The Heart of the Story Part I: Yoda Meets Cognitive Behavioral Therapy

My mother recently sent me a rather long e-mail. That's not a particularly uncommon experience. Answering it here on my blog, however, is very unusual.

You talk a lot about life as the stories we tell ourselves.  I've been thinking about that a lot lately. Do you have a good resource for me to read about this?  Have you written anything about it on your blog that you could perhaps share with me?

Actually, I don't think I have written much here on my blog about stories--and how those stories are the way in which I've come to see as the way we create our own humanity. Since she asked, and since I've been looking for a good topic to write about, why not have you all join in on my response to my mother?

I just finished a book entitled, You Don't Look Like Anyone I Know.  It's a true story about a woman who came from a chaotic, dysfunctional family, as in her mother was a paranoid schizophrenic & her father, a cross dressing alcoholic who was also crazy.  She had been face blind all of her life, but didn't really realize it until she was in her early 40's...  I took some rather extensive notes citing the more interesting parts. 

For those of you who wonder how the Irreverent Psychologist got to be the Irreverent Psychologist: you might find some clues in the above paragraph. The Mother of the Irreverent Psychologist (MIP) notes that she has taken "extensive notes citing the more interesting parts" of the book. As regular followers on Twitter may have noticed, a small portion of the voluminous notes I take while reading appear on my Tumblr page. 

The nut doesn't fall far from the tree. 

...but I digress. The MIP started her email with a question about stories but manage to ask two questions. The first question--about stories--will come a little later. First I'll tackle the MIP's question about cognitive behavioral therapy.

The person in the book visited a cognitive behavioral therapist to treatment of claustrophobia. It seems that the individual in question had a panic attack while having an MRI. MIP wanted to know what I thought of the intervention. 

"Are you ready to kill the monster?"  There was no reason to be afraid.  This fear was just an old remnant signal from the brain stem.  The brain is very dumb! the therapist said.  We can learn to override it.  There is no fear, only fear of fear. There is no such thing as claustrophobia. 

I personally don't see much utility in telling someone they aren't experiencing what they are experiencing. If someone is having a hallucination it does not good to tell someone they aren't having a hallucination. While you and I might not see, hear, or smell what the other person is hallucinating, they are. The better response is to validate the experience of the other while also validating my own. For example, "It must be so scary to be smelling burning flesh. That however, is not my experience of what I smell in the room right now."

Yoda

And there is no fear, only fear of fear? Who is this guy, Yoda? Fear is a physiological response in our body. We are, of course, capable of interpreting it in a variety of different ways. Nonetheless, fear is still fear. It is certainly true that most anxiety disorders become less about the fear response and more about fearing frighting situations. At the heart of most anxiety disorders is avoidance--we begin to limit our life because we avoid situations that we fear might cause fear. Perhaps this is what Yoda--I mean the therapist--means.

He asked me what I was afraid of in the MRI tube and I told him:  suffocating, not being able to get out. 

He said I could get out. No, I said.  I have to squeeze the ball and wait for the technician.  But would happen to you while you wait? he asked.  What is the danger you fear? 

I wanted to go to bed.  I didn't want to get in the tube again.  I didn't need to cure my claustrophobia; it was the least of my problems. "Well, I'm afraid I'll die. I feel like--" 

The therapist replied, "It is a feeling state.  You see?  You won't really die.  You can't.  There's no deadly spiders or deadly toxins...nothing in the tube is really dangerous.  You just want to get out.  You don't need to though.  Nothing bad can happen in the tube.  You just lie there.  Right?  In a tube.  It's a tube." he said. 

Well yes, Yoda/Therapist is right in correcting a cognitive distortion. It isn't likely that a person would die from deadly toxins, spider bites, or anything else while having an MRI. However is this person hallucinating? Are they actively seeing, feeling, hearing, or smelling things that other people do not? I would argue that the experience of the hallucination first needs to be validated before correcting a the cognitive distortion. Poisonous spiders that both you and I see can kill you. Poisonous spiders that only you see, that are a product of a hallucination, are not lethal.

The more he talked, waving his hands, pleading, the better it sounded.  When we were babies, ten thousand years ago, we were afraid if we were in a small space, in a crevice, and with reason:  if a baby was wedged in a tight space, it was dependent on someone else to get it out.  Our heart rate went up.  Our fear response increased our chance of survival.  Not anymore.  Not for a long time.  But the limbic brain, the oldest part of the brain still thinks all tight spaces are equally dangerous.  

I think Yoda/Therapist is being a little simplistic here. Not everyone dislikes tight spaces and panics when they get into such predicaments. It is likely very true that our physiological system has evolved in such a way that when we perceive we are in danger our bodies become flush with "fight or flight" hormones. However small a component it might be, we do have some agency in this process. We first have to decide that the information we are taking in through our senses represent a physical threat. While we might only have a split second to make the decision, there is nonetheless a split second in which we made a decision about whether we are in danger or if we are safe. Folks with anxiety disorders often move so fast into fight or flight that they aren't even aware of that moment in which a choice can be made.

That is the whole point of cognitive behavioral therapy for anxiety disorders--to teach people the awareness of that moment in time when a decision can be made and equip them with skills needed to properly evaluate their perceptions.

"It's a monster in your brain.  We kill him!" he announced, grinning like a kid.  He motioned to me to sand.. He put his fists in a fighting position.  "Right now?" I said.  I thought we were just having a talk.  He was nodding, waiting, smiling, rocking on his toes.  "We give it a try." 

We walked toward the room.  At the threshold, he hit the front of his forehead with his palm.  "We must use this." he said, and smacked the back of his head with the same hand, "to overcome this."  In the room he said, "Well, what is scary to you in here, this room?   What would be really scary?" I walked across the room and stood by the small closet.  "I would go in here."  He said to go in.  I did an he closed the door.  "What will freak you out now?" he said through the closed door. 

I could hear and feel his body leaning against the door.  And the monster leaped.  I couldn't believe I was sitting in the dark in a closet with a man leaning on the door.  I had never been further from who I was, and at the same time I suspected somehow I was becoming myself in there.  This I realized was the gap.  It was funny and fascinating.  He jangled the doorknob.  "Do you see the monster?  Is he near?""Yes," I said.  "He is here."  I was smiling.  It was like the monster was on the screen in the MRI tube, and I was clicking at him.  I was scared, but not in the way I thought I would be.  It was so goofy.  I was outside the scare, having it--it wasn't having me.  Maybe for the first time in my life.  

"Are you laughing at him?  That is good!  See!"  He banged on the door, hard.  I shook, startled, and then I was still.  It was quiet.  The monster grew.  I kept watching him.  He didn't take over.  There was a gap.  I was able to see the monster.  I could see just what he was talking about . 

I heard him leave the room.  He came back, running, threw himself against the door, rattling the knob, pounding.  Again and again and again.  He screamed.  Kick the door.  I sat there and stared at the monster, and he was right.  Each time he pounced, the monster grew bigger, but never as big as before.  Whenever I jumped or startled, I turned up the volume on watching, and each time I did this, the fear got smaller, always much smaller than the time before.  Until it was just really hot in that closet, and extremely boring.   I came out of the closet.  "I am cured," I said.

This all sounds like very creative systematic desensitization to me. It's best, of course, to actually first teach people skills at lowering their physiological arousal before stuffing them in the closet and scaring them.

This has gotten so long that we'll have to continue the answer to the question that the MIP really asked later. Check back in the coming days for part two of this post.