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Chapter 1

Introduction

People walk towards a building. Some look calm, some scared, some excited and some annoyed. We don’t know how they feel but we assume that some feel calm, some scared, some excited and some annoyed. We assume this based on how they look and what they do. Some walk briskly forward. Some hold their companion’s hand tightly. Some drag back, some cry and some look as if they have trouble breathing. We do not know by watching what each person is thinking. We make assumptions based on our interpretion of what we see. We might be right; we might be wrong. We also make judgements, deciding who needs support and who we choose to criticise.

It might be easier for us to understand what we observe if we could hear what people are thinking. It might be easier for us to be compassionate if we knew what they believed. Let’s see.

Here are some of the people’s thoughts:

• ‘I can’t face this.’

• ‘What if it doesn’t go the way I want it to?’

• ‘I’m not going to be able for this.’

• ‘This is going to be OK.’

• ‘I am so relieved to be going in.’

• ‘No one understands how hard this is for me.’

• ‘Other people are looking at me.’

• ‘I don’t want to go.’

• ‘I’m glad I am prepared.’

• ‘I hope this doesn’t take too long.’

• ‘Why am I like this? Why can I not be like everyone else?’

• ‘What’s wrong with me?’

• ‘I hope it works out the way I want it to.’

• ‘I feel sick.’

• ‘I am so thrilled to be here.’

Here are some of their beliefs:

• I am not OK.

• Things are not going to work out the way I want them to.

• I am safe.

• I am protected and looked after.

• Life is exciting.

• Life is terrifying.

Right now, are you feeling puzzled, confused or interested? This is a book about finding hope in the Age of Anxiety so we can assume that some of these people are experiencing anxiety. We won’t know why unless we have some understanding of the particular meaning of the event for each of the people involved.

Let’s look at some possible circumstances:

1. Children and parents walking towards a primary school on the first day of the school year.

2. Students walking towards a secondary school to do an exam.

3. People of all ages walking into a dentist’s surgery.

4. Supporters attending a football match.

5. The bride, the groom and guests going to a wedding.

6. Patients and relatives going to a hospital.

7. Residents and visitors of a nursing home for older people returning from a walk.

8. A family walking into an airport.

Does the particular circumstance make a difference to how you interpret the behaviour of these people?

There are three key points in this book. The first is that it is normal for each of us at times to experience anxiety. The second is that anxiety can be triggered by external circumstances and by what these circumstances mean to us, based on our thoughts, beliefs and actions. The third is that understanding our triggers and experience of anxiety can give us hope and help us to manage it better.

It can be tempting to dismiss the impact of ‘normal’ triggers of anxiety such as the first day in a new job, interviews, visiting the doctor or dentist or going on a first date. We might not realise the impact of other triggers such as a tragedy in another country.

On the evening of Friday 13 November 2015, thousands of people gathered in Paris to enjoy themselves. Some went to a concert, some to a sporting event and some to meet friends and socialise over a meal. None of them was prepared for eight gunmen cold-bloodedly initiating a mass execution that killed 190 people, wounded hundreds and terrorised millions. The horror of this is unimaginable to anyone who was not there; yet millions of us, safe in our homes, felt fear and anxiety as we helplessly watched events unfold on our televisions and computers.

Tragically, this was not a once-off incident. Since then, there have been too many other terrorist attacks worldwide. We have all watched the horrific news reports. Sometimes we distance ourselves from these events; we may even wonder if we have become immune or cut-off until something awful reminds us how vulnerable we all are. Few of us are ever really immune from horror. We just protect ourselves the best way we can, and most of us manage to live on despite the fear and anxiety that has been triggered.

Within the first two decades of the twenty-first century, people have been murdered in their workplace in the Twin Towers in New York, sunbathing on a beach in Tunisia, going about their daily business in Israel and Palestine, partying in a nightclub, watching a fireworks display, walking to a restaurant. Children have been killed in their classrooms and politicians murdered in the course of their work. Reassurances that we are safe are ineffective – the threat of terrorism is real. Any of us could be the victim of a cruel, senseless act.

Triggers of anxiety are not confined to thoughts of possible terrorist attacks. We do not know when we wake up if we are going to be alive by bedtime. People have been killed while skiing, surfing, driving, flying or even walking downstairs. Even people who are very careful are not safe. They could be hit by lightning. Their house might catch fire. They might drown in a sudden flood. They might be murdered by burglars, random strangers or even family members. They might be taken hostage and even killed while they are waiting in a queue to buy stamps.

Triggers of anxiety are not even confined to thoughts of death. The list of things that can trigger us to have anxious thoughts is infinite. We might get sick, we might not get better and we might die. We might make a mistake, it might be noticed and we might get into trouble. We might have a panic attack on a plane, in the cinema or in a shop and people might laugh at us. The stock market might collapse. There might be another recession. Somebody might spark off a nuclear war. There might be a super-bug that kills us all. The world might end.

Rapid advances in technology have led to an increase in the level of anxiety experienced by people of all ages. Devices such as mobile phones have brought freedom and flexibility. They have also brought many challenges, which can cause anxiety. These can stem from practical issues such as how to use them to questions about the long-term effect that regular use of mobile phones, computers or gaming devices might have on our health. Parents worry about how to get their children and adolescents to turn off the devices so as to sleep, as well as how to protect them from the horror that can be accessed via the internet. They bargain about how long computers and video games can be used and they monitor the content their children might see.

Some parents monitor their young people’s use of social media, conscious of the risk of them being exploited or bullied. Sadly, anxieties relating to social media are not confined to parents and their children. People who are self-conscious about their spelling abilities may struggle with writing texts. Those who are self-conscious about their appearance may agonise when they or others post photographs. People who post items may obsess about how many ‘likes’ they get.

More people are living longer now than we did in the past. This is great news, but old age can bring more triggers of anxiety. Older people may worry about where they live and how they are going to manage. They may worry about money, their health, their friends and/or their families so quietly that no one else realises. Their family and friends may have similar worries about them, feeling guilty that they do not get to visit them as often as they would like and dreading hearing that they have had a fall, become ill or died.

How do you think our ancestors might feel if they came back to see how things are for us today? A visitor from the Ice Age, the Stone Age or the Industrial Age might conclude that we live in the Age of Anxiety.

The title of this book is ‘Finding Hope in the Age of Anxiety’. But how can we have hope when we are faced with overwhelming doom and gloom all day, every day? We don’t even have to wait until certain times of the day to hear media reports of the terrible things that are happening in the world. We just have to glance at our phones. How can we have hope when we are becoming more connected to our screens and less connected to the people around us? How can we have hope when everyone is so busy and even telephone calls from friends need to be scheduled? How can we have hope if we experience anxiety to the extent that we have an anxiety disorder?

Reassurance does not work because people who feel anxious generally do not believe that they will be fine and that everything will work out. Instead, they focus on how awful they feel and do whatever they can to feel better, not realising that their thoughts and actions may actually be contributing to their anxiety.

The reality is that we simply do not know that things will be OK. Rapid advances in medicine and technology have enabled us to live longer, but we will all die. Most of us just don’t know when or how. The truth is that sometimes people’s worst fears are realised. Children do get bullied. Visiting the dentist can be painful. Some relationships do break down. People do get sick and people do die. We often do not know how resilient we actually are until we are faced with our worst fears and discover a strength that we did not know we had and we receive support that we did not expect. Too often the dreaded event, when it does arrive, is not worth the many days, weeks or even years of anxiety that preceded it.

My interest in helping people cope with anxiety began in 1986 when I was a newly qualified primary school teacher. I discovered very quickly that my role included helping children who were anxious. They worried about school, learning, making friends, losing friends and that they might get into trouble. I was surprised to see bright, capable children worry to the extent that they did, despite my frequent attempts to reassure them that they were fine. My role also included supporting their parents, who were often anxious too. I quickly realised that my reassurances did not work. Some children and parents worried, regardless of what I said. I began to study psychology in 1988 to help me become a better teacher. When I first came across the key principles of cognitive behavioural therapy (CBT), I was surprised that I had not heard of them before. They made sense to me and I wondered why it was that people needed to have severe difficulties before they were introduced to CBT. Why were its basic principles not taught as a way of helping people understand and cope with whatever challenges they were facing, long before they got to the point where they experienced severe difficulties? I did not realise it at the time but looking back I can see that I have spent the last twenty-eight years responding to that question and making CBT accessible to people of all ages. This book continues that process.

My experience of working with people includes my years as a teacher in mainstream schools, in a school for children with moderate to severe disabilities and in a children’s hospital; as a lecturer in universities; as a clinical psychologist working with children, adolescents, adults and older adults in a range of settings; as a consultant psychologist working with people in industry and as Clinical Director of Aware, which is Ireland’s national charity to support people with depression and bipolar disorder.

I have worked with people who had what we might consider ‘normal’ worries. These include making friends, doing well in school or work, coping with life’s challenges such as bereavement, illness, divorce and bullying. I have also worked with people who had what they considered were ‘abnormal worries’ such as a fear of vomit, a fear of the world being hit by a meteor or a fear of doing something to harm someone else. People responded differently to their fears. Some withdrew, some avoided and some harmed themselves by relying on actions such as drinking alcohol excessively, abusing drugs, cutting themselves, starving, binging or purging in their attempts to feel better.

Practically all of these people believed that there was something seriously wrong with them, that they were different in a way that was wrong, that they had let others down, that others judged them harshly and that they were not good enough. All of them cruelly judged themselves. While each of us is different and each of our particular challenges is unique, I have found that the basic principles of CBT can be very effective in helping people of all ages understand the role that their own thoughts, beliefs and actions can play in how they feel.

My book How to Cope: The Welcoming Approach to Life’s Challenges describes the three steps of the Coping Triangle, which is my way of explaining CBT. This book focuses specifically on how I help people understand and cope with anxiety. CBT is really common sense. It was developed by Dr Aaron Beck, who built on the work of Dr Albert Ellis and Dr Albert Bandura. Its key principle is that our thoughts, beliefs and actions impact on how we feel and on what we do. We can become aware of our thoughts and recognise that many of them are unhelpful. We can become aware of our beliefs and recognise that they might not actually be true. We can become aware of our actions and recognise that however terrible a situation might be, we can always choose how we react. The theoretical framework of my clinical psychology training course was based on CBT. I was fortunate to be supervised during my training by many experienced clinicians who supported and encouraged me.

One of the experiences that has influenced me most in my understanding of how CBT can help people with anxiety was the training I did with Professor Philip Kendall at Temple University, Philadelphia in June 1997. He is an expert in using innovative CBT methods to help children and families cope with anxiety. It was striking to see how many of the children who attended Temple University’s Anxiety Clinic were perfectionists and afraid of getting into trouble. Professor Kendall was creative in his treatment approaches and he and his team of psychologists evaluated their work carefully to find out what worked best.

The children who experienced anxiety were encouraged to do things that initially increased rather than decreased their levels of anxiety. I understand now why this was so and why facing whatever makes us feel anxious is ultimately the way to overcome our anxiety. I also came to see how our thoughts, beliefs and actions can trigger feelings of anxiety or help us to become relaxed. When I was in Philadelphia, I visited Professor Aaron Beck’s clinic and was privileged to see how he worked to help people manage anxiety and depression.

My PhD research involved training guidance counsellors to use a psycho-educational CBT programme to help adolescents cope. The programme was adapted with permission from a programme that Professor Kendall and his colleagues were using in America. My supervisor was Professor Mark Morgan, who, like me, had been a teacher and had gone on to study psychology. He had studied with Dr Albert Bandura and recognised the importance of teaching CBT as a means of helping people understand and cope with whatever challenges they were experiencing.

Some of the people I have worked with in the last fifteen years have given me permission to tell their stories anonymously in this book. They have read and approved what I have written and are happy that they are completely unidentifiable. I am deeply grateful to them for their trust and their support. The book also includes references to work I did with someone over twenty-five years ago. As it has not been possible for me to contact him, I have changed key details while retaining the essence of what he taught me through my work with him.

I have always enjoyed working with people who experience anxiety and as I get older I realise why. I can understand and relate to them directly from my own experience. When I was about three years old, I developed a fear of flies. Whenever I saw one I would cry and become deeply distressed. One of my earliest memories is of my father helping me take my power back from this fear. I sat on his knee as he gently showed me a range of fishing flies. He talked about the different colours and how soft the feathers were. My mother remembers that we sat there for a long time before I finally touched one of the flies. Dad’s patient and intuitive way of helping me to face what was making me feel anxious worked. To everyone’s relief, I stopped screaming with terror whenever I saw a fly.

I had not heard of obsessive-compulsive disorder (OCD) until I studied psychology but I now realise that I experienced aspects of it when I was ten years old. I used to genuflect as I walked past a church on my way to primary school. For a few months, I got into a pattern that if I did not do it to the standard I considered ‘good enough’, I needed to go back and do it again and again and again before I felt comfortable to continue to school. No one else ever knew and thankfully one day I decided that I was going to be late for school and did not go back to repeat my behaviour. I joke sometimes about the day I realised, many years later, that it was not a good idea for me to use yellow pegs to hang the yellow towel on the clothesline, red pegs for the red towel and white pegs for the white towel. Changing that pattern was hard as I genuinely thought the clothes looked better on the line with coordinated clothes pegs! Experiences such as these have enriched me as I have some sense of how frustrating and distressing it can be for people who have OCD and how difficult it can be for them to change their behaviour.

We have all had challenging experiences at times in our lives, but we might not recognise that they can be exactly what we need to help us to become more resilient. I first heard of panic attacks when I was a trainee clinical psychologist. I was reminded as I listened to a particular lecturer describing a panic attack of the deep sense of panic and fear I experienced when I was nineteen years old. I had gone to a disco with some friends wearing a new T-shirt and skirt. The T-shirt had a huge, sparkly motif of an elephant. I felt confident and relaxed until the moment I overheard two people commenting on the elephant and laughing. I immediately experienced a deep sense of embarrassment, shame and upset. I fled to the toilets and remained in a cubicle for ages before eventually forcing myself to leave the safety of the toilets to walk back onto the dance floor. It was a long time before I wore that T-shirt again!

When I hid in the cubicle, I was avoiding the people who I thought were laughing at me. When I decided not to wear my T-shirt, I was protecting myself from the danger of being laughed at again. I did not realise that in doing both of these things I was giving my power away to the very things that triggered my anxiety. Avoiding something that makes us feel anxious may seem perfectly sensible in the short term as it can bring an immediate sense of relief. The problem is that avoidance actually increases anxiety. Paradoxically, facing triggers can increase anxiety in the short term. Just as chemotherapy can make a cancer patient feel worse, people who take their power back from anxiety can feel worse too. If I were working to support someone who experienced a similar event now, I would help her explore what was actually so bad about other people commenting and even laughing about what she was wearing. We would look at how she could understand her feelings of anxiety and manage them without literally running away and hiding.

I am getting better at recognising how anxiety can hit me unawares or how it can steadily sneak up on me. I am getting much better at knowing what to do when I feel anxious. I’m becoming an expert in gently and firmly managing my own anxiety. As a result, I am becoming better at helping other people recognise and manage theirs. My insights into my own anxiety help me understand and support people of all ages. I love doing this and I’m privileged to do so.

So that’s me! Now, who are you? What made you choose this book? Are you concerned about yourself or someone you love? What would you like to get from this book? If your answer is ‘to feel better’ or ‘not to feel anxious’, you may be disappointed. Some people do feel relief when they read about anxiety. Others feel more anxious and some stay the same! Facing our fears can trigger us to feel more, not less anxious. Understanding this is essential so that we do not become more anxious because we feel anxious! Instead, we can learn to recognise and accept that our feelings are normal and make sense.

In this book, I invite you to work in partnership with me as if you had come to my clinic for help with anxiety. First, I will take you through how I work with people to help them understand and cope with anxiety. There will be some exercises for you to do and I will share some stories that I have devised over the years. I still like elephants and one of the key stories I’ve devised to help people understand why anxiety is not stupid is the story of ‘The Elephant and the Mouse’ which I describe in Chapter 3. Chapter 4 reveals the true story of how it helped a man I have called George to take back his power from anxiety. Chapter 5 contains ‘Jenny’s Story’, which illustrates how the simple, practical and effective three-step process of the Coping Triangle is used. Chapter 6 contains a number of points about anxiety. I have checked these out with a number of adults and children I have worked with and they agree with me calling them ‘key truths’.

We can experience anxiety at any age and stage of life, so Chapters 7, 8 and 9 are structured around the key life stages of childhood, adolescence and adulthood. Each chapter contains stories of people who experienced anxiety and of those who strove to support them. Some are true stories (with all identifying details changed). Others are stories I have devised to illustrate certain points.

This is also a book for people who care about others who experience anxiety. It can be so tempting to reassure – ‘Don’t worry’, ‘You’ll be fine’, ‘It will all be OK’, ‘Everything will work out.’ While these reassurances may help initially, the relief tends not to last long. We all experience anxiety and this book explores why it makes so much sense to feel anxious. We will examine triggers of anxiety and focus particularly on how we can all live with hope in the Age of Anxiety.

Ultimately, this is a book of hope. Anyone who struggles to cope with anxiety can adapt. We can learn to take our power back from whatever triggers us to experience anxiety by ‘feeling the fear and doing it anyway’, to quote the late Susan Jeffers. Even better, we can learn to take our power back with understanding, gentleness and compassion. First, let’s focus on really understanding what anxiety is and how it affects us.