Chapter 1. Our story begins with a woman named Ava, who suffered from postpartum anxiety disorder for most of her adult life. She had first experienced anxiety when she was 15. Although she never had a panic attack, Ava would have panic attacks at her place of employment. Over time, Ava’s anxiety intensified. She now experienced full-blown panic attacks regularly. The effects of Ava’s anxiety were crippling. Although Ava continued to work as a physical therapist, the anxiety made it impossible to focus on tasks. The anxiety also kept Ava away from her family. At home, she experienced severe anxiety symptoms. She also experienced other debilitating symptoms, such as irritability, insomnia, hypervigilance, and hyper-reactivity to certain stimuli. Her body would jerk and tremble involuntarily, and she would have bouts of insomnia. Whenever she heard a siren or saw an ambulance, her anxiety would increase, and the symptoms became more severe. Ava felt the world was closing in on her, and she dreaded socializing and being with other people. The severity of her symptoms began to take a toll on her physical and mental health. Ava consulted her therapist, and asked how to get better. Her therapist explained that there are two basic methods of treatment. The first method is a behavioral approach, which suggests the use of breathing and relaxation exercises, and learning how to respond calmly to anxiety. The second method is cognitive-behavioral therapy, which primarily helps people understand the nature and consequences of their anxiety. As Ava was seeking treatment for a specific disorder, the therapist suggested the cognitive approach first. Ava also looked into self-help books. She discovered that there were self-help books on all the major anxiety disorders: panic disorder, generalized anxiety disorder, post-traumatic stress disorder, and social anxiety disorder. Some books offered treatment, and others promoted preventive techniques. Ava wondered why preventive techniques existed when she couldn’t prevent her anxiety attacks from happening. One of her books mentioned a preventative treatment called “propranolol.” The medication was developed to treat hypertension. As Ava read about it, she learned that propranolol was also approved to treat anxiety disorders. The side effects of propranolol included light-headedness, dizziness, abnormal dreams, restlessness, and trouble sleeping. The biggest drawback of propranolol was the fact that it could be habit-forming. In the months before her appointment with her therapist, Ava began a regular regimen of propranolol and self-help books. Her therapist suggested that Ava visit the office to discuss what she had learned. “What’s the best way to address your anxiety?” the therapist asked. Ava said she was continuing to do the propranolol regimen and to use self-help books. The therapist said she believed that propranolol was counterproductive, and she was concerned about Ava’s reliance on self-help books. The therapist wondered what Ava did before she began reading self-help books. Ava said she never thought about it before. In the therapist’s mind, the first step toward healing was to figure out what caused her panic attacks. Ava’s therapist felt that propranolol and self-help books did not treat the root cause of anxiety. Rather, they treated the anxiety itself, which was a symptom of another problem. The therapist said that, for most people, panic attacks are a result of a complicated mix of physiological, psychological, and environmental factors. Healing comes from finding and fixing the source of these factors. Ava said that she agreed with the therapist. She said that she knew that she had problems in her life, but had never identified them. She realized that, up to this point, she had considered her thoughts, beliefs, and behaviors to be “just the way she was.” She knew that she was a person with problems who was working to improve her life. She said that the first step in self-help was to “be honest” with herself. She was willing to accept whatever feelings and thoughts emerged. The therapist explained to Ava that panic attacks are a common reaction to stressful situations. The situations provoke the reactions because these situations upset people’s lives. During times of stress, the people experience bodily sensations called symptoms. Ava understood that the therapist believed that the problem was “out there” and that the therapist’s job was to point out the source of the problem. The therapist wanted Ava to examine her life, so she could discover the factors that caused her to have panic attacks. The therapist made it clear that Ava’s anxiety and other problems were not her fault. Ava was not being selfish. She was not crazy or weak. The therapist said that she, herself, had “problems” as a result of the factors that caused her to have panic attacks. The therapist told Ava that these problems made it hard for her to achieve success. Ava asked the therapist how long the therapist thought she needed to recover from her problems. The therapist said that the length of treatment depended on the problem. There were some problems that heals over time (for example, low self-esteem and body dysmorphia), while others need more intensive treatment (for example, post-traumatic stress disorder and addiction). In the therapist’s opinion, “propranolol and self-help books were not likely to help.” Ava said that she believed that the way she felt was due to a lifetime of things that happened to her. Ava said that she hadn’t done anything wrong or selfish that led to her problems. She said that she thought the therapist was putting the blame on her. The therapist listened to Ava and said that it would be helpful if Ava understood what had happened to her. The therapist explained that it is sometimes impossible to trace the history of why someone has problems. If someone has a disorder, there may be a complex set of factors that caused the problem. The therapist said that she was aware that the therapist’s job was to help Ava identify what factors caused her problems, not to make judgments. She advised Ava to pay attention to the signs and symptoms that she was feeling, to try to put a word to them, and to think about the times she felt the symptoms. “Sometimes, when I’m in bed, before an anxiety attack, I try to fight it off,” Ava said. “When you try to fight it off, what do you do?” the therapist asked. Ava said that she tried to get angry at the anxiety. “I focus on the feelings of anger. I try to stay angry.” The therapist asked what would happen when she could no longer suppress her anxiety. “My body and I will get worse,” Ava said. Ava believed that she was facing an impossible situation. She didn’t know how to make herself better. She hoped that her therapist would help her understand the problem, identify the source of her problems, and fix the problems. The therapist felt that she had answered Ava’s question. When Ava arrived at the therapist’s office for her next appointment, she asked the therapist what she should try next. The therapist said that she was “confused” about what Ava’s problem was. She had not used cognitive behavioral techniques before, so she knew that she had not been trained to do this. In addition, her training on cognitive-behavioral techniques required her to study scientific research on these techniques. In the past, cognitive-behavioral practitioners relied heavily on client experiences. The therapist wanted to talk to Ava about the research that she read on anxiety disorders and to explain that Ava’s problem was not the result of the factors that Ava was currently reading about. Instead, it was the result of what Ava had been exposed to, and how she dealt with that information. The therapist said that her job was to help Ava focus on the information about anxiety disorders, and then consider what she had learned so far. The therapist said that Ava seemed confused about whether she needed to study cognitive behavioral techniques. She felt that Ava’s confusion was caused by two problems: First, Ava was not clear about what her problem was. Second, Ava had not been exposed to information on cognitive behavioral techniques. The therapist said that he felt that Ava had not been exposed to enough information on cognitive behavioral techniques. Ava said that she had read enough self-help books to know that cognitive behavioral techniques would not help her. The therapist disagreed. She said that she believed that Ava would learn something from the lessons she read. The therapist believed that Ava did not have the knowledge to make a choice. She said that Ava did not have the ability to choose whether or not to use cognitive behavioral techniques. The therapist was afraid that if Ava read enough information about them, she would conclude that she was stuck. The therapist felt that she needed to tell Ava that she was not alone. The therapist said that she needed to help Ava understand the role that she played in the problems she was facing. “What role do you play? You’re not really a bad person, are you? You don’t have anything to be ashamed of. You’re normal,” Ava said. “Yes,” the therapist said, “you’re right. You’re normal. You have feelings.” “I’m more normal than others are,” Ava said.