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Why CBT Can't Regulate Anxiety

In Scott Stossel's new book, he details his failed search for peace of mind.

Our most basic way of regulating emotion is approach/withdrawal. We feel safer when the use of our own two feet is unrestricted. For some persons, even the slightest restriction leads to difficulty. Some of us need an aisle seat in a theater rather than one in the middle of the row. Or, being on a high floor of a building restricts escape.

Withdrawal, as a means of regulating anxiety, is not available in flight. When high above the ground, escape seem very remote. Though we understand that flying is safer, proximity to the ground makes driving seem safer. Such is the power of approach/withdrawal.

Cognitive Behavioral Therapy tells us that feelings are based on our thoughts. But when flying, this theory does not hold up. In spite of diligently maintained thoughts that flying is safe, emotion does not follow suit. As one anxious flier put it, '"I know flying is a hundred times safer than driving. But if I crash my car, it doesn't fall 30,000 feet first."

Since planes sometimes crash, it is impossible to know, as you board a flight, whether or not your plane will crash. Based on statistics, it is rational to expect that your plane will arrive safely. A cognitive therapist may say it is rational to rely on the high probability of a safe arrival. But is it truly rational to give up all means of escape? Though only a tiny percentage of flights crash, if your flight is that one in several million that crashes, you are 100 percent dead. This fact does not go unnoticed; a certain amount of anxiety is perfectly reasonable.

Can anxiety be kept at a reasonable level? It is not so simple. Cognition that regulates anxiety when escape is a backup may be unable to regulate anxiety when no safety net exists. When there is no safety net, isn't it rational for a high-wire artist to be more comfortable when 10 feet off the floor than when 100 feet above the floor?

Lack of escape is a problem. In flight, there is no guarantee of safety, no control, and no means of escape. Without a safety net as a backup, cognitive measures cannot adequately regulate anxiety. For this reason, some cognitive therapists advise an anti-cognitive approach. They advise anxious fliers to avoid awareness of the situation though dissociation or selective focus. This is a fragile strategy that falls apart when turbulence intrudes into awareness. When it does, selective focus and dissociation fail. The person is forced to suddenly face the situation they are in. Feeling trapped, the person may panic.

Scott Stossel, the author of My Age Of Anxiety also found cognition inadequate to control anxiety on the ground. Donald Hebb, the father of modern neurology, said cognition exacerbates the problem. He wrote "emotional susceptibility increases with intellectual capacity." From what I have seen, Hebb was right: fearful fliers are intelligent enough to think of scores of things that could go wrong, and imaginative enough to put each of them in mind vividly and cause the amygdala to release stress hormones.

I tried for years to get CBT to work with anxious fliers. Their heroic efforts to control flight anxiety produed only limited success. if we are to control anxiety adequately (ground or air) we need the sophisticated unconscious (non-cognitive) regulation that generally develops in early childhood when a child has a secure base. The method I stumbled upon relies on this unconscious regulation. To deal with fear of flying, the client deliberately establishes links between challenging situations and the calming presence of an attuned person that should have been developed serendipitously during early childhood.

The only method I know that works adequately in the air is the method I stumbled on. It was not clear at the time why it worked. But it did. Now, research by Stephen Porges explains why. Certain relational moments cause the release of oxytocin, which inhibits the amygdala, preventing the release of stress hormones. Other moments apply what he calls the "Vagal Brake" which slows the heart rate and activates gut level calming by the parasympathetic nervous system.

Automatic and unconscious regulation of anxiety can be established by linking stress hormone triggers to a moment in which the presence of another person produces oxytocin or activates the Vagal Brake and the parasympathetic nervous system.

According to Dodson-Yekes, executive function (left brain) that supports CBT shuts down when arousal goes too high. Some persons have good enough executive function that they can quickly mobilze CBT strategies and keep arousal from rising to the point where their cognition is overwhelmed. But others can't. Their executive function shuts down quickly and their left brain's ability to regulate collapses.

Neuroscientists say the right brain can continue to operate even after a high level of arousal has shut cognition down, and may be able to take over and regulate affect automatically and unconsciously.

In an American Psychologist article titled "The unbearable automaticity of being," Bargh & Chartrand say "nonconscious mental systems perform the lion's share of the self-regulating burden."

In The Science of The Art of Psychotherapy, Allan Schore cites "Emotion Coming of Age" by Leslie Greenberg in which Greenberg  says there is a "fundamental implicit affect regulatory process performed by the right hemisphere . . . to allow the . . . building of implicit or automatic emotion regulating capacities . . . important for enduring change, especially for . . . personality-disordered clients."

So here is where the problem is. CBT and insight therapies rely on the left brain which, compared to the right brain, is emotionally fragile. When arousal becomes too high, executive function is overwhelmed and shuts down. Cognition can no longer regulate arousal or anxiety. At this point, the right brain may be able to save the day. Whether it can or not may depend upon whether early relationships allowed the person to develop the unconscious and automatic regulation the right brain is suited for.

When anxiety is a problem, CBT helps can only so far because it depends upon cognition that shuts down when anxiety becomes too great. The potential for dealing adequately with anxiety, then, depends upon improving the right brain's ability to regulate anxiety based on links established in the client's mind between the therapist's attuned presence and situations that cause hyperarousal. These links stimulate the vagus nerve - and even if stress hormone levels are high -  slow the heart and provide gut level calming via the parasympathetic nervous system.