 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome everybody to today's presentation using a strengths-based biopsychosocial approach to addressing anxiety. So that's a mouthful. We're going to start out by looking at what a strengths-based approach is. And I'm going to try not to say that too many times because I always get tongue tied. But it's one of those things that we started talking about, golly, probably 15 years ago. But we don't necessarily do a wonderful job of implementing it. So we'll look at ways that we can incorporate more strengths-based interventions in our treatment. Define a biopsychosocial approach. That's, you know, a lot older than strengths-based. And we'll talk about that. Explore the symptoms of anxiety. And you're like, well, I know how to diagnose anxiety. Yes, you do. But let's look at why those symptoms are there and what function they serve. Because that'll help us help the clients understand why they might be experiencing them. And then we'll identify potential causes of and biological and psychological and social interventions for those symptoms. Because not everybody's going to want to use the same interventions. I've found over the many years I've been working with clients, some clients really like a cognitive approach. Some clients prefer a more holistic biomedical approach with a little bit of counseling in there. So we really want to talk with the client about, and here's a clue about strengths-based, what works for them. So why do we care? Well, anxiety can be debilitating. Even if you're seeing a client who maybe recently was diagnosed with a chronic illness or a chronic pain condition or something, they may have some anxiety. And that constant revving, if you will, think about when you're anxious. You're kind of feeling like you're revved up. You're sitting in the driveway with a car in park. Just kind of revving that gas. This low-grade chronic stress erodes your energy and your ability to concentrate. Which means that anxiety can be a major trigger for addiction relapse because people just want to escape it for a while. They want to be able to rest. Increased physical pain. We know that anxiety increases the stress reaction. We know that stress reaction reduces serotonin because serotonin is our calming chemical. And when we're stressed, we don't need to be calm. We need to be doing something. So through the HPA axis, we know that anxiety triggers the stress reaction and may lead to an increased perception of physical pain. It can also lead to actual increased pain. I mean, think about it. When you get stressed, when you get anxious, do you carry some of that stress in your neck, in your back, in your belly? I do. So thinking about how you experience anxiety can give you a little bit more sympathy and empathy for what your clients may be going through. And anxiety triggers sleep problems. When you are anxious, especially generalized anxiety, you know, your body is perceiving that there's a threat and it can't really put its finger on what that threat is. So it's staying on alert most of the time. Which means when you go down to lay down to sleep, you may be sleeping, but you're probably not getting into that deep quality sleep, because your body wants to make sure that you can wake up and be alert at a moment's notice. And when you're in deep sleep, you wake up and you're hard to wake up, but then it takes a minute to kind of get your bearings. So a lot of times we find with people with chronic anxiety, they're not sleeping well. So what does strength-based mean? It's easier and more effective to build on something that already works to some extent. So I'll ask clients, what do you do that helps you feel less anxious? What do you do that helps you sleep better? Even if it's not a panacea, it may not fix everything. But I want to know what they're building on. What are they using right now that works 10%? I'll settle for 10%. I'm cool with that, because we can build on that. If it works a little bit, then they're going to be more likely to be treatment compliant with trying to strengthen that intervention than if I just threw something at them that they'd never heard of before. And they might try it, and it might work. But there's a whole learning curve with it. If they're already doing something, they've gotten that initial learning curve out of the way, and we're just going to have gradual improvements. Strength-based approaches help people identify how they're already trying to cope. So I want to empower them to realize that you've already started doing something. It's not me. I'm not going to wave a magic wand and make you less anxious. You've already started trying to figure out what to do, and it's within your power to keep building on that. And there are two types of strengths, and this is kind of important. Prevention and resilience strengths or vulnerability prevention, if you think about DBT, what you do on a daily basis to stay healthy and happy and prevent vulnerabilities. Think about times when you've been more susceptible to getting anxious, irritable, angry, any of those dysphoric feelings. What was going on? Were you already stressed out? Were you not eating well? Were you not sleeping well? Did you have too many irons in the fire? So you felt like you were pulled in 15 different directions. So we're going to talk about prevention and resilience strengths in terms of, just in general, what you do to keep yourself on your A game. And then we're going to talk about specific intervention coping strengths by asking them in the past, when you have felt this way, whatever this way is, what helped, when you've experienced this symptom, maybe feeling like they can't breathe because it feels like an elephant sitting on their chest. What's helped? What do you do? And, you know, oftentimes we don't go here. What made it worse? Because we don't want to do that. But if you can help them start sorting between, this helps, this makes it worse, this helps, this makes it worse, we can start seeing themes and trends in what works for that person, which can also help the rest of the diagnostic team get a better handle on what might be causing the anxiety. And we're going to talk a little bit in this presentation about differential diagnosis, because there's a lot of stuff to, for lack of a better term, that can cause symptoms of generalized anxiety besides just cognitive stuff. Hormone imbalances, thyroid hormone imbalances, all those sorts of things may trigger those sorts of feelings. Also blood sugar. When your blood sugar drops, your body secretes cortisol and adrenaline in order to cause your liver to put it more glucose into the system. So if people have unstable blood sugar, hypoglycemia, diabetes issues, anything like that, they may feel symptoms of anxiety. So if we're starting to look at the interventions they're using, then we can get a better picture of what might be triggering it, what might be causing it and make referrals if they're not already seeing other multidisciplinary providers. So a biopsychosocial approach. I'm not going to spend a lot of time here because I think it's pretty well known. But your biological interventions include balancing those neurochemicals. And that doesn't necessarily mean medication. It can mean making sure that they are getting adequate nutrition. And we're not nutritionists. We're not going to make that prescription for what they should eat. But we do want to educate our clients that what you eat has a direct effect on whether your body has the building blocks to make the neurochemicals that help you feel calm and happy. We're also going to talk about nutrition and how things like caffeine and nicotine not only rev up the system and can cause symptoms of anxiety, but they can also impair sleep, which can intensify symptoms of anxiety, which brings us to sleep. You see how all this just kind of feeds in on itself. Sleep is important because that's when the body rebalances all the neurotransmitters, or at least that's what they think. But think about a time when you've been sleep deprived. And I mean, DBT looks at this as one of those vulnerability prevention things. And just common sense would tell you when you're feeling fatigued and foggy headed and however you want to describe it when you're sleep deprived, a lot of times you can get anxious. It's harder to deal with life on life's terms as I say, because you don't have the energy. All of your energy reserves are kind of being stretched thin because you didn't rest and recharge overnight. And sunlight and circadian rhythms. This is one people don't think about very often, but it's not just seasonal effective disorder leading to depression. If people are not getting enough sunlight and their circadian rhythms are out of whack and there's a lot of reasons that can happen, including taking too many naps during the day and other things like that. But if they are not getting their circadian rhythms in whack, they may start not sleeping well. And if they're not sleeping well, they can have some side effects. So we do want people to note from a prevention, those things that you do every day to keep yourself happy and healthy, how are you maintaining and making sure your body machine is operating well. Psychological. Now this is right up our alley. We want to help them identify mindfulness techniques. What can you do and how can you do it so you can remain mindful of what your needs and wants are. And I talk about anchored mindfulness. So at every meal before they eat or after they eat, they eat. I usually prefer before. They just kind of do a quick scan and go, how am I feeling? What am I thinking? What am I needing? It's not super in depth, but it's a start. It's a start to get people paying attention to kind of where they're at instead of operating on autopilot and ignoring something until it makes the entire system breakdown. Distress tolerance skills. A lot of our clients with anxiety issues are plagued or use distress intolerant thoughts. I cannot deal with this. I cannot tolerate this. So we want to teach them distress tolerance. We want to teach them about urges and how they come in and go out like waves. We want to teach them the improved and accepts acronyms from DBT to help them figure out, you know, when there's something that happens that you can't control. And I use these examples a lot this Saturday. My daughter's dog had this major anxiety attack. And yeah, it's a dog, but it's my daughter's pride and joy. And she's older. So it kind of freaked me out a little too. But there was nothing we could do. The vets were closed. There was nothing that I really could identify that said, need to go to the emergency vet. But we had to wait until Monday morning to get her into the vet. So helping my daughter use distress tolerance skills and myself to get through the weekend. So we didn't perseverate on is rena okay is rena okay is rena okay. So distress tolerance skills can be really helpful to providing clients tools to get through something that they just can't change at the moment. We'll talk about other coping skills and cognitive restructuring techniques. And then the social part of biopsychosocial a lot of times, again, we forget is talking about improving their self esteem and their relationship with their self. Oh, new concept. Never knew where that belonged exactly. We'll think about it in order to have a good relationship with others. Probably important to at least like yourself some. Otherwise it's probably going to, you're probably going to form more dysfunctional relationships based on external validation. Sometimes in general, I find that to be true. So helping clients improve their sense of self worth and do for themselves what they would want a best friend to do for them. Empowers them to start moving forward and it powers them to make friends and friendships that are based on mutual respect and all that kind of stuff instead of just needing somebody to validate and fill a void. And then we talk about improving relationships with healthy supportive others. This doesn't necessarily mean biological family. It can. So we want to ask who are your healthy supportive others and how can we help you get them involved in your life? Support groups are another great place to find supportive others who kind of understand this whole anxiety thing. So if there are good support groups in your area and your person doesn't have a lot of social support, that might be one place to make a referral. So it's another avenue, another strength that they can build upon. If they've already got one or two friends, but they might need some people who understand a little bit better what's going on, that's one way to do it. So what is anxiety? It is half of the fight or flight response. It's an excitatory response, which means it's going to get you revved up. It's going to go up. Your breathing is going to go up. You may start to sweat. Its function is to protect you from danger. For some reason, your body thinks there's a threat and it's saying you either need to fight or get the heck out of here. Well, cool. I'm glad my brain's looking out for me. It becomes a problem when it's over generalized though. So every bump in the night makes you jump up and have an anxiety reaction or every time you hear sirens going by, you start to have an anxiety reaction. It can be a problem if it's overly intense or uncontrollable. And this is kind of more your panic attacks, but falls under that anxiety umbrella. And that can be debilitating. And it can become a problem when it's constant due to, and I use the term brain injury pretty loosely. They find that there are similar brain changes or injuries, if you will, in people who have PTSD as well as people who have traumatic brain injury from a concussive sort of force. There are actual changes in the brain when there's exposure to extensive trauma related stuff. So these people may experience more anxiety. Okay. Well, we got to accept where the client is at and what they're dealing with. And then we can start figuring out what might be most helpful. Like depression, anxiety can be caused by excess serotonin. Yeah, who knew? Some of the research has indicated that too much serotonin may actually serve to trigger more depression. And serotonin has also been linked to some anxiety. It's also been linked to reducing some anxiety. So the question is, well, when is an SSRI helpful? And my short answer is ask the psychiatrist. But the long answer is that the neurochemicals in our brain are always operating in a balance. So it's not as easy as just going, oh, you've got that symptom. That means there's too little of this. Could be too much of something else. So it's kind of like developing a warm bath. You've got to kind of figure out what the balance is for that person. And that's obviously going to be something the psychiatrist is going to handle. But helping them understand that our feelings are a direct result from the balance of neurochemicals in our brain. So our symptoms, generalized anxiety can vary. They may include persistent worrying or obsession about smaller, large concerns that is out of proportion to the impact of the event. OK. So fine. Most of our clients who present with generalized anxiety are going to have this symptom. What do we do about it? Well, my first question is what helps? When you are worrying, what helps you change gears? What helps you get a breather, even if it's just for 30 minutes? What helps you stop worrying or at least not think about it for that small period of time? And do you have tools that you use to help rain it in and consider the proportion? They may or they may not. Some people are like, yeah, I start to worry. And then I realize that I'm really making a mountain out of a molehill, blah, blah, blah. And I'm like, OK, great. How do you do that? What skills do you use? I mean, it doesn't mean that the anxiety is not a problem. It's still coming up frequently. But they at least have a couple of things that they're doing when it happens. Inability to set aside or let go of worry. So as soon as they stop worrying, they get worried because they're not worrying. So acceptance and commitment therapy. We'll talk in a little while about the acronym fear and unhooking from emotions, realizing that we don't have to act on them. We'll talk about some challenging questions that we might encourage clients to ask. But again, starting out with when you notice that you're worrying and you try to ignore it and it keeps coming back. What do you do? When you have an inability to relax, you feel keyed up or on edge. Is there anything you can do that helps you relax? A bubble bath, going on a walk, pulling weeds. You all know pulling weeds is mine. If I go out and I get outside, I'm too focused on the little weeds that keep popping up mocking me. And I forget about whatever it was that was bothering me for that period of time. So we want to ask clients if they have anything like that. Difficulty concentrating or the feeling that your mind just goes poof, blank. Well, you know, we know that lack of sleep can do that too. So as we're listening to these symptoms, we also want to identify when did this start? Is there anything that it's related to? Do you have episodes where it's worse and where it's better, which could indicate that there's a relationship to hormones or blood sugar or something else? Distress about making decisions for fear of making the wrong decision. When you have to make decisions, and we all do, how do you get past this fear? How do you go ahead and make that decision anyway? And what happens if it's wrong? How do you deal with that? Those are the things I want to know because we're going to be encouraging people to make decisions. And if it happens, decisions sometimes, we want them to have the skills to be able to deal with that as well as if it's a right decision. Carrying every option in a situation all the way out to its possible negative conclusion. So I was getting ready to go to this job interview. I didn't really know what I was walking into and I did poorly in the job interview. So that means that I'm probably not going to get the job. And if I don't get the job, then in three months, I won't be able to pay my rent. So I'm probably going to be homeless. And then I'm not going to know what to do with my kids and I'm going to lose my kids. And I'm just like, dude, take a breath. So sometimes people can go all the way out to the catastrophic sky is falling conclusion. Okay. So then we want to talk with them about what's the probability that it's going to get to that point. And, you know, generally they come back with, you know, not real probable and they can give explanations for that. And on difficulty handling uncertainty or indecisiveness goes back to that fear of making the wrong decision and fear of rejection, fear of not being what somebody else wants them to be necessarily. Other signs that we want to pay attention to, fatigue. Okay. Well, there are like a bazillion different things that cause fatigue and a lot of medical diagnoses. Not that I'm going to start throwing this out at clients because that'll just increase their anxiety. Well, it could be Lyme disease. It could be this. It could be that. No, no, no, no, no. But in my mind, I'm listening for what they do when it started, how they deal with it. If the fatigue predated the anxiety, you know, that's something I'm going to ask about. Irritability. How do they handle that? What makes it worse and better? Muscle tension or muscle aches, trembling and feeling twitchy. This is one of those signs potentially that blood sugar is low. It may have nothing to do with cognitive stuff. It may be the brain going, I need more fuel. So we want to explore this and talk with clients about, you know, family history of diabetes and, you know, what they think may make it worse or better. Being easily startled can be a sign of PTSD. Can also just be anxiety. Trouble sleeping, sweating, nausea, diarrhea, irritable bowel syndrome and headaches. Like I said, when we get stressed, we tend to feel it systematically. Our body sends out cortisol, norepinephrine, turns everything kind of up. So everything starts running faster and, you know, you can just take that image all the way to the end for yourself. In kids, and I don't often talk about kids, but kids present a little bit differently with anxiety. They may have a lot of worry about performance at school or sporting events, being on time and punctuality. Or having earthquakes, nuclear war, or other catastrophic events that, you know, unless there has recently been one, if you live in California, then earthquakes are something that could be a prominent concern and could cause generalized anxiety, sure. And it's important to look at the probability of these things happening, what to do in those cases. A child or teen with generalized anxiety disorder may also feel overly anxious to fit in. What teen do you know that doesn't? I mean, there are periods of anxieties. How frequently and how debilitating is this anxiety? They may be a perfectionist, lack self-confidence, strive for approval, or require a lot of reassurance about performance. So just paying attention to this in kids, does it mean that if kids show any of these symptoms, they need to be seeing a psychiatrist and on medications and da da da da. No. But if we see these signs, the earlier we see them, the easier it's going to be for us to say present them with some other intervention-based coping skills and look at what they're doing preventatively. Are they getting enough sleep? Are they eating a healthy diet or are they eating a pop tart on the bus on the way to school? And I ate pop tarts on the bus on the way to school. I'm not knocking it. I'm just saying every morning might not be the same thing. So biological interventions, let's start at the beginning. When you feel anxious, your body thinks there's a threat. Figure out why. Is there a threat? Is there something biologically going on that could cause you harm? Are you in harm's way? If you're walking through a parking garage at one o'clock in the morning by yourself and you feel anxious, well, you know what? That's probably pretty spot-on. It serves a purpose. It is there to tell you something might be going a little bit wonky. So figure out why. If you feel anxious and you realize, you know, I haven't eaten in a while, hey, you tuned into a clue. And part of helping people with anxiety is to help them realize their body is trying to tell them something. And it doesn't mean there's necessarily a problem. It could be overgeneralized. But let's check in and rule out the biggies first. Do you need to eat? Do you need to get some water to drink? Kind of what's going on? Have you had too much caffeine? Well, maybe not all of us. Many of us have had those days where we've had just a little bit too much of the full calf, or we've gone to Starbucks. And yeah. And you can feel like this anxiety or revved-up sensation kind of coursing through your veins. So being aware of what's going on. If you went to Starbucks and all of a sudden you feel like a chihuahua that's been drinking Starbucks, be aware of it. You may not need to do anything. You know, it may not be... It's something that's probably going to pass in four to six hours. Other things for biological interventions. You know, obviously have people see their physician, get a blood workup, make sure everything's normal, and rule out what I mentioned before. If they have a thyroid imbalance that's easier to treat, and then long-standing cognitions that we're going to deal with. Supportive care. Encourage people to make sure that they're preventing vulnerabilities by creating a sleep routine. Quality sleep helps the brain and body rebalance. It can help repair adrenal fatigue or chronic fatigue. It can help me wake up and I just can never actually feel energized. And it improves energy level and concentration and a whole bunch of other things. So sleep routines, roughly the same time each night you want to go to bed. You know, don't be too rigid with it. Make sure you do the same two to three things just like you would with a little kid. You know, with kids they eat dinner, that sets their body up as soon as they start eating dinner, their brain's going, it's starting to be time to wind down. Let me make that melatonin. We want to do that for ourselves. Nutrition. Minimize caffeine and other stimulants. I'm realistic. People who drink caffeine are probably not going to just be like, oh, that's not helpful. No problem. I'm going to cut it out. They like their coffee. They like their coffee. They like their coffee. They like their coffee. They like their coffee. About the effect of caffeine and nicotine and other stimulants, including pre-workout supplements, if they're avid athletes. And let them make a decision and educated decision with their healthcare provider. Encourage them to prevent spikes and drops in blood sugar, which can trigger the stress response in the body. Make sure that they don't get water. Water is required for all of those electrical impulses and everything to go through our body. If we're dehydrated, even 1%, we start feeling foggy headed and have difficulty making decisions. Make sure they get sunlight. Vitamin D, they've actually implicated in mood issues, but they're not sure why. They know the areas of the brain are vitamin D, but they're not sure how it all works together. Sunlight prompts the skin to tell the brain to produce neurotransmitters, which sets circadian rhythms and impacts the release of serotonin, melatonin, and GABA. Now your natural serotonin typically is your anti-anxiety antidote. And GABA is too. So when serotonin levels are low, people tend often, when their natural serotonin levels are low, people tend to experience some more anxiety. But, as I said in the beginning of the presentation, the research is somewhat conflicting on this, which is why I encourage patients to advocate for themselves and if they start on an SSRI or something because they think that's going to help them and it doesn't talk to their doctor. If it makes their symptoms worse, talk to their doctor. Because there are other medications if they need that. But we also want to look at what can you do lifestyle-wise to help your body function efficiently. Think about your body as a car, you know. Think about whatever really nice car you want. But you wouldn't run that car on the same oil for 15 years with 100 pounds of dog food in the trunk and expect it to operate efficiently and effectively. Well, stress is kind of like 100 pounds of dog food in the trunk. And not getting enough sleep is like putting in really bad gas, if you will. So we want to help people make sure their body machine is doing as much as it can. And then we can figure out where to go from there. Exercise does have a relaxing effect, but start slowly. I'm not saying go to the gym and bust hump for 40 minutes three times a week. I'm saying walk around the block a couple of times with your dog. That is doing something is better than nothing. Obviously, have them clear it with their physician first. Other supportive care things, medication as I said SSRI selective serotonin reuptake inhibitors and selective norepinephrine reuptake inhibitors have been used in interventions with anxiety. And benzodiazepines have as well as boost bar, which doesn't nicely fit anywhere else. Benzos typically are your volume, your Xanax highly addictive. So I personally make sure I educate clients about Benzos, especially if they have a history of addiction in their family. But, you know, that's obviously going to depend on the individual client and be between them and their prescribing physician. Aromatherapy can help. And think about a time when you've walked into somewhere and like the mall and you've walked past Cinnabon and you've just been like oh my gosh and you just kind of feel this wave of relaxation go over your entire body and then you realize you probably don't want to eat that many calories. Before that happens you have a feeling you have a sensation smells are some of our greatest triggers for memories. Encouraging people to find smells that they find relaxing. And we all have certain smells and it may take some playing to figure out what they are, but we all have certain smells that can help us feel more relaxed or at ease than, you know, other smells. You know, smells that remind me of, you know, certain places tend to stress me out more than smells that remind me of my grandmother's house, which is pine salt. So, you know, I can just clean with pine salt and I'm good. But they found that Clary Sage is a great essential oil for anti-anxiety as well as lavender, rose, vetvier, ylang-lang, bergamot, chamomile, and frankincense. You can go to davidwolf.com, doctorax.com to read more about those. Now remember aromatherapy especially essential oils clients don't want to put those directly on their skin, especially without working with a licensed aromatherapist, but smelling them can have a similar effect. I sprinkle Clary Sage on my pillow every night but that's me. So figuring out what works for that client. We also use on our dogs. I don't like to give them actual oral supplements Valerian and I put it on their collars before there's a thunderstorm and it helps. I've done an A-B test and there's definitely a difference in their mood and their shakiness and everything when a thunderstorm comes for the two that have thunderstorm anxiety. So do some exploration or encourage your clients to do exploration. They don't have to buy these right away. They can go down to the local health food store. Most of them have essential oils. Have them sniff them. If they sniff it and they go oh that's disgusting. Well that's probably not going to work for them but they might find some that they smell and they're like, I like this. It could be a scent that's not even related to a prior memory. They found you know these essential oils here aren't necessarily related to a memory when they help calming which is why lavender and chamomile are in a lot of baby baths and baby shampoos. Well babies certainly don't have any point of reference for that but there's something about those oils that can be soothing. So psychological interventions anxiety equals threat threat equals activation of one or more of those basic fears so what are they? And this is where we get into the practical and I like to help clients understand that their brain is trying to tell them something and if we can step back and go you're right or you're wrong they're going to be more empowered to take control of their anxiety. So what are these basic fears? Failure. None of us likes to fail but some people perceive failure as a road to rejection and if they need external validation then rejection is scary as crap because if somebody else isn't there to tell them they're okay then who's going to tell them they're okay? Rejection and isolation can be huge for people which is you know we have whole diagnosis of social anxiety some people feel very threatened by other people's opinion of them and not being accepted. Loss of control you know if you're not in complete control of a situation well you know what if you're not in complete control you have a greater risk of possibly failure you know if you have perfect control over it then you assume that you will be able to come out victorious or whatever. The unknown some people love it they like spontaneity some people hate it because they like to be in control all the time and then the last one is death slash loss and depending on how you want to characterize it death obviously of a person or of yourself if you're afraid to fly in an airplane because you're afraid it's going to crash yeah that's a fear of death if you are facing a situation where you're afraid you're nervous about going into a job interview you know you may be fearing failure but you also may fear loss of self-concept if you don't get that job what does that say about you you can lose dreams if you're applying for a college that you want to get into really desperately and you don't get into that college that's a loss you've got to accept that that dream you had since you were knee-high to a grasshopper isn't going to happen so that's something that needs to be grieved and dealt with but leading up to it there is probably going to be some anxiety about well if this happens is my life going to fall apart so we can help clients start understanding and identifying the sources of their anxiety then I move on to mindfulness and acceptance alright so you know what the categories are observe yourself when you get anxious accept that you feel angry or anxious and just be like okay I'm stressed out right now or I'm anxious I'm panicky whatever word they use okay radical acceptance label it and let it go which takes some practice for people in order to not fight with it and go well I shouldn't feel anxious right now there's nothing to be stressed about I don't know why I'm anxious they can talk to themselves for an hour about that or they can just say you know what I'm anxious let me let that go and figure out what I can do to improve the next moment encourage them to identify trigger thoughts when they're being mindful they're going to tune in more to that internal critic that's probably telling them you're going to fail or if you don't get this you're going to be rejected so tuning into those trigger thoughts that internal critic and telling him to shut the heck up distress tolerance it isn't always about controlling your anxiety anxiety comes it's just a warning signal if you've ever had a fire alarm malfunction in your house it's kind of like the anxiety sometimes it's telling you there's smoke and there's a problem other times it's telling you that there's smoke because I forgot something was in the oven or nothing at all I've had fire alarms go off for no apparent reason so it's about identifying that there might be a threat and then addressing it if there's nothing there or nothing you can put your finger on sometimes it's better to distract not react you don't have to get yourself all wound up wondering what should you be worried about just say you know what I'm feeling anxious right now I don't see anything around that's going on I'm going to take a breath and redirect my attention and use distancing techniques when clients start getting stressed encouraging them to put the phrase I'm having the thought that in front of instead of saying I am freaked out about this upcoming interview saying I'm having the thought that I'm freaked out about this upcoming interview why? because then we can say well what are you going to do with that thought what else can you do can you let it go is there anything you can do to change that thought? encourage clients to relax this is preventative as well as interventative my new word for the day diaphragmatic breathing can help people slow down their heart rate and slow down that stress response what I learned to call combat breathing you may call it something else you breathe in for a count of four you hold for a count of four and then you exhale for a count of four by slowing your breathing your heart rate automatically slows so people who are having a panic attack who are having an anxiety moment can calm themselves down if you get cut off in traffic and you have that panic moment slowing breathing will help get you back to baseline more quickly if you're in the place where you can and you're willing to do it meditation can help you focus on your breath and really focus on what the energies in your body are doing another relaxation skill and I always tell you guys that there are all kinds of resources on the internet for it but you know I don't usually show you so and of course that's not going to come up the way I wanted it to well I'll do that at the end of class so we get through it but I googled the verb progressive muscular relaxation videos and I found a bunch that were on youtube I'm not recommending any particular one because I haven't watched them all obviously you're going to watch it before you recommend it to a client but this way they can lay down on their bed and just let a video walk them through the progressive muscular relaxation and help them relax self-esteem interventions you know I keep talking about this fear of failure fear of rejection wanting to make sure that you are your own best friend to improve social relationships with others yada yada well they need to figure out how their self-esteem is right now so what's the difference between their real self who they are right now or how they think about themselves right now versus who they think they should be I have my clients write that down and then we look at the should-bees and we cross out the things that are just completely unreasonable you know I'm never going to be five ten and redhead that's just well I could I guess I could be redhead but naturally no so cross those off that's not what's going to ever happen so what's important in my ideal self what things do I want to leave that are important and then go back and compare it to the real self and if there are differences then you're improving and becoming the person they want to be I mean it's a pretty academic exercise encourage compassionate self-talk too often our clients are just nasty to themselves they hold themselves up to this standard and they hold everybody else to this standard down here and I'm like well if you're not going to hold anybody else to this standard why do you hold yourself there you're just creating a situation for yourself and you feel like a failure hmm there's a concept encourage them to spotlight strengths what strengths do you have what do you bring to the table what is awesome about you and a lot of times they hate answering this question so I'll have them write it down in a journal add to it over a couple of weeks and then we look at it together and encourage them to accept imperfections I present to them the concept of Yin and Yang everybody has their strengths and everybody has their weaknesses and that kind of is what balances everything out if everybody had the same strengths then the weaknesses would go untended and everything would be chaos so it's great if you've got these strengths and somebody else has you know opposite strengths because you can assist each other and make a more balanced project or relationship or whatever it is so accepting imperfections and going yep you know that's not my strong suit is important but helping clients look at it in terms of not a rejection or a failure but just as a statement of what is oops cognitive restructuring we want to help them address and identify irrational thoughts cognitive distortions this is something they probably already do a little bit on their own and we can build on it but once they understand especially the cognitive distortions the all or nothing thinking the catastrophizing etc they can start sorting their thoughts and it empowers them to go yep I can see where that was kind of extreme I can see a different way to restate this where it's a little bit of a struggle of the road or more empowering reframe challenges in terms of current strengths not just past weaknesses instead of saying I failed at every relationship I've been in look and say look at everything I've learned from all the relationships I've been in that I can bring to this new relationship and encourage them to create an attitude of gratitude and optimism focusing on what they do have and what they can do because as they develop those those fears that threat goes down you can't be empowered and scared to death at the same time most of the time most of the time they balance themselves out so I talked about ACT earlier the fear acronym fusion with your thoughts if clients fuse with their thoughts and they feel like they have to act on every feeling and thought they have then they're going to be stuck in that anxiety roller coaster if they can separate and going I'm having the feeling that I'm anxious or if they can view their anxiety as a bubble and let it float up there are a lot of different unhooking or diffusion exercises that they can do so they can let go of that anxiety and focus on what is in the moment evaluate their experience in a way that empowers them instead of disempowers them instead of looking at it as a failure looking at something as evidence of courage to step out of their comfort zone and try something that they wouldn't necessarily succeed at and a learning opportunity so I encourage them to look at how else could you restate this that would be empowering and positive if they want to avoid their experiences a lot of us don't go headlong into fear that's just not what we want to do so gradual exposure is one of those things and finding exceptions I worked with a client who was terrified of driving she got to the point where she could hardly drive from her house to my office and without having a panic attack so we would talk about you know as you came here you know what happened were there any threats was it safe, was there anything that could have harmed you and found exceptions to her belief that driving was the most dangerous thing in the world gradual exposure I'm not telling her well you just need to get over it and go out and drive that would be cruel however the things that she did do we talked about okay how can you do this in a way that compromises your anxiety maybe getting on the interstate at rush hour isn't the best route to take to go from point A to point B you have to get there so how else could you do it getting her used to making workarounds and feeling confident and comfortable with driving and then reason giving for behavior when clients start explaining why they're anxious and why they're avoiding doing something we want to ask challenging questions you know the thought that this is dangerous or this is fearsome okay what is your evidence for and against you know let's look at it rationally let's look at it like an attorney and argue both sides of the case let's figure out if this is based on feeling or fact if you're feeling scared so you tell yourself it must be dangerous that's different than knowing it's dangerous and then feeling scared the challenging questions worksheet we've gone over in a bunch of activities so I'm not going to belabor that one too much recreation and relaxation there's always stuff you can do but a lot of our clients with anxiety disorders don't take time to relax so we want to encourage them to do that but they need to make a list of fun things to do because a lot of times when they do have a moment they're like I don't know what to do because they haven't rested and relaxed for so long encourage them to make a list maybe a little bucket list of fun things they want to do this month social interventions encourage them to identify their needs and wants with mindfulness preferably anchored mindfulness so they're doing it at least three times a day encourage them to be their own best friend if they start thinking I wish somebody would well do it for yourself yeah it's not quite the same but as you start doing it for yourself you realize you deserve it which creates stronger healthier other relationships help them understand the difference between internal validation the ability to say I'm okay and external validation needing others around solely for the purpose of telling you that you are worthy of breathing the air and encourage them to be compassionate with themselves we already talked about that help them develop healthy supportive relationships and learn about boundaries and develop assertiveness skills in dbt this falls under those interpersonal effectiveness skills the biggest one that I find with people who have anxiety is asking for help and being able to say no to requests without fearing that they're going to be rejected or somebody's going to get mad at them so those are skills that we can work on so it's for help when they need it so they don't feel isolated but they can also set boundaries so they don't feel pulled in 18 different directions have them describe the ideal healthy supportive relationship and then separate the real from ideals because a lot of times TV media Disney gives us a really skewed perception of what a healthy real relationship looks like like we never fight oh okay anyway so encourage them to look at relationships more realistically identify who these persons that they know are that they might be able to develop these relationships with that are currently in their life you know instead of starting from ground zero start with what they've got the other technique I like is playing the what does it mean game what does it mean when your boyfriend girlfriend doesn't respond to your text right away what does it mean when your significant other calls and says you know what I can't go out tonight a lot of times the way they answer this will help us understand and help them understand some of their fears of abandonment and anxiety reactions and be able to come up with three alternatives to well why didn't she return your text right away resources the anxiety and phobia workbook really like that one ACT for anxiety disorders anxiety food solution I like this one just because it really educates clients about how what they put in their body is important in terms of the building blocks for health and happiness coping with anxiety 10 simple ways to relieve fear and worry it's a good book and the 30 minute therapy for anxiety now new harbinger has a lot of resources on anxiety these are my five favorites you may hate them you know we all have our different preferences you can look them up on they have the Google previews so you can read some of them and figure out if it's something that you like I went too far summary anxiety is a natural emotion that serves a survival function excessive anxiety can develop from lack of sleep nutritional problems other causes neurochemical imbalances failure to develop adequate coping skills so you can't deal with that threat cognitive distortions low self-esteem and a need for external validation recovery involves improving health behaviors identifying and building on current coping strategies addressing cognitive distortions and developing healthy supportive relationship with self and others so then let's go real quickly here to if I can get it to come up course exam so strengths based you know just to kind of review means identifying what the client is already doing that's helping them it doesn't necessarily mean using a best practice best practices are great but we don't know if that's going to work for the client or if the client's already even engaged in those we know for example that acupuncture is a best practice for treatment of certain disorders however some clients may be like oh heck no not going near the needles well that may not work so strengths based means identifying what the client is already using and building upon that biopsychosocial means addressing the physical mental and interpersonal mitigating and exacerbating factors for the person's current problems we can't deal with everything that's ever existed we want to look at this particular problem in context your anxiety right now what's causing it what makes it worse what makes it better but we do want to look at the person as as a complex entity not just as a psychological phenomenon and anxiety is there for a purpose it tells the body tells the person check it out you know like I said it's like a smoke detector could mean there's a problem may just be a false alarm but anxiety is there to help protect people and a variety of skills including distress tolerance and relaxation skills can be very helpful in helping people deal with anxiety because when they start to feel that anxiety reaction when their heart starts to race they might start to feel like they're spiraling out of control by giving them tools to be able to kind of get their heart rate under control get their breathing under control and deal with some of those distress intolerant thoughts that are prompting the stress reaction we can empower them to take control of their current situation are there any questions let me see if I can find that um let me bring if you enjoy this podcast please like and subscribe either in your podcast player or on YouTube you can attend and participate in our live webinars with Dr. Snipes by subscribing at allceuse.com slash counselor toolbox this episode has been brought to you in part by allceuse.com providing 24-7 multimedia continuing education and pre-certification training to counselors therapists and nurses since 2006 use coupon code counselor toolbox to get a 20% discount off your order this month