Patience on the Out-Breath
Learning to Relax Into Anxiety Instead of Relaxing It Away
One of the most robust findings in the field of psychotherapy research is that people can overcome anxiety by systematically facing what they have been avoiding. Therapists call this exposure therapy. It has been a central component of behaviour therapy, and cognitive-behavioural therapy (CBT) since the 1950s. Exposure involves deliberately facing feared situations, in reality or in vivo, rather than avoiding them. That also works well when done in imagination or in vitro, which clinicians usually call imaginal exposure. This requires imagining a situation that provokes anxiety, as if it’s happening now, and doing so for longer than normal, often repeatedly. By exposing your mind to the triggers for anxiety, and sometimes other unpleasant feelings, you can effectively get used to the experience.
The basic idea of exposure therapy is very familiar, and can even be found in the ancient folk wisdom of Aesop’s Fables. For example, in one fable, the fox is frightened when he stumbles across a lion in the woods but by returning to the same spot each day, because the lion turns out to be harmless, his initial anxiety eventually wears off. In another fable, a boar is mocked by a fox for putting so much effort into sharpening his tusks when there is no danger around, but the boar replies that by preparing himself to cope in advance, he will be ready when one day he hears the huntsmen’s horns. You can read that fable, for comparison, at the end of this article.
There are many ways of doing this. In the past, it was common for a therapist to guide a client through prolonged exposure, perhaps ten or twenty minutes, or more, until their anxiety had reduced to a minimal level — around 1 or 2 points, say, on a 10 point scale. That’s called the “emotional habituation” approach. You can compare it to getting into a very hot or very cold bath and waiting for your body to get used to the temperature naturally. Most anxiety will naturally wear off over time, if you maintain the exposure long enough. It’s perhaps easiest to think of it in terms of your heart rate going up, and then slowly returning to, more or less, its original resting level, even though you remain in the feared situation. That can require patience, though, and it’s usually easier with the guidance of a therapist, or at least by listening to a recording. Moreover, in recent decades, emphasis has shifted toward the goal of learning that your feelings can be tolerated safely, as we’ll see below.
Voluntary exposure to a moderate dose of stress now can prepare us to cope better with greater challenges in the future.
In the approach I’ll describe, I’m also drawing on a closely-related form of evidence-based therapy called Stress Inoculation Training (SIT), developed in the 1970s by Prof. Donald Meichenbaum. Over the years, SIT has been tested pretty rigorously in many settings, with many different types of clients coping with different problems. Its name comes from the analogy with medical inoculation: voluntary exposure to a moderate dose of stress now can prepare us to cope better with greater challenges in the future. As Meichenbaum explains: “a person’s resistance [to stress] is enhanced by exposure to a stimulus strong enough to arouse defenses and coping processes without being so powerful that it overwhelms the individual.” In other words, with practice, especially practice under stress, we can become more skilled and confident at coping with our emotions.
In this article, I’m going to describe a variation of classical imaginal exposure and SIT that I teach to clients. I like to call it virtues-based exposure. It combines some elements from different approaches found in cognitive-behavioural therapy (CBT). It also adapts a simple meditation technique, made famous by Herbert Benson, a professor of cardiology at Harvard Medical School, in his bestselling book The Relaxation Response (1974). Benson carried out research on a variety of different meditation and relaxation techniques and concluded that simply repeating a word or short phrase while adopting a passive mental attitude was one of the simplest methods capable of inducing a reduction in sympathetic nervous system arousal, which he dubbed the “relaxation response”. However, I don’t recommend viewing this as a relaxation technique. Rather, I think of it more as a simple cognitive exercise, used to centre the mind on the idea of accepting uncomfortable feelings, and building up tolerance of them, by cultivating an attitude of patience.
Stage One: The Benson Method
The basic method is easy to describe.
Sit in a comfortable, neutral position, in a room free from distractions, and close your eyes. Most people sit on a chair, with their hands separated and feet flat on the floor. Some choose to lie down, although you should avoid doing this if it causes you to fall asleep.
Focus your attention on your breathing. On each exhalation of breath, repeat the word “patience” to yourself, in your mind. You may find that it helps to say the word a little more slowly than normal, and in a slightly more calming tone.
Continue for 12-15 minutes per session. If your mind wanders, that’s natural, so just adopt an attitude of indifference to distractions, as if shrugging it off, and patiently return your attention to your breathing and the word you’re repeating.
I would usually recommend that people do this once or twice per day, for around 2-3 days before proceeding to the next stage.
During this exercise, you may notice:
That your attention is more grounded in the present moment than normal
That you are more aware of the distinction between voluntary thought or what you are doing (repeating the word) and automatic processes (everything else) happening in your body and mind.
That you become more aware of your stream of consciousness and bodily sensations as a process unfolding over time, rather than as something static.
That the exercise requires maintaining acceptance and detached indifference toward automatic thoughts and feelings, which Benson described as an attitude of “Oh well.”
That the exercise requires temperance, or doing less for a while, and temporarily letting go of certain urges and desires.
Benson originally emphasized that the word could be neutral, or even meaningless, and the relaxation response would still follow. However, he later revised his views, having found that his method worked better when people combined it with what he called the “Faith Factor”, by which he meant that they connected the meditation with their personal beliefs and values.
A number of years ago, I thought that this approach was all that was required to elicit benefits from the Relaxation Response. And it’s true that the basic procedure is as valid as it ever was for helping individuals reduce stress, lower blood pressure, and otherwise enhance their physical and mental well-being. But now I’ve come to understand that the effects of this simple technique, combined with a person’s deepest personal beliefs, can create other internal environments that can help the individual reach enhanced states of health and well-being. — Herbert Benson, Beyond the Relaxation Response, 1984
Building on Benson’s observations, you can select a word or short phrase that encapsulates your core values. For example, if you’re interested in Stoicism, the four cardinal virtues: wisdom, justice, fortitude, or temperance. For most clients, however, if they’re undecided, I think it’s a good idea just to begin by repeating the word “patience”, as that’s central to the practice anyway, and can often be connected with other values, such as wisdom and resilience.
Stage Two: Virtue-Based Exposure
What’s missing from many meditation practices, and self-help techniques, is some element of exposure to feared situations. The Benson Method, in my experience, combines well with imaginal exposure, precisely because it’s very simple. Imagining yourself in a stressful situation takes some attention and that can be difficult if you’re also trying to practice a more complex meditation technique at the same time. So picking the simplest possible method is ideal for our purposes here. If you’ve already spent a few days practising the Benson Method, it will have become more familiar, which also makes it easier to add in a new component to the exercise.
Therapists normally construct what’s called an exposure hierarchy, by drawing up a list of situations that provoke anxiety when imagined, and rating them 0-10 on a subjective units of distress (SUDS) scale. Don’t begin with your worst memory or most overwhelming fear — it should be manageable. For this exercise, unless you suffer from a severe anxiety disorder such as panic disorder or posttraumatic stress disorder, I’d normally recommend beginning work on a scene that’s moderately high on the scale, though, say around six or seven out of ten SUDS, if possible.
That could be a memory of a recent event where you felt anxious. It could also be an anticipated or hypothetical situation, where you fear becoming anxious. Often, I recommend starting with memories as they’re usually easier to imagine, then moving on to anticipated situations, where appropriate. NB: If the scene involves trauma, dissociation, self-harm urges, panic attacks, or overwhelming distress, don’t use this as a self-help exercise without professional guidance.
Don’t worry about visualizing things perfectly. Most people report picturing incomplete, fragmentary, or somewhat vague images at first when asked to use their imagination. In fact, I prefer to talk more about imagining the scene or even pretending you’re there rather than visualizing images. It’s probably more cognitive than visual, in the sense that believing you’re in the real situation for a moment, or pretending that you are, may be more important than trying to conjure up photorealistic mental images. So you’re just going to imagine you’re really there, reliving the memory, or experiencing the anticipated scene.
Don’t try to suppress your anxiety, or any other uncomfortable feelings. In fact, I’d recommend you imagine you are relaxing into acceptance of the anxiety rather than trying to relax it away. Why do I say that? Surely your goal is to eliminate or control your anxiety? Research suggests that when people try too hard to suppress their anxiety, it can backfire and make them more anxious. It can make you tense up physically and mentally, which is the opposite of what you want. It can also encourage your nervous system to view anxiety as a sign of danger, triggering what we call second-order anxiety, anxiety about anxiety, which is also not what you want.
Recent research on exposure therapy has supported the view that it works mainly through what psychologists call “inhibitory learning”, which means that you are repeatedly proving to your nervous system that you can cope with the unpleasant feelings, and that they are not really threatening. Over time, the brain learns to treat the trigger as less dangerous, and the alarm response becomes less easily activated. For that to happen, though, it’s important that you allow yourself to experience your anxiety, without avoidance or too much distraction. In fact, instructing people to actively tolerate their feelings of anxiety during the process has been found to enhance the benefits of exposure therapy. It also means that if your anxiety returns for any reason, which it might, you’ll be able to cope with more skill and confidence.
So here are the steps:
Assume a neutral position: Sit in a quiet room, close your eyes, and settle in by doing the basic Benson method for two minutes.
Evoke the scene: Imagine you are reliving the stressful memory or anticipating the future anxiety-provoking situation. Allow yourself to actually feel the tension creeping into your body, your heart beating a bit faster, or other unpleasant sensations.
Exhale and accept: With each repetition of “patience” on the out-breath, imagine yourself relaxing into the scene and leaning into acceptance of the discomfort.
Continue for 12–20 minutes: Let the feelings run their course naturally without trying to fight, suppress, or control them.
Evaluate: At the end, rate yourself on a scale of 0–10 for how well you practiced patience (or whichever virtue you’re practising). Optionally, also note your anxiety SUDS level.
Don’t try to get rid of the feelings of stress or anxiety, or even to control them. Just let them run their course naturally. Your role is to completely abandon the struggle against them, and just accept them more fully, allowing your brain to process them naturally, in its own time.
That said, they will often tend to reduce over time. It’s helpful to know that the anxiety response tends to come and go in waves and the initial surge of nervous arousal may only last a few minutes in some cases, although it can take longer for the body to recover and return to its normal state. In other words, you’ll often find that with patience your body naturally settles down over time.
Placing more importance on your own character than on the feelings can shift your attention slightly, and create an increased sense of confidence in your ability to cope.
As mentioned above, by linking this exercise to your core values, you potentially add another dimension, which can make it more rewarding, and more beneficial. For example, think of “patience” as precisely the character trait of someone who copes well with stress or anxiety, and something that you admire in other people. Perhaps it is a quality you would like to model for your children, or others close to you. Imagine you’re becoming the sort of person you want to be in life — it’s about your self-image and sense of identity. That attitude may be at the back of your mind throughout the exercise, but it can change things significantly. Placing more importance on your own character than on the feelings can shift your attention slightly, and create an increased sense of confidence in your ability to cope. Whereas, in a sense, anxiety is mindless, coping is mindful. Bringing your values into things can create subtle changes, though, that are best experienced through practice.
Conclusion
The technique is very simple. That makes it easy to learn, and possible to adapt to different needs and circumstances. It allows room for multiple processes to take place, which can benefit you psychologically. You can view it, from the perspective of Rational Emotive Behaviour Therapy (REBT), for instance, as an exercise in developing High Frustration Tolerance. As you confront unpleasant feelings triggered by the imagined scene, imagine that you’re proving to yourself “This may be uncomfortable, but I can handle it”, “It’s unpleasant but not unbearable”, and so on.
Troubleshooting and things to avoid:
Try to identify the real fear, and focus on the real triggers.
Don’t keep jumping around from one image to another, but stick with one scene until you’re pretty confident that you’re ready to move onto the next one.
Don’t keep changing your phrase. Pick something and stick with it for a while, because it’s not all-important anyway. Change it later, if necessary.
Don’t try to avoid, control, or suppress your anxiety or other unpleasant feelings but rather prove to yourself that you can tolerate and accept them, and let them run their course naturally.
Don’t fidget so much that it becomes a distraction.
Repeat the stage two exercise about once a day for about 2-3 weeks, and you should begin to notice that it’s becoming much more familiar and habitual, and that the stressful situations are less upsetting than before, as though you’ve started to get used to them.
