Tag: Anxiety

Four Existential Givens

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Four Existential Givens (and the implied responses)

So, Yalom (e.g., 1980) talks about the four “existential givens” or “ultimate concerns”:

  • Death (i.e., death anxiety)
  • Freedom
  • Isolation
  • Meaninglessness 

And I’m surprised how rarely (or if ever?) I find someone cogently and overtly expressing that the implied responses to each of these ultimate concerns are the bedrock principles of existential therapy (and maybe ALL therapy):

  • Approaching (rather than avoiding) anxiety (thus reducing anxiety and also the foundation for living fully)
  • Taking responsibility (and recognizing limits of both responsibility and freedom)
  • Building and maintaining connections (maybe Existential Therapy proper doesn’t do a great job of this one, but Frankl certainly talks about it at least) 
  • Defining (and then living in) valued directions 

See what I mean, though? Why is this not just a chart in all theories textbooks? Why do we always get the idea that the main things to do is SUFFER with these ultimate concerns rather than use them as guideposts?!

 

Comment below: From your own theoretical orientation, how do these play out? Is anything missing? 

 

Yalom, I. D. (1980). Existential psychotherapy. New York: Basic Books

 

 

 

Productive Purposeful Pleasant

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Productive – Purposeful – Pleasant

After ending last week’s blog, I realized I haven’t ever posted about this little language-based motivation/behavioral activation technique that I sometimes use with clients. Probably because I really don’t like it when people make (or especially seem to force) alliteration or acronyms, and I don’t want you to think I did that! Haha! This actually just popped up in a session one day, fully formed (fully P’d!) and it has been useful several times. 

This little technique seems to be sometimes beneficial with clients who have mild/moderate depression, the kind of anxiety that keeps them sort of paralyzed (not catatonically paralyzed! Just keeps them from moving forward effectively), and some who deal with procrastination. (Although straight mindfulness is good for all of these, too, especially procrastination.) 

The technique is really simple – it just involves (Step 1) taking the things on the client’s to-do list (whether that is take a shower and check the mail in the case of depression or the long list of household chores or whatever), and dividing them into these categories, or labelling them… is the task Productive, Purposeful, or Pleasant? (or some combo?)

*Wouldn’t it be nice to have lots of things on the list that are all three?!*

Step 2: Just take anything else off the list! What’s it doing on there, anyway?! This can sometimes bring a sense of relief and permission to clients who need it. 

Step 3: Make sure there are items in every category, especially the pleasant category! (This is a kind of sneaky way to measure anhedonia and sometimes to figure out distress tolerance ideas!) 

Step 4: Invite clients, in session if it’s possible or as homework, to choose items from anywhere on the list.

I often start with Productive… is there anything on there that they have the motivation/energy/etc. to do right now? If they can, they often feel a sense of accomplishment and also relief from “checking something off the list.” It’s ok to make use of session time to get this started! Do they need to make a dr’s appointment – just have them call, right now! Do they need to update their credit card information on their bill pay? OK, do it! 

If not, how about something purposeful (meaning tied to values, even if it doesn’t “get things done”)? Is there a value of relationships or being a kind person – choose text a friend from the list (add it right in the moment if it comes up!) Is there a religious/spiritual value – choose read a scripture verse. Is there a value of being a good parent – write a sticky note for your kid and put it in their room. Is there a value on making progress in therapy? Listen to your affirmations, read a few pages in the homework book, etc. Make sure that plenty of these are easy, low energy, low cost options. (This is a kind of sneaky way to get to identification of values, as well, which can be helpful in most cases.)

Nothing doing there, either? Well, no problem! Because you have a list of activities that are for nothing but pleasure! Encourage clients that choosing something from the pleasure list is OK! (There might be a little bit of cognitive work to do here, about being “allowed” to do something for pleasure when there are things on the productive list. And one of these days I need to do a post on how “laziness” is just a really good energy management strategy! HA!) But remember – doing something is better than doing nothing, and often increases motivation and productivity in the long run. Even if the pleasant thing is doing “nothing,” like taking a nap, sitting quietly, etc., doing it mindfully is a positive step! 

Comment below: What do you do to help clients with behavioral activation? 

 

 

 

 

Online Resources Vol. 4

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Online Resources Volume 4

If you haven’t seen them, here are Volumes 1, 2, and 3!

  • The Reveri app  – It’s free (of course!) and the BEST actual hypnosis app I’ve ever come across. (And I’m ASCH certified in clinical hypnosis). I’ve previously recommended Comfort Talk, and stand by it, but Reveri is also excellent and covers a lot of great, specific topics – e.g., sleep, anxiety, chronic pain, smoking cessation – the kind of stuff it’s probably ok to work on by yourself without a therapist. 
  • Greater Good Magazine – Honestly, this isn’t a great resource for therapists, as far as I can tell. But I think it’s one of the better lay-accessible internet resources.  It’s mostly research-based and comes out of Berkeley, and has lots of different kinds of content, all focused on well being. Worth a look. 
  • Andrew Huberman Podcast – For nerdy therapists (and maybe clients), Huberman is a neurobiologist and does a lot on mental health related topics – sleep, depression, addiction, stress, etc. – as well as some stuff that’s more like “optimizing wellness.” Easy to listen to, extremely knowledgeable, great sources, smart occasional guests. Honestly, his mental health series was not my favorite, but when it’s outside my direct area, I learn a lot. 
  • Kardia Deep Breathing App – FINALLY!!!! I finally found an app that lets you control the timing of the breathing! Remember the cardinal rule – breathe out longer than you breathe in. The end. But finally, there’s an app that will let clients personalize that, rather than putting them on a strict 5-minute, 5 seconds in, 5 seconds out, rigid program! THANK YOU! It’s $0.99 for the full functionality, but the free version works perfectly well for my personal use and for how I use it with clients.  
  • Spanish & Mandarin relaxation tracks – offered by the University of Texas Counseling Center, There’s a 3-minute breathing and a body scan available in both Spanish & Mandarin – I have a hard time finding resources for clients who, even though they may do their therapy with me in English for various reasons, might prefer or better utilize resources in their native language. These are free and you don’t need to be a student to access them. 
  • Various Downloadable Workbooks – The Govt of Western Australia has a resource that includes free, downloadable self-help workbooks on lots of issues – body image, depression, procrastination, distress tolerance, panic, health anxiety, etc. I haven’t gone through the whole workbook on all the topics, but the ones I have looked at are pretty legit. Maybe a good option for clients who want to work outside of session, or for your own use as smaller handouts or in-session activities if you break them up.

Comment below: As always, if you know of great, free, online resources, let us know, too! These things are out in the world to be shared and used!  

 

 

 

 

Avoidance Sucks

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Avoidance Sucks

Here’s what I mean by that: 

  • Avoidance of feared stimuli increases rather than decreases fear. So it perpetuates itself at your expense. This is approximately 35% of all therapy, possibly. 
  • Avoidance is painful by itself. Every time you avoid, you’re having a measure of the pain you would have in confronting. But you avoid it over and over and over… so you have a partial measure of pain over and over and over, which almost always ends up being more painful over time. 
  • Avoidance narrows your options. I mean this in small ways, but also in the very big, existential way – like the “untimely deadness of a too narrow existence” 

Some caveats, in case you’re thinking any of these things:

  • Staying away from genuinely toxic or dangerous things/people/situations isn’t avoidance, it’s wisdom. 
  • If you believe you benefit from a “change of scenery,” you need to give a good think about if it’s escaping/avoidance or something else. A lot of that is how you use that time. If you just get away from stressors and enjoy that, it’s avoidance. If you use the time away to actively work on stuff that will improve your life when you’re back, ok. 

Comment below: How have clients sometimes gotten in trouble by avoiding? How have you?? 

 

 

 

Best Quick Tips Ever (Vol 1)

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Best Quick Tips Ever

 

There are a bunch of super effective, super-fast, super-easy techniques for stress reduction, emotion regulation, and more that therapists just aren’t teaching clients! Why?! I think it might be because people don’t know about them? Here’s a list of a few of my favorites, each with a little video. Well, except for the really self-explanatory ones. For those, I’m attaching some research because it’s hard to imagine these commonplace little tactics are actually effective! 

(Ethics moment – definitely don’t use these if the underlying theory isn’t already part of your clinical repertoire, please!)

 

  • The Dive Reflex – If you’re a mammal (and you are), and you’re stressed, put your face into cold water for 30 seconds. Instant changes in the stress response, thus calming anxiety and other dysregulated emotions. 
  • The Physiological Sigh – You do this, unwittingly. It’s that sobbing sort of thing you sometimes do in the middle or near the end of a big cry, or you at least do it in your sleep! It’s like taking 2.5 inhales and then a long exhale, repeat 3-5x. The end. Really good for quick emotional calming. (Side note: In real life, when your body does this naturally, it’s more like 1.5 inhales, but when I’ve taught it in therapy, clients are usually breathing very shallowly, and teaching them to do this consciously, 2.5 seems to work better – the first inhale to baseline, the second to what feels like “capacity” or a “deep breath,” and then that last little bit that “overinflates.”)
  • List 3 Things You’re Grateful For – Lots of research about this, but here’s a fun study about how gratitude reduces Repetitive Negative Thinking and thus reduces depression and anxiety. Even a single, small intervention, like listing 3 things you’re grateful for in the moment can change perspective and improve mood. 
  • If you already do EMDR, consider the Flash Technique – it’s like a quickie version of reducing SUDS, without processing the actual trauma (but has some limitations, of course). Remind me one day to do a post on what actually makes EMDR work (which isn’t bilateral stimulation).
  • Call a Thought a Thought – the simplest  of cognitive defusion strategies. Notice you’re thinking thoughts. Then say it to yourself, “I’m noticing I’m thinking XYZ,” or even “That’s just a thought.” Crazy powerful, quick, and accessible anytime. 
  • Controversial but interesting…. Take a Tylenol – Acetaminophen (paracetamol) reduces the pain of social rejection and of making tough decisions. Careful, though – it may also increase risk taking, reduce empathy, and decrease the intensity of positive experiences, as well. (And, of course, mind the risk of overdose!) 

Comment below: Share your favorite, research-based “quick tips” for clients!  

 

 

 

Great Books Volume 5: Contemporary and Wildly Useful Books Written by People I Know

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Great Books Vol 5: Contemporary and Wildly Useful Books Written by People I Know (at least on Twitter!)

Transcend by Scott Barry Kaufman – This book is for everyone! It’s deeply humanistic and optimistic and transformational. If you thought you knew anything about Maslow’s “hierarchy of needs,” you should FOR SURE read this! It’ll both blow your mind and give you a great new metaphor for understanding human needs and actualization. Also, SBK is just this very cool, super authentic, and genuinely KIND human person. Oh, and he has the best podcast ever, too – The Psychology Podcast.

Show Your Anxiety Who’s Boss by Joel Minden – This is my favorite CBT book for clients. It’s easy to read, and the take-home message is simple and easy to remember (even though Joel knows I always roll my eyes at acronyms that are made to be cute, it turns out they are memorable!). One of my favorite things is how comprehensive it feels without turning into a long list of cognitive distortions. And I just really like the term “anxious fictions!” 

The Habit of a Happy Life: 30 Days to a Positive Addiction by Jeff Zeig. Jeff has written a lot of books, and I like all of them that I’ve read (because the way he thinks, especially about therapy, is just brilliant), but they’re not all for a very broad audience. This one, however, would be very useful for many clinicians and clients alike. If you ever read Positive Addiction by William Glasser, I’d say this is like an update version – same great concept, newer research, and I like Jeff’s writing better than Glasser’s, too! 

The Suicidal Thoughts Workbook by Kathryn Gordon – Is it weird to get really excited about a book on so heavy a topic? NO! Not for therapists, it’s not! Haven’t you lamented how few good resources there are for clients around suicide? This workbook is incredibly compassionate and thorough, gentle and practical. There’s no shying away from any difficult topics, and everything is handled with confidence in and grace for the reader. This is an indispensable resource for therapists, and I have no doubt it will be life-saving for clients. 

Brains Explained by Micah & Alie Caldwell (and sort of by their cats). Look, I know I’m an intense nerd and so you won’t like all the books I like. But if you’re one of the HUGE number of therapists who is both really interested in neuro/brain stuff but sometimes also intimidated by neuro/brain stuff, you’re going to SWOON for this book! There’s definitely enough in there that’s genuinely relevant to clinical practice to make it worth the buy on its own – but be prepared to accidentally get swept up in all the rest of it, too. It’s just so…. accessible and hilarious! And the chapters are almost bite-sized. They’re like…dessert-sized. What more could you want? (Oh, they have a fun YouTube channel, too!)

ZigZag by Michael Apter – Michael is one of my most treasured mentors. If you’ve read any of the Reversal Theory blog posts, you have also benefitted from his brilliance! He’s also written several books, but this one is the newest introduction to RT and it’s really accessible. So many more people (including your clients and yourself!) will find this book somewhere between interestingly useful and life-changing, so give it a try! 

Updated! Come As You Are by Emily Nagoski CAYA is my all time favorite book about sex!! Although it’s geared toward women, I almost always have men in relationships read it, too, especially if they’re in relationships with women. Emily is an incredible writer – she has a wild gift of taking really good, dense research and turning it into something both understandable and meaningful for the lay reader. Make sure you get the newest (revised & updated) version that was published in 2021, mostly because she says she likes it better. 

Also, CAYA has a workbook! (In fact, two cool things about the workbook. One is that I am one of the people who helped review it for initial edits, which was super fun! The second is that I’m pretty sure my husband is the reason the book exists – when we first read CAYA in 2013, before Emily was crazy famous and busy, he just emailed her to ask if she had any of the exercises in PDF, so we didn’t have to mark up the actual book and we could have 2 of each of them. So, she made them into PDFs and emailed them. Then, she put them on her website. Then, this book became a thing!)

And, yes, I’m a Nagoski superfan, so Burnout: Unlocking the Secret to the Stress Cycle (by Emily & Amelia Nagoski) makes this list, too. Incredibly useful, especially for that subset of adult female clients who grew up learning that they had to always play support roles, even unto exhaustion (and maybe developed resentment, anxiety, or low self esteem as a result). Goes along nicely with the podcast The Feminist Survival Project 2020. Just a note – both the book and the podcast lean pretty heavily liberal, but as long as I have warned my conservative clients about that, it’s been ok. 

Oh, and SURPRISE! I wrote a book, too! 😉 But you can’t have it until August! 

 

 

Comment below: What are your favorite therapy-oriented books these days? 

Post Concussion Syndrome

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Post Concussion Syndrome

Diagnostics is always more complicated then it seems – more like a DND roll than a simple symptom checklist or binary “has it” or “doesn’t have it” question. Here’s a great example:

 

Post concussion syndrome (PCS, or postconcussional syndrome) is a relatively vague set of symptoms that can continue to occur well after someone has had a head injury. The symptoms are wide and many of them are mental health symptoms, which is why it’s especially important for us to know about it. A headache is usually accompanied by symptoms like:

  • sleep problems
  • depressed mood
  • irritability
  • anxiety
  • trouble concentrating
  • difficulty with memory

Sound familiar?! YIKES! 

In fact, it’s so closely associated with other mental health conditions that 10-20% of student athletes meet criteria for it… even if they haven’t had a head injury – just because they’re stressed and somewhat sleep deprived! So, it’s important to consider all facets of this diagnostic mess!

 

 

PCS codes in ICD-10 as F07.81. Now, we probably wouldn’t want to diagnose Postconcussional Syndrome…. but we very well might want to put it in as a Rule Out or make a referral for additional testing/diagnosis with a physician or neuro specialist. 

 

We definitely want to have a question on our intakes that helps us keep this possibility in mind. For example, on my regular intake I have this question:

Have you experienced:
– chronic headache, migraine, vision changes, loss of consciousness, or dizziness?
– changes in your vision, hearing, other senses, or movement? (e.g., blurry vision, ringing in your ears, difficulty swallowing, trouble speaking, weakness or paralysis)
– difficulties with your memory, planning ability, or thinking clearly?

If so, when did you experience these symptoms and for how long?

That allows me to consider PCS, along with some other potential issues such as mild neurocognitive disorder and functional neurological symptom disorder (formerly conversion disorder). These answers can also “flesh out” other conditions, such as chronic headache associated with generalized anxiety disorder or difficulty concentrating as part of a depressive disorder. Loss of consciousness sometimes maps onto a substance use disorder. It’s a big question, but it gives lots of data and paths to follow-up on during the actual intake. 

Comment below: What are some of the diagnostically oriented questions you have on your intake? 

Easier to believe what we fear

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It’s easier to believe what we’re afraid of…

It’s easier to believe what we’re afraid of, than what we hope for. (Almost always, for almost everyone.)

I can’t tell you how much it changed my practice when I realized this phenomenon, and began explaining it to clients. Here are two ways to think about it.

 

  • Let me tell you a story about evolution. (Just a story, mind you. This isn’t the time to get bogged down in phyla and epigenetics and all that.) Long ago, there were two kinds of people. One group of people saw a coiled vine and assumed it was a coiled vine. They were promptly bitten by a sneaky snake and all died. Thus, they have no living descendants. The other group of people saw a coiled vine and jumped away, thinking it was a snake. They did a lot of unnecessary jumping, a little necessary jumping, and a lot of staying alive and going on to make babies. They are our great-great-grand-cestors. So, we’re all evolved to be a little jumpy (get it? “jumpy”? haha!).
  • If you don’t like to think about it think way, you can also think about it from a very pre-frontal cortex, literature informed stance. Humans tend to be risk averse – a loss of $5 is more distressing to us than a gain of $5 is joy-inducing. In any given situation, we’re likely to put more emphasis on what we could lose than what we might gain. Fear and aversion conditioning (under most circumstances) also happen faster than other kinds of associative learning. So, if you mistake a snake for a coiled vine once and have a near miss – you’re quick to avoid vines in the future. (But you don’t so quickly change your approach to potential snakes when just one turns out to be a vine – thank goodness!) So, it’s easier to believe what we’re afraid of than what we hope for.

 

Let me just give you a few examples of application:

I know you’re already thinking of your classic GAD catastrophizer. Good, that’s #1.  Also, this leads to exacerbated social anxiety, as clients overestimate the likelihood of negative judgment. It contributes to the ever-building cause-effect sequences in OCD, because clients misjudge the likelihood that events are related. Phobia maintenance, misinterpretation of panic symptoms, etc.

And it’s not limited to anxious clients. This is the dad who can’t listen to his teenager’s needs because of his fear for her safety. It’s the workaholic (whose husband is in therapy because she can’t squeeze it in) who doesn’t realize she has a dual income family. It’s part of what maintains the hopelessness of your depressed client, the migraines of your “under-adequate”-mom client, and even the frantic relational grabbiness of your client with BPD.

Also true in your couples – when one partner is afraid of being cheated on again – he wants to hope it won’t happen again, but it’s much easier to be afraid that it will. When sex is painful, she wants to hope that it won’t be next time, but she’s afraid it will be. That’s easier to believe, and that leads to tension, and that leads to more pain. When he has an erectile “failure,” it’s harder to hope it won’t happen than to be afraid it will, and that leads to performance anxiety, and that leads to more “failure.”

It’s the beginning of so many self-fulfilling (self-defeating!) prophecies. And while we can’t change the fundamental neurology (and maybe don’t want to), bringing our own and clients’ awareness to this little quirk of our brains can help us all to pause, and bring a little more prefrontal cortex to our otherwise limbic reasoning. Here are a few specific things that can help:

 

  • Accept their fears with gentleness, and help them to extend self compassion
  • Work on reducing the actual and/or perceived consequences of the feared event
  • Co-create strategies to gain information that will help client evaluate potentially fearful situations
  • Teach this phenomenon to help clients reduce their emotional reasoning

 

Comment below with examples of how you’ve seen this in action with your clients!