 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 on using a strengths-based biopsychosocial approach to addressing anxiety. Try saying that fast three times. We're going to define a strengths-based approach and a biopsychosocial approach and we're going to look at how they work together. And this is one of the courses I do for sort of family education to help clients and their families start to see what it is that they're already doing and what they can build off of so they don't feel like they're reinventing the wheel and so they can start picking up things that they might be able to start doing to feel better already. So they walk out and they say, oh, okay, some of this is starting to make sense. So why do clients care and why do we care? Well, anxiety can be debilitating if we're seeing somebody for fibromyalgia for chronic pain for depression for something besides anxiety, but they also have anxiety. It can cause a lot of problems in progression of their treatment plan because they are exhausted because they have difficulty concentrating and it's a major trigger for addiction relapse if they happen to have that issue. Increased physical pain. Think about when you get anxious or sometimes we just call it stressed, but you know, it's all along a continuum. You know, where do you feel physiologically feel your stress? I know I feel it in my neck and my back. Some people feel it in their low back. I'm lucky. I don't feel it there. Some people feel it in their gastrointestinal area. You know, it can really exacerbate Crohn's disease and things like that irritable bowel syndrome and can cause a lot of pain. So increased physical pain. It can cause sleep problems. When people are anxious, they're in a state of alert. They're in that fight or flight mode. Maybe not super high, but they're in that mode. So it's going to keep them from being able to get as much good quality sleep. If at all, it's going to be a keep them a little hyper vigilant even when they're sleeping possibly. And again, think back to a time when you were stressed out or anxious about something. What was your sleep like? Did you dream a lot? I know when I'm stressed out or anxious about something, I tend to have really weird dreams and they make sense retrospectively. But, you know, it happens. So we want to have people be conscious of the fact that anxiety will impact their sleep. And when they start getting sleep deprived, then the neurotransmitters get even further out of balance. Their body perceives them as being fatigued, which it perceives as a threat. So it again intensifies that threat response system or HPA axis and anxiety is a major trigger for depression. This is something we really need to get across to clients. Some clients can have simple depression. Of course, it exists. Many clients also have concurrent anxiety. They've been revved up. They've been sleeping poorly. They've been doing all this for so long and they're not getting relief. So they start developing a sense of hopelessness and helplessness. The fatigue is setting in the lack of motivation. All those things that would characterize clinical depression. So we need to treat anxiety in addition to whatever else we're treating. And many times, whatever we're doing for helping clients with depression or bipolar or addiction is also going to help address the anxiety issues, but we do need to make sure we're checking in with them if they've got some underlying anxiety. So strengths based just to kind of recap, focuses on guess what people's strengths and they may look at you like you're crazy when you say we're going to focus on working on your strengths and they're like, I'm here because I feel hopeless and helpless. What strengths do I possibly have? Well, that's where it comes into the assessment and you're really helping people take a good look at wow, you're a survivor. So strengths make it easier and more effective for people to start their treatment program because they're building on something they already have. For kids, for example, think about as they go through school, they start out when they're in, you know, primary school learning basic math and then they move up to starting to do a little bit of algebra solving for X. I mean, it's nothing huge and then they build on that strength that they're good at that and they move into full scale algebra. If you don't have strengths in math, you're probably not going to continue on a mathematical track to where you're taking differential equations and advanced calculus because that's not your strength. If it is your strength, you're probably going to continue to build on it and it's going to be easier than saying, you know, after you've taken five years of math, hey, guess what? I'm going to be an English major. Okay, well, you got to start all over again and reinvent the wheel and start with English 101. So we want to build on the strengths. Now, just like for the kid in math class, what you learn in primary school is not going to help you very much to solve calculus questions. Well, we'll just go with algebra because algebra has fewer letters in it and it still has some numbers. But when they get to algebra, you know, when they're solving for X, for example, we say, okay, we're doing, we're still doing pluses and minuses here. We just happen to have this little letter that's in the way. So we're building on the strengths that they already have. They already know how to do basic math. Well, we're going to add another step to it or skill to it and build on that. Strengths based approach helps people identify how they're already trying to cope and builds on that. So we ask them when you're not anxious, what's different? We ask them when you do get anxious, what helps you calm yourself down? Even if a little bit, maybe they go from being a nine or a 10 to a seven and they want to go to a two, but they're able to go from a nine or a 10 to a seven. So okay, something is working there. What can we do to help them come down the other five points? Two types of strengths that we talk about their prevention and resilience strengths and preventing vulnerabilities. However you want to phrase it, but we talk about what people do on a daily basis to stay healthy and happy. Think about a time when you were tired or when you were sick or when you had too much going on and you know, how did that affect your mood? Physiologically, if we're not on our A game, then emotionally, we also may be more vulnerable to anxiety, depression, anger, etc. So encouraging people to start understanding the mind-body connection. When they're in pain, how does it affect their mood? When they're, you know, taking certain medications, how does it affect their mood? It's important for them to be aware of that and do what they can to keep a healthy body machine. Cause we got to have this functioning in order to get it to output the information or the emotions that they want. A lot of people are not averse to looking at their health and wellness practices. And I find that a lot of times this goes a long way. Intervention and coping strategies are the other types of strengths that we look at. And again, in the past, when you felt this way, what helped you feel better? If they say, I've never felt this way before, you know, then we ask, what about somebody you know when they get anxious? What do they do and what helps them build on some strengths that they may have observed? So they have some observational learning to build off of. But they also know what makes it worse and it's important to ask them this, not just what makes it better? Cause we want, we definitely want to do more of that, but what makes it worse? Well, we want to do less of that. So if it makes it worse, when somebody's anxious and they drink and it makes, tends to make their anxiety worse in the long run, well, you probably want to avoid that skill. If you know, well, you can, you can speculate about what will make it worse, but when they identify things that make it worse, we want to make note of that and encourage them to minimize those things. And then we move on to talking about what a biopsychosocial approach is and too often even clinicians that I work with, they think of biological as just general, you know, are you going to the doctor and getting your annual physical? Well, that's part of that is an important part because hormone imbalances and thyroid hormones, sex hormones and certain conditions, physiological conditions can cause mood symptoms. So no doubt it's important for that people to go get their annual physical and or go to their doctor if they start feeling depressed or anxious all of a sudden. So they can get some blood work run around here and you know, I came from Florida where it was sunny all the time. And when I moved out of Florida, I realized that it's not that sunny a lot. And I realized that I am also a little bit sensitive to lack of sunlight. You know, I can get predisposed to seasonal effective disorder. And that's just being aware that I need to get outside and get some sunlight and get my vitamin D levels up. And when I lived in Virginia, the doctor I had up there said, you know, most people up here, especially during the spring, early spring, all of winter and most of fall, their vitamin D levels are deficient because they're not getting outside at all. A ton of vitamin D receptors are in those areas in our brain that are responsible for mood. They don't exactly know how vitamin D plays a role, but they know it does. So, you know, we want to look at that. We want to look at people's nutrition, neurochemicals that are responsible for our mood and our focus and everything come from nutrition. Well, we're not going to recommend diets for anyone because unless you're a registered dietitian or a medical doctor, we can't educate them that nutrition is important in order to help their body function just like you wouldn't drive your car without oil in it. You know, you want to make sure that you're getting good nutrition to allow your body to do what it needs to do. We talk about the importance of sleep and good quality sleep and some people will say, well, I sleep a lot and I'm just I never wake up. Well, then we want to look at the quality of sleep and also maybe resetting those circadian rhythms. So we want to look at sleep hygiene with my clients. I do an entire group on sleep hygiene because most people have really poor sleep habits and I'll admit I don't have the best but I have better than most if you if you want to look at it that way. And that's what I'm asking people to do. I'm not asking them to be perfect. You know, they may not be willing to give up this one thing or change this one thing, but any changes they make that are positive are going to be helpful in their recovery and encouraging people along with, you know, nutrition and getting that vitamin D in there nutritionally, but also to get out and get sunlight. Sunlight triggers your brain to say stop making melatonin. It's time to be awake. Let's secrete some cortisol and let's get up and get up and go cortisol levels peak in the morning and gradually go down throughout the afternoon. Now some books that you read say that cortisol levels, you know, will peak again and then drop a couple of times. So it's not a steady like this. It's more of a undulating, but it's important for people to know when their energy levels are highest, but sunlight can help set your circadian rhythms so your body knows when it's time to sleep and it knows when it's time to eat. Psychological interventions include mindfulness, distress, tolerance, coping skills and cognitive restructuring. And we're going to talk a little bit more about each of these as we go through it and socially improving self-esteem and your relationship with yourself is really important and a lot of people when they think biopsychosocial, they think relationships with others and that's true, but we can't have good relationships with others very easily unless we've got a decent amount of self-esteem and a decent relationship with ourselves. We know who we are. We know what we want in general. We know what our opinions are in general. We're able to set boundaries, etc. and improving relationships with healthy supportive others. So then we move into talking about what is anxiety? You know, we've talked about, you know, strengths-based approaches and what we might be looking at for recovery, but what is anxiety? And it's important for clients to understand that it's half of the fight-or-flight response. You know, if you're fighting, you're angry generally. If you are anxious, you're probably fleeing, but what are you fleeing from? It's an excitatory response. So it's going to keep people revved up. It's going to make your heart beat faster because your brain is saying there's a threat or there may be a threat. So you need to be able to run. You need to be able to fight. The function is to protect them from possible danger. And I encourage instead of clients, instead of getting angry about the fact that they're feeling anxious to thank themselves. Just say, you know, thank you, brain. Thanks for the heads up. I will check it out. And I've used this example a bunch before, but it just is so appropriate. Fire alarms. You know, we have a fire alarm in our house and sometimes the fire alarm goes off for no apparent reason. Sometimes it goes off when the windows are open and the wind blows particularly strong. I don't know why. Sometimes it goes off because I forgot something in the oven. But when it goes off, it doesn't necessarily mean there's a fire. It could mean, you know, in the case of the kitchen, it could mean that there possibly will be a fire if you don't do something or it could mean nothing at all. So anxiety is the body's response based on past learning that says, okay, in the past, this meant that there might be a problem or that this meant that there might be danger. So the body registers anxiety and it says, okay, get up and do something. Check and see if there's a problem. That's all it's saying. That's all anxiety is designed to do. It's not meant to solve anything. Then you check it out and say, is this truly a problem right now? Anxiety is good. It's a normal feeling and we want to, again, embrace it just like anger. It's there to protect you because your brain thinks there's a possible danger. And I just keep emphasizing with clients that it's not always right. It's a possible danger. It's a warning signal. Anxiety can become a problem when it's overly intense and uncontrollable. So normal anxiety here and there, totally normal. It can become a problem if people overgeneralize. So any situation similar to this, maybe they had a bad experience when they were public speaking, when they were in high school. And so now any time they have to speak in public, they develop significant social anxiety because of whatever that happened when they were in high school. Okay, that's, you know, overgeneralization and it's having a significant, potentially negative impact on their life. So, you know, that's when it becomes a problem. It can become a problem if the person has poor coping skills because then they take that anxiety and they don't know what to do with it and they just hold on to it and they worry. And they fret, but they don't know how to hand it off. If they use emotional reasoning or cognitive distortions, it can, anxiety can become uncontrollable because if every time they feel anxious, they look for a reason to be anxious. You know, I feel scared. So this must be scary. Well, if their threat response system goes off and every time it goes off, they say, I feel scared. So this must be scary. They're going to be anxious a whole lot of the time. So it's important for them to be able to separate from that. And then biochemical issues, nutrition and hormones are two big ones that can kick in there. When people's blood sugar gets low, a lot of times they will start to get kind of shaky. And when the blood sugar gets low, the body secretes cortisol, your stress hormone, in order to make your body release glucose into the blood. So that stabilizes it. But sometimes when people start to get shaky, they don't know what's going on and they feel like they're having a panic attack or they get anxious and they're trying to figure out where it's coming from and make sense, sense of it. So helping them understand that. Hormones. When people start going, when women start going through perimenopause and menopause as the hormone levels fluctuate, they've shown that it can't affect heart rate and some people's heart rate will increase 18, 20 beats a minute for a while during a hot flash, so to speak. And some people can misassociate that with there must be a problem. And a lot of times when your body starts doing something funky and you're looking around going, I don't know what I'm stressed about, then people start getting stressed out that they might be having something going wrong inside, that they might be having a heart problem or whatever. And then they start worrying about that. They're trying to understand why their body's doing this. Which is again, why it's so important to have an MD involved in the process so they can look at anything that might be causing some of the symptoms. Anxiety can be caused by excess serotonin, excess norepinephrine, which is your motivation chemical or one of them, or excess glutamate. These are norepinephrine and glutamate are both excitatory neurochemicals or too little GABA. Now glutamate is your excitatory neurochemical and it's broken down in order to make GABA, which is your natural Xanax. So if you either don't have enough glutamate to make enough GABA or if you have enough glutamate but you don't have all of the other things needed in order to break it down to make GABA, then you could have somebody who has anxiety. If they don't have enough serotonin, serotonin is one of our common chemicals. It can cause anxiety, but according to a couple of studies that I looked at and they're cited in the class, having too much serotonin can also cause anxiety. So we need to figure out what's going on. One of the best ways to do that is help people get their body as healthy as possible because the body wants to maintain homeostasis. I mean, the body wants to do what it's supposed to do. So if we make sure everything, it has all the tools and stuff that needs in order to function, it's going to naturally rebalance itself and then you can figure out kind of what's wrong if there's anything wrong after that. Some studies indicate that as many as 80% of adults have a neurochemical imbalance due to lifestyle factors. So poor nutrition, sleep problems and excessive chronic stress are the three biggies, but you can also look at other lifestyle factors that may be contributing to it. The question comes in, is it an oversimplification to assert that this anxiety response is the root of trauma responses like PTSD? PTSD as well as grief both have anxiety components to them. And PTSD, I would add on that, is a protective reaction. When you look at the symptoms of PTSD that people have all the way from emotional numbing to hypervigilance and intrusive memories, if you look at it from a functional perspective, it's the body's way of trying to protect itself from encountering that again. So would I say that PTSD is related to anxiety? Yes. Now, if I remember correctly, the DSM-5 took PTSD out of the anxiety related disorders, but there's definitely some overlap in the symptomatology. We need to ask ourselves or have clients ask themselves what's causing the neurochemical imbalance? You know, we know, you know, if you're here and you've got anxiety, then there's probably some stressors going on out here that are triggering the stress response. And you may also have a neurochemical imbalance that's keeping and we need to look at why. You know, why is your norepinephrine staying high? And it could be from stressors out here. It could be from biological factors. It could be from a lot of things, but we need to look at it. The example that I use sometimes is of a water heater. When you have your water heater and you have it set on 120 degrees and you take your shower and you know where to set the dial and it's perfect and you've got it. And then all of a sudden, you know, somewhere around late December, early January, you get in the shower and you turn it on and you put the dial right where it's supposed to be and you're like, oh, this is way too cold. So is the water heater, the water heater is not heating the water enough. So what's causing that problem? Do we need to turn it up because an element is out, you know, inside or is it because the garage where the water heater is has gotten too cold and so now the water heater is having to work harder. So is it an external factor or an internal factor or maybe it's both? In order to get that water temperature to where you want it to be, you have options and, you know, most people will crank up the water heater. Okay. Well, that's one way of solving that problem, but then if it gets colder, you're going to have to crank it up more and eventually you're going to have it cranked up as high as it'll go. So you want to look at what's causing the water to be too cold. You know, maybe it's not that you just need to crank it up. So we want to look at do we want to just tell people and, you know, you know how I feel about meds that take a pill and it'll help balance you out. Well, we know that that doesn't work in the majority of people. Only about 36% of people experience relief from medications. Now, it doesn't mean that medications can't help more people feel better, but it means, you know, they may not stay in long enough to find the right concoction. But okay, so you start medicating somebody, but what caused that imbalance to begin with? You know, is it something situational? Is it something biological? Is it something that always existed that needs to be medicated? So we want to look, help people look at that to try to figure out what needs to happen in order for them to feel happiest. Generalized anxiety symptoms can include persistent worrying or obsession about small or large concerns that are out of proportion to the impact of the event. So people just fretting about everything. Inability to set aside or let go of worry. And this includes people who are trying to do thought stopping and they're trying to not think about it. Not just people who are obsessed or consumed with their thoughts, but people who are trying to set it aside and they just don't feel like they can. Inability to relax, restlessness, feeling keyed up on edge, difficulty concentrating, distress about making decisions for fear of making a wrong decision, carrying every option in a situation all the way out to its possible negative conclusion. So this is another one that, you know, I ask clients, do you do this? Whenever something happens, do you look at what, how could it possibly go wrong? And difficulty handling uncertainty or indecisiveness. So, I mean, we are familiar with most of those. People also tend to have, you know, sleep changes in sleeping and things like that. Other physical signs and symptoms can include fatigue, irritability, muscle tension or muscle aches, trembling, feeling twitchy, being easily startled, trouble sleeping, sweating, nausea, diarrhea, irritable bowel syndrome, headaches. You know, there's a whole range of things here and a lot of these symptoms overlap with PTSD and depression as well as grief. So, helping people kind of ferret out what's going on here. With kids though, and I put this in here because kids demonstrate things or manifest things differently than adults do a lot of times. So we want to look for kids about or look at kids who are having difficulty with excessive worry about performance at school or sporting events, being on time, you know, punctuality. If they're excessively worried about earthquakes, nuclear war or other catastrophic events. Now, you know, there are things that they have every, you know, it totally makes sense to be worried about if there's a hurricane coming their way and they're worried about that, totally understand that. But after the hurricane has passed and if they continue to worry that another hurricane is coming and it starts disrupting their life, then, you know, they may need to intervene. A child or teen with generalized anxiety disorder may also feel overly anxious to fit in, have a lot of anxiety about rejection and need for approval. They may be a perfectionist. So whenever I see these symptoms, I try to ask myself and ask the client, you know, what happens if you're not perfect? Many times it comes down to I will lose so-and-so's approval. So there's abandonment anxiety issues to be dealt with lack of confidence. They strive for approval and require a lot of reassurance about their performance. A lot of times children or teens with generalized anxiety also have low self-esteem and rely on others for external validation, not always. And yes, you know, the situation right now in the schools with gun violence and, you know, not even just in the schools, but with the violence that's going on in the world. Yeah, it increases youth's anxiety. Is that anxiety overstated? You know, it depends on the child. We want to look at how is it impacting their life? Should they be a little bit concerned? You know, I would say that's a perfectly normal reaction. If it's to the point where they can't go to school, where they can't concentrate, where they're, you know, getting sick all the time because of their anxiety, then obviously we need to intervene and help them focus on what parts of it they have control over. But yes, I mean, there's a lot of anxiety in youth. Biological interventions, like I said, a lot of clients are really open to intervening here because it seems relatively easy, relatively painless, and it's usually something they can start doing today, the day that they learn about it. So encourage them to look at, you know, if your body thinks there's a threat, try to figure out why. You know, are you run down? Are you tired? Are you not getting enough of certain neurochemicals? Supportive care. Encourage them to create a sleep routine to help their brain and body rebalance. And it's not just about getting deep sleep. They need a certain amount of both deep and light sleep because different things happen during each phase of sleep. So they need good sleep. Do the same three things each night before bed. That helps cue your body in just like you did with kids. They would come home from school. They would eat dinner. They would take a bath. They would read a book. They would go to bed. You know, it's da-da-da-da and their brain started saying, okay, so by the time they were finishing dinner or getting into the bathtub, the brain was saying, okay, time to start making melatonin so we can go to sleep. That helps set circadian rhythms. It helps the body know when it's supposed to secrete the sleep chemicals. It can help repair adrenal fatigue. And we want to look at that HPA axis, the hypothalamic pituitary adrenal axis. And when it is, that's your threat response system. And when it is always on, it gets worn down. You know, it gets tired. So we want to allow that system to relax and good sleep is one of those ways. And obviously, if you're getting good quality sleep, energy levels tend to be improved as does mood. Nutrition, encouraging clients to minimize caffeine and other stimulants, which cause the body to dump cortisol. You know, if you're telling your body to dump the stress hormone, then yeah, you're probably going to feel a little more stressed. Try to prevent spikes and drops in blood sugar. This is one of those things they probably need to, you know, I don't want to make recommendations for any clients if they're diabetic or if they have certain nutritional recommendations, you know, there's all kinds of things that could be an issue, but it's important for them to figure out how they need to manage their nutrition in order to keep themselves from getting really low blood sugar where they start feeling shaky. And encourage them to drink enough water because lack of sufficient water dehydration can cause foggy head of this difficulty concentrating and anxiety in some people. When you get really dehydrated, your heart will start beating faster. Medication, people can take SSRI's selective serotonin reuptake inhibitors and SNRI's selective norepinephrine reuptake inhibitors have been shown in higher doses to be effective with anxiety. Benzodiazepines, not my favorite because they're highly addictive, but this is your Xanax and your Valium. Those can be useful for some people. And Bosporone is another one that's not exactly a benzo and it's not a serotonin reuptake inhibitor. It's just kind of in its own little world, but it has been found to help significantly with anxiety in people and it's not addictive like the benzodiazepines are. So it's an option for people to consider who have, especially who have a history of addiction issues who don't want to look at something more sedating like one of the more sedating SSRI's like Paxil or something even stronger like like Saracwil, which is an atypical anti-psychotic. So there are there are a variety of options out there to people is my point and if one doesn't work, all hope is not lost. Sunlight, vitamin D deficiency is implicated in mood issues. Sunlight prompts the skin to tell the brain to produce neurotransmitters and it sets circadian rhythms, which impact the release of serotonin, melatonin and GABA. So sunlight is important and it doesn't have to be a bright sunny day. You know, if you go outside, there's enough sunlight coming through the clouds most of the time that you're going to get the effect that you need and it's not a lot. They say 15 to 30 minutes a day. So think about how much time it takes you to walk to your car to drive home or to drive to the office to walk to your car and to drive home. That's probably 30 minutes. If you're doing it during the sunlight and when days are shorter, like during the winter, I remember driving to work when it was dark, working inside in an office that had no windows all day long and then leaving when it was dark and my body just kind of didn't know what to do with that. So if you're in that situation, especially during the winter, it's important to get out during the day at some point so your brain can see the sun and go, oh, it is daytime. Um, light therapy can also help with anxiety and depression and it's not any old bulb that you can buy at Home Depot. There's a special spectrum that it has to be in in order to be bright enough to have the effect that it needs, but you know, you can get them and it has been demonstrated effective in studies and exercise has shown that it can have a relaxing effect. You're thinking, yeah, right. No. Over exercise, you know, going in there and keeping your heart rate, you know, up for 40 minutes, that can be exhausting, but even just going out and walking the dog can have a relaxing effect and exercise, especially if you can get your heart rate up a little bit for 20 to 30 minutes has been shown to regulate estrogen as well as increase serotonin secretion. So, you know, things to consider. Talk with your clients about what exercise is. It doesn't have to be going to the gym. It can be cleaning your house like a mad person. It can be mowing the lawn. It can be walking the dog or playing with the kids. There are a lot of things that people would think, you know what? I really don't mind doing that. It's just getting up and getting your body moving for 20 to 30 minutes kind of at a shot. So all the neuro neurochemical processes can take place that need to psychological interventions. Now, if you remember from dialectical behavior therapy, you have the two acronyms accept and improve except meaning accepting. It is what it is radical acceptance and that stands for activities contributing comparisons emotions by the opposite emotion pushing away which is thought stopping thoughts using cognitive distractions like playing Scrabble or doing something that occupies your brain cognitively and gets you out of that emotional mind and sensations which can be loud music holding an ice cube taking a hot shower and imagery or improve improving the next moment you accept it is what it is. Now, how can I improve the next moment? You know, instead of fighting with how you feel because you feel how you feel how can you start making it better you can use imagery find meaning in it pray do something that's relaxing focus on one thing in the moment take a mental vacation and or give yourself and or get some encouragement. So we're going to talk about those things but you know you can Google dbt and acronyms or dbt accepts and improve and you can get these online. Those are handy things for clients to have around so they can identify what they do but we're going to talk about them kind of tangentially here. So the first step for psychological interventions is mindfulness and acceptance clients need to start observing how they're feeling because a lot of times our clients who have anxiety let that anxiety get up here before they even note it there. They are so used to feeling this low level of stress and anxiety that they don't even register that they're getting anxious until they're way up here on the scale. So encourage people to regularly stop and observe themselves you know how am I feeling when they start feeling anxious just to accept it not I shouldn't be feeling angry not I should feel differently just I am anxious right now it is label it I'm feeling anxious and let it go and you know feelings can come and go just like thoughts can come and go just like clouds in the sky if you've ever made a cloud animals which I'm almost 50 and I still do it but whatever you see this cloud animal and you see or whatever image you see in the in the clouds and slowly it just kind of morphs away and that's what our feelings can do as well you know we can if we don't struggle with it if we don't try to hold on to it and remember all the reasons were supposed to be anxious. Our feelings can just kind of gently morph away. So label it and let it go and watch it just kind of blow away identify trigger thoughts becoming mindful of the types of thoughts that people have when they get anxious. I'm going to fail at this I'm going to make a fool of myself I'm going to or it's going to whatever their self their anxiety provoking self talk is if they can become aware of those you know keep a log for a week or so of their trigger thoughts and then develop back talk for each one of those trigger thoughts you know if you say I'm going to fail the first responses who says how do you know you haven't done it yet how do you know you're going to fail you don't know what's going to happen next focusing on you know if they have that trigger thought I'm going to fail at this. Okay well let's look at other times in the past where you've been afraid you're going to fail and it turned out okay so let's look for exceptions to when you fail to kind of provide some evidence that it's not a done deal that you're going to fail you know there's good hope that you'll succeed and encourage people to differentiate between expectations and current reality. If you've been in a situation before where it's been dangerous for example when you're little your parents say don't talk to strangers stranger danger stranger danger and when you're little yeah you know strangers can be dangerous and so can people you know but that's a whole different topic but when you get to be older you know if you're still think you're 25 and you've graduated college and you're still thinking stranger danger that's not the current reality I mean unless you're in a really bad part of town or something you need to remind yourself that you know most of the people walking around around you and Target or Walmart or wherever you are probably don't even notice you're there so your expectation that strangers are dangerous hasn't been checked maybe since you were knee-high to a grasshopper when strangers were dangerous but now that you're older the current reality is you're grown up you got this strangers aren't near as dangerous you know especially like in at the grocery store at the mall or wherever basic fears that people get worried about anxious about fear of failure so encourage them to explore the dialectics how can failure be bad and good at the same time and you know the answer to this one you know it teaches you you learn how not to do it and failure also teaches you that you can try again and it also shows you that you had strength to get outside of your comfort zone so there are a lot of good things about failure and so encouraging clients to explore the dialectics yes nobody likes to fail that's just the way it is nobody likes to fail if you take a pro athlete and they go out there and they lose the game are they going to be bummed about it yeah however what are they going to do they're going to go back they're going to review the game tapes and they're going to do it differently the next time so explore the dialectics how can what are the how can both things be true it's a bad thing but it can also be a good thing and go out and seek encouragement give yourself encouragement for having the courage to go out and try to try to do something that you weren't guaranteed a success at but potentially solicit encouragement from your social supports it's easier to do things if you're afraid of failing it's easier to do things if you've got people cheer leading you from from behind when I defended my dissertation my husband came and sat in the back of the room while I defended and it was nice just to have the moral support there you know it helped me get through it rejection isolation is something else that people fear you know we don't like being rejected nobody does whether it's for a job or to get into a certain school or for a relationship it hurts it stings a little bit helping clients learn how to depersonalize from that and looking at you know you've made relationships in the past or you've gotten jobs in the past so look at the times that you've succeeded at this or you've been accepted and you know let's build on those strengths what have you learned from this particular rejection you know again exploring the dialectics what could be the positives from this maybe it'll give you more time to spend with your other friends or maybe there's another job that you don't know about that you can apply for in in six months or something there's a saying that you know when one door closes another another door opens but those hallways they're a bitch so getting through that hallway that dark hallway until that other door opens can be a little anxiety provoking but encouraging people to again seek encouragement from their social supports look at how they've handled rejection in the past because we've all been rejected even if you're talking to an eight-year-old they've been rejected before loss of control and the unknown you can't predict what's going to happen five minutes from now let alone five hours or five months from now and that can be really freaky for some people so encouraging them to focus on one thing in the moment what can I do now if I want to get this promotion if I want to you know stay in this marriage if I want to have healthy productive kids whatever it is you want that you're fretting about you know that's way out here what can you do right now to help you move closer to that goal focusing on one thing in the moment instead of worrying about that you know focusing on worrying about whether you're going to make the cheerleading squad well I don't know what's going to happen then but what I can do now is I can practice my routines and encourage people to think of prior experiences where they approached something that they had no control over or they didn't know how it was going to turn out whether to try out or an interview or whatever and how did they handle it you know how did they deal with that I remember when I was pregnant with my son the initial test came back that you know he might have Down syndrome and so we had to go in for other testing and you know I was out of control at that point I had this little thing and I couldn't fix it I couldn't you know make it better as I wanted it to be so I had to figure out how to deal with that so encouraging clients to look at times in the past and maybe they don't have an example like that but maybe they can talk about moving or starting a new school when you start college for example or even when you go from middle school to high school there's a lot of unknowns when you start a new school even if you're going with your same cohort there's a lot of unknowns so how do people handle that distress tolerance it's not always about controlling your anxiety and we don't want to control it we want to figure out how to improve the next moment acknowledge it accept it distract don't react that's one thing you can do because some things are just they're going to make you anxious I don't like getting shots I'm terrified of needles so whenever I have to go in to get a shot I'm like oh and I can fret about it or I can choose to distract myself because fretting is not going to do any good and again I think about a time in the past when I went to the doctor and I got a shot and I didn't even know she gave me a shot she was that good and reminding myself that I'm using emotional reasoning and get out of that so distract yourself can help you know before you go up and do a presentation or try out for something is going to be anxiety provoking because you're putting yourself out there you're taking a risk it's the unknown you don't have control over it once you're out there you don't have control over the judges and you're risking rejection so there's a lot of stuff right there should you is it reasonable to expect somebody to feel anxious sure but does dwelling on the anxiety do any good now we need to encourage them to distract you know do something to keep themselves occupied until it's their time to try out ride the wave and we've all heard this you know analogy that emotions come and go like a wave they will come in they will crest and they will go out now some people will say ride that wave just like you ride a surfboard well when you're riding a surfboard you're focusing on that wave what I usually encourage clients to do is know the wave you know know that it's going to crest and it's going to go out and rank it so when they start feeling anxious kind of rank it you know it's a three on a scale of one to five and then they check in with themselves again when they start feeling themselves get really knotted up okay we're at a five now well the good news is not going to go up any higher and it's going to go down from here so then they can distract again for a little while and the next time they think of it for whatever reason they can check in and realize that it's down to like a two or three now so you know it's crested and it's going out use distancing techniques when people are upset when they're anxious when they're fearful they may say I am scared I am terrified okay and again there may be a perfectly rational reason to be scared about something or anxious about it that you're getting ready to do because you're getting ready to be vulnerable and some in some way anxiety is okay anxiety when you have it for a second that's your body's natural reaction to protect you so what do you do with that you feel it now what do you do with it well you can ride the wave or you can put the phrase in front of it I'm having the thought that I'm having the thought that this is really scary thoughts come and go you know a lot of us have thoughts that we need to get something from the kitchen we get to the kitchen and can't remember what it was thoughts come and go when we say I am scared that's part of us if we say I'm having the thought that we can take thoughts and put them over here and encourage people to use imagery encourage them to use imagery of whatever this is being set successfully resolved so you know closing their eyes of getting a shot for example imagining going to the doctor having them clean your arm give you the shot and you didn't feel it using imagery to help you get through the situation if you're getting ready to do something anxiety-provoking like ask your job ask your boss for a raise before you go in there envision doing it envision doing it successfully envision it several times and then you can go in and do it relaxation skills relaxation is when we tell our body you know you have the fight or flight or the rest and digest and relaxation tells your body rest and digest so we want to help your brain your brain know it's time to slow down one of the ways that happens is when your heart rate slows down how can you slow your heart rate if you're anxious and your heart rate is going faster how can you calm down one way is what I've always been taught to call combat breathing when you breathe in for four and out for four some people also hold for four but when you slow your breathing your heart rate naturally slows down so encouraging people to focus on their breath when they start getting anxious so that number one they're not holding it my daughter does that when she gets upset she holds her breath I'm like Haley breathe but encouraging them to slow their breath down but still keep breathing meditation can also help so encouraging people just to meditate on something you know an item an object there are multiple different styles of meditation people can use but it helps get their body into that rest and digest sort of phase and turns off or turns down that HPA axis that threat response system cute progressive muscular relaxation this used to be my favorite unit to teach when I taught it at UF because I would go into class and I would say all right everybody clear your desk and get out of pencil we're going to have a quiz and you could see everybody's eyes get like saucers because they're like no not a quiz not a pop quiz okay well we didn't really have a pop quiz but my goal was to show them how a word pop quiz could elicit a very strong physiological reaction in at least some of them cute progressive muscular relaxation is when people practice progressive muscular relaxation tense and relax and notice the difference between tense and relaxed but they also pair it with a cue so every time they relax they say calm or breathe or whatever their cue word is eventually with practice and it takes a few months they can just think that word calm or breathe and their body will start to relax so cute progressive muscular relaxation can be a really good tool for people self esteem work helps people focus on their real versus ideal self and figure out which things are important encourage them to recognize you know what's realistic and go through and figure out what is important in my life what things people activities are important in my life and then go back over that list of what their ideal self is and figure out if that matches what's important in their life a lot of times there's a lot of extra stuff on that ideal self list that they can start marking off because right now that's not as important they want to use their energy for what's important encourage compassionate self talk not rejecting yourself when people get anxious a lot of times there's a lot of really negative hateful self talk you're stupid you're a failure you're going to fail your whatever you can't handle this encourage people to be compassionate with themselves to also not judge themselves for feeling anxious they feel how they feel and that's just the way it is so they need to silence that inner critic and go I am me I am good my feelings are what they are and then move on to okay so how can we improve the next moment if your kid comes to you and they've got a problem you know they tell you what happened and hopefully you don't lay into them going you are so stupid how could you do that again instead you go all right that's unfortunate how do we fix it you know very calm compassionate not critical supportive encourage people to do the same thing to themselves don't be hateful to themselves when they're nice to everybody else encourage clients to spotlight strengths and accept their imperfections too often clients with anxiety focus on the problems and the times they've failed in the past and the times they've been rejected in the past encourage them to focus on the times they've succeeded in the past and the times they've been accepted and balance it out yes they're going to have some of both no doubt but encouraging them to get a more balanced view of the good and the bad cognitive restructuring helps address cognitive distortions I love using this because a lot of times clients well we all have cognitive distortions we can personalize things thinking all or nothing terms cognitive restructuring can help reframe challenges in terms of current strengths not past weaknesses so if you're getting ready to go on a job interview instead of getting anxious and think think you know every time I've gone on a job interview I've failed nobody's going to ever want to hire me da da da da da well you know that's focusing on past weaknesses when maybe you didn't get hired maybe it didn't work out they didn't want to hire you so focusing on current strengths I'm going to try I'm going to learn from this I've already researched the company etc so looking at challenges in terms of learning opportunities maybe you don't succeed completely but at least you will learn and you will be a different person from there encourage them to create an attitude of gratitude and optimism instead of walking into an interview or walking up to somebody to ask them out on a date going yeah there's no way that this person's going to accept me thinking to themselves you know what anything's possible and having that attitude of optimism and gratitude for what they do have you know even if they do get rejected focusing on the good friends that they do have in their life or the job that they do have or whatever it is can help balance out some of what's going on another technique is using the acceptance and commitment therapy there's a matrix that they can use psychological flexibility now in the center is how things are right now so a storm's coming in and you're worried that it's going to bring a tornado okay so that's where you are right now there's a storm coming in and you're worried that it's going to bring a tornado so what is your mental experience what are you telling yourself a tornado could come it's likely a tornado is going to come whatever you're telling yourself what are you experiencing your physiological what are you smelling feeling you know do you feel tension okay that's where you are right now that's okay now the next question is what do you do with that to improve the next moment what things can you do to move yourself toward what's important to you like the safety of your family and friends so what can you do to ask yourself or to experience this so maybe one of the things you can do in terms of the five senses is get to a safe place if you think a tornado is coming get to a safe place another thing you can do is turn on the weather radio so you're hearing and you're doing something that's going to help you protect yourself and your family instead of you know going out and having a cigarette or you know just worrying about it and not doing anything which would move you away that would just be kind of spinning your wheels so to speak mentally what can you do that helps move you towards what's important remember good relationships and having your family and friends there so mentally you can tell yourself it's going to be okay because if you're getting yourself all tied up in knots and worrying you're probably not going to be able to engage with them quite as well so people need to first know what's truly important to them what are they working towards what is the most important stuff to spend their energy on then they need to ask themselves in the situation you know this tornado is coming what am I thinking and what thoughts can help me move toward what's important well the thoughts are it's going to be okay you know if tornado comes and rips off the roof it's just a house you know we are safe those are mental thoughts or those are thoughts they can help me move toward what's important and what are you experiencing seeing hearing feeling smelling so what can you do say listen to or stop listening to they can help you move closer to what's important you know I remember it living in Florida when the hurricanes would start coming in if you listen to the weather radio or the weather forecasters 24-7 it would keep your anxiety up because they'd be telling you usually the worst-case scenario so I would check you know once every eight hours until the storm got closer than once every four hours I would check the path with the National Weather Service instead of listening to you know reports from all of the destruction and that helped me feel calmer about what was going to happen recreation is important there's always going to be stuff to do but for people to deal with their anxiety they also have to have some fun in their life you can't be fun and anxious at the same time but engaging in recreation generally helps people increase their happy chemicals so to speak and sometimes a break is what you need to get a breakthrough have you ever had a thought that was on the tip of your tongue you're like I remember that's going to drive me crazy and you just can't get it off the tip of your tongue or you're trying to solve a problem and you've been working at it for three hours and you just can't seem to see the solution but then you take a break and you come back and you're like it's so clear or whatever it is you were trying to say just comes right off the tip of your tongue sometimes a break is what you need get your mind off of it for a few minutes so make a list and encourage clients to have a list of fun things they like to do so this engages those opposite emotions activities that they enjoy doing what they can do to contribute volunteering you know even just neighborhood cleanup or sensations that they enjoy that help them recreate maybe they enjoy sunbathing or taking a hot bath anything that they enjoy that can help them relax and recreate can help de-escalate anxious emotions but if used preventative preventatively it can also help them prevent the degree of emotional upset social interventions include encourage people to improve their relationship with themselves by identifying their needs and wants this will help them figure out what they need to get upset about you know they don't know where there's a threat if they don't know what's important to them so if they know what their needs and wants are then they can get those met and they don't have to worry about them be your own best friend you know if you were going to say whatever you're telling yourself would you say it to your best friend well if you wouldn't say it to your best friend don't say it to yourself and also be kind to yourself if your friend goes out for a job interview and fails or breaks up from a relationship and is devastated you know okay so how are you going to treat that person well treat yourself the same way instead of beating yourself up over it encourage people to develop the ability to internally validate not rely on other people to tell them they're okay but to know all the reasons that you know I'm a pretty good person and encourage them to be compassionate with themselves they also need to develop healthy supportive relationships you know anxiety one of the greatest buffers against anxiety and stress is healthy social relationships emphasis on healthy sometimes they can also cause a lot of anxiety if they're not healthy or helpful so it's important for people to be able to learn about boundaries and not get all caught up in what other people think or how other people feel to the exclusion of their own feelings they need to develop assertiveness skills again so they can say what they need and not feel anxious that people are going to reject them you know their your opinions important and my opinions important encourage them to describe the ideal healthy supportive relationship and separate the ideals from the reels so when we think of the ideal relationship you may think of warden june cleaver well that's TV you know it's wonderful but to expect to never fight and have walley and beavers your kids a hundred percent of the time that's not real realistic so what is real let's look at what is real and what is what does it look like you know do people get into arguments and relationships yeah they do they get into disagreements is that okay you know and work through defining what a healthy relationship looks like and identify who the healthy support people are that clients have who is it you can call when you're anxious who is it you can call to get encouragement when you're feeling a little nervous about something who's the voice of reason so to speak and if you don't have somebody like that where do you think you could find someone you know where might you be able to make some relationships with good supportive people at the end of group I always ask clients identify three ways you could have used this information in the past week so we talk about at the beginning why this information is important and then we go through it and talk about strengths and encourage them to think about things like I did through this presentation but then we get to the end and I want to sum it up and I want them to see how what parts of this might have been helpful so what was the situation what did you do how effective was that for you in the short or long term if you would have had this new information that we talked about today what could you have done differently and how would that have changed the outcome and finally how can you start integrating this knowledge into your routine so everything we talked about today isn't going to apply to everybody you know each person is going to pick and choose what's useful and helpful for them but okay if they take one thing if they pluck one thing out of today's lecture great now how can you start integrating it into your routine to help you start reducing your anxiety and yes I've been watching this conversation in the chat room going webmd my doctor told me to quit reading it too because it always is death and destruction and doom so yeah you know it's important to be educated but it's also important to have you know some balance in there anxiety is a natural emotion that serves a survival function excessive anxiety can develop from lack of sleep and just feeling run down and like you can't deal with one more thing so you start getting anxious anytime anything else comes your way you feel overwhelmed stressed out there's a lot of different words for anxiety nutritional problems can have you not having the building blocks to make the calming neurochemicals neurochemical imbalances caused by a variety of things including hormones hormone changes medications and brain injury failure to develop adequate coping skills cognitive distortions low self-esteem and a need for external validation so all of these things we can help clients address and actually each one of these is probably an independent group that you can do and recovery involves improving health behavior so your body machine is functioning and balanced as well as it can be identifying and building on current coping strategies you know what do you do when the going gets tough because it does sometimes addressing cognitive distortions so you're not adding fuel to the fire and focusing on the negative and developing healthy supportive relationships with yourself as well as with others to kind of help bear the burden when anxiety kicks in and you're worried about rejection or the unknown if you're worried about rejection but you've got a group of good friends then a rejection may not hurt as much if you are worried about failure you know being able to have people cheerleading you and saying you know what if you fail we're here to catch you when you fall makes it a lot less anxiety provoking encourage clients to look at what they already do what they want to do and how to start making that a priority in their daily lives resources that I really like the anxiety and phobia workbook by Edmund born acceptance and commitment therapy for anxiety disorders being anti anxiety food solution you know I talked a lot about nutrition today really like this one coping with anxiety 10 simple ways to relieve anxiety again by Edmund born and by one of my favorite authors Matthew McKay 30 minute therapy for anxiety there are a lot of other anxiety books out there these are just 3 or 4 that I really happen to like and I use a lot with my clients depending on you know their temperament and you know what which one I think would work best with them are there any questions do your clients need a little help staying on track between sessions are you looking for a great aftercare resource look no further than docsnipes.com for as little as $15 per week Dr. Snipes provides concierge coaching services to clients through online weekly groups chat availability seven days a week and members only resources learn more at docsnipes.com