some therapeutic experience reading this may wonder, whether he does not actually traumatize himself by doing what he does. The answer is an emphatic no, as long as one important condition is fulfilled: Throughout this process he needs to feel that he is in the driver’s seat, that in other words he remains within his window of tolerance for stress. If during the storm he was to lose his capacity to be aware and apply his mindfulness meditation tools, and instead fell into an unmanageable panic, then yes, it would not make sense to try to be heroic; there would be a real danger of causing more harm than good. After many years of intense mindfulness meditation training, this is clearly not his situation anymore.
A few questions remained: Why did the symptoms disappear the moment he made an appointment and considered taking Cipralex, why did the symptoms start in September when his children are now grown and independent, and there is no back to school stress anymore, and is it wise to go back on Cipralex, which is the kind of medication he would have to take daily for at least a 2 to 3 months period? My answers were not pronouncements written in stone, but hypotheses Sean will have to examine as he continues to develop his expertise in dealing with his anxiety.
The moment he decided he might go back on Cipralex at the height of his anxiety, could in fact psychologically be the moment he surrendered his left brain’s compulsion to solve the problem. Although he was using some cognitive tools to remind him that his thoughts were not reality, this whole anxiety phenomenon can never be resolved with his left brain function alone. It requires an integration of the left brain with the contextual, nonverbal right brain. By surrendering to the possibility that he psychologically may not be able to overcome his anxiety, he relinquished in fact deeper resistances to experiencing these anxious energy flows. The result is an even greater spaciousness with which he relates to his own anxious experience, accompanied by a decrease or even disappearance of the symptom.
Booking an appointment with me would have been an act of faith by hoping I may have some answers up my sleeves that could help him. This could be called a placebo effect, which in fact is not anything negative, but a powerful psychological force that helps us tap into the unknown potential of the organism that we are. Metaphorically speaking, by calling me he actually reached out to his own internal unknown potential for healing. It is not surprising that this would mobilize healing energies that at least temporarily would make the symptoms go away.
With regards to the symptoms appearing in September, I reminded him of all the years his children were growing up and the busyness of life resumed in the fall after a quiet summer. I pointed out the possibility that after many years of conditioning, September has now the symbolic meaning of back-to-school stress, despite the fact that his children are gone and there is no back to school stress anymore. Whenever September approaches, his unconscious implicit memories of years of stress, now deeply embodied in his brain’s neurofiring patterns, get activated . This idea struck him as very resonant, causing an immediate additional sense of relief while we were talking. Knowing about this possibility will make it possible for him during the end of summer when fall approaches, to pay particular attention to the fine somatic sensations in his body and whatever faint memories of past years they cause. This may allow him to recognize the mechanism, by which implicitly encoded stress signals from previous years begin to stir in his body when the fall approaches and eventually lead to the development of anxiety.
We can ask an even more radical question: Why bother with such intensive mindfulness meditation training, when one could just take Cipralex and presumably live effortlessly happily ever after? The answer is simple (not simplistic), complex (has many facets) and compelling. On medication people often feel numb or not quite themselves, and they don’t like the side effects. Even with medication the symptoms often don’t disappear and are more likely to be just mitigated. If they do disappear, it is usually time-limited, and over time they tend to return, at which point other medications need to be tried or the dose has to be increased, causing an increase in side effects. Last but not least, the person learns nothing about the psychodynamic meaning of their symptoms, causing unresolved or psychological conflicts to continue to feed the tendency to develop such symptoms and stress, and thus interfere with the overall integration of the organism that promotes the person’s health.
When I talk about these things, highlighting the psychological mechanisms involved in psychiatric symptoms and trying to elucidate the complex decisions that have to be made between psychological and psychodynamic growth and medication treatment, people sometimes come to the wrong conclusion that I am against medication. Far from it. Medication is one of our tools in our toolbox, which wisely used can be extremely beneficial. The problem nowadays lies in the fact that biological advances in medicine have been so spectacular as to eclipse the importance of the mind in our human lives. Whether we like it or not, the mind is still the most important organ we have, and without paying attention to, training and respecting the mind, our attempts at curing illnesses, maintain function and healing fall far short of what is potentially possible.
Copyright © 2018 by Dr. Stéphane Treyvaud. All rights reserved.