Quick Thoughts

woman with anxiety

Washington Post on Panic Attacks

Cara McDonough did a wonderful job in her Washington Post article on the trauma of panic attacks, including her personal experiences. I’m honored to be included in the story.

Featured Therapist Article

I want to thank the Association for Behavioral and Cognitive Therapies (ABCT) for choosing me as a Featured Therapist. They interviewed me about my work as a psychologist, my tips for new therapists, my opinion about cognitive-behavioral therapy (CBT), my mentors, and what I do for fun (!!) outside of my work.

cat and lion

How to Be Scared and Do It Anyway

I sat down with Geneva Atkinson and the We’re All Mad Here Podcast to discuss why you should want to feel the fear and uncertainty that you don’t want to feel; and the benefit of having 2 internal voices available to you, not just one. 

Why Boys Don’t Cry

I have the feature article on today’s (3-13-14) The Good Men Project, called “Boys Don’t Cry”


A Podcast on Overcoming Anxiety

Earlier this month I sat down with Matt Townsend BYUradio to discuss Overcoming Anxiety.

Anxiety and Its Influence on Weight Loss & Strength Training

I had a chance to talk about anxiety, and especially its influence on strength training and on efforts at weight loss, with Jason Leenaarts on the Revolutionary You! podcast.

Courage First, Comfort Last

Belief trumps behavior. With anxiety, a common belief is “I should defend myself.” Thus, clients decide to play it safe by backing away from challenges. If they want to reverse this pattern, if they want to take back territory lost to anxiety, they must act on the decision to push forward aggressively into arenas where they previously surrendered. When I offer a behavioral assignment, I subsume it underneath the primary goal of generating an aggressive offensive strategy. Since anxiety requires that the person seek out comfort and certainty, clients should voluntarily and purposely seek out opportunities to feel clumsy, awkward, doubtful, and distressed by exploring new territory. “Courage first; comfort last” should be their motto.

Two Forces that Support Anxiety Treatment

When someone is anxious, their worries can dominate consciousness, and people who respond to worries defensively will avoid, seek reassurance, run away, or brace. Treatment introduces clients to unfamiliar, paradoxical strategies. These protocols are strengthened by two powerful forces.

First, clients can commit to the positive intention to take back their life, including a return to productivity, intimacy, relaxation and pleasure, as well as a chance to explore new territory again.

Second, since everything new involves doubt, clients can choose to feel scared and act anyway. That’s courage: choosing to tolerate doubts about the outcome of a task, including the possibility of losing instead of winning. Help clients access their positive intentions, and then coach them to be courageous until they are capable of coaching themselves.

The Case for Acting without Thinking

It is poor therapeutic strategy for clients to wait until the moment of threat to choose a response, because the mind tends to regress back to a defensive mode at these times. Instead, it’s best to adopt rules of action in advance of the actual action. A good time to do so is when they are thinking rationally and calmly during the treatment session. Then they must decide to follow them unquestioningly during their threatening events.

These rules, of course, are paradoxical. And they ought to incorporate these qualities:

  • Shooting for clumsiness is a winning strategy
  • Wanting to feel awkward will counter their dysfunctional strategy of trying to get stronger while they simultaneously stay comfortable
  • Seeking out uncertainty gives them a competing alternative to their impulsive commitment to feel certain

The Paradoxical Secret of J Krishnamurti

Every spring for 60 years, the great Indian philosopher, J Krishnamurti, gave a lecture in southern California. In 2007 he was speaking to a crowd of 2000 people in a beautiful oak grove. He paused at one point and asked the crowd, “Do you want to know my secret?” The crowd became still, as though it was leaning in, listening for the essence of this spiritual leader’s wisdom. “This is my secret,” he said quietly, almost shyly. “You see, I do not mind what happens.” And there it is. This same, paradoxical secret can transform our relationship with the symptoms of anxious worry. Let’s work on shifting away from the resisting stance of “I’ve got to stop this. What can I do to get rid of this?” If we can start with, “I accept that this is happening, even though I don’t like it,” then we free up consciousness to focus specifically on what we might do next. Moving away from the present experience is fine. But we will accomplish that most efficiently by first accepting it.

Focus On a New Frame of Reference, Not on Technique

Clients need to shift away from content—“it’s about my heart/ my debt/ the safety of the plane/ germs”—and toward the very best strategies to recover from their anxiety disorder. These strategies will always address the intentions that currently motivate their actions. Most decisions by anxious clients have two functions: 1) to only take actions that have a highly predictable, positive outcome, and 2) to stay comfortable. And that makes sense. Everyone seeks comfort. And everyone wants to feel confident about certain outcomes. Most people who experience traumatic events—a near drowning, a panic that resembles a heart attack, blanking out in the middle of a conference presentation—initially react by seeking comfort, safety, and reassurance. So persuading clients to change must include a convincing explanation that their solution to the problem—avoiding and resisting, and seeking comfort and certainty—perpetuates their problem. Anything that is resisted will persist; therefore, the best perspective is a paradoxical one: When facing a problem, one must purposely and voluntarily choose to go toward uncertainty and distress.

How to Embrace When You Want to Resist

If it’s true that our working memory can only hold on to four chunks of information at any one moment, then consider the interference caused by resisting what’s in front of you. “I hate this chore.” “When will this be over?” “Why does this always happen to me!” – – all these messages chew up consciousness that otherwise could be devoted to handling the present moment. What might you gain by moving to a position of acceptance? As Werner Erhard has said, “If you want to hit the bull’s-eye every time, throw your dart first and then draw circles around it.” Here’s a way to fool around with this idea. Tune into the moments when you seem to be resisting the task in front of you. Then, willingly take on the paradoxical stance implied as you subvocalize, “This is exactly what I need to be doing right now.” Don’t bother looking for justification for that position. Simply adopt the stance. If such a definitive attitude is hard to adopt, try this one: “I’m now going to act as though this is exactly what I need to be doing right now.” Simultaneously, and most importantly, invite your mind and body to respond to your new message. Find out how that stance influences your next moment.

Helping You Cope with Your Social Anxiety at Work Events

Getting socially anxious at work? Here’s a Q&A on that I did with USA Today.

Don’t Panic Makes Top 24

I’m honored that my book, Don’t Panic, made BuzzFeed’s 24 Books That Are Straightforward About Mental Illness.

Anxious Kids, Anxious Parents Makes Washington Post Reading List

We are happy to see that our book, Anxious Kids, Anxious Parents, made a very unique summer reading list in the Washington Post.

An Important Twist on the Mindful Moment

Anxious clients enter treatment in the position of resistance. If they are diagnosed with an anxiety disorder, they’ve got to be resisting. They want that discomfort to go away, which is totally understandable. But the stance of ‘I don’t want this to be happening’ gives Anxiety the upper hand, because the mind & body will move into battle mode. If we teach them permissive skills, like brief relaxation or mindfulness, they are more likely to say, ‘Let me take a mindful stance in this situation. And I hope this works, because I’ve got to get rid of this feeling.’ These skills associated with permitting & accepting the symptoms often allow the client to slide right back into resisting. If clients can truly say ‘yes’ to the encounter, & accept exactly what they are experiencing in that moment, then they will be back in control. This is manifested in the supportive message of ‘It’s OK that I’m anxious, I can handle these feelings, & I can manage this situation.’ This approach has a paradoxical flair to it that people often miss. You take actions to manipulate the symptoms while simultaneously permitting the symptoms to exist. With physical symptoms, you are saying, ‘It’s OK that I am anxious right now. I’m going to take some Calming Breaths & see if I settle down. If I do, then great. But if I stay anxious, that’s OK with me, too.’ We attempt to modify the symptoms without becoming attached to the need to accomplish the task. This is a critical juncture in the work, & the therapist must track closely the client’s expected move of, ‘I’m going to apply these relaxation skills because I need to relax in this situation.’ No! While it is fine to relax in an anxiety-provoking situation, it is not OK to insist that you relax. That’s how anxiety wins.

The First Moves of the Game

You must play an existential game when dealing with Anxiety. People make a judgment that anxious symptoms are unwanted intruders & threatening enemies, & they want the trouble to end. They keep hoping that one day, if they work hard enough, they won’t experience any of these symptoms. That’s TOTALLY understandable. Yet, by actively focusing on this goal, whether in anticipation of symptoms or in the middle of symptoms, they become trapped by their expectations. Existentially, there is no need for such judgment. The symptoms of anxiety disorders can simply exist, without being deemed good or bad. Anxiety wins when clients judge the symptoms to be wrong & to be banished. In order to win over Anxiety, they need to start by stepping back from their current experience, observing it & labeling it as acceptable to them in the present moment. Sounds simple enough in theory, & in the end, clients who recover will master this skill. They learn to stop playing the game by Anxiety’s rules. But initially it takes all the clever persuasion a therapist can muster to unhinge clients from their old frames of reference.

Shifting the Client’s Game Plan

Anxiety is a mighty competitor, & it hides the true task of treatment. Anxiety shrewdly misdirects clients’ attention toward the content of their fears, such as the worry of causing harm to self or others through carelessness (OCD); worry about health concerns, money, relationships or work performance (GAD); the fear of criticism or rejection (social anxiety). This is a clever distraction, since the true nature of the challenge is tolerating the generic themes of doubt & distress. Early in treatment, in addition to correcting misinformation, I have 2 goals. First, I want clients to recognize this distinction between the distracting content of their worries & the actual issues of doubt & distress that they must address. Second, I want them to take actions in the world that are the opposite of what Anxiety expects of them. Instead of seeking certainty & comfort, I encourage clients to voluntarily, purposely, choose to look for opportunities to get uncertain & anxious in their threatening arenas.

Ten Commandments for Remaining an Insecure, Worried Partner

  1. Look, act and sound overwhelmed. Insist that you are not capable. Make sure you frequently worry out loud. Whenever needed, say, “This is all too much for me. I can’t handle it.”
  2. Cling to your partner. Don’t act independently, and don’t think for yourself.
  3. Continually pose “what if” questions and ask for reassurance.  Added bonus: they will lower their expectations of you. 
  4. Don’t try anything unless you are confident that you will succeed. Never put a high value on courageous acts or risk-taking. Back away from any new adventures. Only do things you’ve done in the past. Don’t experiment. Resist change!
  5. Be a perfectionist. Always shoot for an “A” in any task you undertake. Elevate even minor tasks to the status of “critically important,” and insist that if you cannot do it right, you should not try.
  6. Seek comfort! Run at the first sign of distress. Avoid or escape scenes when you feel unsure. Underestimate your ability to cope.
  7. Overplay the genetic card. “I’ve always been this way. I was so intimidated by kindergarten that my parents had to homeschool me that whole year!”
  8. Mindread. Interpret people’s tone of voice, gestures or facial expressions as implying criticism of you. Don’t ask them about it; just worry.
  9. Remain vigilant. Look for threat in ambiguous situations. If there is the smallest chance that something could go wrong, focus on it, brace for it, and expect it to happen,
  10. Don’t take responsibility for your mistakes. Blame yourself for them instead.

by Reid Wilson, PhD, in Ten Commandments for Couples (Ed. by Zeig & Kulbatski, 2011,Zeig, Tucker & Theisen)

Ten Commandments for Keeping a Worried Partner Worried

  1. Perceive them as a victim. Imagine that they are too fragile to manage on their own.
  2. Help them feel as comfortable as possible. Make it your mission to rid them of any anxieties, pressures, or expectations. Don’t let them struggle.
  3. Lower your own expectations of them. Believe them when they say to you, “I can’t do it.”
  4. Run defense for them. Make excuses; cover for them. Do for them what they should be doing for themselves. Assume that it is your job to fix problems for them.
  5. Reassure them.  “Don’t worry. Everything will turn out fine.”
  6. Tell them what to do. Act domineering, and generate an atmosphere of intimidation through subtle criticisms and disappointments. Tell them, “Why don’t you do it my way?”
  7. Demean them.  “What’s wrong with you? It’s no big deal. Just do it!”
  8. Don’t ask their opinion on decisions.  And dismiss any opinion they offer.
  9. Perceive any gestures of physical, intellectual, social or psychological independence as a threat to your closeness, and squash them.
  10. Stay worried yourself. And keep reminding them of the serious nature of your worries.

by Reid Wilson, PhD, in Ten Commandments for Couples (Ed. by Zeig & Kulbatski, 2011, Zeig, Tucker & Theisen)

What’s It Take to Handle Worry?

To win over the moments of anxious worrying, consider that the therapeutic strategy should hit six benchmarks:

  1. It competes with the emotional power of fear & distress. You need to generate an emotional response that is strong enough to win over the drama of anxiety. (This variable is often missing in treatment.)
  2. Your actions are directed by a simple point of view that makes sense to you. You should be able to translate that point of view into a clear-cut message that guides you during fearful anxiety. Otherwise, your choices get swallowed up by the forces of conditioning. Example? “Purposely, voluntarily, choose to move toward what scares you.”
  3. Repeating these actions has the potential to influence your neurology over the long-haul.
  4. You need to believe that these actions are within your skill set. You don’t have to win every encounter; you just have to think it’s possible to win.
  5. The strategy helps you feel in control instead of out-of-control. Anxious people often regard themselves as victims of the anxiety condition. You need to feel in charge, to see yourself as the subject, not the object – as the dominant one, not as the prey.
  6. When you get anxious, your mind can turn to mush. Don’t expect some complex protocol to be mentally available during that time. The actions of the strategy are simple enough & available enough for you to use during a confusing, anxiety-provoking situation.

The Paradox of Worry

When a person experiences crippling anxiety, then the goals of worry— “I need to get this anxiety to go away!” or “I’ve got to prevent this from to me again!”—make perfectly good sense. The problem is that this strategy of worrying-to-prevent-harm only serves to increase the problems that it is designed to prevent. Why? Because, paradoxically, when we resist the physical symptoms of anxiety, we ensure that anxiety will continue. (Anything that is resisted will persist.) The adrenals secrete that muscle-tensing, heart-racing epinephrine through the body, the brain matches it, & we will become more anxious. A permissive response—like “I’m willing to handle these feelings” or “If these feelings come back, I’ll cope with them the best I can… and I’ll keep moving”—makes much better sense. And a provocative (instead of permissive) response can work even better. (More on that later.)

Strategic Practice of Homework

I’ve posted a new 6 minute video called “Strategic Practice of Homework”. It’s an excellent example of a client taking charge of exposure.

Accelerated Treatment for Anxiety: Core Concepts

My final DVD in the series–Strategic Treatment of Anxiety Disorders–has now been released by psychotherapy.net: Accelerated Treatment for Anxiety: Core Concepts. You can read more here, and view a video clip:

Anxiety & Depression Insights

Anxiety & Depression Insights new free e-resource from ADAA with research & practice news. Sign up today.

Radio Interview on Anxiety in Kids

Here’s a 50-min. interview Lynn Lyons & I gave on helping worried kids:

Download Our Free eBook for Kids with Anxiety

Click below to get the FREE download of our new e-book, Playing with Anxiety: Casey’s Guide for Teens and Kids.

My Brief Interview on Fear of Flying

Here’s my 10-minute fear of flying interview (RadioMD):

Do you know why clients tend to drop out of cognitive-behavioral treatment?

Here are the most likely factors: their motivation is low, they have poor readiness for change (Prochaska’s pre-contemplation or contemplation stages), they don’t believe the treatment is credible, they have poor alliance with their therapist, or they prefer an alternative treatment, like medications. Up to 30% of OCD clients drop out. The primary cause is poor insight: they believe the obsessions are realistic and that their compulsions are necessary to prevent harm. So if we want to improve treatment, we need to pay attention to all these variables.

What Every Therapist Needs to Know about Anxiety Disorders

An EXCELLENT new book: “What Every Therapist Needs to Know about Anxiety Disorders” by Marty Seif and Sally Winston.

Great, Free Podcasts from ADAA

ADAA has amassed 53 excellent FREE podcasts for professionals on every conceivable topic related to anxiety and many related to depression. An incredible resource.

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