Is Cognitive Behavior Therapy Really The Best Treatment For Panic Attacks?

I recently came across the most excellent 2019 BBC documentary Nadiya: Anxiety and Me offering profound insights regarding conventional treatment of anxiety and panic disorders. It follows the brave journey of UK celebrity chef and panic attack sufferer Nadiya Hussain as she seeks mental health treatment for her chronic anxiety for the first time, on camera.

Talking about mental health in a public forum can go a long way to reducing stigma and shame, and can even be healing in its own right. This is a great documentary and I highly recommend it for anyone suffering from or with a lived experience of anxiety or any related mental health condition, and their friends and family. I also recommend it to anyone working in this field and encourage you to check out my detailed review notes below.

Nadiya’s experience seeking help highlights a lot of what is wrong with mainstream mental health treatment due to its emphasis on Cognitive Behavior Therapy (CBT) and psychoactive medication, which are currently the dominant paradigms in psychology and psychiatry respectively.

Here’s the documentary, so you can watch it as you read along to the observations I made as I watched for the first time. I’ve included timestamps in parentheses (minutes:seconds) below so you can tell where I’m up to in my commentary below:

If you prefer a video commentary, you can watch it here:

 

Adult mental health issues are often caused by unresolved childhood trauma which often stems from emotional attachment wounds with our mother as described by John Bowlby’s Attachment Theory. Insecure forms of attachment further compound the traumatic effects of adverse childhood experiences because it means we lack the safe base of an emotionally available mother to return to in times of emotional overwhelm.

Although I know nothing about Nadiya’s personal circumstances yet, I’m going to go out on a limb and speculate that she has probably experienced some kind of childhood trauma that remains incomplete and is manifesting as adult anxiety. Let’s see if my theory pans out.

At the start of the documentary, Nadiya uses the words “we” and “you” several times when talking about her experience (0:26):

• “You are your own worst enemy”
• “You live inside your head”
• “We need to talk”
• “You worry about dying every day”

Using “I” statements when talking about ourselves is a basic assertiveness skill which lessens anxiety, especially in interpersonal situations. Because we identify with “I” statements more deeply than “You” statements, they are also more likely to trigger an emotional release that can heal the sort of underlying trauma I speculated about earlier. I’m hoping that if she goes to therapy, which I’m guessing she probably will, her therapist teaches her assertiveness skills.

Later on, she uses “I” statements and talks about physical symptoms (1:30). This is a good omen.

However, they are often combined with negative catastrophic judgements about her anxiety:

• “I worry about the most ridiculous things” (3:58)
• “I worry about everything” (4:09)

She also hints at shame about her panic attacks by not wanting her children to see them  but doesn’t actually say “I am ashamed” directly (4:27).

Nadiya intellectualizes her anxiety, saying: “To me, It’s like a monster” and describing it in abstract terms most of the time rather than as concrete physical sensations in her body. This abstraction has the potential to distance her from the felt sense experience of her feelings and hence suppress emotional processing required to heal trauma with techniques such as Peter Levine’s Somatic Experiencing (5:16).

Instead of feeling her admittedly overwhelming feelings, she distracts herself by keeping busy and using a morning routine including prayer, exercise and baking (5:37).

When she searches “anxiety” online with her husband, Nadiya relates to the description of the symptoms (7:15). When he says: “They can’t remember the last time they felt relaxed”, this resonates with her and she begins to cry (7:35). This is an emotional release of trauma making its way to the surface in the presence of perceived empathic understanding from the stranger online who wrote the description she related to. Empathy can even heal trauma remotely.

However, while her husband is obviously supportive, he inadvertently shuts her down by asking “What are you thinking right now? … What’s wrong? … What are you thinking?” which engages her rational mind and halts the healing emotional release in its tracks (7:40).

Thinking blocks feeling.

The rational brain has the ability to suppress our emotional brain for short periods of time; but the emotional brain always wins in the long run, which is why Nadiya can’t think her way out of her panic attacks. The neurobiology behind this is described by a bunch of leading affective neuroscientists including Jaak Panksepp, Stephen Porges, and Daniel Siegel and in The Healing Power of Emotion.

A better response would be:

• To wait for her to spontaneously describe how she feels
• To identify her feelings empathically: “You’re sad”
• To inquire about her feelings: “What are you feeling?”

Any of these would support the processing of emotions better than a question about her thoughts. The therapist goes on to have an intellectual discussion about anxiety divorced from the actual emotion itself, instead of empathizing with her emotions and providing a safe place for her to feel what she feels without judgement (8:02). She responds by suppressing the healing emotional release that was taking place which is understandable but counter-productive in the long run.

When the producer asks, “Do you think you want treatment?”, Nadiya’s husband talks over her and answers for her rather than giving her time and space to elaborate (8:12). She responds “You answered that very quickly” with a hint of anger. I suspect Nadiya may be angry at the way her husband subtly dominates her in conversation rather than giving her the overt empathic support she needs. Unexpressed anger can also manifest as anxiety.

David Clark says that the two most effective treatments for panic attacks are medication and Cognitive Behavior Therapy (CBT) (10:25). He fails to mention the role of attachment wounds and other childhood trauma in the development of adult anxiety, or emotionally focused therapies and that can heal them such as Accelerated Experiential Dynamic Psychotherapy (AEDP), nor body-based emotional release techniques such as breathwork or somatic experiencing.

Having only been told about two options, Nadiya chooses to try CBT first. Clinical psychologist Paul Salkovskis’s intention for their first therapy session is to assess the extent of her anxiety so he can give her an exact diagnosis (11:26). A more therapeutic intention would be to establish a deep sense of trust and safety for Nadiya so her nervous system can calm down and begin to heal. As Diana Fosha writes in The Transforming Power of Affect, “The most important goal for the first session … is that whatever else happens, the patient should have a therapeutic experience”.

At the beginning of the session she expresses her fear that if she saw a professional, they would say she was crazy, tie her up, stick her in a white van and take her children away (11:59). Her therapist misses a golden opportunity to acknowledge and empathize with her anxiety in their very first interaction, and instead responds by normalizing with a reassuring rationalization punctuated with a condescending “OK” (12:01).

A better response would be to reflect back what he had just heard:

• “You’re worried that if you seek help, you’ll be told you’re crazy, tied up, put in a white van and have your children taken away”

This would leave her feeling understood, which is what caused her to cry in a healing emotional release earlier in the program while searching about anxiety on the internet. It also signals that it’s safe to talk about her fear of the therapeutic process itself, which is an example of what Diana Fosha calls meta-therapeutic processing.

When Paul asks Nadiya how anxiety restricts her life, she says: “I’ve stopped seeing any friends”. He responds with sympathy rather than empathy by saying: “I’m sorry to hear that”, and then interrupts when she resumes talking by asking: “Does that make you at all sad?”

Sympathy is better than another rationalization, but it doesn’t build the empathic bond his client needs to heal her anxiety as effectively as empathy does. Nor does interrupting someone when they’re talking about their fears.

While her therapist has finally asked a feeling-oriented question, it’s a closed question which can be answered without much emotional engagement. It would be better to use an open-ended emotionally centered question such as:

• “How does that make you feel?”

Or to make an empathic statement that connects with the cause of her sadness such as:

• “That must feel very lonely.”

If he misses the mark with an empathic statement by identifying the wrong emotion she can still feel the positive intention behind it and simply correct him provided he identifies her emotions accurately most of the time. Even just phrasing his original question as an empathic statement is more likely leave her feeling understood than a closed question:

• “You must feel sad about that.”

Nadiya says “Yeah” but doesn’t actually appear sad or cry because Paul hasn’t established a safe empathic connection that would help her connect with the grief underneath her anxiety (12:29). She appears to be more frightened than sad, which makes sense for someone with panic attacks who is losing her social support. A suitable response would be:

• “You’re worried you’ll lose your friends.”

Even if losing friends isn’t her main fear, this statement at least acknowledges her anxiety and gives her the opportunity to correct him if there is some other reason why not seeing her friends is distressing for her.

When Nadiya says: “I don’t have any friends anymore”, Paul missed another opportunity to empathize with her fear and instead challenges her belief that she doesn’t have friends by saying “You don’t have them, or you don’t see them?” (12:39). This is classic CBT: focus on challenging catastrophic thoughts rather than the feelings that are driving them.

Nadiya clearly isn’t feeling heard so she gives Paul a second chance to empathically acknowledge her reality by repeating herself. He replies “OK”, breaks eye contact and takes notes instead of offering her empathy (12:42). This is an example of a therapist emotionally abandoning a client when they are talking about a distressing subject.

The break in eye contact is important because the unspoken emotional bond formed by eye contact is a powerful non-verbal force for healing a client’s emotional distress. It tells their nervous system that it’s safe to feel how they feel around other people, which is something that often wasn’t the case in the past for people who have experienced relational trauma.

The reason this works goes right back to infancy as explained by John Bowlby’s Attachment Theory. Adult anxiety can stem from infantile attachment wounds caused by emotionally unavailable mothers who were unable to maintain eye contact with their infants when in distress. The empathic, non-verbal bond between mother and child is how infants with emotionally healthy mothers acquire emotional self-regulation. Without the secure attachment of this bond, children often end up perpetually anxious and grow up into anxious adults with generalized anxiety.

A therapist can heal deep unconscious attachment wounds by acting like a proxy idealized mother who maintains eye contact when their child is in distress, and using co-regulation to calm the child/client’s nervous system until they learn to self-regulate unconsciously. Diana Fosha refers to this scenario of maintaining empathic connection with a client in distress as feeling and dealing while relating, and eye contact helps the healing process enormously.

Conversely, breaking eye contact to take notes does not foster the sense of safety a client’s nervous system needs to fully process painful emotions. We don’t know yet whether Nadiya’s mother was emotionally available to her or not, but either way it’s pretty harsh to break connection like this when she’s discussing her upset. No therapist is perfect so invariably there will be missed opportunities for empathy in any session, but this is becoming something of a trend for Professor Salkovskis. He’s treating taking notes as more important than being there emotionally for a client in a critical time of need.

Paul launches into an intellectual discussion about Nadiya’s anxiety and panic, calling it “the monster”, which is a common metaphor for anxiety (12:50). Nadiya feels happy about this because she calls it a monster too, so she feels understood. The discussion establishes some safe common ground, but it also allows her to avoid dealing with her painful feelings a little longer, which prolongs her maladaptive strategy for managing her anxiety.

When Paul asks, “Were you a child who worried a lot, or do you remember being worried?” (13:12), Nadiya reveals that she was bullied in primary school (13:12). Bullying makes people feel unsafe and could well be a source of emotional trauma contributing to her anxiety.

While describing the details of her experience she breaks eye contact and looks right, left, right, which is an eye movement similar to that used in Eye Movement Desensitization and Reprogramming (EMDR), a popular and mainstream therapy for healing trauma. Nadiya’s nervous system is seeking resolution of her bullying trauma.

She goes on to say:

“In the last year of school, they flushed my head down the toilet.” (13:41)

I suspected at the outset that there would be childhood trauma in Nadiya’s case, and it turns out that there was. This was obviously a traumatic incident for her.

Nadiya couldn’t breathe with her head being flushed down a toilet, and not being able to breathe is terrifying. Her panic attacks could well be her nervous system replaying the experience in an attempt to release the trauma and get back to homeostasis. She just needs a safe environment and lots of empathy to complete the process.

This is the first time she’s sought treatment for her anxiety and may well be the first time she’s ever spoken to anyone about this, so the therapist’s response here is critical. However, rather than exploring her feelings about the incident, the therapist distracts away from feelings by asking:

• “Did you tell your parents?” (13:45)

This is not an empathic response to a client disclosing a traumatic experience for the first time. It could even be perceived as victim-blaming by a sensitive client.

However, it does uncover the fact that her parents were preoccupied with her brother’s illness when she was a child, which appears to have caused her considerable death anxiety and left her emotionally abandoned in the face of this fear. Even the most well meaning parents can inadvertently cause traumatic emotional wounds to their children.

The therapist identifies the potential link between Nadiya’s childhood bullying and adult anxiety that I speculated about, saying “Can you see that that might have set you up to be a bit worried later?” (14:00)

Her response is to close her eyes and look down, which is an indication of shame. Rather than acknowledge her reaction, the therapist carries on by normalizing:

• “There was a lot to be worried about.” (14:02)

Normalizing can be helpful, but it would have been better to acknowledge the full extent of her childhood anxiety empathically:

• “You were really worried that your brother might die.”

Nadiya goes back to Paul so either she found the session helpful, or perhaps she didn’t want to disappoint her therapist and the producer of the program by giving up so quickly. There were some moments of connection between them, he has offered her hope for the first time, and we have only seen short segments of the whole process.

CBT does work to some degree but it could be so much more powerful when delivered with more empathy. Her therapist could easily establish a deeper sense of safety and connect more emotionally with his anxious client by using basic Rogerian reflective listening along with open rather than closed questions. This is basic Counselling 101 type stuff.

In the vignette about her childhood (14:45), Nadiya reveals that:

• Her anxiety started when she was young (possible childhood trauma)
• She is a first-generation Bangladeshi (potential for cultural trauma)
• She is from a large family (potential for parental emotional neglect)
• She never really talked about her anxiety (lack of emotional processing)
• Two of her younger siblings had life-threatening illnesses (death anxiety)

These are further clues that her anxiety has its roots in childhood trauma. In addition to the bullying which both came up in her first session, she had an intense fear of dying which wasn’t validated as a child. Remembering back, her sister recalled seeing Nadiya “absolutely hysterical” and thinking:

• “Why does she have to be so dramatic?” (16:13)

This is an invalidating, judgmental response that destroys empathy and lacks compassion.

The obvious answer is: because she was terrified. Nadiya wasn’t being just dramatic, she was expressing how she felt and trying to get her needs met. Her sister was being insensitive, and she’s still acting like that now which suggests this may be a long-standing pattern. Nadiya goes on to describe the cognitive and behavioral strategies she used the manage the anxiety she felt as a child, but even now none of her sisters offer her empathy for it (16:27). Empathic support from her siblings could potentially heal her nervous system from the effects of the overwhelming fear that she still feels.

Instead, her sister intellectualizes her negative thoughts asking: “Why worry about it?”

Intellectual analysis does not heal childhood trauma.

When Nadiya’s sister asks her what the voice in her head sounds like, she lists the negative core beliefs it has constructed in order to make sense of her anxiety; again, using “You” statements to avoid feeling the strong painful emotion attached to them (17:10):

• “You’re not good enough”
• “You’re inadequate”
• “You’re a bad mother”
• “You’re the worst sister in the world”
• “You’re the most disappointing daughter that ever lived”
• “You’re an inadequate wife”
• “You are not good enough”

These beliefs both feed off and help sustain anxiety, forming a vicious cycle driven by unprocessed childhood trauma. Note that the list is circular, beginning and ending with the basic underlying belief attached to Nadiya’s social anxiety:

“You’re not good enough”

Nadiya’s sister’s attempt to challenge her negative core beliefs by telling her “You are the best sister in the world” fails because she hasn’t acknowledged the painful emotions involved (17:30). Faced with a cognitive challenge to an emotional problem, the emotion will always win because it occurs in the more powerful, evolutionarily primitive part of our brain. Hence Nadiya’s response aligns with her negative core beliefs: “I’d say you’re lying”.

Nadiya expresses fear that if her anxiety is genetic, she may pass it on to her children (18:30) and seeks comfort by talking to some twin study researchers exploring the role of nature vs nurture. They reassure her that environmental factors are also important, and she jokingly asks them the question she desperately needs to hear:

“How does that make you feel?” (19:46)

There is clearly a huge environmental component to Nadiya’s anxiety because her siblings don’t appear to suffer from it, and she’s had some unique traumatic experiences which are yet to be healed. My guess is Nadiya is a highly sensitive person raised in an environment where her emotional needs simply weren’t met and this is why I relate to her story.

Prior to Nadiya’s second session with Professor Salkovskis, he says she has high levels of anxiety and is keen to focus on that (21:39). He starts the session discussing her diagnosis, labelling her with Panic Disorder and possibly Post Traumatic Stress Disorder (22:00). She breaks eye contact and looks down when he says: “some of the things you describe clearly haunt you”; suggesting she is feeling ashamed. He misses this and instead continues talking about his diagnosis as though it was the most important thing going on in the room (22:20). This was an opportunity to acknowledge her upset by saying something like:

• “I notice you had a reaction to what I just said”

Instead, he reassures her that she has one of the easiest disorders to treat. She’s obviously happy to receive this news (22:40), but we haven’t seen much in the way of the emotionally focused therapy she’ll need to heal it yet. So far, the sessions have been largely theoretical.

Paul asks Nadiya to show him how she controls her breathing when she has a panic attack, and encourages her to keep going when she starts to feel “weirdly lightheaded” (23:00). She starts to feel sick and her heart starts racing as her deep breathing elicits painful feelings trapped in her nervous system. This is the basis of emotional release breathwork therapy. Releasing painful emotions doesn’t necessarily feel good at the time, but cathartic breathwork can be life-changing, which is why some people call it breathwork rebirthing.

When Nadiya asks: “Is this supposed to be helping?”, rather than reassuring her that she can work through the painful emotions that she has connected with and encouraging her to continue, Paul says:

• “No, it’s not supposed to be helping” (23:27).

Actually, it would be helping if he didn’t keep interfering with her nervous system’s natural healing processes. She just needs some empathic support because facing overwhelmingly painful feelings from childhood can feel overwhelming without the empathy she needs.

Instead of continuing to access and process Nadiya’s traumatic sensations elicited by the breathwork, Paul changes the topic and asks about the physical sensations she feels when she is intensely excited. Nadiya says they are “almost quite similar to when I’m having a panic attack” (23:40). He convinces her that the feeling is exactly the same and only the meaning she gives it changes, suggesting she could stop the anxiety in its tracks just by labelling it excitement and recognizing that nothing bad is going to happen to her (24:00).

This is an example of cognitive reframing, another classic CBT trick which works to some degree. But it won’t help her manage anything but the mildest of panic attacks because the meaning she attaches to her anxiety isn’t her real problem: overwhelming feelings attached to unresolved childhood trauma is. Also, it’s only partly true: Anyone who has both been excited about a wedding and had a panic attack can tell you that despite both involving heightened physical sensations, they are very different qualities of experience.

In their third session, Professor Salkovskis plans to take Nadiya to her fear in therapy and confront it, a process known as exposure therapy (25:00). She starts by using breathing to access unpleasant feelings and begins to cry, which means the process is working. However, rather than facilitate her emotional release by being empathically present in her distress or asking an emotionally focused question, he asks her to rationalize it:

• “What’s going through your mind?” (25:47)

As a result, her crying diminishes, she breaks eye contact and talks about being under the sink, having her head flushed down the toilet and breathing in a lot of water (26:15). This was clearly a traumatic experience for her. However, the therapist cuts her emotional processing off with a rationalisation by explaining that breathing makes her anxious by reminding her of a time when she couldn’t breathe, and she thought she was going to die.

While this is probably true, a better approach would be to remain silent and let her cry to completion or give her empathy to allow her to complete emotional processing more deeply (26:37). He could then explain the emotional dynamics of trauma to satisfy her intellectual curiosity after she’s finished healing it and no longer feels anxious anymore.

At the end of Paul’s explanation Nadiya says “I feel fine”, which is probably because she’s relieved that he has distracted her attention away from the painful traumatic memories along with the feelings attached to them that are behind her panic attacks (27:00).

When talking to camera after the session about her memory of the toilet incident and her first ever panic attack, Nadiya’s voice crackles with emotion as she says, “That memory is always there.” Emotions are what keeps our memories alive so this indicates that the emotion attached to it hasn’t been fully processed yet (27:05).

The metaphorical onion of emotional trauma has many layers and processing a particularly frightening incident can take more than one session; especially if her therapist doesn’t support her to stay with painful feelings long enough to complete processing them.

Paul has also failed to explain to Nadiya that since emotion and memory are linked, her memory of this traumatic event will fade once it’s fully processed. Explaining this would have been a more productive use of valuable therapy time than discussing her diagnosis. Not having been taught the nature of traumatic memories, Nadiya assumes: “That memory is always going to be there”, while choking back the very tears she needs to cry in order to heal it (28:00).

Paul’s idea for the next session is to “get control of the panic so that she can then more effectively deal with the traumatic stuff; the flashbacks and the reexperiencing she’s got.” This is completely backwards: the way to get control of Nadiya’s panic attacks is to heal the trauma that is causing them, not the other way around (28:15).

Nadiya visits a school with an effective anti-bullying and mental health program. This is potentially very healing by going back to a school environment in a safe context this time and talking about experiences she didn’t feel safe talking about when she was in school (30:00). It’s like real-life regression therapy because she goes back to a school and feels safe there. No bullies flushing her head down the toilet this time around. As a result, she feels empowered and inspired instead of anxious.

Having only been offered two alternatives for treating her panic attacks, Nadiya explores the second alternative of medication. She tried medication once before but stopped after two weeks because she didn’t like the way it suppressed her feelings (32:40). This is a major drawback in using medication to deal with childhood trauma because the emotional processing involved in healing trauma requires access to feelings.

Nadiya visits mental health blogger and fellow panic attack sufferer Laura Bartley, who says that medication gave her horrendous side-effects for about a month, making her feel even more anxious initially (33:23). Ultimately the medication reduced the extremity of her anxiety and panic attacks but has not eliminated them (34:57).

Then she visits Psychiatrist Dr Mirza Mohamad who starts their session by describing the way Selective Serotonin Reuptake Inhibitors (SSRIs) act on serotonin in the brain (35:40). When she tells him that she took medication at age 26 but stopped taking it abruptly after 2 weeks, he interrupts her and asks whether the purpose of the drugs was explained to her (36:15). This would have been a good opportunity empathize with her as she shares her experience. Instead, he talks about the licensing of medication prescribers rather than ask more about her experience or her emotions.

When Nadiya expresses frustration about doctors not taking enough time with their patients, Mirza again misses the opportunity to empathize and instead comments on health resources adding that “these things take time” (36:45). She gives him another opportunity to empathize with her situation by continuing to talk about what it’s like being a vulnerable patient, but he cuts her off mid-sentence to explain how long it would take him to explain all the side effects of medication to patients (36:55). Her response is to break eye contact and look sullen because he’s failed to acknowledge her feelings so she’s been emotionally invalidated again.

Recognizing that medication isn’t a good long-term solution, Nadiya decides to focus back on CBT. Having identified childhood trauma as the root cause of her anxiety, Professor Salkovskis wants to “put that to one side for now and concentrate on controlling her panic attacks” (37:27).

Huh? What was that?

I was aghast at this point. My own inner frustration was at boiling point: He knows what the root cause of the problem is, and rather than address it in their next session he wants to “put that to one side”!?!

This would be laughable if it wasn’t a vulnerable person’s mental health that they’re dealing with. “Where on earth did the producers find these people?”, I thought to myself.

Well, it turns out that Professor Salkovskis is a world-renowned cognitive behavioral therapist with hundreds of articles to his name, cited thousands of times by other researchers. Yes, it’s really true. If this is the best modern psychology has to offer, it’s no wonder rates of mental illness are skyrocketing.

A study released in 2019 showed a 71% increase in serious psychological distress among young adults in the U.S. aged 18–25 from 2008–2017.

This is a serious problem that has reached epidemic proportions among the next generation and they need an effective solution; not an emotionally detached therapist who puts trauma to one side so he can play cognitive mind games with his clients.

The obvious solution to Nadiya’s anxiety is to use breathwork to access her traumatic childhood memories, and empathic reflective listening to help her fully process the emotional residue from them. We know breathwork works for Nadiya because it has already worked in a previous session, and we know her trauma hasn’t been fully processed because she still chokes up when she talks about what happened to her. This is not rocket surgery.

Once the painful emotions attached to her underlying trauma are processed, Nadiya won’t have to keep applying cognitive strategies or employing safety-seeking behaviors in order to control her panic attacks because they will be gone.

Professor Salkovskis acknowledges that the structure and routine Nadiya uses to control her anxiety are counterproductive in the long term so he wants to explore how her safety-seeking behaviors can “keep her anxiety going” in their fourth session (39:00). However, her safety-seeking behaviors help her avoid the overwhelming emotions attached to her painful traumatic memories, which is something he is now also avoiding.

She is feeling anxious in the session and says: “I just don’t know what to expect from each session” (39:27). This suggests that her therapist hasn’t done a good job of establishing a basic sense of safety for her nervous system yet. A better approach would have been to give Nadiya an empathic response right from their very first interaction and maintain an emotional connection throughout the therapeutic process rather than continually intellectualizing her feelings.

Paul wants Nadiya to introduce an element of randomness to her life and face her panic by taking a train to London. When she says “Just the thought of going on the train makes me feel sick”, Paul fails to acknowledge this physical sensation or do any exploration of it. He says he “wants to get the panic going so they can flatten it”, but she is clearly anxious already. This is another opportunity to tap into the trauma causing Nadiya’s anxiety in the safe confines of his office. After asking him three times if they are really going to London, Paul stands up and walks away, effectively abandoning Nadiya while she is in distress. She turns instead to the cameraman for support and reassurance (40:00).

On the way to the train to London, Nadiya says “My heart is racing a little bit”. Paul asks her:

• “What is it you are worried about?”

This is another cognitive question that doesn’t engage very deeply with Nadiya’s felt sense experience. Instead, I’d acknowledge Nadiya’s physical and emotional experience:

• “Your heart is racing. Sounds like you’re feeling anxious.”

This could then lead into deeper somatic questions that connect with her body and nervous system where the fear is stored as physical tension that made her feel sick, such as:

• “Where in your body do you feel the fear?”
• “What color is it?”
• “What shape is it?”
• “What texture does it have?”
• “How big is it?”

The aim of these questions is to help Nadiya connect with the physical sensations attached to the fear during the exposure exercise, so she can release it from her nervous system and learn to tolerate its somatic residue, rather than attempting to rationalize it away. The best place to do this would be in the safe confines of his office back when Nadiya said she felt sick just thinking about taking the train, rather than on a London street.

Nadiya says she doesn’t like not knowing where she is going, and Paul reassures her that it’s OK to just let her heart pound because he wants her to experience nothing bad happening (41:44). This is a key component of exposure therapy, which can be extremely powerful. I’m happy to see that he’s reassuring her, but again it’s a missed opportunity to verbally acknowledge her unpleasant feelings and uncomfortable physical sensations.

The problem with Paul’s cognitive behavioral approach is that it’s so analytical that it just doesn’t go deep enough to heal Nadiya’s nervous system. Since traumatic emotions and physical sensations attached to her panic attacks still haven’t been processed, I predict that her fear is likely to return when he’s not around to reassure her.

Talking to camera (41:51), Nadiya again uses “you” statements to describe the voices in her head, which say things like:

• “You’re not good enough” (fear of abandonment)
• “You can’t do this” (fear of failure)
• “Remember you’re going to have a panic attack” (fear of fear)
• “Everyone’s going to know that you’re weak” (fear of vulnerability)
• “Everyone’s going to know that you’re sick” (shame)

The voices in Nadiya’s head are her rational mind trying to make sense of the latent anxiety that she feels from her childhood trauma. Her therapist hasn’t asked her anything about her relationship with her parents, and the voices she describes are typical of the internalized self-talk of someone who grew up with a critical parent. Attachment Theory was described in the  1970’s and attachment wounds with critical, controlling, abusive, neglectful or emotionally unavailable parents are the major source of anxiety for my clients. I’m both surprised and disappointed that Paul hasn’t even asked about Nadiya’s key attachment relationships in the therapy sessions so far. Perhaps he did and the producers edited those parts out because they thought it wasn’t important, but Bowlby also pointed out that the importance of secure attachment is under appreciated by psychiatrists and psychologists.

Paul has also failed to help Nadiya process the anxiety and shame underlying her self-talk, possibly because he believes in CBT’s broken schema that thoughts create feelings. This is particularly stunning in Nadiya’s case given that he’s identified childhood trauma as the underlying cause of her panic disorder yet bizarrely chosen to “put it aside” instead of helping her process it. Her panic attacks are clearly not a cognitive problem.

At the train station, when Nadiya says she feels tense, Paul normalizes instead of giving her empathy (42:20). She looks terrified, saying “The closer I get to the train, the more I feel the panic rising inside of me”. Normalizing isn’t bad when done in moderation after empathy. But he does it instead of empathy. He’s with her physically, but not emotionally and this seems to be a pattern.

Nadiya describes a somatic symptom of anxiety on the platform saying “I feel really tense. My mouth feels tense” (43:18). Rather than acknowledging or exploring what is going on for her internally, Paul normalizes with: “It’s OK to be tense, but it’s unnecessary.” This may be true and is reassuring to some degree, but it certainly doesn’t reflect Nadiya’s subjective experience in that moment.

On the train she still looks somewhat scared but says: “It’s not as bad as I thought it would be.” (44:10)

Paul misses the opportunity to empathize with her relief, by saying:

• “It never is.”

A better response would be to reflect and reinforce her pleasant emotion, with:

• “You’re feeling relieved.”

Identifying with his client in this way would build deeper rapport, reinforce her feelings of calm in the presence of what was previously a distressing stimulus, and establish a deeper sense of safety in her nervous system; all of which would help her deal with any triggering situations that may still come up in the future when he’s not around.

She gives him yet another chance to empathize when she says: “It isn’t scary at all”, and he misses it yet again, engaging her in a redundant conversation about how she would handle a panic attack if she was to have one again (44:30).

Why is it redundant?

Once Nadiya’s childhood trauma is healed, she won’t have another panic attack.

At the end of the day, Nadiya is clearly excited to have made it to London on the train, exclaiming “I was not expecting to be here today, but here I am!” (45:13)

Paul’s muted response is “We’ve still got a bit of work to do”, without even coming close to mirroring her excitement. Perhaps he is habitually suppressing his own emotions, so it’s no wonder he’s not emotionally available to his client (45:20).

Nadiya’s frightened inner child is reaching out to an emotionally unavailable proxy parent.

By avoiding the explicit use of empathy, Paul has probably exposed Nadiya to more anxiety going with him on the train to London than she would have otherwise felt. This could make the exposure therapy all the more powerful, but I’m curious to see if the effect lasts when he’s not there to distract her from the panic with his cognitive rationalizations.

Nadiya continues her search for a solution to her panic attacks and finds an online peer-to-peer service run by former anxiety sufferer Barry McDonagh. This lessens her sense of isolation, which is a core component of attachment trauma. She doesn’t seem to be convinced it will help her though because she doesn’t join up (45:53).

As I predicted, a week after catching the train with Paul, Nadiya’s anxiety takes hold again (49:30). Her husband says she couldn’t cope with a problem, was crying in a corner at one point, feels quite dejected, and it’s really worrying her. He clearly wants to help and asks her what he can do, but he doesn’t appear to know how to listen reflectively or give his wife empathic emotional support.

He suggests letting go of control and accepting the consequences, which is a reasonable exposure-based strategy in the presence of emotional support (50:40). However, Nadiya isn’t getting the empathy she needs while from him either. He’s engaging in typical male problem-solving behavior when what his wife really needs is to express her emotional pain and feel heard and accepted on a very deep level. In short:

Nadiya needs to feel loved and accepted in the presence of the overwhelming emotions she had to suppress in the past to survive her childhood trauma.

Love expressed as empathy when she is feeling upset is probably what was missing in her childhood when she formed her underlying core belief: “I’m not good enough”.

Her husband is in a great position to do this with her, but probably nobody has taught him how to support his wife emotionally. This documentary doesn’t teach this valuable skill either because Paul doesn’t model it for us since he’s emotionally unavailable to her too.

Nadiya expresses frustration with her husband while smiling and saying: “Why are you so bad at everything?” He understandably takes this somewhat personally and gets defensive rather than acknowledging her anger (51:12). Smiling when she is angry is a common reaction from women in our society where women aren’t supposed to get angry. It suggests she isn’t comfortable expressing anger directly, and unexpressed anger can also manifest as anxiety.

Nevertheless, she has a go at letting go of control and feels anxious watching her husband cook an omelet without her help. This is challenging for celebrity chef Nadiya (51:25).

Nadiya believes that getting better is going to be hard. Her therapist is only helping her manage and understand her panic attacks, rather than processing the trauma that is causing them (52:45). He “put that to one side” and still hasn’t got back to it. It’s little wonder that she starts to question whether CBT really is the answer (52:30).

When Nadiya expresses her doubts about his preferred style of therapy, Paul misses yet another opportunity to empathize with his anxious client, cuts her off saying “No…”, and starts talking down to her while counting out on his fingers all the reasons why he’s right and she’s wrong (53:30). It’s classic defensive behaviour and I’m tremendously disappointed to see a world renowned therapist behaving like this. This is not an empathic response to a client expressing her anxiety about whether the treatment being offered to her is appropriate.

When she continues to express frustration by saying that she wants an instant fix, he cuts her off mid-sentence asking:

• “Fix of what though?”

Obviously, Nadiya wants the anxiety and panic attacks to stop, but Paul is being argumentative and defensive because his inadequate approach is being challenged by an insightful client.

A more empathic response would be to listen to what she has to say, let her finish her sentence, and see if she resolves her frustration by expressing it. He could also empathize with something like:

• “You’re frustrated that you’re still feeling anxious.”

Instead, he engages in some cognitive restructuring by making her wrong, which isn’t going to help her heal the trauma they’re both avoiding dealing with. She’s spent most of her life avoiding it because it felt overwhelming, but now he’s avoiding it too because he doesn’t appear to know how to manage it effectively.

Paul engages in more reassuring rationalizations rather than helping Nadiya heal her trauma in an empathic environment, and concludes “That is something that you’ll be working on for the rest of your life” (54:10).

This would not be true if Nadiya was to get some trauma-informed therapy with an empathic therapist. There are many other healing modalities that aren’t crippled by CBT’s thoughts-create-feelings schema and would be more effective at helping her process her traumatic emotional residue. It doesn’t have to take the rest of her life.

Instead, Paul gives Nadiya a pep talk about applying what she’s learned in therapy in the real world. This makes her feel happy in the short term (54:45), but I predict that it won’t last outside his office if she leaves without the trauma being healed.

Nadiya takes responsibility for her own healing and talks about her mental health issues in front of a live audience at her next cooking show. This is an effective way of reducing shame and stigma, while building trust and rapport, and the audience response is supportive (55:00). Her anxiety is the result of childhood bullying and emotional abandonment which are fundamentally interpersonal wounds, so they require an interpersonal solution and this is a rather intense example of flooding. Fortunately it goes well for her: She puts her glasses on and is relieved to find that she can see the audience without having a panic attack (56:00).

Talking to camera later, Nadiya reflects: “I have realized that it’s not a cure I’m looking for because it’s not that kind of illness. I have to find a way of managing and of living like this without all the things that make me sad” (57:00).

Despite Paul’s lack of empathy, focus on cognitive techniques and avoidance of Nadiya’s traumatic emotions, she has made significant progress and is now talking about feeling sad rather than anxious. Sadness manifesting as anxiety is what lies beneath her childhood trauma, and we’ve seen her release this sadness to some degree when she cried at various points during the program. That’s the way the nervous system works.

Tears heal trauma

The goal of any therapy should be to access the underlying sadness and grief so the traumatic residue can be completed, and the client fully healed; not told they have a life-long affliction.

I felt angry at the way Professor Salkovskis treated Nadia in her therapy sessions, because it reminded me of my emotionally unavailable mother. I also felt sad hearing Nadiya come to the flawed conclusion that she could not be healed. Her therapist simply didn’t facilitate her nervous system’s natural trauma healing process, which is why she’s still anxious and has now believes she won’t find a cure.

She concludes: “I know my treatment isn’t finished and I know I’ve got a long way to go, but I feel ready for it. I already see little glimmers… little, little glimmers, so I know there is hope.” (57:30)

Our nervous system is wired to seek resolution, so there is always hope, even when we don’t initially get the empathic and support we really need to discharge trauma.

I found Nadiya – Anxiety and Me a truly fascinating demonstration of the resilience of the human spirit. Despite being constantly deprived of the empathy she needed to heal her nervous system, Nadiya showed up bravely and still made significant progress. Exposure therapy made huge in-roads into her anxiety on public transport, and she was able to process some of her emotional trauma residue in the therapy sessions despite her therapist shutting her down each time.

It is typical for adults with unresolved childhood emotional abandonment trauma to keep attracting other adults who also emotionally abandon them until they find a way to heal the trauma. This effect operates unconsciously and can even include our choice of therapist, so it’s not surprising that Nadiya ended up seeing an emotionally unavailable therapist.

Imagine how much more powerful Nadiya’s experience would be if her therapist used a trauma-informed empathy-based relational therapy like emotionally focused therapy, AEDP or a somatic therapy such as emotional release breathwork or somatic experiencing.

Nadiya, if you are still managing anxiety using the strategies Paul taught you, please contact me as I believe I can help you put the monster to bed for good.

I commend Nadiya for her bravery and willingness to confront her fears in this program. As someone who has experienced a truckload of anxiety in my own life, I really felt deeply for her. Watching this was very cathartic for me and helped take my own bullying trauma healing to a deeper level, as did writing and publishing this review.

Please leave a comment and let me know how you feel about Nadiya’s experience.