The basic definition of anxiety is a sense of fear out of proportion to actual threat of danger.
The definition in the Diagnostic and Statistical Manual of Mental Disorders (DSM) is varied, because anxiety can be a temporary state, a disorder, or a specific subset of symptoms. I'd like to talk about some of those variations and the subsets of symptoms - in other words, the many faces of anxiety.
Eee-GAD! There is a diagnosis called Generalized Anxiety Disorder (GAD for short). In order for this to be your diagnosis, you would need to have a lot of worries in several different situations more often than not in the past 6 months; worries are difficult to control; and they manifest in some physical symptoms such as body tension, restlessness, fatigue, insomnia, or difficulty concentrating. (NOTE: The DSM adds criteria to each diagnosis to say that another more specific diagnosis wouldn't explain it better, symptoms aren't due to a health problem or substance use, and they "cause significant distress or impairment.") GAD and other anxiety disorders are the most common mental health disorders in the U.S. but only about a third of people with anxiety get treatment (source). Treatment usually consists of Cognitive Behavioral Therapy (CBT), or some form of it. Other forms or off-shoots of CBT are REBT, DBT, and ACT. All of these have shown to be effective in treating GAD.
Social Anxiety Disorder. This is one of the specific types of anxiety. It may overlap with GAD and also lasts for at least 6 months, but the symptoms do not equal GAD, because they only occur in social situations and require: a fear of social embarrassment or criticism, recognition that the fear is somewhat irrational, and intense distress and/or avoidance of situations that might include embarrassment, judgment, or criticism. In addition, people may have panic attacks: physical feelings such as racing heartbeat, sweating, dizziness, numbness, and the feeling that one is going to faint or even die.
I see many adolescents with social anxiety. They often avoid going to school. Some parents or teachers think of their behavior as avoidance of school work or bullying, or they may see it as plain shyness. But to have the disorder means that the symptoms and avoidance are out of proportion with the threat - in other words, they may never or rarely have been bullied, and shy people might be shy, but not have social anxiety. I always tell people with this diagnosis, "Your anxiety is lying to you." Anxiety tells you that the best thing to do is to avoid the thing that causes your anxiety. But the treatment for it is actually the opposite: you must go toward the thing that makes you anxious. Avoidance only temporarily causes relief but strengthens the anxiety response in the long run. Treatment is usually (again) CBT, especially challenging faulty thinking by asking yourself:
Agoraphobia. Social anxiety or other anxiety disorders can overlap with agoraphobia, which is now its own anxiety disorder. People - myself included - used to think of agoraphobia as the fear of going outside, but this isn't true. Agoraphobia means that you fear and avoid of places and situations that might cause feelings of panic, entrapment, helplessness, or embarrassment. For some, it is a fear of standing in line at the grocery store, For others, it is going to a class in school where you know the teacher might not let you leave. Agoraphobia often goes hand-in-hand with panic. This makes sense - if you felt unsafe in a situation and like you could not easily escape it, wouldn't you panic?
Treatment for agoraphobia is often in the - you guessed it - realm of CBT or CBT-like therapies. Again, your anxiety is lying to you: the situation you are in is probably not unsafe, and you probably could leave, if you needed to. Therapy might include looking at irrational thoughts and challenging them (as in the example above). For some, such as adolescents in school, it might require a modification of the rules for that person (in Oregon, this is known as a 504 Plan) - within reason, e.g. giving the student permission to take a break from class if needed. Ultimately, in therapy you may be asked to consider working on coping strategies for panic so that you can face those situations that cause the anxiety.
Obsessive Compulsive Disorder. Another specific type of anxiety, OCD involves intrusive thoughts and (often) behaviors in response to certain thoughts or situations. A person with OCD will usually try to neutralize the thought with a behavior - which works briefly. The subtypes of OCD are worries about:
Anxiety has many faces. You can even be diagnosed with "Anxiety, unspecified," by a doctor or therapist if you have significant distress and worry, but it doesn't meet the criteria of any of the above (or they don't know enough yet about your anxiety).
There are medications that can help, in addition to the therapies and strategies above, but many of them are prescribed less and less often these days because they are opiates and addictive. Doctors and psychiatric nurse practitioners will often use SSRIs or SNRIs, which are the very same medicines used to treat depression, and are not opiate-based or addictive. They take time to build up in your system and must be taken daily, rather than as-needed. Some people don't like this.
Some people don't like therapy, either, but if you are in distress and don't want to live that way, doing something is always better than doing nothing. So, I suggest you start by asking someone you trust and who knows you well. Treatment is personal and your situation will be different from others. Get help right away if you need it (see 3 links here). Or, if you don't need immediate intervention or are just looking for some information, I hope you have found something helpful here.
As my year ends, I thought I'd share the best part of it - my dogs, just hanging out doing what they do, making me laugh (or at least smile) every day. May your next year be full of life's little moments that make you smile (or laugh), too.
It may seem like there is no "magic" to this exercise. That would be one way to look at it.
Another way to look at it would be that there is magic - magic in its own time, and in your own ability to transform yourself through consciously applied effort. Magic is, in some way, a skill. Do you think David Blaine, David Copperfield, Harry Houdini, Harry Blackstone Jr, Cris Angel, or other magicians were blessed at birth with superhuman powers? Or is it more likely that they learned, honed, and demonstrated a skill?
You can use your conscious mind and its logic to transform itself - which is actually awe-inspiring, if you think about it. Your own brain is able to change at any age (see this post for more on that) because of what you do and think. It comes down to whether you are willing to create that change - over time, through applied effort. In the exercise below, which is adapted by me, very CBT-based, but mostly taken from an old exercise by J Roberts, you will learn, hone, and demonstrate the skill of changing your beliefs about yourself.
Step One. Start with a negative belief (you don't want to change a positive one, right?). Some examples: I'm unworthy, invisible, don't matter, not enough, a problem, unloved, weak, etc. If you really don't know what you believe about yourself, pick one of these that rings true or that you could see believing about yourself.
If you discover that you feel unworthy, for example, you may have tried simply to apply a more positive belief over that one - and found that alone didn't always work. In this exercise, you must first discover the reasons for your stubborn beliefs. You can begin by doing the following: a) Write down your feelings about yourself. attempting to be perfectly honest; b) Examine what you have written; and c) Realize that a set of beliefs is involved, not an objective reality.
Step Two. Then you must challenge these beliefs a little. For example, start by acknowledging that there IS a difference between believing that you are unworthy and being, in fact, an unworthy person. No one is an unworthy person, plain and simple. If a friend came to you with the same list of "defects" (beliefs), you would encourage them to challenge these things. It's only fair to do the same for yourself. See this page for a list of more questions, known as Socratic questions.
Step Three. Now, write a list of your abilities and accomplishments. These should include such things as getting along well with others, taking care of yourself or others when sick, being good with plants or animals, being a good carpenter or cook or poet - any talent of achievement should be noted honestly, as if you were a good friend helping you to write your list. Again, you do not need "objective proof." We're not scientists or lawyers here. Science and facts are necessary in the laboratory or court room, but not here.
That's it! These are all the steps. Remembering how I said it takes time and effort, you may ask, What's next? Good question. Well, you know how the shampoo bottle says: Lather - rinse - repeat - ? Now it's your job to: Identify the negative belief - challenge it (this can be with logic, Socratic questions like some of the examples above, or with positive affirmations) - and repeat . . . and repeat . . . and repeat. After all, this is exactly how those negative thoughts got turned into what you believe to be true - you said them over and over again, until you forgot they were just thoughts you kept thinking, and NOT facts.
There is no human being alive who does not have the ability to control and choose their thoughts in his or her own way. There is no human being who does not have achievements and excellent characteristics. You are a human being, so you are no exception. If you follow these instructions you will find out that you are indeed a worthy individual with many fine and wonderful qualities.
If you allow yourself to be more and more aware of your own beliefs, you can work with them. It is
silly to try to fight what you think of as negative beliefs, or to be frightened of them. They are not
mysterious. They may even be there to help you, as you may find that many served good purposes at one time. They simply became overemphasized, unnecessarily repeated. Now they need you in order to have the light shine on them, so they can be restructured or removed, not denied.
2:27 The "CBT Triangle (no relation to the Bermuda Triangle...)
3:45 Watch me do a magic trick with my dog!
3:46 List of "thinking traps" - click here for more.
I don't know about you, but I've been hearing therapy jokes since I was a kid. That's all well and good, and I get it, I really do. When I would see a character in a movie about to get really mad, take a deep breath, and go to their "happy place," I snickered and phfft'ed. I joked with friends about Al Franken's SNL character "Stuart Smalley" ("I'm good enough, I'm smart enough, and - doggonit - people like me,"), joked about anyone trying to get a sense of peace who dared to sit cross-legged, their thumb and forefingers together, chanting, "Ommm."
As a therapist, I can now see how these jokes minimize the therapeutic effect of some actual coping strategies and really turn people off to simple things that might work for them. For example, in doing a therapy called EMDR (Eye Movement Desensitization and Reprocessing), one of the preparations for trauma processing is a resource called "calm, safe place." Yep, you guessed it: It's going to your happy place. In the EMDR version, however, guided eye movements are involved as the client imagines a place with as many sensations possible that makes them feel calm and safe, and then use this later to counteract many of life's little annoyances.
Should we throw out these simple strategies when they seem like tired cliche`s? I don't think we could, even if we wanted to. There are very practical reasons why things like deep breathing, affirmations, and visualization work.
Deep breathing. I wouldn't advise foregoing a deep breath every now and then. In fact, this article on MindBodyGreen provides five very practical reasons and concrete effects from deep breathing. This includes improving fat loss by oxygenating our cells, helping the lymphatic system remove toxins, and easing pain and increasing relaxation through the release of endorphins. And this article on Selfication talks about how our shallow, tense breathing habits can really mess up our body functions - constricting blood vessels and airways, unbalancing the nervous system, and decreasing our overall energy. It's easy to forget how important breathing is, especially because we mostly rely on doing it unconsciously, but I always appreciate reminders of just how vital it is for mental health, not just, well, life itself.
Affirmations. Bringing it back to our non-therapist friend Stuart Smalley, affirmations are quite helpful - and theatrically portrayed as totally ridiculous. We use negative affirmations all the time via our internal mind's anxious chatter: I'm such an idiot. My life sucks. I hate my body. So we need to be aware of this and counteract these with positive statements, because we get what we concentrate and focus upon. To illustrate this, think about how often you find things you aren't looking for versus finding things you are looking for. Lost your keys in the morning before work? Can't find your wallet? Well, you're probably not going to have a lot of luck finding them if you never try. Same goes for affirmations: if you make a point of naming the positive aspects of yourself and others, even if they are just potential aspects, you're much more likely to find them.
Visualization. This can be more than a "happy place." There are many guided visualizations (or guided imagery) on YouTube that you can follow for many purposes, such as insomnia, quitting smoking, relaxation, or self-esteem. Some I like and have listened to include the following channels: Jason Stephenson, Michael Sealey, and YouAreCreators. Inner Health Studio is a website providing free scripts for meditation on a variety of subjects, mostly for relaxation, but they also include a nightmare reprogramming script which is a very good technique for stopping recurring bad dreams. Read the scripts in your own voice into your phone or computer voice recorder and play whenever needed.
I hope you find something helpful in the above links - if not, keep looking for something that helps you do your thing.
And as always, contact a therapist or helpcenter like this, this or this if you are in crisis and need personal help right away.
Click here to read Part 1.
In my first post, I talked about what to expect from therapy, which included a focus on change. I am devoting extra time to this in Part 2 because change is so important and yet so misunderstood.
Recently a nine-year-old girl, whom I've been seeing twice a month for a while, came into the room and started by saying she was having a really hard day. This was somewhat unlike her because she had been putting on such a brave face for most of our time together. She then described the compulsions she had engaged in, and how it caused a big problem. She didn't think that her OCD was part of why we were there until that day, when she admitted that the behaviors actually can and do get her into trouble.
I thought, Finally, we're having a breakthrough! My mind momentarily raced to all the new work we could start: we can talk about the compulsions and gain understanding, we can talk about all the positives from change and gain motivation. . . But no sooner did I think of these things than she slumped into her chair and, with all the stubborn sullenness a nine-year-old can muster, said, "And the worst thing is it's never going to be better because it's my brain that makes me do it and my brain can't change!"
Even though I could hear her using words that were a bit beyond her, like she was repeating someone else's explanation, I knew this idea was etched deeply in her mind: if the problem is my brain, then I can't change it. There's a big piece missing from this theory, but I get where it came from. There is a biological reflection of each mental health disorder within the body, especially in the brain. So often, mental health disorders have been stigmatized and treated with the flippant disregard of the (possibly) well-meaning friend or relative who says something like, "Get over it." A logical response is to point out that there is a physical component that anyone, were they looking inside your brain, could physically see. While I understand that the "get over it" point of view is to say that some mental toughness is needed, just pulling yourself up by your bootstraps is not going to cut it when it comes to mental health disorders. They are called disorders because they cause an impairment in function, i.e. in one's ability to "just get over it."
There's no denying that a mental health disorder can be reflected in the brain. But what I want to add to that is: this does not mean there is nothing you can do to about it. In fact, we do something about it all the time.
It's called neuroplasticity: neuro meaning "of the brain" and plasticity meaning "the quality of being easily shaped or molded." In biology and specifically evolution, plasticity refers to the ability of an organism (plant, animal, bacteria, human) to change and adapt to their environment. Have you ever heard the saying, "Use it or lose it," when it comes to people's ability to use their brains as they age? This is because of neuroplasticity. When you learn something, your brain makes new physical connections, connecting pathways to other pathways. When you practice that thing over and over again, you're making those connections stronger and deeper. If you don't practice, they become like a path through a grassy field that no longer gets used: the once clear path starts to grow over with grass and weeds. It may all but disappear. Neuroplasticity is lifelong. That's why they say: use it, or lose it. It goes for a 90-year-old as much as a 9-year-old. In the case of my 9-year-old, she has repeated certain behaviors over and over, strengthening and clearing the pathways, which makes them more obvious, deep and strong. The result she now feels is a compulsion. It isn't going to be obvious that she can change it, because the pathways that exist now are already so obvious that it will seem like she must follow them. But it only seems that way. She wasn't so keen to believe me that day, but I taught her the word neuroplasticity, and she liked knowing that. Knowledge and observation of this is where we can start. Later, we'll move on to the next stages of change.
Stages of Change is a model that was first introduced and applied within the field of addiction by DiClemente and Prochaska. It is also called the transtheoretical model of change. We know now that these stages can be applied to anyone with a problem that can be changed. Sometimes you'll see the stages listed as such:
Learning about how we change, and then accepting and expecting the phases of change, helps people feel empowered. I've seen it happen. It normalizes change. It illustrates the path. And it can do this for you, too.
Change is a vital part of life. We are doing it whether we know it or not, and we can use the available knowledge and research about change in order to empower the process of change for ourselves. Expect it if you're going (or considering going) to therapy.
Change can be good. You can do it!
And you already are.
There are two kinds of people: people who think there are two kinds of people, and people who don't.
Okay that was a joke to the effect that dividing people into two kinds is oversimplifying. That being said, sometimes people (of any kind) simplify things in order to make a clearer illustration of those things. Let's say your therapist were to ask you to name five words to describe yourself. It's not because you can be reduced to five adjectives and that is all you are. It's because to simplify things is to notice the biggest, most standout qualities in a given time. And what stands out in a particular time has particular meaning.
Now that I've qualified my next statement to death, I should actually make the statement. Ready? Here goes. As a therapist I've noticed there are two kinds of people who come to therapy: those who say, "There's something wrong; fix it," and those who say, "There's something wrong; I need to talk about it." Of those two kinds, the first are usually dissatisfied with therapy pretty quickly. They're the ones who come back maybe once or twice, and who say about counseling, "I tried that; it didn't work." They are the ones who may define themselves as "broken."
And if they don't give change a fair chance, they are also the ones who get to be right, but probably not happy.
The second group - those who need to talk about something - can be broken down further into two groups: those who expect that talking about what's wrong is going to "fix it," and those who don't. Of those, the ones who don't have expectations of fixing the problem by talking about it make up the largest number of people I see on a regular basis.
So, what IS therapy if it's not talking about problems you want to fix? Well, it is that - but it has to be much more than that. Therapy also has to:
Define what "fix" means to you. This includes whether and how it may or may not be done. Let's say you start with something like: I need to fix my spouse/make the chronic pain go away forever/make sure I never have another panic attack again/prevent my teenager from cutting. These kinds of statements are a place to start, but unfortunately these are not goals. Therapy is honing in on what is fixable, feasible, and in your control. A good therapist will help you with this. Then, you can work on the next steps.
Be collaborative. Essentially, you should have your own goals. A good therapist will help you figure out what yours are. I keep saying "a good therapist" because, unfortunately, not all therapists are good. Some of them out there basically just want to play the expert and tell you what to do. Now, I've had a client tell me that is what I should do, but I would neither want to be nor see a therapist like that. There are no two ways about it: therapy is work for you as the client. Unless your safety is in question and you need to seek medical or other crisis help, your therapist should not tell you what to do. They are also not the expert on you. Part of therapy is change and part of change is empowerment. If you start working toward change with someone who's telling you they are in control, or tell you each and every step you need to take, how empowering is that? Which brings me to my next point that therapy should . . .
Be honest. I've done a lot of different types of therapy. I once worked at an inpatient facility for dual diagnosis - the same one that Augustin Burrows of Running with Scissors talks about. I don't know what it was exactly, maybe the fact that some people were not there by choice, but many of those who came to therapy just wanted to tell stories. And when I say stories, I mean lies. I didn't always know it in the moment. But after consultation and some time, I realized that people sometimes come to therapy and just plain don't tell the truth. It's a tough situation, and it can be for a variety of reasons. I mean, I've had clients tell me they thought they were boring, or weren't doing therapy right, or needed to be a "good patient," so they lied. I was so glad they admitted it because then we could really get to some good work! Also, because I use CBT which involves homework, people have either told me they did something they didn't do or called in sick because they didn't "do their homework." This is also not great therapy. But I know people aren't always honest because, honestly, it's hard to be honest! All I can say to that is that you are human and so am I. Change is hard. You won't always do your homework, and it's okay! Just try to be as honest as you can, for your own sake. (And then, also try to do your homework.) Last but definitely not least, therapy must . . .
Focus on change. The scariest thing sometimes is facing change, but if there is a problem you want to be different, therapy must focus on change. And it is a process, not a product. In the next blog, because it is so vital, I will focus exclusively on the need for, theory about, and possible paths toward change.
The most popular request I hear from people, especially when they're referred to counseling by their doctor at the clinic where I work two days a week, is for coping strategies.
Coping strategies will be different for everyone. Aside from personal preference, it also depends on the diagnosis. For example, if a person has a trauma-related disorder like PTSD, I will recommend ongoing counseling for trauma processing. This might mean cognitive behavioral strategies that ask you to tell your story to the counselor and then work together on desensitizing you to the intensity of the memories; Trauma-Focused-Cognitive Behavioral Therapy or TF-CBT is a recommended best practice for this. Or, it might mean finding a therapist trained in doing Eye Movement Desensitization and Reprocessing (EMDR), another best practice for trauma.
In general, though, all of us should find coping strategies or coping skills that work for us in times of stress or when symptoms of depression or anxiety increase. In order to find the ones that work, we have to try them out. Makes sense, right? Try them not just once, and maybe not even twice or three times, but really give these things a good effort every day for, say, a week. Depression and anxiety symptoms involve patterns or habits that took a while to develop and then got stuck in your mind or in your life. Let's be honest: it probably took much longer than a week. So it's only fair to give new skills and habits a shot to stick in your mind and life, too.
Below is a list of fifteen coping strategies that could be good for a variety of situations: feeling down, depressed, negative, panicked, worried, overwhelmed, betrayed, or grief, for example.
You may like to put these on small index cards - just print, cut out, and glue to a card. Maybe spend some time on the card, such as by giving it some meaningful doodles, decoration or just coloring it in. Spending some time on each card in this way can help you remember it.
And as always, if you are in need of help because you're having thoughts about suicide, please go straight to #1 - reach out to someone near you and ask for help. Or call 1 (800) 273-8255.
Above: "Orange Mocha Scones - ASMR/no music version"
Peaceful Cuisine is first and foremost a YouTube channel. There is so more to it. Its owner/creator, Ryoya Takashima, is a self-taught cook and videographer who combines his talent, along with his desire for "world peace through the food choices we make," to create vegan cooking instruction videos that range from 3-15 minutes long.
Videos include anything from a homemade mocha with cacao and almond milk, to traditional Japanese recipes like amazake and making your own ramen noodles, to restaurant-worthy desserts like flourless lemon curd tarts and non-dairy black sesame ice cream. While many of his recipes are not gluten- or allergen-free, many of them are; if they're not, it's often a quick fix to find a substitution or just find the recipes that you like and leave the rest.
But you may not have to leave the rest - not completely. Peaceful Cuisine includes a series (playlist) of dozens of "ASMR" videos. For those unfamiliar, ASMR stands for Autonomous Sensory Meridian Response and specifically describes a tingling sensation that usually starts in the head and travels down the neck after certain triggers like repetitive movements or sounds. The more widespread definition has to do with a growing movement popularized by YouTubers posting videos that depict themselves (usually) making a wide variety of repetitive sounds that may trigger this response. Urban Dictionary states the goal of ASMR is simply "to relax people" and lists examples of "triggers" as whispering, gentle hand movements, tapping or scratching on different surfaces, or brushing sounds.
How I hear about it in therapy sessions, especially from teens, is that ASMR can be a coping mechanism for anxiety. If the goal is to relax people, then anything that produces a relaxing effect is going to reduce anxiety to some degree, right? Well, if you're someone who needs more information or data, there is a university of ASMR website conducting research right now via a survey you can take, whether you've experienced the physical sensation, haven't, or just don't know. The site, headed by Dr Craig Richard, also includes a podcast along with examples of ASMR and informative articles on its "art" and "science."
Back to Peaceful Cuisine. . .
Aside from the recipe ideas and clear, pleasant visuals, many Peaceful Cuisine videos are in fact very relaxing. I can't say I've gone as far as having scalp-tingling effects, but there's something so, well, so peaceful about the quiet movements and everyday kitchen sounds of pouring, bubbling, scraping, counter tapping, and mixing. And the video quality is, to my untrained eye anyway, expertly done.
Included above is a link to one of these videos. See what you think about the recipe ideas, the presentation, and even the possibility of increased relaxation while watching. You might even find other things you like on his site - for local people, he has a travel vlog on his visit to Portland (OR) and gives a lot of helpful information on local vegan restaurants!
I am Lisa and I believe we create our reality. I hope to help empower people to create more mindfully, be kind to oneself and others including animals and the environment, and just generally feel better.