Author: southislandwellness

Anxiety – Frequently asked questions

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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

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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

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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.

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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).

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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

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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.

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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.

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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.

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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

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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.
 
 

Welcome to mindfulness

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You should do breathing exercises. Maybe do yoga a few times a week and you’ll feel better. Go for a walk daily. Start your day off with a 10 minute meditation.

I cannot count the number of times people have given me advice like this to me. These are probably good suggestions and they do indeed have a reasonable amount of research supporting them, but I believe they are insufficient for promoting lasting composure. I do see a lot of value in maintaining a relaxed, composed state of mind while going through my day. When we are calm our brains function differently, we have superior reasoning and problem solving abilities. I think many people can relate to the experience of reacting inappropriately when distressed. How can 10 minutes of meditation in the morning, a walk, or yoga a couple of times a week maintain my composure throughout the day? I do not believe it can. Instead, perhaps I need a tool I can easily use throughout the day to maintain my composure. For me, this tool is practicing mindfulness.

Mindfulness refers to paying attention to the present moment, without judgement. Practicing mindfulness is simple and incredibly effective for regulating my emotimg_3307ions throughout my day. What does practicing mindfulness look like? Take a breath, notice the air filling your lungs, notice your rib cage expanding, notice your heart beat, just notice how it feels. Focus on those things, and without judgment (“It should be deeper”, “it should be slower”, “it should be…”), just notice the way it is. Congratulations, you have just practiced mindfulness. It’s that simple.

Paying attention to your breath can be convenient because we always have our breath, even in a completely dark room, late at night but we do not have to pay attention to our breathing to practice mindfulness. We can be focused on anything in the present moment without judgement to practice mindfulness. By “judgment” I mean assigning interpretations like “good”, “bad”, “better”, “worse”, etc. For instance I often look at a tree outside my office window. I watch how the sun hits each leaf, I look at the shades of green and grey, I watch it move in the wind. Instead of thinking “that is a beautiful tree” or “that tree should be bigger” I just notice and accept how it is in the present moment.

I direct my attention to the present moment hundreds of times a day. As the people in my life can attest (with some frustration occasionally) I do very little worrying about the future. I also try and rarely think about the past, besides considering what I can learn from it and moving on. My paying attention to the present allows me to avoid much of the anxiety and depression that is associated with worrying about the future and regretting the past.

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But I need to problem-solve and plan! I can’t just be sitting around looking at trees all day! I agree, that is impractical. However, I would argue that many people do far more worrying and regretting than are truly necessary. How many times have you lay in bed and lost sleep because you were trying to worry your way out of a problem? So we problem solve and plan when we must, and we stay in the present as often as we can. This way when we do have to problem we are composed, and our thinking is productive.

Okay, so what happens when I’m paying attention to the present moment and my mind just naturally thinks about the future or the past? It takes practice to stay in the present moment for any extended amount of time but while we are training our minds we want to be compassionate with ourselves. Like training a puppy, we want to be consistent, reliable, and gentle. So when our minds wander to a place they don’t need to be, we gently guide it back to the present.

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I find practicing mindfulness to be most helpful in distressing situations. For example, when talking in-front of people I find it very helpful to just take a deep breath and just for a moment notice the air filling my lungs and my ribs expanding. This relaxes me immediately. Or after a stressful experience I will take a breath and just ask myself “what is going on in my mind right now?”, “what am I feeling?”, and “where are these emotions coming from?” I find this to be much more helpful for regulating my emotions than thinking “stop getting angry”, “I shouldn’t (judgement) worry about this”, or “I’m being too dramatic (judgment).”

Improve your Relationships by Understanding and Managing Anger

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You never listen to me. I fell like you are overreacting. I can’t do anything right, I’m always the bad guy. Don’t get upset. You always do this. You’re an asshole. Why do you have to be such a bitch? This is why this shit always happens to you.

Have you ever been hanging out with friends and have the displeasure of watching another couple’s argument turn into a full-blown fight? Have you ever been shocked by the devastatingly hurtful things family members say to each other? I’ve both been the shocked observer and I reluctantly admit to having been one of the people saying the hurtful things. On the surface, these statements appear to be motivated by anger. However, anger is described as a “surface emotion” and underneath anger there is usually a more vulnerable emotion like hurt, sadness, embarrassment, grief, etc.

anger

Our angry behavior (yelling, intimidating, saying hurtful things) can be a way of communicating more vulnerable emotions. Unfortunately, communicating in this way is inherently manipulative because we are not communicating directly about what is going on for us. Instead of using the words “when you said I was lazy, I felt hurt because I really value your opinion. I also felt afraid because I was concerned you might not want to be in a relationship with someone you think is lazy”, we hope they get some form of this message through our angry behavior.

Our anger can also serve as a tool to teach another person about what we want. People learn through processes like reinforcement, punishment, and extinction. When another person does something we don’t like, we can use anger to punish them, in hopes they will not replicate this behavior in the future. For example, when Person A says something hurtful (you’re lazy), Person B may retaliate to punish the other person to reduce the probability of future hurtful comments. However, when we are in a relationship with a person and they are continuously punishing us we are likely going to develop resentment because, by definition, people don’t like being punished. So while anger can be a powerful form of punishment, it can seriously poison a relationship.

Holding on to anger is like grasping a hot coal with the intent of throwing it at someone else; you are the one who gets burned. – Buddha

One of the best examples of these two concepts is when we get angry about another person getting angry. Getting angry at another person for getting angry at you is like trying to put out a camp fire with gasoline. Person A gets mad, then Person B thinks something like “I don’t deserve to be treated like this!” and gets angry to punish Person A. In addition to feeling anger, Person B is also probably feeling fear, hurt, and maybe even embarrassment.

If you have the goal of intimidating someone, expressing anger in an aggressive way may move you closer to achieving your goal. However, if you have the goal of having a good relationship with the other person, expressing anger in an aggressive way will be less helpful.

So how do we reduce the likelihood we will get extremely angry and how do we communicate better when we are angry?

Reducing the likelihood of getting extremely angry. CBT recommends we begin by identifying our “triggers” and times when we are more likely to become triggered. “Triggers” are things (people, comments, situations, etc.) that rapidly increase our emotional responses. For example, if you are triggered by criticism, you are likely to have an extreme emotional response to being criticized. Common triggers include perceived rejection, failure, abandonment, and loss. Identifying your triggers in advance is a form of exposing yourself to your triggers through the use of your imagination. This “imaginal exposure” actually can reduce how distressing these triggers will be when you are exposed to them in real life. Furthermore, identifying your triggers in advance allows you to plan how you want to respond when faced with this trigger.

We are more likely to be triggered in certain circumstances. For example, I am more likely to be triggered when I am tired, hungry, or while drinking alcohol. So I make reasonable attempts to avoid situations that may trigger me during times when I’m more likely to become triggered. For example, if I have to talk to a friend about a sensitive topic, I do so when I’m rested, fed, and sober.

These two principles of identifying triggers in advance and considering times when we are more likely to become triggered can be useful for managing all extreme emotions, not simply anger.

Regardless of whether or not we identify triggers and times we are more likely to be triggered, we may still get triggered unexpectantly. While there are a ton of relaxation skills out there, some are more effective than others. These are the ones I recommend to people managing intense anger.

Minimize risk. Stop yourself from the “knee-jerk” reaction that often accompanies anger. Then I recommend you remove yourself from the situation if it is reasonably possible, it may also be useful to say something like “I don’t mean to be rude but I have to go calm down for a moment” and go for a walk.

Relax the body. Then cool off by splashing cold water on your face, taking a cold cloth and putting it on your face or the back of your neck, or taking a cold shower. You’ll learn that it is really difficult to stay mad when your face is frozen. Take some breaths, one useful breathing exercise is the 4-7-8 breath where you breath in for 4 seconds, hold your breath for 7 seconds, and breath out slowly for 8 seconds.  Intense exercise and something called “progressive muscle relaxation” also can be very effective for calming our bodies.

According to Baranowsky, Gentry, and Schultz (2011, p. 127), when our fight/flight/freeze response is activated we are using our “sympathetic nervous system” and when we are calm we are using our “parasympathetic nervous system.” When the sympathetic nervous system parts of our brain are dominant our thinking is reactive, we have an increased threat perception, and we have diminished brain functioning. By contrast when the parasympathetic nervous system parts of our brain are dominant, we are more capable of creative problem solving, we have better decision making, and we are better at regulating our emotions. By relaxing our bodies we can shift from sympathetic nervous system dominance to parasympathetic dominance.

Calm down the mind. Once our bodies are calm, we are more capable of communicating and problem-solving. We can use cognitive-restructuring strategies to identify the thoughts causing our intense emotional reactions, challenge the validity of these thoughts, and replace them with more realistic thoughts. The automatic thoughts commonly associated with intense anger include thoughts about fairness (How dare you call me a jerk after all I do for you! I don’t deserve this!) and about how we want people to behave (You shouldn’t be acting like this! I should better at this! You should take out the trash!).

We can also use mindfulness skills to calm our mind. Put simply, when using mindfulness we are paying attention to what is going on in our mind, without judgement. We notice, accept, and let go of our anger inducing thoughts. It sounds simple but it takes practice.

Communicate. Once our bodies and our minds are calmer we may choose to communicate. Some good skills for communicating assertively include “I-messages” and the “assertive message format.”

I-messages typically include a description of how we feel, explaining the reasons for this emotional response, and clearly describing what you want. Some examples:

I felt angry when you said that I never listen to you, I’d like to talk about this.

I felt concerned when you raised your voice earlier, I’d appreciate if you could avoid doing that in the future.

I felt sad and surprised when you said my family is crazy, I’d like to understand where that comment came from.

 The assertive message format includes: a description of behavior, an interpretation, describing your emotions, consequences, and your intention/position. These components can be combined in any order.

You were running behind yesterday and (behavioral description), as a result we were late to meet up with everyone (Consequence), I’m sure you didn’t mean to be late but (interpretation), and honestly, I was feeling a little annoyed and frustrated (feelings), next time, I would appreciate it if you could toss me a text if you’re running behind (intention/position).

“We can say what we need to say. We can gently, but assertively, speak our mind. We do not need to be judgmental, tactless, blaming or cruel when we speak our truths”

― Melody Beattie

Both I-messages and the assertive message format are designed to open a dialogue with the other person, while reducing the probability they will respond defensively. When using these skills it is important to avoid blaming (you are responsible for your own emotional reactions), generalizing (“You’re always late”), or name calling. I’ll revisit more communication skills in future posts.

To summarize, anger is a surface emotion, usually with more vulnerable emotions underneath. Anger can be used to communicate more vulnerable emotions as well as punish other people to behave in ways that we want. We can reduce the likelihood of becoming extremely angry by identifying our triggers and times when we are more likely to become triggered. When we do become angry, we can manage our anger by reducing the risk, calming our bodies, calming our minds, and communicating effectively in a respectful and compassionate way.

Improve your approach to dealing with problems in life (Part 1)

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The Jewish psychiatrist Viktor Frankl remembers the day he entered the camps:

Then the train shunted, obviously nearing a main station. Suddenly a cry broke from the ranks of anxious passengers, “there is a sign, Auschwitz!” Everyone’s heart missed a beat at that moment. Auschwitz – the very name stood for all that was horrible: gas chambers, crematoriums, massacres. Slowly, almost hesitatingly, the train moved on as if it wanted to spare its passengers the dreadful realization as long as possible: Aushwitz!

His book Man’s Search for Meaning tells a harrowing tale of some of the worst conditions humans have been exposed to in modern history. As I read this book for the first time, several years ago, I was mesmerized by Dr. Frankl’s seemingly endless ability to recognize the opportunities within his experiences. His beliefs about problems and suffering were infectious.

Negative Problem Orientation

Put simply, a person’s problem orientation refers to their beliefs about problems and their ability to solve problems. People with a negative problem orientation are more likely to view problems as excessively threatening, they typically doubt their ability to solve problems, and they believe negative outcomes will occur regardless of how much effort they put in to solve them. As a result of these beliefs, researchers Dugas and Robichaud suggest people with a particularly negative problem orientation are more likely to be frustrated, irritated, anxious, or depressed when they face a problem. Behaviorally, people with a negative problem orientation are more likely to procrastinate and/or avoid problem solving. As a result, they can make new problems for themselves and increase worries.

Perhaps unsurprisingly, negative problem orientation has been connected with a wide variety of mental health difficulties including generalized anxiety disorder, depression, pathological gambling, and post-traumatic stress disorder (Robichaud & Dugas, 2005).

Locus of Control

In my opinion, a person’s problem orientation plays a massive role in how they approach the world. There seems to be a large overlap between problem orientation and something, in psychology, we call “locus of control.”  Our locus of control can be described as our beliefs about how much we influence what happens in our lives. People with an “internal locus of control” typically believe they greatly influence their destiny. While people with an “external locus of control” typically believe that what happens in their lives is largely controlled by forces outside of them. Research over the last 65 years has suggested that people with an internal locus of control have greater academic success, are more motivated, are more socially mature, have less stress and depression, and live longer. They “earn more money, have more friends, stay married longer, and report greater professional success and satisfaction” (Duhigg, 2016, p. 24). So to summarize, people with an internal locus of control will usually be less threatened by problems, work harder to solve problems, and believe they can mitigate negative outcomes through effective problem solving. In other words, they have a more positive problem orientation.

locus of control

So if a negative problem orientation and an external locus of control are typically unhelpful for promoting health and wellbeing, what can we do to change?

Luckily, research suggests there are a few things we can do to improve our problem orientation and our beliefs about locus of control. Dugas and Robichaud suggest we first have to learn how to identify problems. Many clients enter therapy and believe that their emotions are the problem, they just want to be happy. However, emotions are not the problem. Emotions are data, they are just information giving you clues something is or is not working for you in life. The problem is not that you are depressed, the problem may be you are stuck in a relationship that is not good for you, it could be that your habits are not particularly healthy, it might be that you are stuck in depressive thinking habits, perhaps the problem is that you are in a concentration camp, etc. Once we can see our emotions as information, this can help you identify appropriate solutions to the real problems.

The belief that we are exceptional because we experience problems can keep us stuck. Why does this keep happening to me? Why was I the one who was dealt a bad hand in life? We can improve our problem orientations by challenging these kinds of beliefs and recognizing that experiencing problems in life is normal. Suffering is an important part of life, it is times when we suffer the most that we are motivated to adapt and grow the most.

Challenge filtering and overgeneralizing (see our cognitive distortions list). An internal locus of control and/or a negative problem orientation occurs because we are not paying enough attention to all the times your effort and practice have influenced outcomes. We conclude because we could not have possibly prevented ____________ from happening in the past, why bother trying in the future? While there is a lot in life that you cannot control, there is a massive amount that you can. By just focusing on the things we cannot control, we are underestimating the number of choices we have. When we underestimate the choices we have, we are reinforcing the belief that we are not responsible for what happens to us and this can be a very comfortable delusion to live in. However, this short term comfort comes with a price, it disempowers us and maintains a victim mentality.

Lastly, and perhaps most importantly, we can improve our problem orientation by recognizing the opportunities that are within all of the problems we experience. Every problem has opportunities associated with it. Few people illustrate this better than Viktor Frankl. While in the camps, he became very sick, and with the sickness came a far greater likelihood of being “selected” to go to the gas chambers. Despite his sickness he remembers:

We were sick and I did not have to go on parade. We could lie all day in our little corner in the hut and doze and wait for the daily distribution of bread (which, of course was reduced for the sick) and for a daily helping of soup (watered down and also decreased in quantity). But how content we were; happy in spite of everything.”

This sickness gave him the opportunity to rest. More generally, by being a prisoner within the camp, Frankl recognized he was given the opportunity to study what happens to a human under such circumstances. He was given the opportunity to understand how people find meaning and purpose even in the worst of conditions. Gordon Allport describes Frankl’s conclusions beautifully in his preface:

In the concentration camp every circumstance conspires to make the prisoner lose his hold. All the familiar goals in life are snatched away. What alone remains is “the last of human freedoms” – the ability to “choose one’s attitude in a given set of circumstances.”

Being in the camp presented many, very real and horrifying, problems. However, Frankl was also given the opportunity to choose how he was going to cope with these problems. He was given the opportunity to search for answers to some very fundamental human questions – what prevents some men from committing suicide in such horrible conditions? Why choose to live when one can simple run to the electric fences at any time? What motivates a man to treat prisoners a particular way? Etc.

When your partner says something you don’t agree with, you are being given the opportunity to practice your non-defensive communication skills. When you lose a relationship you have the opportunity to be a kind, loving, and respectful person even when things do not go your way. When you get lost, you have the opportunity to become familiar with somewhere new. When you are in a concentration camp, you have the opportunity to study how humans adapt to such horrible conditions and find meaning and purpose despite great suffering.

If you have children, it is likely they will experience their own challenges in life (divorce, trauma, accidents, health problems, etc.) and every time you experience these things, you are being given the opportunity to teach your kids how to effectively face these problems in their own lives. By recognizing the opportunities within the problems we face, we are going to be more likely to accept when problems occur and we will be more motivated to engage with our problems in a helpful way.

Duhigg, C. (2016). Smarter, faster, better: The secrets of being productive in life and business. Doubleday Canada.

Frankl, V. E. (1959). Man’s search for meaning: An introduction to logotherapy. Washington Square Press, New York.

Robichaud, M., Dugas, M. (2005). Negative problem orientation (part I): Psychometric properties of a new measure. Behavior Research and Therapy (43)3, 391-401.

Worry – The illusion of action

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What if I lose my job? If I lose my job then, I won’t be able to pay rent or afford food. Then I’ll have to move back in with my parents, or worse!- I’ll be homeless. I can’t get fired, oh please god, I need this job or I’m in real trouble. What if I do lose it though? I won’t be able to pay off my debt either, then I’ll get even more interest or I’ll damage my credit, and I’ll be in a financial hole for the rest of my life.

 

These thoughts may seem a little excessive to some people, but many of us have had worries like this countless times – usually when our guard is down, when we are tired, lying in bed with nothing to distract us. What is it about worry that can be so difficult to control? Researchers Rodebaugh and Heimberg suggest that worry “acts as a trick the person is playing on himself or herself to provide the illusion of action, when useful action seems impossible.” In other words, in our minds, worry resembles problem solving or planning. We convince ourselves that if we just worry enough, we will be better able to prevent “something bad” from happening or we will be better able to cope if this “something bad” does happen.

However, worry is not problem solving or planning. Worry is simply thinking about a problem or fear, it is not a productive attempt to create solutions. Worry typically leads to anxiety, which is a physical reaction priming your body to deal with threats, it is preparing you to run away and/or fight. Now in some situations this is helpful, but in the vast majority of situations in modern society, we do not need to run away or fight. Therefore, this is an inappropriate and unnecessary reaction. Sometimes the first step in overcoming worry is actually accepting that worrying is not helping us. Moreover, in many situations worrying, and the associated anxiety, is actually reducing our ability to cope with challenges. Many clients enter therapy and want to get rid of the suffering cause by anxiety without having to stop worrying, but this is an unrealistic expectation. So long as we keep our pattern of worrying, we will keep our pattern of feeling anxious.

Cognitive model of GAD

There are several different types of anxiety. One such type is called “generalized anxiety.” People that struggle with generalized anxiety worry more than most people about everyday things, and have trouble controlling it. Generalized anxiety can keep you awake at night or make you feel sick. Sometimes people with generalized anxiety refer to themselves as “worriers.” The Cognitive Model of Generalized Anxiety Disorder, created by Dugas and Robichaud, illustrates the connection between situations, wondering “what if something bad happens?”, worry, anxiety, and demoralization/exhaustion.

So if we accept that worry is not particularly helpful for us, and we want to change this pattern of worrying, what can we do?

According to many CBT therapists, the first step in overcoming anxiety is understanding our worries. We can do this by writing down what we are worried about several times throughout the day. Then you take this list of worries and divide them into actual current problems and hypothetical “what if…?” worries.

 

worries

Now you might look at this list and think “but I could get sick!” or “but my partner might leave me!” Yes, but in neither of these situations will worrying help problem solve. You might also look at these lists and think “but my worrying helps motivate me! If I quit worrying, won’t I lose my motivation??” Let me answer this question with a question – many, many, many very motivated and successful people do not worry very much, so why do you have to play by different rules? Also, we can problem solve, set goals, and plan all without worrying, don’t get sucked into the tricks worrying is trying to play on you. One huge difference between the things in the “actual problem” category is that the things on that list are current and actionable. You can choose to make something for dinner, choose to write a paper, choose to schedule a time to exercise, and choose to create a resume. The things on the “what if…?” list are uncertain because they are in the future and greatly influenced by forces beyond your control. It would be a beautiful world if we could just choose to not get sick or choose to have everyone like you.

God grant me the serenity to accept the things I cannot change,

Courage to change the things I can,

And the wisdom to know the difference.

The Serenity Prayer.

In the sections above, I suggested that worrying is not problem solving, this begs the question “what is problem solving?” In problem solving we first (a) identify the problem, (b) identify possible solutions to a problem, (c) evaluate the pros and cons of each solution, (d) select a reasonably good solution, (e) try it out, (f) evaluate how the solution worked to solve the problem, and (g) repeat this process as necessary. I strongly recommend you write these steps down for your more serious concerns, or chances are when you worry about the problem at 2 in the morning you won’t remember the plan to created yesterday to solve the problem.

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The exercise of identifying which worries are actual problems that we can do something about, from those worries that are beyond our control can be a powerful tool for challenging unhelpful thinking patterns. As we become more aware of these unhelpful patterns, we can replace unhelpful thoughts with more helpful ones. When we think “I might lose my job” we can challenge this worry by thinking “yes, it is possible, however I cannot control this. Instead I’m going to focus on things I can do to decrease the probability of this happening – such as improving my performance.”

Unfortunately, there are times where there is nothing we can do to prevent a catastrophe from occurring. In those situations, we are faced with a choice – continue to worry (and suffer) or accept the uncertainty. This can be extremely difficult for some people. One way we can increase our tolerance of the uncertainty is to review the evidence that the catastrophe will take place. What is the evidence the catastrophe has taken place? What are the actual probabilities of the catastrophe occurring? Will your worrying change the probability?

As is usually the case for the topics I choose to write about, this is a huge topic that has been explored in many studies, articles, and books. However, I hope this article helps expand your understanding and will be of some help.

If anyone has any questions or comments, please e-mail!