The Woman Who Cracked the Anxiety Code

Sally Satel writes in the WSJ:

The turning point came when she confided in a friend, a World War I veteran, that she suffered from a frenzied heartbeat. “Far from being surprised or concerned,” Ms. Hoare writes, “he shrugged,” saying: “Those are only the symptoms of nerves.” He told Weekes, in Ms. Hoare’s paraphrase, that “her heart continued to race because she was frightened of it. It was programmed by her fear. This made immediate sense.”

The explanation was deceptively profound, going straight to the core of the mind-body connection. It evoked the mid-19th-century work of Charles Darwin (who also happened to suffer from debilitating anxiety and palpitations). Emotions like fear, Darwin believed, emanated from primitive regions of the brain, in both humans and animals, and served as a survival mechanism that was beyond conscious control. The psychologist William James also explored the mind-body interface. In the 1890s, he argued that it would be impossible to think of the emotion of fear without a physiological accompaniment. As James asked: Do you run from a bear because you are afraid or are you afraid because you run? In short, without physiological arousal, it isn’t possible to consciously feel emotion.

Weekes had hypothesized a “first fear and second fear” process. The first is a reflex—and the problem in many anxiety disorders is that the reflex is set off for no obvious reason. The second is the conscious feeling of fear. Relief of suffering, for her, came when she learned to quell the “fear of the first fear,” thereby short-circuiting the cycle that was set in motion by the original, unbidden rush of panic: the pounding heart. According to Ms. Hoare, Weekes “immediately grasped the point that she needed to stop fighting the fear.” She had cracked the code.

But this insight would not reach the public for another 30 years. After becoming the first woman to be awarded the degree of Doctor of Science at Sydney University, Weekes conducted research in endocrinology and neurology. Eventually she sought a more pragmatic occupation and enrolled in medical school at age 38. During her work as a general practitioner, she felt special sympathy for her anxious patients and began to counsel them to do as she herself had done: “float past” panic, give bodily sensations and fearful thoughts no power. One of her patients asked for written advice. Her pages to him became “Self Help for Your Nerves,” published in 1962, when Weekes was 59; the book rocketed up the bestseller lists in the U.S. and the U.K. As Ms. Hoare shows, Weekes’s contributions to human welfare live on in mindfulness training and forms of behavioral therapy, sometimes combined with medication. Contemporary neuroscience has vindicated her theory.

Here are some highlights from this 2020 book:

* Australia was the second country in the world to give women the vote at a national level, in 1902, the year before Claire was born. New Zealand was the first, in 1893…

* On 16 July 1881 the then chancellor [of the University of Sydney] Sir William Manning announced ‘the full opening of the University to students of your sex. Ladies! And the offer to them, if they will accept it of all of its advantages and privileges and complete equality with men.’

* If the early education of Weekes was shaped by one idea, it was evolution. Many branches of science were still investigating Charles Darwin’s famous theories, and vigorous efforts were made in the late 19th and early 20th century to expand on them and to identify the linkages between animals and humans. In 1924, Weekes narrowed down her academic interest to zoology, which guaranteed immersion in the evolutionary debate.

* He told Weekes that her heart continued to race because she was frightened of it. It was programmed by her fear. This made immediate sense. ‘All the time I have been doing this to myself?’ she asked. ‘He said “yes” and laughed,’ she later recounted.
His words spoke to the scientist in Weekes. War offered empirical examples: soldiers got scared, their hearts raced, and often continued to race after the threat had passed. John had noticed they then became distressed by their racing hearts, which further aroused and primed them for panic. Yet there was nothing wrong with their hearts. They were consumed with a fear that felt overwhelming in the body and so the mind concluded something was terribly wrong and continued to feed the fear.
Weekes had experienced the tenacious loop between mind and body, and here it was explained by someone all too familiar with it: a soldier. Of all the emotions, the feeling of fear was primal. This was the instinct for survival. Once frightened by the feelings in her body, Weekes had kicked off a vicious cycle.
She had already discovered that fear could not be extinguished by the rational brain. Thinking inevitably lost the battle to feeling. Weekes’ substantial cognitive abilities, which delivered scholarships, awards, and opportunities, were sidelined by an all-consuming dread. It was this feeling she was desperate to extinguish, this feeling against which she fought so futilely, this feeling that was accompanied by racing panicked thoughts.
The discovery that she had been frightened of fear itself was a profound revelation. Weekes was shocked that not one of the handful of doctors and specialists she had consulted had explained how fear could have such a deranging effect on the body.
She immediately grasped the point that she needed to stop fighting the fear, which was an instinctive response yet counterproductive. There was no benefit gained by striving, trying to think rationally, or attempting to exercise willpower. She later reported it as the breakthrough insight.
‘After my friend told me the cause, I just lay as calmly as I could, “OK, I’ll just go to sleep, palpitating if necessary.”’ Once she ceased engaging so intensely with her symptoms, her heartbeat returned to normal. ‘The whole thing cleared up,’ as she put it. Once she understood ‘fear’ was bluffing her, she decided to ignore the messenger. She accepted the palpitations instead of fighting them. No battle, no fighting. The keyword was acceptance.
The turnaround was swift. If Weekes had been devastated by her lack of understanding of what ailed her, she now felt exhilarated, liberated by an explanation from what had been incomprehensible suffering. With this new understanding, she regained control… The other revelation was that her suffering had been so long and the cure so swift. Two years of mental torment were almost instantly relieved by a credible explanation. Not every reader of her books would find recovery as instantaneous, but, like her, many were relieved to be given an understanding of their bewildering and terrifying state.

* In The Expression of the Emotions in Man and Animals, Darwin concluded a book full of examples of animal and human emotional behaviours with what could have been advice to an emotional patient.
“The free expression by outward signs of an emotion intensifies it. On the other hand, the repression, as far as this is possible, of all outward signs softens our emotions. He who gives way to violent gestures will increase his rage; he who does not control the signs of fear will experience fear in a greater degree; and he who remains passive when overwhelmed with grief loses his best chance of recovering elasticity of mind. These results follow partly from the intimate relation which exists between almost all the emotions and their outward manifestations; and partly from the direct influence of exertion on the heart, and consequently on the brain. Even the simulation of an emotion tends to arouse it in our minds.”

* In his own efforts to crack the code, [William] James asked if it was possible to feel emotion without physiological arousal. He showed the interconnection, in the same way as Darwin had done in his final book. James wrote physiological psychology. He explicitly demonstrated how the nervous system primed the body without reference to conscious thought, and that emotions were often beyond control. Fear was the primal example. Of all of the body’s autonomic reactions, the unconscious threat response was unalterable.

* It’s not hard to see why Weekes infuriated the professionals, according to Andrews. ‘Here was a lady saying don’t take barbiturates, which were the sedatives of the day, and I’m sure doctors found her challenging because she did not think much of the way they treated people. She challenged the orthodoxy of the medical profession, which was embracing for the first time the antidepressant drugs, anti-anxiety drugs, and antipsychotics as drugs. Here was this lady saying, there’s a better way to do it.’
By the early 1960s, the mental-health profession was atomised between psychiatrists and psychologists, between those who believed in drugs and those who didn’t. Did you treat the whole person or a set of genes? Did you plumb the unconscious or did you try to change behaviour? How do you change people’s attitudes and therefore their moods.

* The same year that Weekes published her book, the psychologist Albert Ellis — considered along with Aaron Beck to be one of the main originators of the so-called cognitive revolution in psychology7 — wrote Reason and Emotion in Psychotherapy, ushering in cognitive therapy, which would be blended into behaviour therapy. Now thoughts mattered, along with behaviour. Where Ellis saw irrationality, Beck saw inaccurate thinking — but both worked at changing the way people thought about themselves, and the world around them. CBT, of which Ellis’ Rational Emotive Behaviour Therapy was the first form, would come to define modern psychology.
Yet Ellis had a high opinion of the work of Weekes. Professor Raymond DiGiuseppe, who worked with Ellis from 1975 until Ellis’ death, says, ‘Al Ellis used to talk about her work when I was a postdoctoral fellow in the 1970s. We would regularly refer/recommend the books by Dr Weekes for clients. Bibliotherapy was a big part of REBT and Dr Weekes’s books were at the top of the recommended reading list as long as the books were available.’
Weekes would later be identified as a precursor to CBT, yet her approach involved a package of ideas that did not fit neatly into that box. Changing how you thought about things, replacing negative thoughts with positive thoughts, was not her approach, although she certainly acknowledged that attitude was important, and that thoughts could have an impact on the nervous system. Yet she reversed the order of importance. Treat the nervous system first and the thoughts second. Ellis, a large charismatic New Yorker with a willingness to have his own dogmas challenged, would come to understand this himself in later years and would publicly acknowledge the work of Weekes, particularly the idea of the fear of fear.
Accepting that a sensitised nervous system could not be controlled, Weekes’ advice was to ‘float past’ disturbing thoughts and give them no power. They were just thoughts. Her advocacy of non-reactivity, or masterly inactivity, was then quite a foreign notion. Hers was a unique therapeutic approach.
The decade after she died, another iteration of CBT was popularised by Professor Steven Hayes from the University of Nevada. It was called acceptance and commitment therapy, and had more in common with her approach, given its emphasis on acceptance. ACT has been called the third wave of CBT, and offers another example of her pioneering approach.

* There was a century of building, tearing down, and rebuilding, and, by the 1980s, CBT had seized the day, although its own statistical claims to success were themselves contested. Strict statistical measurement of the efficacy of therapies treating the muddy waters of despair required a superhuman divining rod.
Over the years, it became clearer that drugs were not an unmitigated success, that psychoanalysis could cause as much harm as good, and that so-called behaviour therapy, or exposure of the kind championed by Dr Joseph Wolpe, had limitations in relation to one group hat was proving refractory to this approach. Members of that group suffered panic attacks, especially when experiencing the great outdoors or public spaces.
Agoraphobia had no clinical profile at all until 1980, when the labellers gained the upper hand in the psych wars and it was listed in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). This was the professional psychiatric manual that defined mental disorders, and it came to underpin the legal and regulatory framework around mental illness. It offered benchmarks upon which to base an industry response. The DSM — which classified and measured — offered an implicit claim to scientific validity.
Weekes wrote about a landscape that she understood well. She had traversed it in her own life, and in her surgery she had extended her understanding. Although there were plenty of varieties of suffering, Weekes remained a lumper, not a splitter. They were variations on one theme: fear.
She inherited no psychiatric or psychological tradition, she followed no ideology or school of thought. If her analysis was not entirely new and was supported by the medical science of the nervous system, then no one had told the story to the public in quite the same way. And the professionals had no treatment protocol that they could prove worked. This lack of empirical results would continue to tear psychiatry apart.

* There was a breakout box called ‘14 Do’s and Dont’s’. This was a crisp cheat sheet of her work.

Don’t run away from fear.
Accept all the strange sensations connected with your breakdown, recognise them as temporary.
Let there be no self-pity.
Settle your problem as quickly as you can, if not with action, then by accepting a new point of view.
Waste no time on ‘what might have been’ and ‘if only’.
Face sorrow and know that time will bring relief.
Be occupied. Don’t lie in bed brooding. Be occupied calmly, not feverishly trying to forget yourself.
Remember that the strength in the muscle may depend on the confidence with which it is used.
Accept your obsessions and be prepared to live with them temporarily. Do not fight them by trying to push them away. Let time do that.
Remember your recovery doesn’t necessarily depend ‘entirely on you’ as so many people are ready to help you. You may need help. Accept it willingly, without shame.
Don’t be discouraged if you cannot make decisions while you are ill. When you’re well it will be easy enough to make decisions.
Don’t measure your progress day by day. Don’t count the months, years you have been ill and be dispirited at the thought of them. Once you’re on the road to recovery, recovery is inevitable however protracted your illness may have been.
Never accept defeat. Remember it is never too late to give yourself another chance.
Face, accept, float, and let time pass. If you do this, you must get well

* The year after Self Help for Your Nerves was published, Roche Lab launched Valium on the market as one in a new drug class called benzodiazepines, which included Librium, Klonopin, and Xanax. These were sedatives, with addictive power. Then came the antidepressants. The idea of chemical imbalance in the brain was starting to take hold. Never mind that drug efficacy was often a serendipitous accident. The chemical-imbalance theory would become increasingly powerful over the years, as psychoanalysis and psychological treatments struggled. Drugs offered a potential magic bullet.

* The pressures on Weekes, and her self-absorption, meant she hit the wrong note in her personal life from time to time. The woman who spoke with such authority and compassion to distraught strangers for hours on the phone could be insensitive when not fully engaged. One day, a youth she knew well came to her in distress, about to get married but concerned it was to the wrong person. Either because she could not be bothered, or because she decided it might stray into some uncomfortable sexual terrain, Weekes spectacularly missed the point and snapped the door closed with an inappropriate aphorism: ‘All black cats are the same in the night.’ It was a piece of biological reductionism that was never forgotten, and she was never asked for advice from that quarter again.

* Coincidently, 1969 was the year when ‘the field of neuroscience was officially born as a discipline’, according to Joseph LeDoux, a renowned US neuroscientist himself.7 With psychoanalysis and behavioural psychology still jostling for pre-eminence, it would be years before a more biological approach would be back in therapeutic favour, ushered in by neuroscience. Weekes, with her emphasis on the nervous system and the concept of first and second fear, anticipated the return to biology and the physiology of the brain decades later.

* Weekes’ approach was that the dreaded bridge should be crossed, but in a special way, her way, with total acceptance and an understanding of the way in which memory had conspired with the nervous system to keep the body trigger-happy and ready to fire. This was exposure therapy for sure, but on very exact terms. By learning to walk with fear, the individual learned how to walk without it.

* Under another reader-friendly headline, ‘First Fear Must Always Die Down’, Weekes asserted that the whiplash of first fear was followed by a second fear, which she identified as a feeling that could be described as ‘What if (add in catastrophic thought)’. First fear launched an orchestra of bodily responses to a perceived threat; and to the pounding heart, the churning stomach, the trembling body was added second fear. ‘Oh my goodness here it is! I can’t stand it. I might make a fool of myself in front of all these people! Let me out of here! Quickly. Quickly. Quickly.’

Although she did not give it a neurological definition, her ‘second fear’ invoked another brain process in human beings — that of conscious emotion, which involved a different matrix in the brain, or what LeDoux later called ‘cortical consciousness networks’,5 a more-recent evolutionary development. These networks (rather than the more popular notion of the prefrontal cortex) gave rise to consciousness, which allowed for reflection, thought, self-consciousness, and anxiety.
The first fear that Weekes identified took the fast road and manifested itself in less than the blink of an eye. The second fear, which consciously reflected on the first and was a fearful appraisal of it, was infinitesimally slower. Weekes identified the treacherous collaboration between the two that delivered the vicious cycle of panic. The first fear, she said, was ‘normal in intensity; we understand it and accept it because we know that when the danger passes, the fear will also pass’. However, in the case of a sensitised person, that flash of first fear can be ‘so electric in its swiftness, so out of proportion to the danger causing it, that he cannot readily dismiss it. Indeed, he usually recoils from it, and as he recoils he adds a second flash of fear. He adds fear of the first fear. Indeed, he may be much more concerned with the physical feeling of panic than with the original danger. And because that old bogie, sensitisation, prolongs the first flash the second flash may seem to join it. This is why the two fears feel as one.’
LeDoux years later concluded that ‘threat processing contributes to maladaptive feelings of fear and anxiety’, and that people who suffer from fear and anxiety disorders are ‘hypersensitive to threats’ and become hypervigilant.
Weekes ‘acceptance’ protocol was designed to short-circuit the fear cycle that was launched by sensitisation or hypervigilance. It also assumed that the more modern part of the brain, its reasoning system, could not override the more primitive survival circuits of fight and flight.
Therefore, to achieve ‘peace from nervous suffering’, the body, not just the mind, needed to be engaged, and this was the point of her treatment mantra of ‘facing, accepting, floating, and letting time pass’.

* The ultimate personal disclosure to The Australian Women’s Weekly, however, was an announcement that may have surprised her own family. She declared she was thinking of moving permanently to London. What she called her current ‘visit’ to Australia ‘could be her last’. Weekes struck a new critical note about her country and her profession, although it said as much about the missing pieces in her personal life.
She deplored the fact that young doctors did not make home visits, as this, she believed, was where ‘real doctoring’ was learned. Her main complaint, however, was her local invisibility, given her high profile abroad. Professionals in Australia were not interested in her work. When she spoke about returning to London to live, she added ‘it was with regret’ that she had received ‘no invitation’ to tell her colleagues in Australia about her work.
Weekes was chagrined that her work was being ‘taught in clinics throughout Britain and America’, while in Australia ‘only a few therapists are beginning to realise what can be done with my method’. It was this — her work — that was the most important thing in her life. When she referred to her ‘work’, it was as if it required a capital letter. Always central, it was now an essential stabiliser, as she was unmoored from Coleman. There was more opportunity for her overseas: ‘In America I’m dealing with 200 million people, in Britain with more than 50 million.’

* Following the ideas of Weekes was a clear reversal of the usual practice. Psychiatrists — and to an extent, psychologists — followed theorists, not the writers of self-help books. For years, tension shook the leaves on these two different branches of the same tree. Psychiatrists enjoyed a higher status than psychologists because they were trained medical doctors and yet ironically employed very little biological science. They regarded psychologists as less well trained, and, immersed in the mysteries of the unconscious, they bridled against incursions into their terrain.
Such was the popularity and acceptability of psychoanalysis that demand did not inevitably meet supply. Psychiatrists were expensive, too, and there was a gap in the market for psychologists1 and social workers.
Winston remembers ‘the many absurd clinical case discussions’ she had heard when working in psychoanalytic hospitals in the 1970s. She was unimpressed with ‘how often energy and time was wasted in damaging ways’. She notes that the psychoanalytic treatment seemed inflexible and endless, and anxiety symptoms rarely improved.
‘You didn’t explain things to people, you didn’t answer their questions. What you did was act as a mirror for patients’ projections, and you left all the questions hanging because it otherwise invited dependency, and the power of the relationship would be ruined by answering the questions. You didn’t talk directly to patients and explain things to them. You just didn’t.’
Psychoanalysis was not only ineffective but often had a perverse outcome — some patients got worse rather than better, particularly those patients who suffered from agoraphobic anxiety and obsessive-compulsive disorders, the very people Weekes was treating more successfully.
On the other hand, Winston saw that Weekes worked apparent miracles, having witnessed the remarkable recovery of Zelda Milstein, an intractable agoraphobic who had been cured after reading Hope and Help for Your Nerves and Simple, Effective Treatment of Agoraphobia.

About Luke Ford

I've written five books (see Amazon.com). My work has been followed by the New York Times, the Los Angeles Times, and 60 Minutes. I teach Alexander Technique in Beverly Hills (Alexander90210.com).
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