So, this is life. Long, busy workdays and weekends with little rest. A weak economy and constant worry over the prospect of losing a job or even a home. Nonstop technology that never allows us to unplug. Ever-growing pressure on kids (and therefore on parents) to be involved in every activity under the sun. Two wars, one of which is the longest the nation has ever endured. A variety of natural disasters, from hurricanes to tornadoes to floods, that turn people’s lives upside down in a matter of seconds. Now toss in the typical trials and tribulations of everyday life, and it should come as no surprise that many clients who walk through the counselor’s door today are simply stressed out. If such a thing as “the simple life” ever really existed, it is confined to history.
Dawn Ferrara, a private practitioner in Mandeville, La., has worked with many clients to address the stress and anxiety in their lives. One client she remembers in particular was a stay-at-home mom who reported a growing inability to get her daily tasks done. “She was feeling so overwhelmed that she started avoiding things, creating more distress as they piled up,” says Ferrara, a member of the American Counseling Association. “She was also complaining of poor sleep, fatigue and headaches. She had been to the doctor already, and nothing physical was found to be causing her symptoms. So, we began by looking at her world, how she saw herself in that world and the things she identified as stressors.”
The client expressed a belief that it was her role to carry the lion’s share of responsibilities at home. She also held another belief — that it was neither possible nor OK to take care of herself. “What was most striking about this lady was that when I asked her, ‘When was the last time you took some time for yourself and what did you do?’ she looked at me like I was speaking a foreign language and burst into tears,” Ferrara says. “It had been so long since she had taken some meaningful time that she couldn’t even recall [it]. So, we challenged some of those beliefs and began to implement some behavioral strategies.”
First, Ferrara and the client worked on prioritizing and defining which tasks were legitimately necessary and which ones the woman shouldered simply because she thought she “should.” They also examined whom the woman could delegate some responsibilities to and determined certain tasks that weren’t really hers to carry. “[That] was a hard one for her,” Ferrara says.
Next, they identified the client’s support system, mapping out how she could ask for help and for which tasks. In reality, her spouse and kids were willing to take responsibility for certain areas and were happy to be asked for help, Ferrara says. Ferrara and her client also looked at lifestyle management, including eating well, getting good sleep, getting fresh air and sunshine, and making a schedule for the day and limiting what was on it.
“Carving out personal time to relax and recharge was the cornerstone of her treatment,” Ferrara says. “She had ignored the need to relax for so long that in some ways, she had to relearn how to do it. She was mentally on ‘go’ all the time. We started with 15 minutes of being still and present, not in bed, every morning after the kids were on the bus and before she started her day. She chose to sit on her back porch with her morning coffee and listen to the sounds of the morning. At first she struggled with being able to quiet her mind, so we focused on some basic mindfulness techniques. Over time, she came to enjoy this time and began taking a walk. This became a daily ritual for her and, eventually, she was able to add some other activities such as taking a yoga class or a girl’s night with her friends.”
Although this client’s worries didn’t stem from trauma related to a natural disaster, Ferrara says she has noticed an overall increase in anxiety issues ever since Hurricane Katrina struck the Gulf Coast in 2005. Ferrara, whose office is directly across Lake Pontchartrain from New Orleans, now puts more focus on stress and anxiety topics in her practice. “People down here live in a state of heightened alert, especially as hurricane season approaches and the talk about being prepared escalates,” she says, noting that each hurricane season lasts six months — a long time to remain on pins and needles.
Ferrara also encounters a lot of worry over the economy and job security. People feel anxious about their continued ability to provide for their families, hold on to their homes and make sure that everything gets done at work in hopes of protecting their jobs. Nadine Rosen, a counselor practitioner in Charlotte, N.C., is witnessing that same level of employment stress among her clients. Charlotte-based Bank of America recently announced a plan for future layoffs in the range of 30,000 jobs. Many of Rosen’s clients work for the bank and are naturally anxious about the news. In constantly wondering whether their jobs are at risk, they are also dealing with performance anxiety, hoping they can impress their bosses enough to save their spot in the company.
Kathleen M. Horrigan, who works in private practice in Severna Park and Towson, Md., says she sees more stress among clients than she ever has before in her 20 years of being a lay and professional counselor. The economy and a difficult job market are surely factors, she says, as are relationship issues, whether between romantic partners, parents and children, or clients and in-laws.
The continuing wars add another element of stress, says Horrigan, a member of ACA. Not only are service members feeling this added pressure, but so are their families and significant others, who are often left waiting to hear from the soldier, possibly not even knowing where their loved one is, all the while having to juggle the household responsibilities on their own. “It’s a high level of stress [for them],” Horrigan says.
Georgene Dwyer, a counselor in private practice in Tulsa, Okla., isn’t necessarily sure that she’s seeing more individual cases of stress than in years past, but she has noticed that less stigma is attached to anxiety than there used to be and that clients are more willing to come forward and talk about it.
Ferrara agrees, saying more people today are willing to seek help to deal with stress and anxiety. “It’s a good thing because I don’t think there’s any shame in asking for help. The shame is in not asking for help,” she says. “There are so many good counselors out there.”
“A perfect storm”
Stephnie Thomas, an anxiety disorders specialist at the Anxiety and Stress Disorders Institute of Maryland, says stressors are a normal part of life, but when people ruminate on those stressors without problem-solving, anxiety can enter the picture. “Most people think if I worry enough about something, I’m going to solve the problem,” says Thomas, a member of ACA. “But actually, that doesn’t always happen. Worrying very rarely solves it.”
As described by Ferrara, stress is what is going on in our world that creates discomfort for us, whether conflicts at work, relationship problems or any number of other things. Anxiety is the resulting worry. “What happens is we start worrying about one thing and stressors pile on, and that worry generalizes to everything,” Ferrara says. “I have clients who tell me they can’t turn it off.”
Unchecked chronic stress can lead to anxiety, with symptoms that might include insomnia, appetite change, distractibility, a feeling of being overwhelmed, avoidance of activities and even absenteeism from work, says Rosen, a member of ACA. Everyone’s tolerance level for stress is different, she says, and that level is often determined by a person’s coping skills, natural temperament, support systems and physical well-being, as well as by the health of his or her relationships.
Current life stressors aren’t the only elements that can figure into a person’s anxiety level, Horrigan says. Anxiety can also be the result of genetics or of past stressors that occurred in a person’s environment over a long period of time — for instance, she says, being exposed to abuse, being abandoned by a parent or growing up in a household where anxiety was the norm. “Then, enough stress in their adult life can lead to anxiety. The biological, the psychological and the environmental all come together at one point. It can be a perfect storm,” Horrigan says.
Ferrara points out that stress can also serve as a positive influence at times, such as propelling people to meet deadlines and get things done. But when stress builds to the point of affecting a person’s ability to function the way he or she wants to, it becomes a problem. “And when it starts to impact health, that’s absolutely a big red flag,” Ferrara says.
For Ferrara, the biggest indicator that clients have “crossed the line” into the realm of anxiety is when they tell her they can’t sleep, even if they have been good sleepers historically. Another warning sign is experiencing body aches, including headaches, stomachaches or other pains, for no apparent reason. Anxiety can also decrease productivity, leading people to feel as though they’re working nonstop and still not accomplishing anything, Ferrara says.
Other symptoms of anxiety include angry outbursts and feelings of being pulled in every direction, Horrigan says. Like Ferrara, she also reports seeing clients with physical ailments that can be traced to anxiety. Oftentimes, she says, these clients have gone to the doctor, received a clean bill of health and yet are still experiencing chest pain, jaw pain, stomach issues, high blood pressure or migraines. But in order to rule out any medical problems, Horrigan asks clients to schedule an appointment to see their doctor if they come to her with physical symptoms of anxiety. If a client’s daily functioning is impaired — for instance, if the client can’t get out of bed or is dealing with panic attacks — Horrigan also asks him or her to see a psychiatrist for an evaluation.
Thomas has also experienced this situation in reverse, receiving clients through referrals from a physician. “[Clients will] often say, ‘I’m not quite sure why I’m here. And then we talk, and a lot of the stress will come out,” she says. Seeing a physician is often the first stop for individuals experiencing anxiety, Thomas says, especially for those whose cultures stigmatize counseling.
Taking the first steps
These counselors say the first order of business with clients seemingly struggling with anxiety is a careful assessment to determine the exact nature of the issue. Anxiety often goes hand in hand with other disorders such as depression or attention-deficit/hyperactivity disorder (ADHD), Ferrara says. Rosen agrees, adding that clients who have a history of trauma, undiagnosed ADHD or untreated depression might have a tougher time coping with everyday stressors.
A good clinical assessment will ascertain which symptoms the client is experiencing, how intense those symptoms are, when those symptoms occur and what context they occur in, Ferrara says. Counselors should also ask about the client’s family history, substance abuse history and functionality at home and work, she says. Horrigan adds that having a client complete a genogram can offer insight into the individual’s family history and tip a counselor off to any potential genetic predisposition to anxiety.
After finishing a thorough initial assessment, Dwyer immediately teaches breathing and relaxation techniques to her clients. She works with them on noticing the physiological changes that take place when they slow down their breathing and on visualizing a calm, safe, peaceful place where they can take themselves when feeling anxious.
Similarly, one of the first things Ferrara discusses with clients is how they’re feeling and acting physically because in stressful times, she says, people often neglect their health. She works with them on deep breathing and taking time during their day to disconnect. Also important, Ferrara says, is what she calls “sleep hygiene.” Do clients have a set time to go to bed? Is the room in which they sleep quiet, cool and comforting? Are animals or kids in the bed as well? Sticking to a schedule, both for going to bed and for waking up, is helpful, Ferrara says. “If people can get good restorative sleep, they’re more likely to function well the next day,” she says.
Horrigan follows a two-pronged approach with clients who present with stress and may have underlying anxiety. First, to reduce some of their physical symptoms, she teaches them relaxation techniques such as abdominal breathing, progressive muscle relaxation, guided imagery and meditation. She also encourages clients to practice yoga, listen to calm music, eat well and stick to a routine sleep schedule. “I also have clients look at their daily demands … and prioritize what are the most important things in their lives and what can they alleviate to be able to give more self-care,” Horrigan says.
The second prong is aimed at addressing the underlying issues that might have led the client to experience sustained stress and anxiety. “During this phase of treatment, I work at a slower, more careful pace, collecting information from the client’s history and background, including a complete family history genogram,” Horrigan says. “I have found that in the process of collecting this information, it not only reveals to me a clearer picture of the client’s psychodynamic makeup, but also allows the client more opportunity to see firsthand the development of their own family patterns. This affords the possibility for the client to make the connection [and see] how and why they may be experiencing the stress and anxiety in their lives now from their past.”
Many clients’ symptoms of anxiety stem from genetics, growing up in an abusive home, being abandoned as a child by one or both parents, or experiencing trauma as a child and then repeating this lifestyle as a dysfunctional parent or family system, which can trigger the client emotionally, Horrigan says. “By teaching a client to identify those situations or things that trigger their anxiety, a client can avoid certain situations or prepare themselves for … feelings that may come as a result of a situation,” she says. “This might mean that they reduce their exposure to a situation or learn coping skills to deal with the feelings that come as a result of a given situation.”
Horrigan also works with clients to find the common threads that tend to ramp up the anxiety in their lives. For one of Horrigan’s clients, this was searching for available parking at work. The client would ride around and around in the morning looking for an open spot, often arrive late to work as a result and then have trouble remembering where the car was parked at the end of the day. Horrigan and the client came up with a solution: carpooling, which greatly reduced the client’s stress level.
Everyone experiences some amount of stress, and because the resulting worry can either be exacerbated or mitigated by the way a person handles it, Thomas works with clients to distinguish between productive and unproductive worry. She describes productive worry as something an individual can take action on in the present moment. For example, if you oversleep, worrying about getting to work on time can help hasten your morning routine and get you out the door a little faster.
“Unproductive worry is when you have a thought about something anxiety-provoking, and then another thought and another thought,” Thomas says. “And then you’re back at your original thought and you haven’t made any progress.” Thomas encourages her clients to take their worries one by one, determining if any action can be taken immediately. If not, that worry gets put aside.
“You can’t stop the thoughts from coming, but what you can do is start tuning them out,” Thomas says. She compares this with driving on the highway and merging into another lane while the music is on. Although you remain aware of the music, you’re not focused on it because you’re paying attention to driving. The same approach can be taken with worrisome thoughts, Thomas says. “The thoughts won’t disappear, but treat them like the background noise instead of focusing on them.”
Counselors can also assist clients in prioritizing responsibilities, growing to accept that they can’t be everything to everyone and learning how to take more time for themselves, Horrigan says. She advises helping clients to recognize both the important things and the unimportant things that pull them in different directions. “Sometimes,” she says, “that means saying no to good things to have a healthy life.”
Another relevant topic Horrigan addresses with anxious clients is control. In doing so, she shares a motto: “We can only control one person 100 percent of the time.”
“When a client believes that they can somehow control another person, they begin to have expectations of them,” Horrigan says. “When these expectations are unmet, this can lead to disappointment, which can lead to stress, which can produce feelings of anxiety. Helping and preparing clients to realize that they can only control themselves assists them to depend on themselves and not to have expectations of or worry about others whom they have no control over.”
Issues with control can stem from growing up in a dysfunctional family system, Horrigan says. In some cases, clients might have felt the need to assume too much responsibility for other family members. Or, on the flip side, clients might have experienced a family member exercising unhealthy control over them through the use of guilt or manipulation. When counselors help clients realize that they cannot control others and, furthermore, that they don’t need to take responsibility for others, their thinking changes, which also opens the door to behavioral changes, Horrigan says. Releasing that responsibility helps clients to prevent automatic thoughts concerning how things were handled when they were growing up. It also aids them in avoiding repeated patterns of behavior, reframing their self-defeating thinking and speaking positive statements to themselves, all of which can reduce anxiety, she says.
Staying in the moment
Recently, Rosen was working with a client in her late 20s who was dealing with symptoms of anxiety after losing her real estate business due to the struggling economy. This client prided herself on her accomplishments and her self-esteem was tied to her achievements, Rosen says, and she subsequently went through bankruptcy after her business was shuttered.
Rosen encouraged the client to acknowledge and mourn her losses, explore her erroneous beliefs connected to perfectionism, separate her value and worth from her career accomplishments, build her positive coping skills and utilize her support system. They also worked together on two other techniques: mindfulness and radical acceptance.
“Radical acceptance is more about accepting where you are at a given moment and allowing yourself to have the experience without judging it or having to do something about it,” Rosen explains. “So, for example, if I am anxious, rather than avoiding the feeling or trying to do something to get rid of it in a negative way because I am so distressed by it, I would acknowledge it and allow myself to experience it without labeling it as ‘bad’ or [telling myself] that I shouldn’t feel that way. When we allow ourselves our emotional experiences, they tend to dissipate quicker than if we act out on [them] in a negative way.”
Mindfulness requires us to be engaged and present in the here and now, Rosen says. “It is amazing how distracted we can become, often worrying about the future, as in the case of anxiety, or ruminating and dwelling on the past, as in the case of depression,” she says. “When we are mindful, we are present-focused and, therefore, neither in the future nor the past, which can be very beneficial in dealing with stress, anxiety, depression, etc.”
To teach her clients mindfulness, Thomas asks her clients to list their thoughts on a whiteboard and then discuss whether each thought is related to the past, the present or the future. “Every time you go off to a future ‘what if’ or a past event, come back to the center,” Thomas tells clients. “When people can be more centered, they’re less stressed.”
Rosen also uses mindfulness-based cognitive therapy, a multidimensional approach that combines mindfulness and radical acceptance with cognitive therapy. She says the approach incorporates the cognitive experience by teaching clients to notice when they are engaging in negative thought patterns and cognitive distortions that could be contributing to their anxiety.
Compartmentalization is another suggestion Rosen offers to anxious clients. For example, if a client is dealing with anxiety related to work, Rosen might suggest the client imagine putting those worries in a box at work and leaving them there overnight or visualize hanging them on a tree outside the house each day when arriving home from work.
Rosen has also found it helpful to clients to teach them anxiety-reduction techniques such as progressive muscle relaxation and guided imagery. Also important, she says, is getting clients to examine how they contribute to their own anxiety. Depending on what the client identifies, the counselor can then work with the person to improve time management skills, keep perfectionism in check, prioritize more effectively or establish stronger boundaries and learn to say no.
Ferrara relies heavily on cognitive behavior strategies with anxious clients because they allow clients to become more aware of what they’re thinking and feeling, how that affects their level of anxiety and what they can do to alleviate it. Many clients come to counseling seeking tools to help them get relief from their symptoms, she says, and cognitive behavior strategies can provide them with such tools.
Thomas also finds cognitive behavior techniques constructive because they prompt clients to closely examine how their thoughts help or hinder them in living life to the fullest and then to problem-solve where possible. Rogerian techniques are also useful, Thomas adds, requiring the counselor to be an active listener from a position of empathy and respect. “When clients feel they are being heard and listened to, they are more likely to implement the cognitive or behavioral strategies that are collaboratively agreed upon as ways to cope with stress,” she says.
Dwyer, a member of ACA, finds journaling an easy and beneficial exercise. She asks clients to take out a notebook and simply start writing about their stress and anxiety, instructing them not to worry about making corrections. “Then,” Dwyer tells her clients, “realize that the paper can hold that [stress and anxiety] for you so you don’t have to hold it. And anytime you want to go back and look, it’s right there.”
Stress is an unavoidable part of everyday life, and these counselors say that wellness is one of the key tools in improving the ability of clients to handle their stress and anxiety. “Wellness is the cornerstone of managing stress,” Ferrara says. “The things we do to rejuvenate [ourselves] help in how we deal with stress long term.”
Ferrara is always surprised by how many clients today acknowledge not taking a true vacation. Although they might stay away from the office for a week, she says, they often spend that time working from home, cleaning the house, checking email or pursuing other tasks that leave them feeling depleted. “They don’t ever unplug,” she says.
Making sure to be peaceful and quiet each day is crucial in the struggle to control stress and anxiety, Ferrara says. That’s why she recommends that her clients find someplace to be quiet and still for a few minutes each day, where there’s no email to check, no phone ringing and no kids running around. Ferrara also recommends yoga as a stress buster. She points out that this activity doesn’t require that clients sign up for classes because there are yoga programs on TV as well as inexpensive DVDs that can lead clients through routines. Ferrara owns a few such DVDs and loans them to her clients. She also notes that other forms of exercise are beneficial in reducing anxiety.
Horrigan encourages clients to create a list of fun activities and then to make a plan for actually partaking in some of them. “Some clients report that after a walk or a warm bath, a ride in the country or watching a funny movie, they have felt less stress and experience less anxious feelings,” she says. “For clients who enjoy a massage, I encourage them to consider making a monthly standing appointment so that they have this on their schedule and in their budget.”
“On a different level,” she continues, “we talk about ways in which others — work, friends and family members — may make demands on a client’s time and how this may raise the client’s anxiety due to taking care of everyone else and not having time to properly care for themselves. So we work in sessions discussing ways to build healthy boundaries, especially for the client who grew up in a home where there were not clear boundaries in place. As clients begin to develop more strengths and positive beliefs in themselves, the anxiety symptoms are often reduced.”
Rosen agrees that wellness and self-care are essential to managing stress. “I always recommend that clients make sure they are eating well and getting the proper nutrition, taking care that they get enough rest and sleep, engaging in regular exercise, planning fun leisure activities, spending time with family and friends and leaving time for relaxing and being mindful of their own needs.”
Wellness is a way of living that promotes physical, emotional and spiritual well-being and balance, Ferrara says. “I approach stress management from a wellness perspective and look for action-oriented interventions that promote positive change,” she says. “Consistently engaging in those activities that promote optimal health and well-being can also act as a buffer against the impacts of life’s stressors. Clients struggling with the negative impact of stress can learn to use lifestyle strategies that bring balance and healthy coping back into their lives. I try to provide them with practical tools and lifestyle strategies that they can use to return to healthy functioning and that promote future well-being. The wellness model really allows us to help the client with reducing the current stress load, while strengthening the ability to better manage future stressors as they come.”
Exclusive online sidebar to the cover story: Anti-anxiety medications: What counselors need to know
Lynne Shallcross is a senior writer for Counseling Today. Contact her at email@example.com.
Letters to the editor: firstname.lastname@example.org