 Welcome everybody, today we're going to be discussing using a strengths-based biopsychosocial approach to addressing anxiety. So what are we going to do? We're going to define a strengths-based approach, we'll define a biopsychosocial approach, and then we're going to talk about how that applies to anxiety. Why do we care? Well, there are a lot of reasons why we might care about anxiety because partly it can be debilitating. People who have generalized anxiety disorder or social anxiety or panic disorder can find themselves unable to participate in things like they want to do, which can negatively impact their self-esteem. There's a whole bunch of things. Anxiety also impacts how they sleep. So if you have a high level of anxiety, you may not be sleeping as well. Anxiety is anxious. Eventually it sort of desensitizes to that. So anxiety will go to sort of apathy. So what you normally would feel as anxiety is just now kind of normal for you. Low-grade chronic stress and anxiety erodes your ability to concentrate and your energy. When you're stressed out even, you know, a little bit, it makes things harder. It makes it harder to concentrate. It makes it harder to focus on what you have to do and get it done in a timely manner. Anxiety can be a major trigger for addiction relapse, increased physical pain, and sleep problems. Now, we already talked about sleep problems. Increased physical pain mainly because when we get anxious, sometimes we carry tension in our head, our neck, our shoulders, get headaches, and it can cause gastrointestinal upset. So you have muscle aches, headaches, and tummy aches. And addiction relapse. Well, if you're having difficulty dealing with life on life's terms and you need something to help you escape or relax, guess what? That may be somewhere that you end up looking. So what does strength-based mean? Well, it's easier and more effective to build upon something that already works to some extent. Instead of saying, okay, I am going to teach you this experiential technique. Asking somebody in the past when you have tried to deal with something like this, and it's been, you know, it's worked a little bit. Tell me what you did. You know, if somebody was mildly depressed before when they wake up and they're having a bad day and they're feeling kind of blue, what do they do? All right, now they've got clinical depression. So that is probably not going to be the ultimate solution. But we can say, all right, let's look at what you did when you felt blue. And let's figure out how we can build on that to deal with this more intense level of dysfunction or anxiety or whatever it is. A strength-based approach helps people identify how they're already trying to cope and builds on it. So the other thing you can ask people is, you know, before you came into my office, you were trying to deal with this on your own. What were you doing? What helped? And what didn't? Because we shouldn't bang our heads into the wall and keep trying to do what isn't working. Let's focus on what is working. And understanding that there are two types of strengths. Your prevention or your resilience strengths are the things that you do on a daily basis to stay healthy and happy. We've talked in the past about vulnerabilities. Basically, prevention and resilience strengths are preventing those vulnerabilities. They're keeping you rested. They're keeping you unstressed. They're keeping you organized in order to be able to have enough energy to deal with curveballs when they come your way. Intervention and coping strengths are those strengths that you have that help you deal with the curveballs when they come your way. So when that happened, you say, all right, in the past, when you have felt anxious, what has helped? What made it worse? What do you usually do? Because sometimes we will go to fallbacks that don't necessarily help, but it's just what we've always done. So we want to sort through and kind of make three piles of this helps, this makes it worse, and this doesn't do much of anything. A biopsychosocial approach means we're going to address the person as a whole. Neurochemicals, nutrition, sleep, and sunlight and circadian rhythms. We know that neurochemicals are responsible for causing the feelings of depression or anxiety or hypervigilance. Those neurochemicals send us signals out to our brain. Now we can monkey up those neurochemicals by not giving our body enough building blocks to make the neurochemicals by having negative thought patterns that always keep us on alert. Because if we're thinking negatively, we're telling our body there's a threat. The body says, Okay, you're telling me there's a threat. So I'm going to keep sending out all of your fight or flight chemicals. So we can actually think ourselves into a neurochemical imbalance. So I said nutrition, sleep, you need to rest, you know, even if you don't need to build building blocks or whatever you need to do, we all need downtime to rest. And sunlight and circadian rhythms help the body keep the natural ebb and flow of serotonin and all those other chemicals that tell you, Okay, it's morning. Let's secrete some norepinephrine. It's time to be awake. And okay, it's evening. Let's secrete some serotonin. It's time to start getting ready for bed. Your body naturally does this. And when you start monkeying with it, it gets confused. And we've talked before about how, you know, daylight savings time can really kick in the butt. But when you change your sleep routines, it takes your body a while to catch up, which is why some people have a really hard time adjusting to time zone changes when they travel, or, you know, simple things, even just one hour like daylight savings time can really throw some people kind of out of whack. Psychological, mindfulness, distress, tolerance, coping skills, and cognitive restructuring. These are some of the things that we can look at to help people psychologically help people change the thoughts that may be disrupting their neurochemicals and their sleep and everything else. And then socially, we want to help people improve their self esteem their relationship with their self so they can feel okay without having to have somebody else tell them they're okay. This relieves a lot of stress and a lot of depression for people. If they're like, you know, I'm okay, even if you don't like my choices. When people's self esteem is low, they're spending more time being hyper vigilant, trying to figure out what everybody else wants them to be. And then we want to move on once they've got a good relationship with themselves and they know what they want, what they need and what their boundaries are, and maybe how to communicate effectively. And we want to work on improving relationships with healthy supportive others. And this doesn't mean everybody. We want to focus on those, you know, 135 people that they consider healthy, supportive other people. All of us have, you know, little hiccups and kinks and whatever you want to call it. So you're not going to find somebody that is the picture of mental health. If you do, I want to meet them. But we want to focus on those people that our clients find energizing, compassionate and supportive, because our social relationships help us experience pleasure, but also help buffer us against stress. So what's anxiety? Anxiety is half of the fight or flight response. When your body perceives a threat, it says, Okay, well, can I take it? Am I going to fight? Or do I need to get away from here? Because it's either not worth my energy, or there's no way I can win this. Fight or flight? Now, when we think about it, a lot of our clients come to us and they're talking to us about anxiety, in terms of things that really aren't actual threats, they're anxious about what their boss is going to say when they go in for their annual evaluation. Fight or flight? How is that a causing the fight or flight response? Why is this raising up to the level of telling your body there's a threat? What what's the threat about? Helping people understand their negative self talk and understand why they're perceiving things as threats is half the battle in many cases. Anxiety is an excitatory response. It says, Hello, get up, get off the sofa and do something fight or flee. You've got to do something about it. Anxiety is a natural response telling you that you either need to change the way you're thinking about something, change the something or do something else. You're not supposed to just sit there and go, Oh, wow, this is really worrisome. Anxiety's function is to protect you from danger. Now, again, we think fight or flight, we think cavemen, we think danger, we think death. But there's a lot of other danger out there that people are trying to escape from. When we talk about danger to self, you know, to our self esteem, if we fear rejection, isolation, failure at the unknown or loss of control. I brought up those fears before. And when we look at what people are anxious about, a lot of times we can fit it loosely into one of those categories. They may be anxious about a meeting, an interview that they've got coming up. Why are they anxious? Well, they are putting themselves in a position where they may be facing rejection. They are being evaluated. And they have very little control over how that interview goes. So yeah, I can see why you would be anxious. The question is, is it beneficial to use this energy to be anxious about it? Or what can you do to quell that anxiety? A lot of times it comes down to positive self talk about, if I don't get this job is not the end of the world. If I don't do well in this interview, I can learn from it. Trying to find the positive alternative. So we need to ask people when you get anxious about something, you know, before your first day of school, before our first date before an interview, how did you deal with that anxiety so you could face the challenge? Encourage people to look at things as challenges instead of threats. One of the problems with anxiety is it can become over generalized. So every time you hear a car door slam, you get stressed out because you figure that the cops are coming to arrest your significant other or you know, I'm working for examples here. Anytime you take something and it becomes over generalized, you see someone and you have a transference reaction. And it becomes every single person that has these characteristics is going to cause you fear. Then it can be anxiety provoking. When anxiety is overly intense or uncontrollable. Sometimes we have situations that yeah, they deserve to provoke a little anxiety just like that job interview. On a scale of one to 10, a job interview should probably warrant like a three in terms of anxiety. But if you're responding with a nine or a 10, we need to look at why that anxiety is so intense and potentially uncontrollable. When I was pregnant with actually both of my children, I had something called superventricular tachycardia, which meant that if I sat for too long, all the blood would pool in my feet. And I would have basically what most people would think of as a panic attack. Everything would kind of go black because my body wasn't getting the blood everywhere it needed to be. So I became very, very anxious about having to drive anywhere. I knew where every place was along my route that I could stop if I started getting tunnel vision. The nice thing was, as soon as I had the baby, that went away and I didn't have that problem anymore. And the doctor had told me as soon as you have the baby, the biggest cure for this is just, you know, not being pregnant. So as soon as I had the child, that went away and I was able to drive again. But when I got pregnant with a second child, before it was even happening, I expected it to happen. So I started getting anxious about, okay, when am I going to start having these episodes? It's important for clients to understand where their anxiety is coming from. And again, address whether is this even a realistic thing to be concerned about right now? What is your backup plan? How are you going to deal with it? Or do you just need to let it go? And then anxiety can also be constant, if you will. Some people have low grade anxiety because they have some sort of a brain injury or biological neurochemical imbalance. It's hard to tell what percentage of the population because so much of our bodily reaction is due to how we perceive things. If we perceive a threat, our body is going to react as if there is a threat. So our cognitions play such an important part. It's hard to tell for the majority of the people with anxiety disorders, whether they have a organic issue going on, or you know, a lot of it is sort of a learned behavior. The nice thing is, you can ferret it out and balance it out as you go through treatment. Like depression, anxiety can be caused by excess serotonin. So we don't want to just assume that, you know, if somebody's anxious, it means they don't have enough serotonin. Or if somebody's depressed, it means they don't have enough serotonin. So we do want to make sure that again, people don't just start going off willy nilly and trying to bolster neurochemicals without understanding exactly what's going on. And we want them to be able to talk to their doctor. One of the things they have as a side effect on a lot of the SSRIs is it may increase anxiety. Well, you know, why is that if you already have high levels of serotonin, and you increase the serotonin levels anymore, it may increase your anxiety or your stress response. So it's important for people to be able to talk with their doctor and say, Is this something that'll go away after I get used to the medication? Or is this not the right medication for me? So symptoms of generalized anxiety, and I'm going to go through this really fast because most of you are very familiar with diagnosis of generalized anxiety disorder. But we do want to talk about how this may impact clients, persistent worrying or obsession about smaller large concerns that's out of proportion to the impact of the event. So when clients come to us and they say, I am stressed out constantly. My first thing is to say, Okay, first, let's make a list of all the things that are stressing you out right now. Let me get a snapshot of what's stressing you out. And then let's talk about constantly. My guess is there are times when you're not as stressed out, what's different than highlighting those accept exceptions. And then we'll look at those stressors and look at why they're causing somebody stress or why they're worrying about them and what they could do instead of just constantly worrying and thinking about it. Worrying does no good. It just burns up energy. It's like sitting at a stoplight with your foot like pressed down on the gas, you're going nowhere. You're just going to sit there and get yourself all worked up and burn a whole bunch of extra gas. Inability to set aside or let go of worry. Inability is what we want to focus on here. Most people can decide at a certain point that they want to let go of worry and say, This is not, I'm just going to let this go because I can't deal with it right now. There are some people, especially once you get to generalized anxiety disorder, they can't just say, You know what, I'm just not going to worry about that right now. It's obsessive. So having them identify ways they deal with that so they can go to sleep so they can focus on something else. Have them identify why it's so hard to let go of it. What will happen if you're not worried about this is they're going to be a catastrophic event. Explore that with them because they may be holding on to it, because they're afraid something worse is going to happen if they don't worry about it. Inability to relax restlessness feeling keyed up and or on edge. If your body is constantly sending out those stress chemicals, guess what, you're going to feel keyed up or on edge. Difficulty concentrating feeling that your mind goes blank. When you've got that many things going through your head. Think about it this way. Imagine you are at a place where they make honey. And there are just hundreds and hundreds and hundreds of bees around. And you know, I love bees, I'm not allergic to them. So it doesn't freak me out. You don't know which ones might be a threat to you and which ones not might might not be a threat to you. People with generalized anxiety may have racing thoughts. And they're just kind of swarmed by those thoughts like the bees that are buzzing around your head and you don't know which ones are going to be a threat and which ones aren't. So you're trying to focus on all of them. How exhausting is that? And how difficult is it to go Okay, I'm going to choose this one, this one and this one. But what if I choose wrong? So second guessing yourself about the choices, carrying every option in a situation all the way out to its possible negative conclusion. We've talked before about playing the tape all the way through, which is true. But sometimes you play that tape all the way through and there's a positive conclusion. People with generalized anxiety disorder, almost always end up playing it out and find the bottom falling out or the sky falling down or whatever you want to say. And difficulty handling uncertainty or indecisiveness. That fear of lack of control, if I can't control what's going on, that that fear of being out of control, I'm going to get more anxious. Because whatever is going on in my life, I'm trying to hold on to and trying to control. I'm not able to control my own anxiety right now. I'm not able to control other things that are going on. We want to look at that. Have people keep a log of what stresses them out? You know, it doesn't have to be a journal, just a log, you know, the top 10 things that stressed me out today. And how did you deal with them? Bring that in. Let's look over it. Let's see what worked what didn't what we might be able to do differently. I'm going to throw out suggestions with my clients. I'm going to say, Well, have you tried this? Or, you know, it sounds like this works for you. What if we modified it a little bit and you tried doing it this way? And I tell them from jump. If I give you a suggestion, and you're like, No, there's no way in the world. I'm going to do that. Tell me, there is no sense me keeping trying to get you to do something that you have no motivation or desire to do because you don't believe it'll work. So tell me and we'll go to something else because they are clients are the experts on themselves. Physical symptoms of generalized anxiety. Remember, we keep talking about this interaction between mind and body. Our thoughts can tell our body there's a threat. Our body will then respond with a stress response. The stress response keeps us keyed up and on edge, which makes us irritable, gives us muscle tension, because you know, you're sitting there, you're kind of like the Chihuahua in the side of the boxing ring or something. I watch way too much Bugs Bunny. Anyway, you can only be that keyed up for so long before you start getting exhausted, trembling and feeling twitchy being easily startled. If you're sitting there and you're waiting for something to happen, and all of a sudden somebody slams a door, what's going to happen? You'll probably jump out of your skin trouble sleeping because you can't turn down those stress chemicals. You keep telling your mind, there's a threat, there's a threat, there's a threat, there's a threat. So your body keeps saying, okay, let's prepare, let's prepare, let's prepare sweating, nausea, diarrhea or irritable bowel syndrome and headaches with kids. And I thought it was important to put this in there because kids are, you know, their own unique little individuals. They may have excessive worry about performance at school or sporting events, being on time punctuality, they're worried that if they're late, somebody's going to be very angry with them. They may stress a lot about catastrophic events like earthquakes or nuclear war, tornadoes, hurricanes. These things, I mean, if you live in California, earthquakes probably deserve a little bit of anxiety, be aware of them. But just constantly worrying about whether there's going to be an earthquake just drains your energy. Knowing what to do when there's an earthquake. That's good. Knowing what to do if there's a house fire. That's good. Talk with you talk with the children about what does it mean if you're not on time? What does this punctuality? Why is this so important? A child or teen with generalized anxiety disorder may also feel overly anxious to fit in. They want to be accepted and they're hyper vigilant to any signs of rejection. They may be a perfectionist doing things over and over and over again, even though, you know, they got it 90% right, they would have gotten an A. They're not going to be happy until they get 100% a plus plus plus. They may lack confidence in themselves, which contributes to them trying to be a perfectionist and fit in because they're looking for other people to say, you know what, you're okay. They strive for approval and may require a lot of reassurance about performance. Likewise, they also may be very self conscious about sharing anything because they're afraid of any sort of criticism, constructive or otherwise. So biological interventions. Now we're down to the fun part. Your body thinks there's a threat. Figure out why. What is it that you are stressed out about? What are the threats? I am worried about. I am stressed out about. Sometimes anxiety is hard to put your finger on or for some people to put their finger on. So have them run through a litany of other synonyms to figure out all of the things that are causing them anxiety, stress, worry, anxiety, you know, ask them what's going on in your life that's bothering you. Then you can start to address it and figure out, okay, is this a realistic threat? You know, if so, what can you do about it? Is this something that you are worried about from something in your past? Then we can deal with it. This is where, you know, our tools come in handy, helping people figure out how to deal with the threat. In the meantime, supportive care means creating a sleep routine. So the person can rebalance repair adrenal fatigue and improve their adrenaline level or improve their energy levels. That's easier said than done. But a sleep routine will help start queuing the body that it's time to wind down. So what can they do to a queue their body? It's time to wind down, have two or three things they do before bed every night, you know, the last hour leading up to it. And how can they feel safe when they go to sleep, where they're not afraid of whatever they're worried about will get out of control while they're sleeping. Sometimes keeping a pad by their bed so they can write stuff down as they think about it, keeps them from bouncing it around in their head all night long. Meditation, calming imagery. There's a lot of different interventions that may work for different people and it's important for them to be able to try some things out and communicate what helps them calm down. I'm a big fan of cute progressive muscular relaxation. You know, think back, you may be scratching your head going, what is that? When you were in school, and you came in and you sat down and you were waiting for class to begin. And the teacher said, everybody clear your desks and get out a pencil. As soon as you heard that phrase, you're like, oh crap, it's a pop quiz. And you had an anxiety reaction. Now, if you say pop quiz or clear your desk and get out a pencil to a one-year-old, they'll look at you like you got three heads. They're like, what are you talking about? That phrase has been conditioned to elicit a stress response. So the question is, why are you stressed out about it? Okay, it's a pop quiz. If you're stressed out because you haven't prepared, well, that's one thing and that's something you can address. If you're stressed out because it's just unpredicted and wasn't in your control, what kind of positive self-talk can you do to counter that anxiety? I studied, I've done all my work. This quiz can only be worth 5% of my grade. Yeah, those are the things I used to tell myself. But helping people understand that they can train their body to react with stimulation or with relaxation through cues. If you think about going somewhere and you automatically get excited, that's your body responding to that cue. If you're driving down, driving down the street and all of a sudden you see a cop car coming up behind you with its lights on and your heart starts to race, that may be a cue for you. You may have associated that with past things. So these are all things that we want people to understand our triggers but also cues that tell their body there's a threat of some sort. Minimizing caffeine and other stimulants is really important, especially if somebody has anxiety issues, especially six hours before bed. Caffeine has a six hour half-life, which means it takes 12 hours to get out of your system. So if you drink, you know, if you go to Starbucks at two in the afternoon, all that caffeine is not out of your system until at least two in the morning, which means that first four or six hours of sleep you're getting isn't as restful as it could be. Try to prevent spikes and drops in blood sugar. I was bad when I was in college. My meals when I was on campus were almost always M&Ms, which is horrible. You know, that's a spike in blood sugar and then it crashes and then I was going back to get more M&Ms to get through the next class until I got home. Don't do what I did. Try to plan meals every three to four hours that have something in them that is, you know, nutritional, not just chocolate. Drink enough water. People who don't drink enough water tend to feel and if they have changes in blood sugar, both conditions may cause people to feel a little bit shaky. When your blood sugar gets really low, you may get really shaky. In people with anxiety, they may mistake this for the onset of a panic attack and work themselves up into a full blown panic attack. Things to be aware of. What is it that sets off your panic attacks? What is it that sets off your anxiety, you know, progressions? Medications, SSRIs, SNRIs have been used to address serotonin and norepinephrine imbalances. Those are typically the first line because benzodiazepines are so easily abusable. But some people may need to be on benzos, at least for a short course, until the SSRIs or SNRI kicks in. That's obviously between them and their doctor. Sunlight, my favorite. Vitamin D deficiency has been implicated in some mood issues, mainly depression, but you know, 15 minutes three times a day, not during the peak hours, doesn't really hurt anybody. It prompts the skin to tell the brain to produce the neurotransmitters it needs to. It says hello, it's time to be awake, time to turn on the factory. Sunlight sets circadian rhythms, which impact the release of serotonin, melatonin, and GAVA. Again, in the morning, you don't want to be groggy. You want your body to say, hey, let's get up and go. So let's secrete the get up and go neurochemicals. In the evening, you want to start secreting the calming neurochemicals. But without the sunlight telling it, okay, it's daytime, it's time to be awake. A lot of times your body doesn't really realize that. I've determined that my rooster doesn't realize that either because he starts crowing at 4.15 in the morning and it doesn't matter what time of year it is, it is not light at 4.15 in the morning. So his circadian rhythms are a little bit off. Exercise. Studies have shown that exercise can have a relaxing effect, but start slowly. If you go in and try to run a 5k your first day at the gym, you're gonna hurt. That's not relaxing. That's painful. You can also find that exercise may increase exhaustion. If you've got a lot of anxiety or some PTSD stuff going on, there is some research that indicates that people with those types of symptoms may have adrenal fatigue. So if they're going in and they're exercising on top of that, they're just potentially making it worse. If exercise makes it worse, if it makes you exhausted, don't do it. Talk to your doctor. Exercise should not make you exhausted, especially if you're starting slowly. But that can also be a clue that something is a little bit wonky with thyroid hormones or adrenal hormones of some sort. Psychological interventions. We want to help people identify and address their basic fears. If you're afraid of failure, you know, none of us likes to fail. But if you're afraid of it, if it terrifies you, let's talk about it. Where does that come from? And how can you deal with it? Because you're going to fail. It's just life. You're going to fail at some things. So how can you look at it from an optimistic point of view as a learning experience or, you know, what can you do with it? Another thing that I ask clients to do sometimes, they're like, I don't know what I can do with it. You know, I'm just I've always been terrified of failure and I don't see that going away. I said, okay, what would you tell your child? If your child came home and they got a D on a test, what would you tell them? You're a failure and you're always going to be a failure? Probably not. What would you tell them about failure? If they try out for the football team and they don't make it and they're all depressed, what do you tell them about that? Encourage them to say take that same compassion that they would use for their child or their sister or whomever and turn it back on themselves because a lot of times they're their own worst enemies. Rejection and isolation. Yeah, you know, we're social creatures so rejection hurts. People don't want to be rejected. However, sometimes it's going to happen. What does that mean when you're rejected? What does that mean if you can't control another person? Oh my gosh, that means you're human because guess what? Nobody can control another person. What does that mean about that person if they reject you? And why do you need that person's approval? This may come down to needing to develop your own self-esteem so you don't rely on others to give you all your validation. It also may come back down to trying to replay something from your past. Maybe your alcoholic father, you couldn't help recover and he, you know, ended up dying of, you know, alcoholism. And then you end up marrying an alcoholic and you want to try to fix them and you're not able to fix them either. You perceive that as a rejection because you're not able to control them. So having people understand what they're identifying as rejection, what that rejection means to them and whether it's important. Some people are going to reject you because they've got stuff and it's more about them than it is about you. Do you need that kind of negativity in your life? Obviously, I'm being sort of flip in in the presentation. There are, you're going to approach that with a compassionate tone with your clients but helping them take a look at what rejection means to them. Loss of control. Locust of control is something that I talk about with my clients a lot of times. The serenity prayer is something that we use in recovery. Grant me the serenity to accept the things I cannot change, the courage to change the things I can and the wisdom to know the difference. Hello, the difference. That tells us there are some things we can't control. I can't control other people and I can't control the weather and you know there's a whole bunch of other stuff I can't control. When I start to get stressed out or angry about something, figuring out if it's something that I even have any control over and if I don't then I've got to figure out how I'm going to deal with it and if I do then I need to figure out a if it's worth my energy to deal with and b what to do about it. Too many times when there's some stuff in our life that's out of control, we try to control the uncontrollable. Trying to move a house 10 feet over the property line by pushing on it with your shoulder is never going to work and that's what basically you're doing if you're trying to control something that you have no control over. That's a big step for a lot of people and especially when it comes to controlling others whether it be their children, their spouse, their boss, understanding that it's not all about them that that person has to want to do whatever it is and the unknown. Some people deal with it better than others some people really don't like surprises. Some people get very excited about them so you know it depends on your client what's going to cause them stress but these are things that you can explore with them. Once they start figuring out what their fears are then helping them move into how to deal with them. Mindfulness and acceptance starts out with observation. How am I feeling? Am I anxious? Am I angry? Am I worried? What label am I going to give to it? Accepting that they feel that way and then letting go of it. They don't have to act on it right then unless it's like an imminent threat. It's also important to identify trigger thoughts because you may not even be in a situation when you're feeling this emotion you may be anticipating it or you may have a trigger thought understanding when you start to feel x-way that that's your anxiety. So what caused it? What trigger thoughts? What things did you tell yourself that started your body believing that there was a threat? And then to stress tolerance it's not always about controlling your anxiety. I know that seems counterintuitive. Sometimes you just have to ride the wave. Sometimes, yeah, like going into a job interview, you are going to be anxious and trying to control it may make you focus on it more, which may make it worse. So riding the wave in and out distract yourself. You don't have to react. You're worried about your job interview or and it's at one in the afternoon. What can you do between now and one so you're not just sitting around thinking about all the things that could go wrong? And then use distancing techniques. Step out of that situation. Put someone else in that situation or imagine you're in a situation yourself like a fly on the wall. See yourself succeeding in the interview. See yourself going through sort of a dry run of the interview. Relaxation skills. First people have to understand what relaxation is. Too many people confuse recreation with relaxation. Sometimes they're the same, but not always. Relaxation is actually slowing your body down, slowing your respirations, slowing your heart rate, reducing the muscle tension. Diachromatic breathing is one way to start. Combat breathing is where you inhale on account of three. You hold for account of three and you exhale for account of three. And you do that a couple of times. What does this do? Well, when we get stressed out, when we get anxious, we start breathing rapidly and shallowly. By breathing in this manner, we're breathing deeply and slowly. So our body goes, oh, there may not be a threat. So the heart rate starts to slow down. The heart rate starts to slow down. The neurochemicals respond going, okay, threat's gone. Meditation. You know, I put in combat breathing because not everybody can or is willing to practice meditation. And you know, there are a lot of reasons for that. Meditation is great if that's something that you can do. A lot of people with generalized anxiety have a really hard time with meditation at first because they can't slow down their thoughts. They're just sitting there and those bees are buzzing all around and they can't clear their mind and then they get frustrated and they feel helpless and it just sets up a bad cascade of events. Start with something slow. Then move on to meditation. Maybe guided imagery. Maybe, you know, there are a variety of different meditation techniques that you can explore with your clients. And then, as I mentioned earlier, cube progressive muscular relaxation. Train your body or have your clients train their bodies to respond to a cube like relax or it's going to be okay. Something that can help them calm down and slow their breathing and go, okay, I got this. Help them work on their self-esteem so they're not looking to others for validation. They're not as afraid of failure because they look at failure as an opportunity to learn instead of a ding against their personal image. Having them examine the difference between their real self, who they are, all their characteristics and who they think they should be. This is an activity I do and group a lot with clients. And we look at the ideal self and go, okay, how many of these characteristics are necessary? And of the ones that are left that are necessary, how can we work on them? Maybe in your real self, you're not very patient and in your ideal self, you're just as patient as I'll get out. How can you work on that? Now, let's work on developing that and problem solving instead of just feeling bad and going, oh, I'm never going to be the person I should be. Let's do something about it. Encourage people to develop compassionate self-talk. Like I said earlier, most people are their own worst enemies. So ask them, what are you telling yourself about this interview or about this date or about this whatever it is that you're worried about? What does it mean about you? And most of the time, they'll tell you something that's pretty harsh. And, you know, turn it back around and go, would you tell your child that if they came to you with the same issue? Encourage people to be compassionate with themselves when they're anxious sometimes you wake up and you're stressed out and that's just the way it is. Being compassionate with themselves and going, okay, it's going to be a long day today. Understanding that and understanding that they're already somewhat keyed up on edge so they don't need to take on extra stuff right now. And then have them spotlight their strengths and figure out how to accept imperfections. And that's a big step for a lot of people. Spotlighting strengths is not as hard but accepting imperfections takes some people a while because they want to be perfect and helping them understand that nobody's perfect may come before they can accept imperfections encouraging them to look at people they care about and have them list that person's strengths and their imperfections and hey, you don't love them any less because they've got some, do you? Cognitive restructuring one of my favorite things address irrational thoughts and cognitive distortions. You can Google those. You've heard me talk about those enough but before we can really start feeling like there's not a threat we have to address these thought patterns. Reframe challenges or threats in terms of current strengths not past weaknesses. So if somebody has been in relationships before maybe they have a long history of abandonment and they feel like they are unworthy of being in a relationship explore with them prior abandonment issues prior times when people have left like maybe when their biological parent put them up for adoption and how that's impacting them now. You know, when you were six months old you couldn't do anything and that had nothing to do with you. Let's look at this current situation what control do you have in this situation? And how are you recreating past issues that don't need to be recreated? When children are small they don't have the same coping skills and things that we think probably shouldn't bother a grown-up you know, likely bother a kid that's okay. They're not supposed to be able to deal with everything but if you're 25 and you're still reacting like you're five we need to look at how are you different now? You're older you're wiser you have other coping skills you have other strengths so instead of reacting this way how can you use your current strengths because you have a lot more to work with now? Create an and I use this a lot in terms of helping people who are going through recovery maybe they lost their children while they were in their active addiction and they're working on getting their kids back and I hear a lot of ambivalence and fear that they're not going to be a good parent and that they might relapse and all that stuff and we start looking at how are you different now than you were six months ago? The stuff that bothered you six months ago you didn't have the tools to deal with what tools do you have to deal with it now? And encourage them to look at how much they've grown have them create an attitude of gratitude and optimism this can be really annoying for some people but I encourage them to try it even if it is annoying creating a list of things they're grateful for or every time they have a negative thought they need to follow it up with a positive thought this really stinks but at least blah blah blah and then acceptance and commitment therapy and I encourage you to go online and look at on the YouTube channel you can Google the ACT matrix and there are a bunch of videos on how to use this I'm just going to go over it real briefly here In the ACT matrix he basically talks about how on the top of the axis it's five senses the bottom of the axis is mental so the we're looking at how you're experiencing things bodily you know through smell touch you know physical reactions and how you're experiencing it mentally so something is going on and you want to consider how you're feeling it in your body and how you're thinking about it and then you ask yourself is this reaction moving me toward my goals or away from my goals and why and it gets a lot more complicated than that but when clients start getting really stressed out and they stop and they go okay I'm trembling I'm sweating I can't think straight I'm having a difficult time putting one foot in front of the other I'm terrified that this is going to go south and they say okay now is this moving me toward my goal of getting this job or are all these reactions and negative thoughts moving me away pretty simple answer it's a quick check up is it move is this whatever this is that's going on moving me toward or away from my ultimate goals recreation and relaxation you know I said people sometimes confuse the two recreation is important too there's always going to be stuff that you can do there's always going to be stuff in your inbox there's always going to be chores that need to be done baseboards that need to be touched up whatever you know goes on at your house there's not always going to be time when your kids are small there's not always going to be pretty days outside where you can go out and not sweat the moment you walk out of the door so make a list of fun things and sort of schedule it in make sure you're doing something fun at least a few times a week I try to encourage people to do something fun every day even if it's just for 15 minutes because this increases your happy chemicals it increases relaxation because when you're happy you start to relax and it also generally will increase your positive attitude and willingness and ability to deal with other people which takes us to social interventions a lot of times people with high anxiety have so much such a low self-esteem and they're so worried about rejection but they don't identify their own needs and wants they don't even much like themselves so first they've got to improve their relationship with their self identifying what do they need in a relationship what do they need in the here and now that whole mindfulness stuff and then how can they be their own best friend what would you want your best friend to do for you right now well do it for yourself if you would want your best friend to take you out for ice cream well go out for ice cream then help them understand the difference between internal and external validation encourage them to identify why they are good enough and why they don't need anybody else to tell them they're okay and encourage them to be compassionate instead of saying well that was a real stupid thing to do when they make a mistake go well yep I made a mistake there guess I need to learn from it or if they do say something like that was a stupid thing to do follow it up with how can I not do that in the future once they're compassionate with themselves and once they know what they need once they know what they want once they are able to set their boundaries and go this is what I like and if you don't like it help tiddlywinks then they can start working on healthy supportive relationships and developing assertiveness skills it doesn't mean you always get your own way you know five friends want to go out to dinner and you want to go to Italian and three of them want to go for southern cooking and you know whatever you may not win you said what you wanted and then you can make the choice at that point are you going to go with them to wherever they decide to go or are you going to go by yourself for Italian that doesn't necessarily mean that you're throwing a hissy fit being assertive means taking care of your own needs most of the time people are probably just going to say okay we'll do Italian next time compromise describe the ideal healthy supportive relationship and separate the ideals from the reels relationships you know we create these images you know that we see on television that we read about in books that we create in our own mind of this perfect relationship but they don't exist so what is it that you need in a relationship and how can you nurture that in the relationships that you've got and or where can you find that in people that you may not have met yet maybe there are hiking clubs or somewhere where you can meet people with similar interests that share similar values New Harbinger has a bunch of resources that I really like Matthew McKay and Edmund Born are probably my two of my favorite authors from that particular publisher the anxiety and phobia workbook ACT therapy for anxiety the anxiety food solution does talk a lot about some of the stuff we've discussed in prior presentations about having a healthy diet three colors on your plate and eating the foods to provide the building blocks so your body can do what it needs to do coping with anxiety 10 simple ways obviously that's one of those sort of cliff notes books but it gives people somewhere to start and I really really like the 30 minute therapy for anxiety because it provides tons and tons of different tools for people to try out takes 30 minutes each day they try it out find the ones that work don't use the ones that don't encourage your clients to go online they can get the Google book preview if they want to look and see if any of these seem like they'll fit for them obviously we're not going through a bunch of techniques in this particular course so I wanted to make sure that you had resources you could reach out to make sure your clients had the resources that they needed so thinking about the past week thinking about what the situation was that caused the anxiety and you can ask this of your clients too if you go over some tools and techniques for dealing with anxiety say what was the situation that caused you stress what did you do how effective was that in the long term if you ran out screaming and crying got you away from the situation but long term probably didn't solve anything with this new information about what causes anxiety and maybe what they need to look at what could they have done differently and would it have changed the outcome have them identify two or three things they can do to address their anxiety and talk about how are they going to integrate it into their daily routine um it's important to take it that further step they can say I'm going to start journaling I'm going to start exercising and I'm going to start doing something else which is wonderful but I want to know okay how when are you going to do that and how because if you don't make them play the tape all the way out follow it all the way through then a lot of times it gets dumped on the how anxiety is a natural emotion and it serves a survival function it's saying fight or flee excessive anxiety can develop when somebody doesn't have enough sleep when they don't have the building blocks to make the neurochemicals they need because there's a nutritional imbalance other causes of neurochemical imbalances failure to develop adequate coping skills so they're constantly telling theirself the world is bad and threatening cognitive distortions that again generally tell the person the world is bad and threatening or you're going to be alone forever whatever the case may be and low self-esteem or a need for external validation if a person constantly is looking for other people to tell them they're okay that's very anxiety provoking because what if nobody's there if nobody's there to tell you you're okay are you okay it's kind of like if a tree falls in the woods and nobody's there to hear it does it make a sound recovery involves improving health behaviors identifying and building on current coping strategies addressing those cognitive distortions and developing healthy supportive relationships with themselves and others so a question comes in about the internet and social media and how it plays in with anxiety oh wow that there's volumes there social media well the internet and social media can be a great resource for people with anxiety to join support groups to talk with others who share similar anxieties and phobias but it's also a place where there's a lot of disinhibited discussion which is a long way of saying people can be really ugly and nasty so if you already have a low self-esteem and you're looking for validation you're at least equally as likely to get criticism as you are to get validation online so the internet can be a dangerous place but so can anywhere it's about being cognizant of where you're going and what sort of situations you're putting yourself in I mean I think of Facebook is basically like a whole great big social gathering tea party get to know you sort of thing and I don't like those in face to face and I really don't like those online either but there's very little control there's a lot of people talking about stuff and you get half of conversations so it can be very confusing and anxiety provoking for a lot of people to be online if they can find safe places definitely definitely go there and but be aware that it's not always any place that was once safe is not always necessarily going to be safe so they need to know how to protect themselves um emotionally from potential attacks from others motivational interviewing is useful in my opinion for just about everything because people are not going to start addressing the things that are causing their anxiety their thought patterns unless they're motivated to address them and they're motivated to change them so motivational interviewing really says okay what are the benefits to holding on to this negative thought pattern and what are the drawbacks you know going back to my favorite decisional balance exercises encouraging people to look at you know if you let go of this anxiety what might be different and having them increase their own motivation it's not always going to be a picnic and we talk about internal um internal validation and not worrying about what others have to say that's not always easy with motivational interviewing we can help people bolster their resolve to not let other people's opinions necessarily influence how they feel about themselves so yeah I think cognitive behavioral motivational interviewing dialectical behavioral interventions are all helpful a lot of it depends on your clients some may respond better to more experiential and group work others may respond better to cognitive behavioral it's just I let my clients lead again by asking them in the past when you've done something that has helped what has it been and that gives me an idea about what approaches might work with them any other questions