Anxious Clients, Anxious Therapists
All progress takes place outside the comfort zone
⧖ 9 minute read
Feeling some anxiety is normal and healthy, but living with clinical levels can be debilitating. Similar to my article on depression, below I share my $0.02 on a subject that’s covered thoroughly by therapists who specialize in it, so I’ll stick to an overview. Some definitions:
Anxiety: a future-focused worry about what might happen or go wrong. Its source can be quite unclear at times
Stress (psychological): the degree to which you perceive yourself as unable to meet the pressures or demands placed upon you; overwhelmed. Its source is typically clear and can pass if the situation resolves
Stress (physical): the body’s response to perceived threats, a fight/flight response with cortisol and adrenaline
To normalize sub-clinical levels of anxiety, I explain to clients about an idea from evolutionary psychology: the human negativity bias for survival. I joke that the people who survived were the anxious and pessimistic ones, and we got their genes.
It can be helpful to discern the difference between being uncomfortable and being in actual danger, so questions of how a client is deciding about probability and severity often arise. When we try to control merely uncomfortable anxiety, we may be indicating to our brain that this anxiety is a real threat, which tends to make things worse over time. If we can accept our feelings of anxiety, it is often more beneficial than attempts to control it.
We need a lens with which to view therapy for anxiety, some method to explain its onset and resolution. Evolutionary psychology and biology offer ideas, but there is no ‘right’ way for all clients. As with therapy for any client concern, the alliance is more important than a ‘perfect’ theory or treatment plan. Below I discuss some approaches I find to be of use.
Solution-Focused
I think SFT is elegant, simple, and relativistic enough that it highlights what clients already do well, makes room for change, and honors their existing worldview. It often fits well with minimally invasive interventions. It’s often a good fit for anxiety: the exception seeking questions, presupposing change language, and the SFT tricks I most commonly use:
“How were you able to do that?” to get clients talking about their self-efficacy
Tell me about times you don’t experience anxiety, or at least when it’s lessened (identify patterns)
What are you doing differently during those times when it was better?
What can you do for this to happen more often?
Drawing on client strengths can help them see that their identity is ‘more than’ their anxiety, finding areas they feel competent in and times they already demonstrate courage. Scaling questions can be a great bridge between SFT and exposure therapy (exposure typically being effective for treating anxiety).
Stoicism
For treating anxiety I frequently draw upon stoicism’s perspective on control. The more clearly we can recognize what is in our control versus what is not, the better.
What’s in our control: what we say and do with our body
What’s not in our control: basically everything else! For buy-in, I’ll connect this point to relevant items from the client’s story
It’s common to mistake which is which, and I articulate the mistaken perceptions as the difference between what’s in our control vs what merely happens in our proximity. Sometimes I draw this as a dot with a large circle around it: the dot being what’s in their control and the large space around it indicates what happens nearby us. The further away it is, the less influence we have. You could imagine that while you can sort of influence your friend longterm, the amount of energy required to force larger changes is exponential. Further, for people who feel the need to ‘rescue’ others and take on their responsibilities, letting go of that misperception is liberating.
Once we’ve spent years mistaking things outside of our control as being something we ‘should’ be able to fix, people typically feel exhausted, reduced self-efficacy, and a form of learned helplessness. It also leaves minimal energy to work on concerns that are actually within your control.
Some people with anxiety try to be overly controlling of the people and situations around them. Since they are unwilling to sit with the discomfort of suffering, they will seek to ensure nothing ever happens that is troubling to them. You could further tie in the stoic intervention of seeking discomfort, but likely not until their current anxiety is much lower.
CBT
A cliche, but I’d be remiss to ignore CBT for treating anxiety. Giving clients a system and the language to investigate their anxious thoughts effectively is often transformative. The unhelpful thinking styles and a method to examine anxious thoughts can be effective for reducing anxiety.
I’ll hand clients a sheet of the thinking styles and ask them to look it over, to let me know if any of them seem familiar. Then we’ll talk through a relevant situation they’ve mentioned to me, slowing down to examine their thoughts during that anxious moment—to increase buy in. The point I try to get to is to have my clients understand the ABC cycle (activating event, belief, emotional consequence of the thinking) and then have them ask me a variation of, “ok great, now I see how I’ve been getting myself into trouble with this thinking, but how do I stop?”
A few specific ways of using this: asking “so what if this is true?” “What’s the worst case scenario? Best case? What’s likely?” These can be helpful for clients to move into more logical and creative thinking; CBT is a path for engaging less with our lizard brain and more with our higher cognitive function. When we realize we’ll be okay despite ‘the thing’ happening, that we can make plans for likely scenarios then move on, it’s empowering. Otherwise, these mysterious, anxious thoughts lurk in the darkness and we’re not sure exactly how scary they are—though we tend to believe they’re completely terrifying without checking.
DBT
DBT’s focus on self-acceptance, self-soothing, safety, and balance/regulation of emotions makes some of its techniques useful for anxiety treatment. It’s sort of a mix between CBT and mindfulness. DBT is great for therapists who want some structure and clear guidance on concrete skills. Some that I find useful are (google them):
Progressive muscle relaxation
Grounding activity such as 54321; be creative/collaborative with other grounding technique options based on client preferences
Mammalian dive reflex (cold water on face, hold breath)
Breathing techniques such as box breathing, 4-7-8 breathing.
They’re simple but effective, and I’ll often share (briefly) how deep breathing helps to increase buy-in: how a physical stress response will automatically increase heart rate, breathing etc, and how slow breathing influences that process
TIPP skills
Wise mind
Mindfulness
Mindfulness can be a lovely approach to self-soothing and compassion, sitting with ourselves in a supportive way while having a difficult experience. The more that people practice this, the more they tend to respond thoughtfully and with care rather than reactionary fear, judgement, or anger. It’s a massive topic, and I covered some specific skills above with DBT. Sam Harris is a neuroscientist and lifelong meditator whose app, Waking Up, is my top suggestion to mindfulness clients because it’s very high quality, well organized, and free to access if you ask. Insight Timer is another common app that I find quite good, though some of the content is paid.
As for acceptance, I often share the image of a beach ball (i.e., the anxiety) that they’re avoiding by trying to hold underwater; eventually it will pop to the surface forcefully—unless we choose a different approach to the experience. Acceptance doesn’t necessarily mean I’m happy this situation happened, but it does mean I’m acknowledging the reality of what occurred so I can process the emotion and then move forward.
Miscellanea
There are lots of neat narrative therapy approaches to anxiety, with creative options once you externalize the anxiety and help clients relate to it differently. As with depression, it might make sense to do a screening test for autism—sensory processing issues and the social difficulties of autism can look like anxiety and feeling overwhelmed often.
It’s always a good idea to keep a biological basis in mind and refer clients to their doctor if it seems relevant. Asking about clients’ sleep hygiene will regularly reveal poor habits in anxious clients, so psychoeducation here can be important. Similarly, inquiring about physical activity level may be of use, encouraging walks in nature and so on—but don’t go outside your professional scope. If clients are complaining about an upset stomach, brain fog, getting mild cold symptoms often, etc I’ll mention that these things can be common outcomes of a prolonged or chronic physical stress response, often seen in people with a lot of anxiety. As in, our body steals energy from some systems (frontal cortex, immune function, sex drive, digestion) to prioritize other systems for fight/flight (heart, lungs, adrenaline etc). Obviously stay in scope and refer them to their doctor if it seems relevant.
The book Anxious Kids, Anxious Parents by Lynn Lyons is an excellent resource for therapists and parents. It’s painfully common for parents to bring their child in and insist the child has some issue but that they don’t know where it’s coming from. Often (but not always) the child’s problem is shared by one or both parents.
For only as we ourselves, as adults, actually move and have our being in the state of love, can we be appropriate models and guides for our children. What we are teaches the child far more than what we say, so we must be what we want our children to become. ~Joseph Pearce
Lastly, anxious thoughts are often based in a preoccupation with relational issues. It can be helpful to discuss with clients that other people’s behaviour is almost entirely based upon that other person’s relationship with themselves, rather than a clear statement about the client’s value as a person.
Anxious Therapists
It’s common for newer therapists to have quite a bit of anxiety. Beyond that, some therapists practice for decades while having various forms of clinical anxiety, and this is usually ok. Similarly, many therapists struggle with codependence, people pleasing, and so on—which exposure, reflection, supervision, and your own therapy can help. When attended to responsibly, this kind of concern is normal; we continue to develop personally and professionally as the years pass.
For new therapists there’s so much to learn; it’s all new and clunky. It’s like learning to drive—our brain has to consciously pay attention to the million things that are going on and we make many mistakes. As the weeks and months pass, we gain more experience and some of the basics start to become smoother and more automatic, freeing up mental bandwidth to focus on increasingly complex aspects of the task. Seek the resources and support that you need, when you need it. Trust the process!
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