Resisting Change and the Depressive Paradox

You can take a horse to water but you can’t make them drink.”

There are many reasons people resist making positive changes in their lives. As a therapist, the number of reasons I’ve heard for not making a change is truly astounding. When I talk about this with people in my life, they explain it’s obvious – people don’t make changes because they “fear change.” I’ve always found this explanation to be unsatisfying. It sounds like another example of people wanting a simple explanation for something that is complex. Why do people fear change? What specifically about change do people fear? I tried to answer these questions by reading Robert Leahy’s “Overcoming Resistance in Cognitive Therapy.” From this book, others like it, and my own experiences, I have learned resistance does not interfere with therapy, overcoming resistance is the therapy. Most people have an idea of how they could make a positive change in their lives, but they typically resist making these changes. One of the most interesting chapters in Leahy’s book describes the “Investment Model of Resistance” and how it applies to people with depression.

The Depressive Paradox

When people are depressed they are less likely to engage with activities which would likely reduce their depression. Instead of problem solving, exercising, socializing, working, sleeping 8 hours, and eating a healthy diet, people with depression are more likely to isolate, withdraw, conserve energy, and avoid. This is referred to as the “depressive paradox.” When people are depressed, one would expect them to be more motivated to pursue pleasure and meaningful engagement. Like how a starving person becomes intensely motivated to acquire food. From this perspective, avoiding potentially rewarding and enjoyable experiences seems to make no logical sense. As opposed to accepting a person with depression is simply illogical and self-destructive, Leahy’s Investment Model of Resistance suggests people with depression are primarily motivated to avoid losses, failures, and rejections, as opposed to being motivated by the possibility of acquiring the potential benefits of making a change. Like how a person who is intensely afraid of losing money will turn down a great investment opportunity because they cannot tolerate even a minimal amount of risk. Leahy suggests there is an underlying logic to the decision making of a depressed person, but this logic is based on distorted assumptions and beliefs.

The Cognitive Model of Depression

Aaron Beck is one of the founding fathers of Cognitive Behavioral Therapy. Beck’s Cognitive Model of Depression is an immensely valuable contribution to our understanding of depression. Beck suggests negative life experiences result in the formulation of dysfunctional assumptions about the self, the world, and the future. For example, people with abusive or neglectful parents may develop model 1the assumptions that they are truly inadequate losers, others are a source of rejection and criticism, and they will inevitably fail and end up in unsatisfying relationships or be abandoned. Our dysfunctional assumptions become triggered by critical incidents (losses, failures, criticism, rejection, etc.) and this results in negative automatic thoughts (“I’m a loser”, “why can’t I do anything right”, “I’m going to end up alone”, “I have no real friends”, etc.). These negative automatic thoughts lead to extreme emotional responses (sadness, hurt, guilt, anxiety, etc.) which then leads to exaggerated behavioral responses (withdrawing, isolating, defensiveness, people-pleasing, conserving energy, etc.). We describe this combination of unhelpful and distressing thoughts, feelings, and behaviors as depression.

Combining the Investment Model of Resistance and the Cognitive Model of Depression

I combined Leahy’s Investment Model of Resistance with Beck’s Cognitive Model of Depression in an attempt to better understand how depression can originate and be maintained. Once we formulate dysfunctional assumptions from negative life experiences we may try to avoid critical incidents which may confirm their dysfunctional assumptions. For example, if we believe that we are unattractive we avoid asking potential mates out on dates, because the rejection could trigger too much pain and hurt. Sometimes we can be moderately successful at avoiding critical incidents and we can be “fine” for a long time. Unfortunately, loss, failure, criticism, and rejection are unavoidable parts of the human experience regardless of how much we attempt to avoid or overcompensate. When we inevitably have one of these experiences, this activates our dysfunctional assumptions. We assume our skills are inadequate, we cannot cope with further losses/failures, and our resources are minimal (viewing energy and effort as finite and minimal). We fail to recall previous successes and assume/believe our lives have been an unending and unwavering pattern of misery which influences our predictions about the effectiveness of making positive changes. We also view the costs of even minor failures/losses as catastrophic and assume we will continue to fail into the future. As Leahy explains “To the depressive, losses are not simple inconveniences. Rather, they are interpreted as salient, personally relevant, morally significant, and predictive of further losses in other domains. Ironically, because losses are so overvalued, the depressive will avoid loss at all costs.”

model 2

The Investment Model of Resistance suggests when our dysfunctional assumptions are activated, we fear further failure and loss. This fear motivates us to avoid situations that could potentially give us some benefit (go for a run, call a friend, find a new job, enhance our education, prepare healthy meals, problem solve, etc.) because each of these situations also pose the possibility of failure, loss, and rejection. In some cases the costs of making a particular change are obvious (like financial costs), in other situations the costs are more discrete. An example of a discrete cost might be the loss of energy associated with making a particular change. Some ways we may avoid making changes include requiring more “motivation” prior to making a change, trying to not think about our problems (excessive distraction and sleeping for example), demanding a 100% guarantee we will succeed before trying, and insisting someone else solve our problems for us.

If we do muster the energy and motivation to try something, we often quit at the first sign of failure or loss. Many people that are depressed try problem solving, exercising, socializing, practicing gratitude, etc. Perhaps we tried once, for a week, a month, or maybe even 6 months but our depression undermines our attempts to make progress in a number of ways.

When we are depressed we have a high threshold for perceiving gains and a low threshold for perceiving costs. When we try something and don’t get a full remission of depressive symptoms, we conclude it didn’t work at all and if something even remotely undesirable happens, we believe it to be a catastrophe. Even minor losses/failures are turned into catastrophes by the person’s own excessive and unrealistic self-blame. This is sometimes “all or nothing thinking” or “catastrophizing” and is an example of cognitively distorted thinking. Take for example, the person who musters their courage to disagree with their partner for the first time in their relationship. Naturally, when we are setting boundaries we may be changing established relationship dynamics that may be working for the other people in our relationships. So when we are assertive and our partner responds with anger and frustration because we are trying to change the relationship dynamics that may be working just fine for them, we may have the negative automatic thought “I tried and it was a disaster.” In this example, we are failing to identify our gains – practicing our assertiveness skills and communicating our boundaries. It’s similar to the person who has never played basketball concluding they will never be able to play because they missed their first three point shot. Our high threshold for perceiving gains is also influenced by our causal explanations for our successes and failures. If we do something well, we blame transient and external factors like luck or the task being so easy anyone could do it. On the other hand, when we do something poorly we blame stable and internal factors like our own inadequacy. This reaffirms our distorted beliefs that we are inadequate, all we have done is fail, and all we will ever do will fail.

When we are trying to make positive changes in our lives costs often precede benefits. So if we quit after paying the cost of making a change but before attaining the benefits, we can conclude further effort would be futile. Furthermore, the benefits may be subtle and go undetected. For example, suppose you added daily exercise to your routine. Exercising costs us time, energy, and comfort before we get the eventual, but often subtle, benefits of exercise. In this situation, it may be easy to have the negative automatic thought “exercise doesn’t help at all, I exercise daily and still feel depressed.” However, our daily exercising may be providing us with the undetected benefits of protecting us from further depression, diabetes, hypertension, high cholesterol, chronic pain, etc. While it may be true that we are still depressed despite exercising, we cannot know how much worse we would be without exercising. Also, if exercising does not work (provide a complete remission of depressive symptoms) we also lose it as a possible solution to our problems. As the list of possible things we can do to get out of our depression gets shorter there is additional evidence for our dysfunctional assumptions that we are inadequate and will never get better.

Our outright avoidance of making potentially beneficial changes and our trying a solution but quitting before attaining benefits, not only undermines our problem solving but it actually creates new problems. For example, if we avoid exercising, we not only have to deal with our depression persisting but we may also develop serious health complications in the future. If we try to set boundaries with a behaviorally challenging teenaged child but we quit because it didn’t get the results we wanted quick enough, the child’s behavioral problems could continue to escalate and create new problems. Similar to the patterns above, the development of new problems then reinforces the assumptions about our inadequacy and our inevitable failure.

Sadder but Wiser

Leahy also identifies another aspect depression which may contribute to resistance of making positive changes. Leahy suggests people struggling with depression develop assumptions about being “sadder but wiser” which may reinforce their dysfunctional assumptions. From their experiences of perceiving constant failures and losses, they come to believe they have an accurate view of the world as negative, hostile, and filled with suffering. They may even derive some satisfaction and a sense of superiority from arguing with others about how their view of the world is accurate, which will reinforce these assumptions. Those struggling with depression may even use their own self-sabotaged attempts to make progress as evidence in support of their arguments. This is the “I’m going to fail, I’ll try but quit when I don’t get the results I want, oh look I failed, I was right all along” rationale. As explained by Leahy “By proving that he is correct about his negativity and that the therapist is Pollyannaish in his optimism, the depressive believes that he has achieved some “victory” – he has proven the therapist wrong. Even though this may add to his sense of hopelessness, he at least feels some momentary superiority to the ‘naïve therapist.’” Granted there is no shortage of horror, despair, and suffering in the world but to focus exclusively upon these aspects of the human experience provides a biased and cognitively distorted perspective. Although you may briefly feel satisfied and superior by arguing you are “sadder but wiser”, in my opinion the costs of remaining stuck greatly outweigh these potential benefits. I was unsure about how to add the development and maintenance of this “sadder but wiser” philosophy to my model but I thought it was an interesting idea and worth mentioning in this article.

Discussion

My combining The Cognitive Model of Depression and The Investment Model of Resistance is my attempt to explain how depression is developed and maintained. As opposed to being “afraid of change” or “irrational”, my model suggests people with depression are primarily motivated to resist making positive changes in their lives because of fears of further failure and loss associated with dysfunctional assumptions. I’ve kept Beck’s emphasis on the development of dysfunctional assumptions by negative life events and the activation of these assumptions by critical incidents. I’ve attempted to expand upon the “negative automatic thoughts” portion of Beck’s model by including cognitive processes from Leahy’s Investment Model of Resistance. In my combined model, negative automatic thoughts are expanded to include fears of further failure and loss, underestimating skills and coping abilities, viewing energy as limited and easily exhausted, distorted causal explanations for successes and failures, and all or nothing thinking about progress and failure. The model I created is cyclical, explaining why the depressed individual may become “stuck” indefinitely.

An astute critic of my model may notice I did not include a path out of this cycle. While I’ll likely expand my model in the future, my goal at this time was to better understand the resistance of someone struggling with depression. However, my research suggests there are likely benefits to helping the client identify and challenge assumptions of their own inadequacy and the cost/inevitability of failure through the use of a variety of cognitive and behavioral interventions. These interventions may include cognitive restructuring techniques, activity scheduling, behavioral experiments, exposure therapy, goal setting, and problem solving training (see previous articles for more information).

Leahy’s Investment Model of Resistance is significantly more complex than the model I have created. I should also note that Leahy does not provide a visual representation of his model in Overcoming Resistance in Cognitive Therapy and I have attempted to simplify and approximate how the various factors described by his model may interact. For more information on Leahy’s model, I recommend purchasing his book. The version of Beck’s Cognitive Model of Depression was from Cognitive Behaviour Therapy Case Studies by Thomas and Drake. While I have not conducted any studies to assess the validity of my model, it is consistent with the anecdotal accounts of many people I have met who have struggled with depression, some of which provided direct, but informal feedback, about this model.

I would also like to note that by attempting to identify how the decision making of a person struggling with depression may contribute to maintaining that depression, I am not attempting to blame anyone and make them feel worse. In fact my intentions are to help expand our understanding of depression, so we can better understand and help those struggling with depression. By focusing on what we can control, and the consequences of the decisions we make, we are empowered to make positive changes in our lives.

The Core of Therapy for Anxiety

Exposure Therapy and Behavioral Experiments

Cognitive Behavioral Therapy is the most validated form of therapy for anxiety disorders. In a huge review of studies exploring the effectiveness of CBT, the researchers found “The efficacy of CBT for anxiety disorders was consistently strong” (click here for a link to a free copy of this study). In another comprehensive review of studies exploring CBT for generalized anxiety, the authors concluded “when compared to waiting list control groups, these treatments have large effects on worrying, anxiety and depression, regardless of whether effects were measured with self-report measures or with clinician-rated instruments” (click here for a copy of this study). Many people would prefer their anxiety just went away but research suggests few people who do nothing, reduce their anxiety. As the studies above suggest, one of the things people can do to reduce their anxiety is cognitive-behavioral therapy and at the core of CBT for anxiety is exposure therapy and behavioral experiments.

Exposure therapy:

Simply put, exposure therapy involves exposing the client to their feared situations in a gradual, repeated, and prolonged manner until the client becomes desensitized. For example, if a client is terrified of public speaking they may work with their therapist to create a list of anxiety provoking situations (speaking in class, watching videos about public speaking, taking a class on public speaking, imagining speaking in public, speaking in a meeting at work, talking to a cashier at a store, doing a speech at Toastmasters, etc.). The client then ranks these situations from least anxiety provoking to most anxiety provoking, this is called an anxiety hierarchy. Then starting with a situation that does evoke some anxiety but is not overwhelming, the client would repeatedly expose themselves to these situations, over and over, until they become desensitized to this situation. A useful example of this most people can relate to is learning to swim as children. Many children are afraid or at least tentative about the water, but their parents encourage them to become more comfortable over time, often enrolling them in swim classes. As the child is gradually exposed to the water over time, they become less afraid. Alternatively, the children that are terrified of the water, and refuse to ever go in the water continue fear the water.

*For more information about exposure therapy see my article “Overcoming Anxiety and Avoidance” by clicking here, or download our free anxiety workbook by clicking here.

Behavioral experiments:

Behavioral experiments can take a number of different forms. Similar to exposure therapy, the client and therapist may work together to create a list of anxiety provoking situations. Then the client and therapist will work together to identify the client’s fears about what could go wrong in these situations. Often these fears are exaggerated and extreme but the client sees them as perfectly reasonable. So then we create a little experiment in which the client enters the feared situation and observes to see if their fears come true. Then the client runs the experiment several times in an attempt to gather more information. Once the client has run the experiment several times, they reconvene with the therapist to discuss what they have learned about their fears and their abilities to cope.

For example, perhaps one of the situations on the client’s anxiety hierarchy is saying “no” to other people. Perhaps the fear in this situation is something like “If I say no to my mother when she asks me to do something, she will call me selfish, the rest of my family will hate me, and I won’t be able to handle that.” So then the client and therapist run an experiment in which the client talks with their mother, explains they are trying to be more assertive and wants to work on saying “no” sometimes. Then the next time their mother asks them to give them a ride to the store, the client explains they cannot help that day due to other commitments, then observes what happens. In this situation, the client’s mother may very well call the client “selfish” and their family may complain, but the client also learns they can survive being called selfish and occasionally listening to complaints. Or perhaps the client’s mother understands the client has other commitments and they schedule a plan in which the client gives their mother a ride another time, or the client’s mother finds another way to the store. See the below table for an example how I would write-up a behavioral experiment assignment with a client.

BE

Another type of behavioral experiment involves the client identifying what they suspect other people believe then conducting a survey to assess the accuracy of the client’s assumptions. For example, the client may believe that people believe that women over a particular weight are “unattractive.” Clients may start by simply ask some trusted friends or family about this assumption. They may take photos of themselves or others to friends or family and ask people about their impressions about the people in the photos. In this example, the client ideally learns that attractiveness is not directly related to something as arbitrary and simplistic as weight.

How it works:

In my experience, exposure therapy and behavioral experiments have been immensely helpful for clients. Clients usually report dramatic shifts in their anxiety in only a short period of time. In CBT we assume the client becomes less anxious in situations they are exposed to because they learn that their initial assumptions about the dangerousness of the situation is exaggerated and their beliefs about their abilities to cope with the danger posed by those situations is minimized. In other words, their cognitions change. After exposing themselves to a variety of different situations, the client learns they have a habit of exaggerating danger and minimizing their abilities to cope, and so they become less anxious in other situations they have not exposed themselves too.

For example if you are anxious about travelling but you muster the courage to go to Mexico, you might learn that Mexico isn’t as dangerous as you expected. Then if you go to Germany you might learn that Mexico and Germany are safe. Then if you go to India you might learn that Mexico, Germany, and India can be travelled to safely. Then you might learn that travelling in general can be done safely, not only to those countries you have been to in the past.

Challenges:

One challenge in using exposure and behavioral experiments is explaining the importance of actually facing fears to the client. Some clients have spent decades avoiding situations that make them anxious and the thought of deliberately exposing themselves to these situations is terrifying. People tend to want to avoid situations that make them anxious. Unfortunately, it is this very avoidance which perpetuates the anxiety indefinitely.

Another barrier to effective exposure and behavioral experiments is called “safety behaviors.” Safety behaviors can sometimes resemble the compulsions of someone who struggles with OCD. Safety behaviors are unnecessary, excessive, or unhelpful activities or strategies people use in anxiety provoking situations to protect them from “something going wrong.” When the client is anxious about going to a new restaurant they may excessively research the restaurant online to create a plan to prevent something “bad” from happening. In this example the excessive research is the safety behavior the client uses to keep themselves “safe.” Then when they go to the new restaurant and nothing “bad” happens they convince themselves it is because they researched prior to going. In this situation, the client has not learned that they can safely go to a variety of different restaurants, but instead they have learned they can go to a restaurant when they excessively research it in advance. Other examples include holding glasses very tightly when you’re afraid of spilling, distracting yourself with your phone when afraid of standing in lines, and never disagreeing with people when you are afraid of conflict. Research suggests it is imperative safety behaviors are identified so the client can either avoid using them or gradually reduce the use of safety behaviors over time.

Sometimes a client’s anxiety is about situations to which they cannot be exposed. For example, the client might be terrified of earth quakes, someone dying, their son being in a car accident, getting fired, or being homeless. When the client cannot be directly exposed to their feared situations, we have got to get creative. We can watch videos of these situations, we can do research, we can read stories, we can write then recite our own stories in which the client is exposed to these situations, etc. This is based on the idea that thinking about the feared situation can actually desensitize the client. Some of these interventions are called “imaginal exposure.”

Conclusions:

Research suggests CBT is an effective treatment for anxiety disorders. Exposure therapy and behavioral experiments are core elements of CBT for anxiety. By facing fears the client learns their feared situations are not as catastrophic as originally predicted and their ability to cope is better than expected.

 

How to react when you become anxious – the AWARE strategy

The AWARE strategy can be used to reduce our distress we feel when we become anxious. The five steps of this strategy are:

 A –accept the anxiety.

Anyone that has tried to wrestle anxiety into non-existence can tell you this is not an effective long-term strategy. Fighting with anxiety is like holding a beach ball under water – the harder we push it down, the stronger it wants to pop back up. So our first step to reducing our anxiety is to first accept the anxiety, even though it is uncomfortable. Do not judge the anxiety as good or bad, instead simply acknowledge the physical sensations that you feel in your body.

W- watch your anxiety as a detached observer.

Pay attention to your thoughts and physical sensations in a non-judgemental manner. You can rate your anxiety on a scale from 0-100, then watch it ebb and flow.

A – act.

Continue to live your life despite the anxiety. Slow down if you have to, but stay in the situation and keep doing what you are doing. Continue to breath slowly. If you run from the situation your anxiety will go down, but your fear will go up. If you stay, both your anxiety and your fear will go down eventually.

R- repeat the steps.

Continue to accept, watch, and act until the anxiety dissipates. This will reduce your fear and you will learn to cope with your anxiety for future situations.

E – expect the best.

When we struggle with anxiety, we often catastrophize (predict a catastrophe will occur). We can challenge these catastrophized automatic thoughts by expecting positive outcomes. Expect some anxiety but also expect that you will be able to handle it and it will go down eventually.

 

The AWARE strategy comes from one of the most influential therapists in history Dr. Aaron Beck, one of the founding fathers of CBT. He details this strategy in greater detail in his 15th edition of “Anxiety Disorders and Phobias: A cognitive perspective.” Click here for a video of Aaron Beck and the Dalai Lama.

 Personally, I have found the AWARE model helpful in both my own life, and in the lives of my clients. It combines the non-judgemental acceptance of the present moment of mindfulness approaches with the deliberate continuing to remain in the anxiety provoking situations of exposure therapy. When I was in school I would become anxious prior to having to give class presentations. I would sweat through my shirt and my body would shake uncontrollably. By accepting my anxiety and repeatedly giving presentations, I was able to reduce my anxiety over time. Now I routinely teach classes in front of dozens of students with only minimal anxiety. When we stop fearing our anxiety and avoiding anxiety provoking situations we can learn to trust ourselves and the world a little bit more.

 

When I met fear

Admittedly, it took me a long time to learn to listen to my fear. My earliest memory is from when I was three years old. My Mother, Father, little brother and I went to play in a local river. I did not recognize the danger and I fell into the water. I remember feeling helpless and confused and then my father saved me. Although I’m sure there were previous times, this was the first time I remember meeting fear.

As a man, I met fear on the top of a mountain with the whole universe watching. He greeted me as an old friend and embraced me with genuine warmth.

“What would my life be without you?” I asked.

“Why ask me that my son? Have I not protected you and guided you through all of the horrors in the dark?” he asked.

“I’ll admit there have been times when you have saved me from suffering and almost certain death, but I’ve noticed the times I have truly lived were the times I had the courage to ignore your warnings. When I have wanted to love, you warned me about humiliation and rejection. When I aspired to more, you took the air from my lungs and warned me about losing what I’ve got. And when I prepared to rest you made me uncomfortable and gave me fantasies about failure and suffering. But when I ignored you, I loved with my whole heart, I worked with passion, and I rested enjoying the present.” I explained.

Fear smiled with knowing sadness and replied “Even I am conflicted in this messy existence. I did indeed warn you of humiliation, rejection, loss, failure, and suffering. But, in those times of action and acceptance, I also spurred you forward with an even greater fear – a fear of dying without living.”

As a child I had to learn to listen to my fear. As an adult, I suspect I must learn when it should be ignored.

The Life Philosophy of Rational Emotive Therapy

All counselling theories (narrative therapy, psychoanalysis, DBT, Albert_Ellismindfulness based theories, CBT, etc.) all have underlying philosophies about how human beings “work”, what is “healthy”, and how people can remove barriers to become more “healthy.”  People might be surprised to know there are a number of different variations of cognitive-behavioral therapy (CBT). One type of CBT is called Rational-Emotive Therapy (RET) and it was created by Albert Ellis. This article describes the underlying philosophies of RET and has been adapted from Bill Borcherdt’s book “Think Straight! Feel Great! 21 guides to Emotional Self-Control.”

RET is designed to teach people:

1. Feelings are not externally caused.

  • Our emotions and moods are caused by our thinking, not what happens to us, what others say, or our environment. We interpret the things that happen to us, and our emotions are caused by these interpretations. This is important because you can learn to control what you think and when you can do this, you can control how you feel.

2. Dissatisfaction is not the same as disturbance.

  • Things will inevitably frustrate, deprive, and inconvenience you, but you disturb yourself by insisting that dissatisfactions should not exist.

3. All rejection is self-rejection and is self-inflicted.

  • People may evaluate you and choose to not associate with you, but your feelings of embarrassment, shame, anxiety, and sadness are caused by your thoughts like “because this person does not want to associate with me, this means I’m no good!”

4. Recognize preferences are not demands.

  • While it is normal to have preferences, emotional disturbances occur when we demand to have our preferences met.

5. Nothing “has to be.”

  • You do not have to survive; you choose to survive because you want to survive. When we label “wants” as “needs” this creates desperation and a sense of urgency which can lead to distress.

6. Distinguish appropriate and inappropriate feelings.

  • Intense emotions often get in the way of working towards our goals. It is normal to get frustrated, annoyed, disappointed, apprehensive, and sad but it is often unhelpful to become enraged, devastated, panicked, ashamed, and depressed.

7. Put yourself first and others in a close second without shame or guilt.

  • This promotes happiness and joy, which can make you more fun to be around.

8. Avoid evaluating humans.

  • Humans are too complex and ever-changing to judge or score. Neither yourself nor other people are simply “good” or “bad.”

9. Do the “right thing” for the “right reason.”

  • Pursue goals and accomplishments because they provide you with happiness or some practical improvement to your life, rather than inflating your ego or providing you with approval from others.

10. Avoid overemphasizing change.

  • Learn to co-exist with your problems and imperfections, rather than putting undue pressure of yourself to overcome all problems.

11. Attempt to get better, rather than merely feeling better.

  • What feels good isn’t always good for us. For example, expressing intense unwanted emotions, like anger, might feel good at the time, but it might move us away from our life goals.

12. Abandon absolute thinking.

  • Identify, challenge, and uproot these three core irrational ideas:
    1. “I must do perfectly well or I’m completely worthless,”
    2. “You must treat me perfectly, with no lapses in kindness and consideration, or you are completely worthless.”
    3. “Life must make it easy on me to reach my goals and accomplishments.”

I suspect people will see some common themes in these recommendations. Generally, RET emphasizes personal responsibility and choice, it suggests that we are responsible for our emotional reactions and we can change our emotions, by changing what and how we think. RET also recommends we unconditionally accept our “self” while judging our emotional reactions as “appropriate” or “inappropriate”, which I think is an interesting idea. While I do not choose to use this terminology with my clients, I agree that intense emotions can interfere with our attempts to achieve our goals.

Most clients are resistant to making changes in their lives, usually for a variety of different Albert_Ellis and gloriareasons. People tend to want to minimize their choices and responsibility by suggesting they have no control over what they think or feel. There are several old videos of Albert Ellis working with clients on YouTube, and he has a very direct and almost confrontational style that I believe is reflected in the uncompromising philosophy of RET (click here for a classical example of RET at work). I’m not saying the advice listed above is bad advice, just that I suspect giving this advice in a way that clients could receive it non-defensively could take some tact.

Anxiety – Frequently asked questions

What is anxiety?

Anxiety is a normal reaction to perceiving a threat. When we believe something important to us (our lives, our jobs, our families, etc.) is threatened, our bodies prepare us to deal with this threat. Our muscles tense, our heart beats faster, our breathing may get rapid and shallow, etc. these are the physical symptoms of anxiety.

How does worrying influence anxiety?

There is a lot of research suggesting people who struggle with excessive anxiety have difficulties tolerating uncertainty. In other words they struggle with not knowing what might happen. “Worrying” is attempting to anticipate threats that may occur in the future – trying to figure out what might happen. People tend to believe that if they can just predict everything that could go wrong, they can plan and problem solve, and then they will be safe. However, our brains easily confuse real threats with imagine threats. For example, if you were extremely afraid of spiders, seeing photos of spiders, seeing videos of spiders, or just thinking about spiders might be enough to trigger anxiety – even if you know the spider in the photo is not actually inanxiety blog post the room with you. This is important because when you are worrying, you are thinking about “something bad” that could happen, and your brain gets confused and thinks the “something bad” is actually happening right now. So your brain tells your body to get ready to deal with the “something bad” right now, and as described above, we call these preparations “anxiety.” As advanced as our brains are, its responses to “something bad” happening can be overly simplistic. It doesn’t matter if the “something bad” is someone saying something mean to us or having to run away from a tiger in the bush, our brain and bodies tend to react in the same way (fight/run away/freeze). So the more we worry (think about what could go wrong/perceive a threat) the more your brain tells your body to get ready to deal with what could go wrong by becoming “anxious.”

Why do I worry so much?

Researchers Dugas and Robichaud identify five beliefs that keep people stuck in a cycle of excessive worrying. If we believe these things, we are encouraged to worry as much as possible. These beliefs are:

1)       “Worrying helps find solutions to problems.” While recognizing the problem is one part of problem solving, it is no longer helpful when we start worrying about problems with a low probability of occurring. For example, if you are going camping it makes sense to recognize that it could rain (anticipate a problem with a reasonable probability of occurring) and plan accordingly by bringing a tarp. However, it is less helpful to plan for a satellite falling from orbit and landing on your campsite. This sounds ridiculous but we often do we worry about all the things that could go wrong as opposed to what is likely to happen.

2)       “Worrying helps motivate me to get things done.” Similar to the previous rationalization for worrying, perhaps some worrying does help motivate you. It makes sense to remember you have a test coming up in a couple of weeks, so you can start studying for the test. However, when we excessively worry we can often get overwhelmed by anxiety. If we are worrying about our test in a couple of weeks, about the bus maybe being late, about our partners not actually loving us, about what we are going to get our mother for her birthday, about the assignment due next month, etc. we may experience too much anxiety and being distracting ourselves, procrastinating, using substances to calm down, or use another unhelpful coping mechanism.

3)       ‘Worrying prepares me for uncomfortable emotions.” This belief reflects the idea that if we worry about something bad happening, we will be less disappointed, sad, or guilty should that bad thing happen. Unfortunately, this belief will keep us locked in an endless pattern of worrying “just in case.”

4)       “Worrying can prevent bad things from happening.” Some people believe that if they just worry enough, “magical thinking” will prevent what we are worried about from happening. If this were true, then we would become stuck in an endless cycle of worrying about all the bad things that could happen.

5)       “Worrying is a positive part of my personality.” This is when we believe that worrying shows we are caring, loving, or conscientious. However, worrying too much can actually annoy and frustrate the people in your life, and push them away. Furthermore, there are many ways we can be caring, loving, and conscientianxiety blog post2ous without worrying.

A major theme within these beliefs is the idea that worrying will somehow prevent or reduce our pain and suffering. In other words, people think that if they can just anticipate all the problems, they can create some kind of plan, which “fixes” the “problem”, which will protect us from the pain and suffering we would experience if the problem were to occur. For example, if I worry about my kid using drugs, I can create a plan to talk to them about drug use, so I can avoid the pain and suffering I would experience if my kid were to use drugs.anxiety blog post3

However, when we anticipate problems, our mind tells our body to prepare to deal with problems, it tells our body to become anxious. Most people find anxiety painful and describe it as suffering. So ironically, by anticipating problems, to avoid pain and suffering, we are actually creating our own pain and suffering.

Many people want to spend a lot of time anticipating the bad things that could happen in their lives (worrying) but don’t want the anxiety. However, our brains are not wired for this and by choosing to worry, we are indirectly choosing to have anxiety.

When is it helpful to worry?

Worrying can be helpful in some situations but we want to limit our worrying because excessive worrying will lead to excessive anxiety. For example, it can be helpful to anticipate and prepare for:

a) Things with a reasonable probability of happening,

b) Things we can reasonably do something about now or in the immediate future,

c) Things that would pose a legitimate threat to our health, safety, or goals.

If a situation meets all three of these criteria, it might be worth your worrying. For example, people often worry about public speaking. If we know we have to give a presentation in class, there is a reasonable probability we will have to speak in public. Perhaps a large portion of your grade is dependent on how you do in your presentation, so it may be important to you to do well, in which case it would be prudent to prepare thoroughly. By anticipating this challenge, we can prepare by doing our research and practicing our presentation thoroughly. If we are thinking about the challenges we may face while giving our presentation during a study session scheduled to work on your presentation, this would be helpful. However, worrying about giving your presentation is no longer helpful when you are lying in bed at 3 am wanting to sleep, because these is nothing you could reasonably do at that time and focusing on the presentation is interfering with your other important life goals (like getting a good night’s sleep). Worrying about being laughed out of the classroom and losing all your friends because you did poorly on a presentation isn’t helpful because, in my opinion, it doesn’t have a reasonable probability of occurring. It is also important to put the consequences of giving an imperfect presentation into perspective. While you might not get the grade you want, you will likely be physically fine – no one will chop your hand off for doing poorly.

How do I experience less anxiety?

This is a very old and complicated question with several different answers. For moderate to severe levels of anxiety medication can help, but medications can have side effects. Taking medication can also be relatively easy, you simply take some pills throughout your day. Other ways to reduce anxiety typically take more work, but they also have some benefits medication does not. In therapy, I usually start by recommending daily exercise, getting 8-9 hours of sleep per night, and eating a balanced diet. While people may not see the connection between these habits and their anxiety, research strongly suggests each of these interventions. These habits also come with a wide array of other benefits as well. Healthy living habits serve as the foundation upon which we can build wellness.

Then there are a number of mental exercises people can practice to reduce worrying and anxiety. One of which is called mindfulness which can be described as practicing non-judgmental awareness and acceptance of the present moment. This is when you pay attention to what is happening right now, in the room where you are, in your body, and in your mind. Then we accept the thoughts, feelings, sensations, and images in the present moment without judgement. So maybe you check-in with your body and notice some sadness, and instead of trying to get rid of the sadness because it is “bad” you accept the sadness without judging it as either good or bad. This can help reduce anxiety because when we are paying attention to the present moment, we cannot be attempting to anticipate the “bad things” that could happen in the future. As we continue to practice directing our attention to the present, this gets easier and we actually change the way our brains work.

The cognitive-behavioral therapy (CBT) approach to reducing anxiety includes changing patterns of thinking and behaving which maintain anxiety. We question the beliefs that maintain our worrying, our unhelpful ways of dealing with problems, the beliefs about our vulnerability to “bad things happening”, and our ability to cope with challenges. We largely do this through a series of activities designed to challenge unhelpful beliefs. For example, a person anxious about being in a public place will create a series of exposure exercises in which they expose themselves to their feared situations so they learn that their fear is irrational and that they can cope with being in public places. CBT is direct, short-term, and it can take a willingness to take some “risks.” There is a lot of research supporting CBT as a front-line treatment for anxiety. In my experience, CBT is most effective when the feared situation is concrete and specific. CBT can be offered in individual therapy, group therapy, self-help books, and online.

I’ve tried everything before and it hasn’t worked, now what do I do?

This question is an overgeneralization – there is no way anyone could try “everything.” Instead, it is likely that you have tried several or many things in the past and have not gotten the desired results. However, there are many different medications, many different activities that promote wellness (yoga, joining a sports team, trying a new hobby, finding a new job, journaling, etc.), and many different kinds of therapy. Even among cognitive-behavioral therapists there is a lot of variation in how therapists actually practice. If we are trying to find a reason to give up (“I’ve tried everything”), this might mean we don’t actually want to put the work in to make changes, and that is okay. There may be a time in your life when you are more ready, willing, and able to try something new. If that time comes, hopefully this article has given you some ideas you could try.

Group Therapy – The Great and the Powerful

When I think about group therapy, I cannot help but think of the 1975 movie “One Flew over the Cuckoo’s Nest.” For those who haven’t seen the movie, there are multiple scenes of sedated and unruly asylum patients sitting in a circle, answering questions posed by an authoritarian, cold, and distant nurse. The group therapy seems less about helping people and more about establishing a hierarchy between patients and staff. In the 1999 movie Fight Club, the protagonist frequents several support groups in which people share their struggles with testicular cancer and other challenges. Several poorly lit and despair filled AA groups have been featured in countless TV shows and movies. My point is that, in my opinion, group therapy is generally portrayed as boring, depressing, and hopeless. However, group therapy can be an incredibly genuine, powerful, and fascinating experience.

People might not know there are many different types of group therapy. A cognitive-behavioral therapy group is radically different from a support group or a communication skills training group. One type of therapy groups are called interpersonal process groups (these are the type of group discussed in this article). These groups teach people how to establish and create close and gratifying relationships and are based on the recommendations outlined by Irvin D. Yalom, a professor of psychiatry at the Standford University School of Medicine, in The Theory and Practice of Group Psychotherapy (5th ed.). While interpersonal process groups are largely focused on relationships, Harry Stack Sullivan’s interpersonal theory of psychiatry suggests symptoms of mental disorder are directly related to a person’s experiences in their relationships (as cited by Yalom, 2005, pp. 20-23). Therefore, by focusing on improving a person’s interpersonal functioning we can simultaneously improve mental health.

Research suggests that positive relationships are strongly linked to happiness (Reis & Gable, 2003; Adler et al., 2012) and can reduce trauma symptoms and promote recovery (Briere & Scott, 2013, p. 24). Irving Yalom (2005, p. 24) summarizes significant literature exploring the importance of positive relationships by explaining “People need people – for initial and continued survival, for socialization, for the pursuit of satisfaction.”

Some people may have the misperception that group therapy is only conducted because it is “cheaper” than individual therapy. While there is some truth to the idea that group therapy originates for a post-world war 2 era, where it was valued for economic reasons, since that time we have discovered that it has some real advantages to individual therapy.

Unlike individual therapy or psychoeducational courses, interpersonal process groups possess a number of unique characteristics that make them an exceptional opportunity to improve an individual’s interpersonal functioning. Dr. Yalom explains:

There is evidence that certain clients may obtain greater benefit from group therapy than from other approaches, particularly clients dealing with stigma or social isolation and those seeking new coping skills (p. 53).

Carl Rogers believed three core conditions were most important in therapy – congruence, empathy, and unconditional positive regard. While a full description of the core conditions is beyond the scope of this article, I want to point out the vast majority of modern therapists are thoroughly taught to communicate empathy, to be congruent and authentic, and to demonstrate unconditional positive regard. This facilitates successful outcomes in therapy, but it can also lead clients to wonder if their therapist only likes them because they are their therapist. In other words, when a client tells their therapist “nobody likes me” and the therapist challenges this with “how do you explain me liking you?” The client usually responds with “you’re my therapist, you have to like me.” Many clients will question the relationship that forms between the therapist and client; rationalizing they are only able to form a relationship with a therapist who is extensively trained in forming good relationships with people.

One of the many advantages of group therapy is when you form close and gratifying relationships with the other group members it can be more meaningful, because they do not have to like you at all. When you behave in a genuine and authentic way in the group, the relationships you form in the group, reflect the types of relationships you make outside of the group. This way the group can understand how you might act when you are at home, with friends, or spending time with family. We all have blind spots – things we don’t know about ourselves and what others think about us. In group therapy, the other group members can use their own experiences with you, to help you understand how others might perceive your behavior. You can reflect on the degree to which you behavior in relationships is getting you what you want, which is usually close and gratifying relationships with others. Finally, if you decide your behavior is not helping you form satisfying relationships, with an open mind you can choose to experiment with behaving differently in the safe and supportive environment of the group.

So when someone suggests that your behavior could be perceived as “defensive” and this is echoed by several of the other group members, we can work to uncover what you specifically did that was “defensive.” The other group members can provide you with feedback about how they feel and what they think when you act “defensively.” Then you can consider if this behavior may actually harm your relationships, and if so you can begin experimenting with not being as defensive within the group.

Here is a model I created to explain the overall process of Interpersonal Group Therapy:

Group therapyThis type of group takes a lot of honesty, support, and encouragement. The first few sessions typically involve building trust within the group so participants can get to know one another, and feel more comfortable both giving and receiving feedback. As the group bonds, we learn about how people may typically act in relationships and how this behavior may be interpreted by others. To make the most of this experience, participants must have an open mind and a willingness to try new ways of relating to others.

Unfortunately, group therapy is not for everyone. Some clients are not ready, willing, or able to make changes. Other clients may disrupt the group from achieving their goals. Other clients might be in the middle of an interpersonal crisis and may be too distressed to function within the group.

To summarize, people’s beliefs about group therapy, are generally inaccurate and there are many different types of group therapy. Interpersonal process groups can help people learn how to establish and maintain close and gratifying relationships by increasing awareness about how we function in groups, and providing opportunities to experiment with new ways of relating to others. Group therapy can motivate great change and personal growth but it also requires honesty, a willingness to keep an open mind, and an interest in making changes to how we behave in relationships. Lastly, group therapy is not for everyone, but for those who are ready, willing, and able it can be an amazing opportunity.

Perfectionism: Life-satisfaction and coping with challenges

People with anxiety and panic frequently tell themselves “I must do perfectly well” then ask themselves some version of “will I do perfectly well” and the answer is always “no.” After they have avoided the task, or tried and failed to meet their hopes, they then become depressed because they tell themselves they did not do as well as they “should” have done. These are some of the claims made by one of the most influential contributors to counselling psychology in history, Albert Ellis. (See here)

While, I’m not bold enough to claim that perfectionism is the core of mental illness, the majority of my clients report high levels of perfectionism. There does seem to be a real connection between anxiety, depression, and perfectionism. Therefore, this article delves into some modern research on perfectionism, how to know if you might practice unhelpful perfectionism, and what you can do if you are a perfectionist, to live a more satisfied life.

Perfectionism

According to research, there are two dimensions to perfectionism: perfectionistic concerns and perfectionistic strivings.

concerns-vs-striving

While these two dimensions are related, they are not the same thing and you can have one without high levels of the other. In other words, you can have high personal standards and work to meet those standards, without over-focusing on mistakes, excessively doubting your performance, or being very concerned about what other people may think. Research shows people who report high levels of perfectionistic concerns also typically report lower life satisfaction, neuroticism, low self-esteem, negative affect, anxiety, depression, and suicidal ideation. While people who report high levels of perfectionistic strivings, without high levels of perfectionistic concerns, report higher levels of conscientiousness, positive affect (they are generally happier), endurance, and academic performance (Stoeber & Otto, 2006).

1

When working with clients, I often hear rationalizations like “my perfectionism motivates me to work harder” or “I have to be a perfectionist or something really bad might happen.” The research described above does suggest that there are a number of benefits to having high personal standards and working hard to achieve those standards. However, when we are overly focused on making mistakes, doubting our actions, and focusing on what others think, we lose the positive benefits of our perfectionism. For the remainder of this article, I’ll refer to being overly concerned about mistakes, doubting ourselves, and being focused on how others might evaluate our performance (perfectionistic concerns) as “unhelpful perfectionism.”

Interestingly, unhelpful perfectionism is a recipe for low life satisfaction regardless of how well we actually do. In a study from Pennsylvania State University, 273 students reported engaging in unhelpful perfectionism led to less satisfaction with grades, regardless of how well they did (Grzegorek, Slaney, Franze, & Rice, 2004). In other words, even if they met their high personal standards, they were still unsatisfied if they were overly focused on making concerns, doubting their actions, and focusing on what others think.

How to know if you might practice unhelpful perfectionism

People that practice unhelpful perfectionism might claim:

  • If I fail at work/school, I am a failure as a person
  • I should be upset if I make a mistake
  • I hate being less than the best at things
  • If I do not do as well as other people, it means I am an inferior human being
  • Even when I do something very carefully, I often feel that it is not quite right
  • I usually have doubts about the simple everyday things I do
  • I tend to get behind in my work because I repeat things over and over
  • I find it difficult to meet others’ expectations of me
  • The better I do, the better I’m expected to do
  • Anything I do that is less than excellent will be seen as poor work by those around me
  • My family expects me to be perfect

These are items from two measures of perfectionism, the Frost Multidimensional Perfectionism Scale (Frost et al., 1990) and the Multidimensional Perfectionism Scale (Hewitt & Flett, 2004) and they reflect concern about mistakes, doubts about actions, and concern about other people’s evaluations. Beliefs and behaviors like these tend to interfere with a person being satisfied in life.

 Increasing satisfaction as a perfectionist

In 2011, two researchers from the University of Kent, Joachim Stober and Dirk P. Janssen, wanted to better understand the relationship between perfectionism, how people typically coped with stresses in their lives, and the amount of satisfaction they generally felt at the end of the day. They found people reporting high levels of unhelpful perfectionism seemed to cope with stressors in their lives in similar ways, and these coping mechanisms were contributing to lower satisfaction. People who reported a lot of unhelpful perfectionism reported typically trying to cope with stresses by criticizing themselves or blaming themselves for the “bad things” that happen to them. Unsurprisingly, self-criticism was associated with diminished satisfaction.

Alternatively, people who reported high levels of unhelpful perfectionism reported more satisfaction when they used a coping mechanism “positive reframing” (aka “positive reinterpretation”). These people attempted to cope with challenges by “trying to see it in a different light, to make it seem more positive” or “looking for something good in what is happening” (Carver, 1997).

positive-reframing

Two other ways of trying to cope with perceived failures were related to high levels of satisfaction, acceptance (“accepting the reality of the fact that it has happened”) and humor (“making fun of the situation”). Although, these coping mechanisms seemed to be less effective for people reporting high levels of unhelpful perfectionism.

Positive reframing has been explored in great detail in a multitude of studies over the last 30 years. Back in 1984 Lazarus and Folkam explained that positive reframing allowed people to manage their distress when challenged so they could continue with effective problem solving. This combination of positive reframing and actively trying to deal with stressors in an effective way can be an incredibly useful way to handle challenging situations in life.

Summary

We can have high personal standards and work hard to achieve these standards without over-focusing on our mistakes, excessively doubting your performance, or being very concerned about what other people may think. Indeed having high personal standards is associated with better life satisfaction. However, when we engage in unhelpful perfectionism it leads to reduced life satisfaction, neuroticism, low self-esteem, negative affect, anxiety, depression, and suicidal ideation.

Examples of unhelpful perfectionism include claiming things like:

  • If I fail at work/school, I am a failure as a person
  • Even when I do something very carefully, I often feel that it is not quite right
  • Anything I do that is less than excellent will be seen as poor work by those around me

However, even if we engage in unhelpful perfectionism we can experience greater satisfaction in life, by attempting to cope with challenges by seeing challenges as opportunities, focusing on what we learned from challenging experiences, and looking for something good in what has happened. By thinking about problems in this proactive way, we are better able to engage in effective problem solving.

Overcoming Anxiety and Avoidance

Although this will likely reduce the number of “likes” I get for this post, I believe it is important to begin with some honesty. Overcoming anxiety is hard work. Most people want a simple and easy answer that can make all of their suffering go away. However, for every complicated and messy problem there are many simple and easy answers that are ineffective. For example, in Canada the use of antidepressants increased over 450% between 1981 and 2000, but the demand for mental health services has never been higher. This post is not an “8 easy steps to being less anxious” kind of post, it is more of a “if you work really hard, stay determined despite set-backs, and keep an open-mind about trying new things you may be able to make some real improvements to your life” kind of post.

Anxiety and Avoidance

Anxiety is a normal reaction to perceived threats. However, when we have a tendency to focus on threatening situations, the problems in our lives, we are fueling excessive amount of anxiety. One way we attempt to reduce the amount of anxiety we experience is by avoiding challenging situations. However, avoidance prevents us from overcoming our fears. Furthermore, as we avoid more and more things, our lives become more and more restricted.

For example, if you had social anxiety and were terrified of 1talking to authority figures, you would likely experience anticipatory anxiety before you spoke to people of authority, then when you did have to talk to someone of authority (exposing yourself to the feared situation) your anxiety would likely spike. Then when you avoid the situation by promptly leaving, your anxiety will naturally go down. Unfortunately, when we cope with anxiety by avoiding challenging situations we cannot challenge our assumptions that the situation is dangerous, we cannot challenge our assumptions that we cannot handle the stressful situation, nor can we learn how to handle the situation more effectively. So then the next time we exposure ourselves to the stressful situation we experience a similar amount of anxiety.

2

Overcoming anxiety can be accomplished a number of ways. However, research strongly suggests that one of the most effective strategies for overcoming anxiety is something called “exposure therapy.” Exposure therapy rests on the premise that if we can expose ourselves to our anxiety provoking situations in a certain way, we can learn: the situation isn’t as dangerous as we assume, we can handle the challenging situation, and we can practice skills to better handle similar situations in the future.

3

Exposure therapy

  • Begin by creating a list of situations you avoid
  • Rate how much anxiety you suspect you will experience in each of these situations on a scale from 0-100
  • Select a situation that will provoke a small amount of anxiety – set yourself up for success
  • Create a plan to expose yourself to this situation –when? Where?
  • Expose yourself to the situation
  • When you are in the situation try and pay attention to what is going on around you as opposed to what is happening in your body or distracting yourself (looking at your phone, talking to a friend, reading a book, etc.)
  • Stay in the situation until your anxiety has diminished, do not just leave when you feel some anxiety
  • After your anxiety has gone down, ask yourself what you have learned about how dangerous the situation was, what you have learned about your ability to cope (did you survive?), and some skills you could practice to handle the situation more competently in the future
  • If you notice yourself going over and over the situation in your mind, distract yourself by doing something engaging
  • When you are able, expose yourself to the same situation again and again until you do not feel very much anxiety at all in that situation
  • Once you have completed the first anxiety provoking situation, move on to another situation on your list of anxiety provoking situations and repeat this process

By exposing ourselves to anxiety provoking situations appropriately, we are able to reduce the amount of anxiety experienced when we face similar situations in the future.

4

Some notes about exposure therapy:

Exposure therapy can be immensely effective for anxiety created by many different situations. Personally, I have seen clients make radical changes in only a small number of sessions when they are committed to their exposure plan. However, it is important to remember than some situations are actually dangerous and we are not always exaggerating the danger in our minds. Therefore, I do not encourage people to behave recklessly, for example standing in a busy highway, going down dark alleys at night, or committing any crimes. Also, this article only describes one type of exposure therapy, something called “in vivo” exposure therapy and this type of exposure therapy cannot be used to overcome some anxiety provoking situations. Obviously, we cannot expose ourselves to our fear of our own death (at least not more than once), to fears of loved ones dying, or to fears of natural disasters. For these types of hypothetical fears, we may need to practice something called “imaginal exposure” which is not described in this article.

Some notes for therapists:

Many clients struggle with creating the motivation to engage with exposure therapy. When we are distressed we often resort to coping mechanisms that are familiar to us, even if they are not helpful. It can be useful to go slow with clients and discuss the costs and benefits of avoidance. Encourage the client to consider what their life may be like if they continue to avoid anxiety provoking situations indefinitely and/or consider the opportunities their avoidance may have already cost them. Remember, it is not our job to convince the client to do anything. Instead we are there to help them make informed decisions. If the client chooses to continue to avoid, while knowing the consequences of this decision, that is their choice and that should be respected.

Processing what the client has learned from exposing themselves is just as important as collaborating with the client to design the exposure activity. “what did you learn from exposing yourself to this situation?”, “what did you learn about your ability to cope with the situation?”, “what did you learn about your anxiety in general?” “what did you learn about your fears?” – Questions like these can be very helpful.

Reduce anxiety and improve your mood: Free workbooks

There are two workbooks you can now access in our “self-help” section for free.
The Making Changes workbook can help you learn about Cognitive Behavioral Therapy principles and how to apply them to your life. It can help you improve your living habits, set goals, and change your thinking.
The new Anxiety workbook can teach you about anxiety, skills to manage anxiety, and steps you can take to reduce your anxiety over time. Here is an portion from that workbook:
SUMMARY

· Anxiety is a normal human response to perceived danger.

· The more we worry, the more we are thinking about potential dangers, this then triggers the anxiety response.

· We can practice skills like box breathing, 5-4-3-2-1 sensory grounding, and progress muscle relaxation to cope with extreme anxiety.

· Cognitive behavioral therapy can help use reduce our anxiety.

· Our thoughts cause our emotions and behaviors, not situations. Therefore, our anxiety is being created by the story in our head, not the situation we are in.

· When we experience excessive anxiety we are usually engaging in unhelpful thinking styles.

· CBT teaches us to recognize our unhelpful thinking and then dispute irrational thoughts, replacing them with more helpful thoughts.

· Excessive worry fuels excessive anxiety. Sometimes we believe excessive worry can be a good thing, but these beliefs maintain worry.

· When we believe (1) “problems are threatening”, (2) “I can’t handle problems effectively”, and (3) “problems will turn out badly regardless of what I do” we are preventing effective problem solving. We can solve this by recognizing problems as a normal part of life and seeing the opportunities presented by our problems.

· A problem solving model can be used to help us effectively cope with challenges we can reasonably do something about.

· Graded exposure can be used to decrease the amount of anxiety we experience in situations. Graded exposure is a process by which we practice exposing ourselves to anxiety provoking situations, practicing and developing our skills, and gradually learning situations are not as threatening as our minds make them.

· We can improve our abilities to cope with stressors by maintaining a healthy self-care plan which includes diet, exercise, sleep, relaxation, work , socializing, thinking helpful thoughts, and goal setting.