The treatment of panic disorder is not easy, but it is straightforward. The affected individual has to learn not only to deal with the phobic situations that are almost always a consequence of a panic disorder, but also how to deal with the panic attack itself. This treatment goes under the heading of “exposure therapy,” or “cognitive-behavioral treatment.” Once the panicky person has learned, by experience, that the panic attack, like all feelings, is not in itself destructive, the condition melts away.
But there is something more important, something that hopefully can begin with proper treatment. It is a change of attitude towards life itself. Such an alteration is Impossible to achieve during a limited exposure therapy—or any other brief method of treatment. It a change of perspective on the way someone should live. There are phobics who recover completely from their illness and live thereafter as successfully as anyone; but for many, the tendency to worry unnecessarily outlasts the phobia itself and can make everything—work, marriage, and especially bringing up children—a struggle. It is part of the bedrock of personality and changes slowly when it changes at all. It is a point of view that summarizes to a kind of philosophy of life:
- Since the world is treacherous—by this way of thinking —one must always be alert to the possibility of injury or illness. New business ventures are likely to fail. New relationships are likely to founder. New places threaten vague and shadowy dangers rather than promising excitement and the chance to learn something new. Children must be guarded against all the physical and emotional dangers that loom in imagination. Hidden not very far below the surface of these mundane fears are the more profound fears of helplessness and loneliness.
- Also, by this account, any kind of weakness is shameful. Since any thought or feeling or behavior might be construed by someone as weakness, it is best that others, especially strangers, should know as little about oneself as possible. “It’s none of their business” is the refrain repeated over and over again as instruction for everyone in the family. No other reason is offered to explain keeping silent. Even one’s manner of speech and behavior needs to be controlled carefully lest some embarrassing feeling show through.
- Most of all, it is always important to worry and watch out in order to be prepared for any sudden mishap or misadventure.
The sort of life brought on by these attitudes is a narrow, constrained existence in which the individual strives primarily to feel secure. Everything else is subordinated to the wish for safety. Relationships with parents, often ambivalent, are maintained very closely into the years of adulthood, although sometimes marked on both sides by guilt and resentment. A spouse is chosen sometimes solely because he or she seems “stable.” Employment is chosen because it is safely within the individual’s capacity and therefore does not threaten failure, or simply because it is nearby. Often such a job is kept long after it has proven to be unsatisfactory, unchallenging, or uninteresting. In all matters, the familiar is chosen over the unknown. The personality of such a person is inhibited: shy, self-conscious and anxious to please. These inhibited persons try to contain their feelings, especially any aggressive urges. They are easily embarrassed, made to feel guilty, and depressed in addition to being frightened. They are seemingly faithful forever to their parents’ image of how they should be.
This is by no means necessarily a miserable life. There is room for satisfaction and achievement. And pleasure. But it is not everything life can be. It is not an adventure.
Someone who sees the world the way it really is, on the other hand, has little reason to be afraid. Consequently, he, or she, can look forward enthusiastically to new places and new experiences. Although recognizing that disappointment and failure are inevitable occasionally, the risk does not seem so great or the disappointment so awful that he, or she, is deterred. The prospect of meeting new people is inviting. Social activities in general are fun. Whether or not to change jobs is a decision made only on the merits of the respective jobs and not on the basis of extraneous fears. Such persons are self-confident at work as they are in other places. They are assertive and direct. And open. Because they know that certain important people already respect them– their families and friends, and perhaps their employer– they do not have to worry about what others think. Rather by living by their parents’ standards, they have developed their own values and their own ways of doing things. In short, they are independent. Since they live up to their own standards, they do not customarily feel guilty, and they are not often embarrassed. If they feel fear or anger or any other emotion, they can express it freely, but need not be ruled it. Even though the thought of giving a business presentation is frightening, for example, they may choose to give it anyway if they feel that doing so is in their best interest. Most of all they can enjoy today and expect to enjoy tomorrow, whatever tomorrow may bring.
Perhaps no one can live up to this idealized portrait of a happy, mature person. Someone who is self-confident most of the time will be uneasy or self-conscious on certain occasions. No one is entirely free of self-doubts. To that extent it is natural to want to seek out safety. But the struggle to be safe and secure, to be free of anxiety, is not enough to justify living from day to day. The phobic—ex-phobic—cannot be happy for long sitting in front of a fireplace, however peacefully. Life is supposed to be exhilarating, at least some of the time. Phobics often discover that once they have recovered, those activities that were most frightening are now most pleasurable. A person who used to be afraid of driving finds himself getting in car whenever he wants to be alone. A woman who was afraid of skiing becomes a downhill racer. These startling changes, unfortunately, do not by themselves change a basically pessimistic view of the world into one that is optimistic. Nor do they encourage someone who is preoccupied with himself to get more involved with others. Yet that is what each person must do. Fulfillment is more than the avoidance of certain unpleasant feelings or circumstances. It is a commitment to other people and purposes outside of oneself.
This is an argument, then, for continuing past the point of recovery from a phobia. The practice of challenging one’s fears that is the basis of exposure therapy is a reasonable strategy for coping with other more realistic threats. The danger of getting fired from a job, for instance, is managed best by confronting it directly, by talking to the employer and, perhaps, by looking for other work. Whether it is learning how to swim or learning how to address a group, both scary in their own way, a determined. step by step effort usually brings success—as it does in overcoming a phobia. Being open with others, crucial to the success of exposure therapy is important also for everyone in developing close relationships and in being able to see oneself accurately through the eyes of others. These healthy attitudes are fostered by treatment but require further effort even after treatment is finished. Still, they bear on the final goal of every therapy: an independent, assertive, joyful life. (c) Fredric Neuman