“The Ring of Fire” – Johnny Cash Overview Learning to live with anxiety is a lot different than conquering it. Avoiding it just increases it – The White Bears example. We spend most of our time going back and forth between “doing and achieving” (blue) and “self-protection” (red) trying to avoid feeling anxious and vulnerable. Eventually you will wear out and you will descend into the ring. You then spend your life developing and maintaining a façade (identity) to present to the world while trying to cope with progressive anxiety. If you are reading this piece and don’t think you have anxiety, think again. There are an infinite number of ways to disguise and disconnect from it. You cannot survive without anxiety and disconnecting from this innate emotion has significant mental and physical health implications. Compassion-Focused Therapy A few years ago I was attending a conference on compassion in Louisville, KY. It was a remarkable weekend and I was introduced to the concept of Compassion Focused Therapy (CFT) popularized by Paul Gilbert. The speaker was Dr. Chris Irons who is a London psychologist. He pointed out that there are three core categories of emotions that allow us to function as humans. Those that focus on: Threat and self-protection Doing and achieving Contentment and feeling safe He presented a slide that showed how people go back and forth between these three states. It made a lot of sense. I was excited about the conceptual model and showed it to my daughter who was about 21 at the time and also wise beyond her years. She looked at for a while and said, “These should be in circles.” After some thought I eventually saw her point. Here is what is looks like: Here are some of the reasons that I agree with her. I was raised in a difficult family situation filled with a lot anger and dysfunctional behaviors. As I was the oldest of four children, I spent an inordinate amount of my childhood trying to create some calm, but to no avail. Finally, at age 15, I quietly shut the door on that part of my life and “moved on” – except I didn’t. What I now know what happened is that I disassociated. I completely suppressed the craziness of my childhood and created a life and persona that I wanted and pursued my dreams. Sounds pretty reasonable – right? My new life I became athletic, social, smart, and developed leadership skills. I took extra college credits in addition to working 10 to 20 hours a week. I was having a great time experiencing this new life. I also internally developed an identity of being stable as a rock and “cool”. Nothing phased me or stopped me. I never got angry and thought it was a waste of time. I was somewhat legendary with regards to how much stress I could take for how long. When I entered medical school I developed another identity of “being compassionate, wise and a good listener.” It worked great until it didn’t. Things started to become unraveled in 1990 when I began experiencing panic attacks out of the blue and I did not know what anxiety was. It marked the beginning of a 13-year burnout and descent into hell. By 1997 I had a full-blown Obsessive Compulsive Disorder (OCD), which is characterized by intense and unrelenting intrusive thoughts. I had the internal version of OCD with no outward behaviors. I had an endless string of intense negative thoughts that I would counter with positive thoughts. OCD is the ultimate anxiety disorder. I did not become a major spine surgeon by having anxiety. I achieved it by suppressing it. My modes of suppression included positive thinking, determination, not complaining, and moving through any obstacle that might be holding me back. All these sound great on paper – even now as I am writing this post. Avoiding the ring of fire None of us enjoy the feeling of being anxious and vulnerable so we avoid it. We suppress it, avoid stressful situations, control ourselves and others around us and mask it with anger. The ring of fire is not the place that we want to live. I also did what most of us do is that I worked hard to stay in the blue by creating a life that was enjoyable, busy, interesting and stimulating. Additionally, I became so enmeshed in this process that my identity became the blue zone. For many years I was successful or at least it felt like I was. The energy of my youth kept me hovering above the red to the point that I did not even know what the word anxiety meant. “Bring it on” I admitted a patient with an anxiety disorder during my first year of orthopedic residency and I had to look up anxiety in my textbook of medicine. I was moving so fast that I was fearless – except I did not have a clue that my speed was because I was running so scared. I remember sitting in my office late one evening in 1990 thinking about my day. I had a patient who I had just surgically drained for a huge deep wound infection, another patient, who weighed over 300 pounds had just gotten in an altercation with the hospital security guards, I did not get a paycheck that month because of high office overhead, and I had a malpractice lawsuit notice sitting on my desk. My thought was, “This is a bad day but bring it on.” I thought I could deal with almost anything. Two weeks later I had my first panic attack driving across the 520 bridge over Lake Washington at 10 o’clock at night. It takes a lot of energy staying out of the ring of fire and my hovercraft ran out of fuel. I went into a 13-year tailspin that I survived out of luck or fate depending on how you want to view it. By 2002, I did not have a shred of hope after trying every possible means to pull myself out of it. I did not realize that by spending so much effort trying to both treat and avoid anxiety that I was actually fueling it. I think most of us spend a lot of our time between the blue and the red trying to stay out of the red. It eventually wears you out and it does not work. We spend our lives developing a façade to present to the world and ourselves that does not include having anxiety. “You have anxiety?” The problem is that anxiety is the essence of survival and is the core neurological response to the environment in every living creature – especially humans. How did we become the top of the food chain? Then you become connected to this identity instead of connecting to who you really are. The Center The bigger issue is that you are not connected to the core of who you are, which is the green circle in the center. How can you get there when you are moving at 1000 miles per hour? If you cannot connect with you how can you really see others as they they are and meet his or her needs? I thought I was compassionate and a remarkable listener. In retrospect I was neither. I was attached to the labels. The obstacle stopping you getting to the center is that you have to pass through the ring of fire. It is critical that you learn to live with anxiety and use it thrive, not survive. Your anxiety is not going to disappear, otherwise you would simply die. The paradox is that the more you fight it or try to fix it the more powerful it will become. Also, as you age anxiety will increase simply with repetition. For my generation the age that I think it becomes troublesome is in the mid to late 30’s. My problems began at age 37. This generation is in trouble in that the incidence of chronic pain has risen over 800% in seven years in adolescents between ages 12 to 18. I am witnessing this trend in my office and seeing many patients in their 20’s with widespread chronic pain and crippling anxiety. They are often buckling quickly when entering the workforce with its attendant demands. I now live much of my life in the center and quickly am aware when I am in the red. I am not happy about the way I found my way to the center. I do not think that it is necessary to endure the extreme suffering I experienced to find it. I was in chronic pain for 15 years with the last seven of them being intolerable. The essence of how I ended up in the center is that I was completely stripped clean. Every link to the identity that I had created for me was broken and there really was nothing left. I lived in the red for many years, which was intolerable. During the worst part of my ordeal I was working on trying to survive the next 10 minutes. You do have to go through the ring of fire to get to the center but it is a learned skill and eventually what you initially perceived as a ring of fire just becomes part of your life and becomes somewhat of a non-issue. Procrastination One insight that helped me understand this model was my tendency to procrastinate. To get back to the blue, which is also a critical part of the human experience does require going back through the ring. Every new experience from meeting a new friend to taking on a big project has some level of anxiety associated with it. I realized that my tendency to put things off was associated with fear of failure or of rejection. The longer I procrastinated on a given project the deeper the feelings. This is the topic of another post but you cannot keep passing through this barrier with just willpower. The block is too strong and encompassing. You may have already accomplished a lot or not. But continually charging through this ring by sheer force of energy will also eventually wear you down. Living in center I do live most of my life in the center and am aware every time I pass through the ring of fire in both directions and it is steadily becoming less difficult. I am also sobered when I get stuck in the ring or outside of it. One day of being in this spot sucks out the equivalent of a week’s energy. What is sobering is that I lived so much of my life in this state without any awareness of its existence. It does not require effort to be in the green center and stay there. I am not in a constant mental frenzy. I am aware when I am not there and use the tools that I learned to return to the center. I have almost an endless amount of emotional energy and am limited just by the hours of the day and getting physically tired. One metaphor that has stuck with me one one that I learned from reading a small book, 365 Tao that presents some basic tenets of Taoism. I often become overwhelmed with everything that needs to be done and I do take on too much. The thought for the day described a stork who patiently stands on one leg waiting for a fish to swim by. It simply reaches down and grabs its next meal. You can only accomplish what is in your arena and with your range of skill. I was not aware that there was a green center and I suspect that this is the case for many people – especially while suffering from chronic pain. It is there if you understand how to pass back and forth through the ring of fire. BTW, Johnny Cash’s depiction of the ring of fire is incredibly accurate. The antidote to anxiety is control. Falling in love creates a loss of control – and also freedom. It is a great experience until we try to reel ourselves and the other person back in. What if you could live your whole life like that?