Topic: Anxiety

As a therapist, I help people notice the patterns of the things that aren't working in their lives...that helps them to see the way they tend to make things happen.  Once people are able to see their responsibility in the process, positive change is much more likely to occur.

Sounds easy.

It is not.

It’s really hard. REALLY. HARD.

But do-able. And exciting. And rewarding. 

But then there comes the empowering feeling that a person can impact the world around them, and so can mount the crushing responsibility of feeling like one needs to be the one to make everything work, or the life-sucking frustration and disappointment when, despite one’s best efforts, the results are going south. Fast. Ouch.

Had that happen to me recently. Was working on a project with a team of people, and was trying to help make a difficult situation better. I was the leader of the team, but because of the sensitivity of the project, I checked in often with my team members, making sure that my guidance of the process was “on target” and I wasn’t straying because of a blind spot. They encouraged me that I was working effectively and in alignment with the group's common values. I consulted with outside experts…careful not violate trust, but working conscientiously to get outside input so that myopic shortsightedness wouldn’t be a factor. I acted on their guidance and received their support. I thought hard about what I was doing, thinking through my words and actions at multiple levels repeatedly. I summoned up my courage and gathered my resources when the project challenged me. In short, I bust my butt to give extra effort to give every chance for something to succeed.

And it didn’t go well. Ouch.

I’ve been trying to wrap my head around it. Struggling to find the patterns…scratching my head trying to find my contribution to why it went sour. And then I looked at my dining room table:

I got 3 paperwhite bulbs from the basket of bulbs before Christmas. Had 3 identical glass cups, with the same red sand, and watered them with water from one common pitcher. I watered them at the same time and they stood side by side on my dining room table getting the same amount of sunshine. I didn’t talk to them differently or anything!

Two grew. One did not.

I don’t know why. But I know that I gave it the same opportunities the others had. It actually was a bit of a relief to know that it was something with the bulb. Had I only purchased that one, I would be wondering what I did wrong, what I missed. But it wasn’t me. This bulb may not be dead, but it sure is taking its sweet time letting me see it’s goodness. I think it will come, but long after the others are already finished. The rate of growth for that last one is not up to me.  It's working on it's own agenda, and it will respond to the light and water when it decides it's ready to...chill out, Carolyn!

A good reminder to me that while it is vital to look to see my role in life’s circumstances, I need to allow for circumstances beyond my control, outside of my understanding or knowledge. I don’t know everything, have to allow factors which I need to respectfully aknowledge are beyond me. I need to chill out, relax, and not automatically take complete ownership for what happens in the relationships in my life.

Some people don’t assume enough responsibility for what is happening in their relationships, and underestimate their ability to effect positive change in their world. Some people have to learn to relax and recognize that while they can influence outcomes with their actions, that there is a lot more at play—to influence an outcome is a far cry from determining an outcome.

Which direction do you tend to operate towards. What movement would be a helpful correction?

I thought I’d try listening to a book on CD while I was driving in the car.  The library had “Audition” by Barbara Walters.

I’ve been listening to Audition by Barbara Walters on CD while I’ve been driving in the car lately.  I was struck by how ordinary some of her story was, even amongst the extraordinary bits of interviews with world leaders and leading entertainment figures.

Her memoir is entitled “Audition” because of her feeling that she was always performing, hoping that she would “make it” with others, be accepted, or be allowed to continue working.  Reminds me of when I hear people say, “I don’t feel like I can relax and be me. I feel like I’m performing when I’m around people”.

Barbara grew up as the little sister of a Jackie, a developmentally delayed girl.  Jackie was kept at home, had a stuttering problem, and had no social network of her own.  Barbara had no birthday parties and rarely had friends over out of a family perception that Jackie wouldn’t be understood and the entire family would be judged.  The social environment of that time was inclusive of people with different abilities and in protecting Jackie from critical and curious eyes, they fell into a position of hiding her and then feeling like they had something to hide..

Later on, when she was older, she would be asked to take Jackie with her on a date or out with friends, because her mother saw Jackie as exceedingly lonely.  Barbara was in a “double bind”—take her along and feel ashamed and embarassed, or leave her at home and feel ashamed and guilty.  No win—Barbara felt awful either way.

Barbara studied acting in college—her dad got her an audition with a major play.  Barbara was excited until a few days before when she realized that she might try out and not get the part.  Out of a feeling that she couldn’t handle the shame and rejection of a failed audition, she didn’t even attend it—she was too anxious about it not turning out well.  Reminds me of when I hear people want something, but the fear of failure (and the underlying assumption of how that is an intolerable judgement on one's own character) stops them from even trying.

Although she is not nervous in interviews with famous people (having grown up with celebrities in her home at times because of her father’s occupation—and having seen how they are human and struggling like everyone else), she does work herself incredibly hard, taking on huge tasks of multiple assignments.  The reason?  Anticipating that at any time, it would all end, and she would be unemployed—feeling the pressure to make money while she can. She didn't trust herself to remain gainfully employed over the long term.

This is Barbara Walters, one of the best known interviewers of our time—and she fears unemployment—it shapes her life. The weight of knowing she must provide for her vulnerable sister always and the insecurity she has in her ability do so is what she describes, is the defining factor.  "Self esteem" doesn't come up once (so far-I haven't finished it) in this memoir, but there are ways in which this uber confident professional woman struggles with the way she sees herself personally.

My cat needed a bath…she’s getting older and less able to look after the hard to reach parts.  

What does this have to do with anxiety—trust me, LOTS!!  You shoulda seen  her.  Her style…frozen while she knows she’s trapped, and then lightening quick at the first opportune moment. And oh, lots of crying…Lily can sound almost human when she gets going.  Her eyes have this stricken victim look that could break your heart.  But when she sees her chance, she can move pretty fast for an old girl. This is her MO:  still and appearing cooperative, pleading with her eyes, and always on the lookout to make a break.  That’s our Lily!

Did’ja ever notice how most of us have a style of what to do when we feel like the heat is on? And did’ja ever notice how far back that style can go?

When you were a kid, remember how vulnerable you were?  Needed to make your way into adulthood.  Some are fortunate and grow up secure in the knowledge that we will receive all the essentials from our parents—consistency, food, shelter, love and learning what a kid needs to learn.  Other kids find the grown ups in their lives are abusive, inattentive, depressed and absent, addicted to something because of an unknown pain in their lives, or otherwise well-intentioned, but can make the world a tentative scary place for a kid.  Meals not quite so predictable, or love expressed only with “strings attached”.

So the cute cooperative girl knows that her parents respond to sweetness, cuteness and so learns to be coy and appealing to keep her parents engaged--feeling like they get preoccupied with the country club and work, but love showing off their adorable princess.

The confrontational boy knows that no one is gonna protect him except him, and so he takes on the world as an enemy and lets no one in—that way no one can hurt him.

The helpful hardworking girl realizes that’s how she can sustain an overworked exhausted single mom and ensure there is some room at the end of the day for some TLC for her.

The little boys figures out that when he disappears during conflict, the fight doesn't escalate, he doesn’t get as hurt, doesn't have to see his mom get pushed around (how scary is that for a kid!) and it will be quiet when his dad passes out in a drunken stupor.

Kids aren’t consciously manipulative…just trying to get through life in a world that seems scary and is perceived as unpredictable.  Kids, without a lot of resources, develop a tool that works and use it—generally effectively.  The family system absorbs and adapts to this strategy. The examples are very clear, often a child's fear, and their coping strategies are much more subtle than the above circumstances.

Problem is that when you get to adulthood, the types of situations a person encounters requires more than the one standard approach that worked over and over again earlier in a person’s life.  It’s like having a hammer—works well when your problem is a nail, but not every challenge is a nail. Suddenly what worked so well as a kid, now does not address the adult situations successfully.

When we are anxious, our default position is to go back to the “tried and true” strategies that we learnt were essential (and successful) to our survival over the decades.  

So the cute, adorable girl finds that being cute and adorable attracts men easily and she is well cared for but sets her up to be manipulated by men who take advantage of her.

The confrontational boy becomes a man who becomes defensive whenever challenged--his wife has no way to raise a concern without him blaming her...and gradually she learns to be quiet and not "ruffle his feathers"--though she loves him, she pulls away over time as a matter of survival.

The hardworking girl discovers there are only 24 hours in a day, and when her marriage is in trouble, she can’t fix it by working harder—she’s already exhausted by her efforts—and so she becomes yet more unavailable to her husband as she pushes herself even harder.

The withdrawing little boy loves his wife dearly, but pulls away and retreats to his workshop when she needs to process a disappointment, or flashes anger towards him—and she is left feeling alone and abandoned—and he can’t understand why she becomes disengaged over the years.

It can be a profound revelation to a spouse to realize that what is happening during conflict is actually a response to anxiety…an anxiety response gone awry.  Imagine going from:  “My husband abandons me when I need him the most” becomes: “My husband distances from his feelings of anxiety when I challenge him on something”.  The goal of therapy is to have the individual (or couple) be able to stay in the situation, understand that the behavior is an anxiety response, and to calm oneself in other ways so as to reduce the anxiety enough that alternate strategies can be employed.

Many times, couples come in to “learn communication skills”…which has me chuckle.  These are people who are highly competent communicators professionally and with friends.  They have all the communication skills that they need.  What they don’t have is access to all these communication skills during times of conflict with their spouse…because the anxiety of not feeling fully loved and accepted by a spouse has them going back to the basic skill they used most earlier in his/her life.  

It’s not communication skills that are needed in that situation, it’s safety—ensuring that each partner is aware at a profound and deep level that they are loved, safe and deeply accepted by their partner…and with the anxiety out of the way, a couple is free to communicate effectively.

Imagine this, if you can (and if you can remember high school, you can):

Two girlfriends, wired and getting more wound up by the moment, in that high school, hand flapping (picture Sandra Bullock in Miss Congeniality ) sort of way:

The first one says:  I called my new boyfriend, and he didn’t answer the phone!  What does this mean?
Her friend says:  Oh no.  Hmm…I did see him talking to Britney, the new girl in school the other day.
First one:  You’re kidding!  You think he might be with her, right now?
Friend: Dunno, mebbe.
First one: Come to think of it, he wasn’t home the day before either…THAT time he said he went to 7-11 for a Slurpee “by himself”…a likely story, it seems.
Friend: So, he has been two-timing you, huh?
First one: I can’t believe it.  First what’s-his-name, then this guy. Where (said in a plaintive wailing voice) will it end?  Am I doomed to a life of cheating guys.
Friend:  That’s it.  You can’t trust guys. You just can’t.
First one:  My life is ruined!!!! (notice the multiple exclamation marks)

Now, of course, this is hyperbole, and certainly not how many adolescent girls would behave, but you understand my point. (And, if you’ve been in high school, you might change the circumstances, but you’ve been in a conversation with that sort of catastrophic tone to it.  Just saying.)

The above is what’s known in the counselling business as a “positive feedback loop” that is spiraling/escalating.  As one hears the panic and concern of the other, the other springboards higher, and then the response it one of yet another springboard higher, and so on.

Imagine now, that the positive feedback loop isn’t between excessively histrionic adolescents, but between your brain and your body.  Your boss comes to you and says:  My office.  5 minutes.  You and me.

Your heart sinks—you’ve heard the tone and know it’s serious.  Your brain feels your heart sinks, and remembers that feeling—the last time you had that feeling, something really really bad happened.  Your brain, faster than you can put into words, senses trouble with that sensation.  Your body gets the message of trouble, and your stomach roils and turns, your face gets hot, and your heart starts to pound.  Your brain feels all the energy and heat, and knows that this feeling is “PANIC”.  Once your brain registers “PANIC”, your body has no choice but to respond with a full blown anxiety reaction--an adrenaline rush with increased blood pressure, insulin release, increased muscle tension and a host of other automatic reactions—including the part of the brain that reasons well in a sophisticated fashion begins to decline in function!

Now, if you’re in the woods, a bear is rapidly approaching, this is a perfectly adaptive response!  However, too often, this escalating feedback loop happens in a maladaptive way…and at times, unnecessarily…the boss might merely be letting you know she needs to leave town for a few days unexpectedly and needs you to cover for her.

In therapy, a therapist will often spend some time with the client deciding where the best spot is to break that feedback loop…break the cycle, and the reaction doesn’t escalate (Picture the high school friend saying: You know, you should try again in an hour…maybe he just went skateboarding.)  Sometimes the opportune spot in the cycle happens with the brain with dealing with the thoughts/feelings and sometimes with the body and it’s reactions (or occasionally both).  Body work can include breathing, meditation, prayer, yoga, and a host of relaxation sorts of strategies.  Brain work looks at where it learned to read body responses in the way it does, and to remove barriers to dealing with the current situation for what it actually is (as opposed to, “I imagine (in light of my body)…”

The important thing is to break the cycle so as to stop the escalating spin.  Often just working with a client to understanding where the cycle “gets traction” is enough to start making a difference.  Mindfulness is a powerful way to monitor reactions and then get some control over them.

Sounds hokey?  Don’t dismiss the idea too quickly.  My experience is that many are not consciously aware of what their body is feeling, and how your brain is interpreting those bodily sensations…an important component of counselling can be just slowing things down to have a person slowly begin to discover their body’s sensations.

Yet more on anxiety in a few days.

I remember when I first graduated from Occupational Therapy school…I was working in an outpatient department with patients with workplace injuries.  I was inexperienced in many way, and had much to learn. I was embarrassed one day when a patient (not my own) pulled me aside and said, “You know, your client doesn’t speak English very well, but her hearing is fine.  When you are speaking to her, it’s like  you think if you speak loud enough she will get it.” As humiliating as that feedback was, I remember it as being profoundly helpful.

It did more than change how I spoke to people for whom English is an additional language.

It remains an illustration of how we tend to apply the adage of “If a little is good, then more must be better”.  Nice idea, huh?  Speaking slowly and clearly to a person whose first language is not English helps comprehension, but speaking louder and clearer doesn’t actually improve understanding—rather, there is actually a point at which it is insulting.

More of a good solution often creates its own problems.

I’ve come to see anxiety is rather like that:

It’s helpful for a person to experience some anxiety about how a dinner will go, or in preparation for an exam.  The anxiety serves as a helpful internal cue to become motivated to reduce the anxiety.  So, recipes are researched and effort is put into shopping for all the ingredients, and the cooking starts early allowing time for unforeseen circumstances for a good outcome.  Notes are reviewed and the text read more diligently in preparation for an exam—and people do better when they study.

But too anxious, and a person isn’t calm enough to follow the steps to the recipe, or be calm enough to double check the grocery list—and mistakes made.  Or studying for an exam—the student is too anxious to concentrate on the material, and sleeps so poorly that they aren’t in a good space to write the exam.

One of the important part of changing behavior that is painful and out of keeping with what a person really desires, is to look at how the behavior (however misguided) is/was actually intended to help the person engaging in the dysfunctional behavior.  Often these motivations are so hidden under entrenched behavior that it is only with therapy that they emerge.

With that insight comes new possibilities and options for behaving in a way that both allows the original goals to be accomplished, and with strategies that fit the situation in a comfortable and synchronous way with a person’s values and ideals.

More on anxiety in a day or two...

Years ago I happened to be at the school yard in the morning on the first day of school in September. The bell had rung about 5 minutes before...the excitement of the first day of school that had the hard top vibrating only a short time ago was now in the school. However, the fire alarm rang. Suddenly the playground was unexpectedly flooded with people again. Not being a teacher or involved directly at the school, I pulled off to the side to get out of the way. On one end of the school yard was utter chaos...the children in the lower grades were, well, to put it politely, chaotic. Actually, many were completely losing it.

I'm not sure if it was grief that the school would burn down before they had a chance to even experience 1st grade, or if it was terror from what that very loud sound was, and wondering about their personal safety. The first grade teachers--well, they weren't doing so well either...they couldn't line the children up to do a head count, and there was this sense of hopelessness that the class lists in their hand were virtually useless because there hadn't even been an opportunity for the teachers to learn the students' names--if someone was missing, how would they ever figure out who?

The other side of the school yard, where the bigger children were, was completely different. They were more or less organized--they knew about fire alarms and knew that every alarm they had ever known was a false alarm. They were more or less in line, cuz they literally, "knew the drill". Of course, they saw this as an opportunity for an extra 15 minutes of summer vacation--they were laughing and joking--quite content to visit for as long as they could before they filed past.

Post traumatic stress disorder is a condition that follows the experiencing of something that is traumatic to a person. We are all unique, and so 2 people could be in the same car accident, with one person experiencing the event as traumatic and the other being nonplussed by the event.

Usually within 3 months, but sometimes much (even decades) later the symptoms of PTSD begin to appear...there is an intrusive reexperiencing of the event. This might be in nightmares, or with uninvited thoughts during the day. It might be when the situation is similar (e.g. walking down a sidewalk when robbed while walking home from work), or during an anniversary (e.g. having trouble at a certain time of year, or day, or time of day similar to the original trauma). This is disturbing, even alarming--and can be so distressing that a person can begin to avoid certain situations that might trigger that reexperiencing. At times, the reaction can appear out of proportion to the trigger. For example, a person who has been choked with rope may get agitated even seeing someone with a scarf around the neck. There is sometimes a "hypervigilance" where the sufferer becomes a detective waiting and watching and expecting the trauma to reoccur. Often a PSTD sufferer will say that their head knows it's safe, but their body doesn't get the message (e.g. a person who was assaulted in a high risk country with significant security issues still anticipates being "jumped" while walking down a Winnipeg street)

The person can become disengaged with people around them, as the inner feelings of fear are hugely distracting and managing them takes an enormous amount of energy. They may "put up a wall" to avoid being affected by triggers. They may pull away so as not to have others affected by their symptoms which feel so overwhelming.

Sleep is often affected. A person can have difficulty focusing, or concentrating. Other reactions can happen as well...increased irritability, impulsiveness, guilt, altered appetite, accompanying depression.

Therapy can be helpful to help work through the trauma of the experience and work to have a client understand their body's reactions and what they can do about it. Over time, the traumatic reexperiencing and other symptoms of PTSD can diminish. Part of this process is understanding bodily sensations of PTSD and knowing how to handle them...

In essence, one of the goals of treatment for PTSD is to help a person handle the re-experiencing like a grade 6 kid, and not a grade 1 kid at an unexpected fire drill. In both cases, there is an automatic complete response--filing out and waiting on the school yard, but the older kids are able to understand what it means and what to do with it in such a way that they can handle the reaction much more effectively.

I was having a conversation today about the news story of Stephen and Isabelle Allison, a young couple moving to Winnipeg with big dreams and ambitions. They happened to sit towards the rear of a certain Greyhound bus last summer and their move to Winnipeg hasn't been anything like they expected. They witnessed the brutal killing of a man, imprinted with images that have been indelibly printed like photographs in their brain...perhaps still frames of images with the color red appearing starker than the rest of the frame. The feeling in the pit of their stomach, vaguer now, but reminding them of the terror that immobilized Isabelle, watching the horror, and anticipating her own death as she witnessed unspeakable brutality.

Neither Stephen and Isabelle are doing what they set out to do in Winnipeg. They are the walking wounded, not able to concentrate sufficiently to take courses, not able to maintain normal routines that jobs require, and struggling with finding meaning, purpose and safety as they endeavor to move on.

The interview with the couple states they received compensation to cover their material losses, and six sessions of counselling. Six.

SIX!

The woman I had the conversation said, "If one of them would have had even one slash on part of their body, on a leg maybe, then they would have gotten so much more care and attention. A physical cut would have received extensive treatment. But the wounds they have are so very real...but invisible...and so they are not recognized and not treated."

The conversation perked my ears up...I got an email yesterday about a videoconference happening today out of the University of California at San Francisco by the PainCARE center on, "Post Traumatic Stress Disorder and Pain". I couldn't watch the conference as I wasn't near a viewing site, but I found some of its promotional information compelling:

In recent studies:

•  51% of patients with chronic low back pain exhibited symptoms of PTSD
• 50% of patients experiencing chronic pain after motor vehicle accidents showed evidence of PTSD
• Nearly 50% of women with chronic pelvic pain reported a history of sexual or physical abuse with roughly 1 in 3 of those screening positively for PTSD
• Psychiatric casualties from soldiers serving in Iraq were estimated at 300,000 as of November 2007, a significant number of whom also currently have chronic pain
• Patients with chronic pain, IBS, depression, and anxiety disorder in one urban, hospital-based primary care practice accounted for more than 90% of all cases of PTSD
• In this same urban primary care practice, 25% of patients met the criteria for current PTSD, yet only 11% were identified correctly in the medical record.

The numbers are staggering and should concern us all regardless of our respective areas of practice.

Post Traumatic Stress Disorder is a significant factor that is often overlooked as we look to understand what a person is struggling with. Physical problems like pain in the joints, muscles, headaches, bowel pain are connected to PTSD. Emotional problems of anxiety and depression result from unresolved trauma in a person's life. Relational problems develop as the symptoms of PTSD ripple throughout the relaltionships in a person's life.

I had coffee with a friend this morning who was in a serious car accident..she walked away from the accident, but the car was demolished. She finds herself anticipating disaster, bracing herself at intersections for another collision, and now has less reserve for the normal ups and downs of her life...small things are irritating and potentially overwhelming, she's tired, and finds herself noticing things and dreading some things in ways she is not familiar with. Her doctor diagnosed her with PTSD--this was a relief because she had understanding for what was happening in her body and mind.

I read an article reviewing the research on pain and PSTD in the Psychotherapy Networker the other day (it was an October issue, but better late than never, right?!), recommending sincere and effective collaboration between physicians and therapists to work in their areas of expertise to help people with that which they struggle:

Cummings estimates that at least 60 percent of physicians' patients seek treatment for conditions with major psychological components, such as stress, anxiety, depression, high blood pressure, fibromyalgia, digestive difficulties, eating disorders, nausea, headaches, and certain kinds of arthritis, that are usually more treatable with therapy than medications. Physicians are so eager for the kind of help therapists can provide that therapists who've integrated themselves into medical settings get substantial boosts in their caseloads and incomes.

While physical symptoms need good medical care, they may also need good psychological care. And with trauma of the magnitude of Stephen and Isabelle Allison, psychological treatment will need to be more than lip service. Six sessions--that's lip service.

More on PTSD in a couple of days.

It seems like man's best friend is also a kid-who-is-struggling-to-read's best friend, too.

I heard an interview today with someone from the Humane Society describing a program where dogs help kids learn to read.

I perked my ears up when I heard this...cuz dogs can't read!

The guy says, "It's hard for some kids to read to grown ups or even to other kids. But it's not threatening to read to dogs".

Apparently, they give a dozen kids at a time a chance to come to the Humane Society a coupla times a week for 8 weeks to read to volunteer dogs who come by to be read to.

Sounds hokey right? Not so much, actually.

The results are amazing...some kids increase a grade level in reading.

The more he spoke about it, the more I could imagine how a dog, who will wag his tail with all efforts, and will provide the unconditional positive regard to the child no matter what lowers the risk and increases the safety for the child. When the child is less nervous, performance improves as all the energy can be directed productively towards the reading, without all the static that anxiety creates inside a person.

I love the creativity of this strategy to learning to read...finding novel (pun intended!) ways to help a student focus on the learning task, and not be distracted by the pressure of performance anxiety. Who woulda thunk that dogs could help kids read?

Might be a lesson there somewhere for all the grownups who are feeling the pressure...recession is raising our blood pressure.