Tag Archives: stress & anxiety

Helping clients with post-date anxiety

By Kathleen Smith October 15, 2018

As a counselor, I have a front-row seat for watching anxiety develop in new relationships. It is truly fascinating to observe how quickly two people can become emotionally stuck together. A therapy client will leave for a week and return reporting that he or she has started dating someone new. This former stranger now has the power to make my client very happy or very anxious. Thanks to their phone, my client might spend all day analyzing a text they received — or worrying about the lack of one.

Not a week goes by without me having multiple conversations with people about texting in relationships. For instance, a person is seeing someone who doesn’t quite contact them as frequently as they would like, so their brain sounds the rejection alarm. When the other person finally does text them, their anxiety level goes down. But within a day or two, they need more reassurance. They’ve surrendered their capacity to calm down to someone who was a stranger to them a week ago. And the only way they know how to get that capacity back is to end the relationship.

I don’t think that texting causes emotional dependence, but it can certainly accelerate it and reinforce it. People used to have to wait much longer to hear from a prospective romantic partner. Now people want to hit the eject button if there’s been radio silence for 24 hours. There is an expectation that someone who is interested in us must also be available to us at all times. We are in such a hurry to lock things down as a way of managing our own anxiety and insecurity.

I’m in no position to throw a stone here. After my husband and I went on our first date, he waited five days to ask me out again. Five. Days. For millennials, five days is the equivalent of somebody going off to war and coming back home. Now, of course, I know that he was a mature human being who was simply living his life at that time. But if you retrieved my phone records from that week, I bet you would see a blizzard of worried texts to friends.

When our counseling clients become more anxious in a new relationship, they don’t suddenly become more insightful. They usually just double down on whatever they’ve already been doing. That usually means anxiously focusing even more on this new person. They might stalk them on social media, or stare at their phone trying to decipher old texts. They’ll talk to all their friends about whether they should dump this person for taking so long to reply. They’ll come to a counseling session and ask me to guess what this person — whom I have never met coincidentally — is thinking.

When we feel the potential to be hurt, it makes sense that we focus more on the threat and how to avoid it. This works great if a lion is chasing us. It’s not so great for being in a relationship.

People see a lot of lions when they date, simply because dating is such an anxious endeavor. They interpret a lack of constant contact in a new partner as a sign of flakiness, disinterest or duplicity. People don’t stop to consider whether less contact might be a potential sign of maturity. This is why people tend to end up with other people who are at the same level of emotional maturity as themselves. People who have a higher degree of maturity in their family relationships are likely to seek out a partner who wants the same amount of contact.

I would never say to a someone, “Have you considered that this person is not texting you as much because they’re more mature?” Because that would be a guess based on zero facts. What I do challenge people to do, however, is to see their part in the relationship. Often, if people can stay focused on being the person they want to be rather than on trying to control this new love interest of theirs, then their anxiety will go down. And most of the time, people do not want to be the kind of person who is glued to their phone 24/7.

So, the goal isn’t for clients to change their new crush or to teach the person how to text that Goldilocks (just right) amount. The goal is to lower clients’ anxiety enough to where they can actually think objectively and decide whether a relationship is right. That decision is impossible to make when anxiety is very high, because then we interpret even the smallest behavior as a threat. People will blow up a relationship quickly in order to lower their anxiety.

Anxiety isn’t just present in romantic relationships, of course. We all want people to like us, reassure us and agree with us, but we ultimately can’t control them. People in our lives are not always going to respond as quickly as we would like. They’re not always going to RSVP to the party or share our level of enthusiasm for a television show. If clients can see how the anxiety they feel is a possible sign of emotional interdependence, they might be less likely to act immaturely or irrationally in their relationships. The rejections or silences won’t feel so threatening, and they won’t have to cancel that party out of spite or send a passive-aggressive message.

The simple truth is that we enjoy relationships more when we aren’t as anxiously focused on them. By being more of an individual, we can actually get closer to the people we love. Who doesn’t want that?

 

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Kathleen Smith is a licensed professional counselor and writer in Washington, D.C. Read more of her writing at kathleensmith.net.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

Infusing hope amid despair

By Laurie Meyers September 24, 2018

In 2015, two Princeton University economists, Anne Case and Angus Deaton, published a study in the Proceedings of the National Academy of Sciences of the United States of America that made a shocking claim: After decreasing for decades, the mortality rate for white non-Latinx middle-aged Americans was actually increasing. They ascribed this reversal of fortune in part to what they dubbed “deaths of despair” caused by an increase in alcohol abuse, opioid use and suicide. Their findings grabbed headlines and fueled furious debate in the public health and other research communities, particularly when they published a follow-up report in 2017 in the Brookings Papers on Economic Activity. Some researchers questioned the authors’ interpretation of mortality data. Other experts argued that the factors contributing to the rise in suicide rates and in opioid and alcohol abuse were too complex to be attributed to “despair.”

However, despite their narrow focus on a particular demographic slice, Case and Deaton were perhaps tapping into a greater sense of instability among the American populace. Since 2007, the American Psychological Association (APA) has conducted an annual nationwide survey — Stress in America — gauging both the overall level and leading sources of stress in the United States. The 2017 report revealed that two-thirds of the 3,440 adult Americans surveyed that August were significantly stressed about the future of the country. More than half of those surveyed — a group that spanned generations — said they considered the current time to be the lowest point in U.S. history that they could remember. Nearly 6 in 10 adults reported that the current climate of social divisiveness was a serious source of personal stress. Other significant sources of worry included money, work, health care, the economy, trust (or lack thereof) in government, hate crimes, conflicts with other countries, terrorist attacks, unemployment/low wages and climate change/environmental issues.

Although Americans may not be drowning in despair, research such as APA’s report indicates that many people are feeling more insecure than ever. That sense of walking a tightrope without a safety net can cause significant psychological distress, which can in turn lead to health problems and mental illness. Many experts say the burden of general societal unease is often magnified for disenfranchised groups such as communities of color or those of low socioeconomic status. And trauma — whether caused by being a member of a disenfranchised group or by a history of abuse or violence — takes an even more significant toll on health and well-being. Any or all of these issues may be related to the rise in opioid addiction and suicide across the U.S.

A poverty of health and well-being

To some degree, most people in the so-called 98 percent — those not in the top 1-2 percent of individuals possessing the majority of the nation’s wealth — worry about money: affording a mortgage, sending the kids to college, saving for retirement. The Great Recession may be over, but recent research from the Federal Reserve Bank of San Francisco (FRBSF) indicates that the economy hasn’t fully recovered. In its Aug. 13 economic letter, the FRBSF states, “A decade after the last financial crisis and recession, the U.S. economy remains significantly smaller than it should be based on its pre-crisis growth trend.”

The letter goes on to speculate that this is due to substantial losses in the economy’s productive capacity post-crisis. These losses were so significant, FRBSF researchers assert, that they could result in a lifetime income loss of $70,000 for each American.

This is staggering news for most Americans, but for those who live in poverty — 40.6 million Americans according to a 2016 U.S. Census Bureau study — such an amount is catastrophic. The poverty threshold is broadly defined as any single individual younger than 65 earning less than $12,316 annually and any single individual 65 or older living on less than $11,354 annually. The poverty threshold for two people under the age of 65 living together is $15,934, and the threshold for two people over the age of 65 living together is $14,326. For a family of three — one child and two adults — the poverty threshold is $19,055. For a family of three with one adult and two children, the threshold is $19,073.

For people who have never been impoverished, it can be difficult to comprehend all the ways in which poverty can affect health and well-being. Forget vacations, higher education and saving for retirement. People living in poverty are often unable to access basic needs such as safe shelter, food and, in some cases, even running water, says Chelsey Zoldan, a licensed professional counselor (LPC) practicing in Youngstown, Ohio. She has also counseled clients in the rural, impoverished Appalachian region of Ohio.

“I’ve worked with many clients over the years who have had their utilities turned off and lived in homes without water, heat or electricity,” says Zoldan, an American Counseling Association member. Missing that foundation at the bottom of Abraham Maslow’s hierarchy of needs, these clients struggle to stabilize their mental health symptoms, she explains.

People living in poverty often have to reside in low socioeconomic status areas with higher levels of violence and crime. Zoldan says many of her clients have lived in supportive housing and regularly heard gunshots in their neighborhoods at night. Although some clients seemed to get used to it, others — particularly those with trauma histories — had trouble feeling safe in their own homes.

Those who live in poverty also often lack access to quality health care. “Not only are individuals limited in terms of health care coverage, but they may also struggle to obtain transportation to get to health-related appointments,” Zoldan says. “In my area, there was such a high demand for medical transportation to appointments that they stopped providing door-to-door transportation and only provided bus passes.”

Instead of a 15-minute ride to appointments, Zoldan’s clients now had to navigate public transportation, which could take up to two hours each way with a change of buses. Riding the bus also poses another significant challenge — having to walk numerous blocks to the stop, which during winter in northeast Ohio means navigating “tons of snow” and double-digit subzero windchills, Zoldan says. Even in more clement weather, many of Zoldan’s clients were unable to devote two to four hours a day to traveling to health-related appointments, so they stopped receiving services.

Self-care can also prove challenging for those living in poverty, and it doesn’t include vacations or nights out. Zoldan works with individual clients to identify free activities that they enjoy and can engage in at least weekly, such as taking a bath, attending a Bible study, going for a walk in the park, meditating, and reading books or magazines at the library. Unfortunately, some of these activities may not be available to all clients, either because they live in rural areas with few resources or because they are unable to arrange child care, Zoldan points out.

Zoldan advises counselors working with this client population to get outside the walls of their offices. It is critical that counselors make community connections, she says, so that they can help clients access resources such as shelters, housing authorities, food banks, clothing providers, programs that offer financial assistance for utilities, medical transportation and vocational services.

“In connecting our clients with these resources, we can work to build a safety net for our clients and create some more stability in their lives so that they can thrive,” she says.

The legacy of racism

Racism happens on both a micro and macro level, says Cirecie West-Olatunji, a past president of ACA. Microaggressions are more nuanced and under the radar and involve everyday interactions with individuals who exert privilege. It might be the shop clerk who ignores an African American person in favor of a white shopper or a student of color who is consistently not called on, despite raising her hand. Macroaggressions are overt and meant to intimidate members of a group, such as neo-Nazis marching in the nation’s capital and people openly using racial slurs. Together, the macro- and microaggressions create pervasive, chronic stress that is handed down through intergenerational trauma, explains West-Olatunji, an associate professor at Xavier University of Louisiana and director of the Center for Traumatic Stress Research.

Over the past 20 years, researchers have been studying a phenomenon they first witnessed in some of the grandchildren of Holocaust survivors. Despite not having experienced the Holocaust themselves, and instead having grown up in a middle-class environment in the U.S., these individuals displayed survivor-like trauma symptoms. The findings were startling but have proved not to be unique. After 9/11, researchers studied children who had not been born at the time that their parents served as first responders at one of the attack sites. Like the grandchildren of the Holocaust survivors, these children of 9/11 trauma survivors displayed corresponding symptoms despite not experiencing the trauma themselves, West-Olatunji says.

Chronic, pervasive stress and trauma can be seen in changes at the DNA level, she says. Some researchers believe that these DNA changes play a part in handing down the trauma from generation to generation.

For African Americans, the trauma is also handed down on a systemic level, West-Olatunji says. “It is evident in social structures, education, lack of power and aggressive acts that threaten the psyche of individuals who are culturally marginalized,” she says. Slavery still casts a long shadow, its legacy evident in the school-to-prison pipeline, the number of African American children who are in low-resource schools, their overrepresentation in special education and the disproportionate diagnosis of behavioral disorders. “Children are being tossed out of the American dream by a lack of resources,” she says.

The effects of openly expressed racism are also manifesting in society, West-Olatunji says. “We’re anxious and irritable and feeling less hopeful about the world,” she says. These “symptoms” match those displayed by culturally marginalized groups.

Courtland Lee, also a past president of ACA, believes the effects of racism extend beyond the targeted group. In fact, he contends that racism can be considered a mental illness.

Lee began thinking of the concept of racism as mental illness after reading Stamped From the Beginning: The Definitive History of Racist Ideas in America, a book by Ibram X. Kendi that examines the intellectual roots of racism. Although many people may consider racism the purview of poor, white, rural Southerners, it has historically been handed down from the best and brightest minds in science, medicine, philosophy, religion and psychology, Lee explains. Racism is woven into our intellectual and social fiber and is used to manipulate people through fear of the other, he continues.

Lee says that targets of racist behavior are ground down by the constant micro- and macroaggressions, leading to “cultural dysthymia,” or collective low-grade depression. This collective depression is manifestly not conducive to mental health, and he argues that its effects aren’t felt solely by those who are targets of racism.

Lee believes that the fear and hatred of those who perpetrate racist acts is also mentally traumatizing — not just to those who are targeted but to the perpetrators themselves — and that the trauma must be addressed to treat the mental illness of racism. Counselors can do this on a systemic level through advocacy and on an individual level by helping people who are racist see that the agitation, irritability, hostility and hypervigilance they experience is caused by their beliefs. The challenge is getting perpetrators of racism to see that the defensiveness and fear inherent in racist thought can also bring those fears to life, Lee says.

For instance, one commonly cited reason to block immigration from Mexico is that these immigrants are stealing American jobs and damaging the economy. However, a lack of visas and fear of anti-immigrant violence have kept Mexican seasonal workers away from sectors such as the Maryland crab industry. In their absence, merchants who sell crab meat to restaurants and stores cannot recruit enough employees to clean and process their haul, even at high wages. That means the crabs cannot be sold, which is a major economic blow to the industry.

As a country, the United States needs to discuss racial issues, Lee says. Counselors, who are trained to encourage conversation, can and should facilitate these dialogues in their communities, through churches or community centers, he suggests. “We really do live in a sick society,” Lee says. “We can help people get well, but the only way to get well is to cure the society.”

As individuals, counselors can also play an important role in validating the experiences of people of color and speaking out when they witness micro- or macroaggressions, West-Olatunji says. She also urges counselors to explore non-Eurocentric methods, such as using the tradition of storytelling in the Latinx community or testifying in the African American community. Non-Western traditions can be applied effectively across cultures, making them a useful addition to any counselor’s toolbox, West-Olatunji says. 

Touched by trauma

“Life is a traumatizing experience,” says Cynthia Miller, an LPC in Charlottesville, Virginia, whose practice specializes in trauma. “It’s full of challenges, unexpected and uncontrollable events, and losses. I don’t think any of us gets through it unscathed.”

Miller, an ACA member, says trauma is on a spectrum that begins with ordinary stress and gradually progresses to completely overwhelm a person’s ability to cope. Eventually, it can even put them at risk of death.

A seminal study that the Centers for Disease Control and Prevention and Kaiser Permanente began in 1995 established a link between adult health problems and adverse childhood experiences such as emotional and physical neglect, sexual and physical abuse, exposure to violence in the household, and household members who had substance abuse problems or had been in prison.

These experiences fall on the more extreme end of the spectrum — often referred to as “big T” traumas. However, Miller cautions against discounting the “little t’s” as sources of distress. Where a trauma falls on the spectrum is individual and variable. “Some people might experience the loss of a job as stressful but wouldn’t be completely overwhelmed by it,” she explains. “Others might experience it as very overwhelming and become immobilized. So one person’s stressful event is another person’s traumatic event, and one person’s traumatic event is another person’s ordinary stressful event.”

Miller notes that mental health professionals recognize events such as the loss of a job, economic insecurity, divorce and family problems as sources of stress but often don’t accord them the same level of treatment as “real” mental illness. “It’s really a false distinction,” she says.

Someone who has lost a job or is going through a divorce is experiencing significant stress and is likely flooded with cortisol in the same way that a person who has experienced violence is, Miller asserts. “It’s really the chronic stress from either a ‘little t’ trauma or a ‘big T’ trauma that eats away at us and sets us up for depression, anxiety, anger problems, health problems and substance use,” she explains.

“There are a lot of things going on in society that could be experienced as traumatic,” Miller continues. “Globalization and automation are rapidly changing communities and workplaces, eliminating some industries and leaving workers scrambling for jobs that pay less and offer less job security. Economic inequality is growing, and housing costs keep rising. People feel increasingly insecure and like their futures are being threatened. That’s leading some people to feel helpless or hopeless. Others are angry and lashing out.”

Trauma-informed counseling is critical to recovery from both “big” and “little” traumas, Miller says, as well as for building ongoing resilience.

“I think that the biggest thing that trauma-informed counselors bring to the treatment process that less-informed counselors may not is an alternative explanation for behaviors that are often seen as purely manipulative, obstinate, oppositional, attention seeking or antisocial,” Miller says. “Trauma-informed counselors may be more likely to view a client’s reactions and behaviors as attempts to cope or protect themselves rather than chalking them up to resistance, treatment noncompliance or poor motivation. They also bring an awareness of the importance of creating a sense of safety and control for a client, and they work to create environments in which clients have as much autonomy and input into their treatment as possible.”

Miller also decries the traditional “split” between substance abuse and mental health treatment. Although she doesn’t believe that all substance abuse is caused by mental illness or trauma, she says these are often underlying factors that go untreated, which puts clients at risk of relapse.

Regardless of the cause, substance abuse is an illness that needs to be treated, she asserts. “For far too long, substance abuse has been treated as a problem of weak moral character rather than an effort to soothe emotional pain that someone doesn’t feel able to cope with,” she observes.

Miller also points to the contrasting public reactions to the crack and opioid epidemics. Whereas the crack crisis of the 1980s and early 1990s was considered a criminal problem, the current opioid epidemic is recognized as a public health problem, she notes. Miller ascribes this difference not only to the traditional judgment of substance abuse as a moral failing but also to the reality that crack was seen largely as affecting African Americans, while opioids are generally viewed as affecting white Americans. (Some researchers and commentators have also begun noting that the growing number of opioid-related overdoses and deaths among African Americans has largely been left out of the national narrative.)

Seeking solace

Just as crack enveloped areas that were economically devastated — at the time, predominantly African American urban neighborhoods — opioids are most common in rural areas that can no longer depend on the industries that once sustained them. West Virginia is one of the epicenters of the opioid crisis, and Carol Smith, an ACA member and past president of the West Virginia Counseling Association, believes that isolation and the lack of opportunity in much of the state are helping to fuel opioid abuse.

A frequently spun narrative of the crisis is that of unsuspecting people who get addicted after being prescribed opioids for pain after injury or surgery, but those cases make up a small percentage of those who are addicted to opioids, according to Smith. Indeed, people have been using opioids for pain relief for decades without becoming addicted on a large scale, notes Smith, a counseling professor and coordinator of the violence, loss and trauma certificate of studies at Marshall University. The people who do get addicted after being prescribed opioids usually already have substance abuse problems, she says.

However they first encounter opioids, the people most at risk for addiction are those who lack good coping skills and social support, Smith says. They typically also have a certain degree of existential despair, which is only reinforced by the long-term abuse of opioids.

Smith explains that West Virginia is particularly vulnerable to this sense of despair because its topography of mountains and waterways makes building roads and installing cables prohibitively expensive. This isolates the state not just physically but virtually because of the lack of high-speed internet access, she says. This lack of connectivity discourages new economic development, further reinforcing the cycle of poverty. As a result, many of the state’s inhabitants don’t feel that they have a lot to lose or much to strive for, Smith says, leaving them vulnerable to anything that might make the day go by faster or easier.

With its emphasis on treating the whole person, counseling is integral to the effort to stem the tide of addiction, Smith says. Counselors can help clients fight despair by guiding them to regain a sense of purpose through goal setting and identifying reasons for living. In addition, counselors can aid clients in dispelling their sense of isolation by teaching them relationship skills and helping them build support networks. Smith also stresses the importance of combining counseling with medication-assisted treatment, which addresses the physiological aspects of addiction.

Dying of despair?

According to the Centers for Disease Control and Prevention (CDC), 45,000 Americans 10 years and older died by suicide in 2016, the most recent year for which statistics are available. In the June CDC Vital Signs report, the agency said that from 1999-2016, the suicide rate rose by more than 30 percent in 25 states. While acknowledging that those suicide statistics are the most accurate figures available, the American Foundation for Suicide Prevention has stated that it believes actual rates are much higher.

Case and Deaton’s study connected the rise in the suicide rate in part to despair caused by a dearth of employment and lack of opportunity, but some experts say that causation is far from clear.

“It is hard to pinpoint a specific cause,” says ACA member Darcy Granello, a professor and director of the Ohio State University suicide prevention program. “Frankly, the numbers are increasing at such an alarming rate and across so many different demographic groups that we have to be careful not to paint broad brushstrokes and assume that specific factors apply to all of these different groups.”

Granello, whose research focuses on suicide prevention, does believe that Americans are feeling more isolated and disconnected, however. “That pervasive sense of loneliness is especially dangerous for those who already struggle with depression,” she says. “We know that social connectedness, feeling supported and having a sense of belonging all are protective factors that help minimize the risk for suicide. When those are taken away, suicide risk increases.”

Granello says myriad factors may be contributing to the rise in suicide, but recent research has caused experts to question their understanding of suicide. For example, historically, 90 percent of those who kill themselves have some kind of mental illness — often undiagnosed or untreated. However, more and more people who die by suicide do not have a diagnosable mental illness at the time of their death, Granello says.

“This is challenging to everyone in the field, and it causes us to rethink much of what we know,” she says. “It means that suicide is more and more the result of people who simply do not have the resources to cope with life’s problems, whether this inability to cope is because they are living with a mental illness or simply because they are overwhelmed by life and have never developed healthy coping strategies.”

Granello urges counselors to focus on helping clients develop those strategies. Those at risk for suicide are often ill-equipped to face life’s challenges, make long-term plans and envision a future, she says. For many people, the key to survival is getting through the crisis period — that window when they are most tempted to end their lives, she continues.

Counselors can teach clients to move out of their isolation, reach out to others and develop healthy coping strategies, Granello says. But to do that, counselors need to be adequately trained in suicide prevention, assessment and intervention — something that Granello doesn’t think is happening often enough. She stresses the need to push for comprehensive, empirically supported suicide prevention training in counselor education programs and through continuing education.

“We have to do this,” Granello says. “We are, quite literally, fighting for our lives.”

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

Books and DVDs (counseling.org/publications/bookstore)

  • A Contemporary Approach to Substance Use Disorders, second edition, by Ford Brooks and Bill McHenry
  • Counseling for Social Justice, third edition, edited by Courtland C. Lee
  • Multicultural Issues in Counseling: New Approaches to Diversity, fifth edition, edited by Courtland C. Lee
  • Suicide Assessment and Prevention, DVD, presented by John S. Westefeld

ACA Mental Health Resources (counseling.org/knowledge-center/mental-health-resources)

  • Trauma and Disaster
  • Suicide Prevention
  • Substance Use Disorders and Addiction

Podcasts (aca.digitellinc.com/aca/store/5#cat14)

  • “Counseling African-American Males: Post Ferguson” presented by Rufus Tony Spann (ACA285)

Webinars (aca.digitellinc.com/aca/pages/events)

  • “Traumatic Stress and Marginalized Groups” with Cirecie A. West-Olatunji (CPA24341)
  • “Dissociation and Trauma Spectrum” with Mike Dubi (CPA24333)
  • “ABCs of Trauma” with A. Stephen Lenz (CPA24329)

Competencies (counseling.org/knowledge-center/competencies)

  • Multicultural and Social Justice Counseling Competencies

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Conquering the fear of flying

By Bethany Bray August 15, 2018

National Football League (NFL) commentator John Madden famously crisscrossed the United States for years in a custom coach bus so that he could make it to games and other commitments without having to board a plane. The former head coach of the Oakland Raiders and Pro Football Hall of Famer’s aversion to flying also led him to decline the opportunity to call the NFL’s annual Pro Bowl in Hawaii.

Madden is hardly alone in his avoidance of air travel. Research indicates that up to 40 percent of the general population experiences flight-related anxiety.

One of the things that makes aviophobia, or fear of flying, so common is that the average person just doesn’t do it that often, says Stephnie Thomas, an American Counseling Association member and licensed clinical professional counselor at the Anxiety and Stress Disorders Institute of Maryland.

Assuring clients that a fear of flying is relatively common can lessen the sense of shame or embarrassment that they might feel about it, Thomas says. This plays an important first step in addressing the issue with a counselor.

“Sometimes the counselor may be the first person the client has ever revealed this ‘big secret’ to,” she says. That is especially true with male clients, she adds. “For some [clients], it’s been so long since they have flown that the plane has grown into a monster in their mind — more enclosed, larger and scarier than it actually is.”

For most people, Thomas says, the fear of flying is rooted in loss of control — of their surroundings, of navigation, of travel schedules and of their own bodies (some people experience panic-related symptoms such as heavy breathing, sweating or vomiting).

Thomas works with clients to find ways to tolerate the distress and anxiety they feel regarding air travel rather than trying to avoid or make those feelings disappear altogether. She explains that if they work through their anxiety, it will lessen naturally over time.

“The goal is not a reduction of their anxiety. The goal is to learn tolerance, which is really hard. I always tell clients that I wouldn’t wish this on my worst enemy,” says Thomas, who has a private counseling practice in Westminster, Maryland.

In Thomas’ experience, fear of flying is rarely a stand-alone issue. Careful assessment is essential with these clients, she stresses, because their phobia can be tied to other issues that need therapeutic attention, such as obsessive-compulsive disorder, panic attacks or posttraumatic stress disorder. It can also dovetail with other anxieties, such as a fear of enclosed spaces or germs — for example, obsessing over disinfecting their armrests and tray tables on the airplane.

“The clients who only have a fear of dying in a plane crash are few and far between, even though this is a common reason many give for avoiding flying,” Thomas says.

In her work at the Anxiety and Stress Disorders Institute of Maryland, Thomas flies with aviophobia clients as part of their therapy program. Boarding a plane, however, is a final step in a thorough process that begins with traditional talk therapy. She uses cognitive behavior therapy from an acceptance and commitment therapy perspective, in addition to exposure therapy and other techniques.

Lessening the anxiety symptoms that clients experience when flying is a byproduct of therapy, not a goal, Thomas emphasizes. She works with clients to accept the feelings that come with flying and to deflect catastrophic thoughts. It can also be helpful for clients to focus on their reasons for boarding an airplane.

“I ask, ‘Why is it important for you to do this? Let’s hold on to that value,’” says Thomas, a fellow of the Anxiety and Depression Association of America. “In order to get through to that outcome, we’ve got to go through this swamp of anxiety. We’re going toward that anxiety rather than running away from it.”

Some of Thomas’ clients want to overcome their aviophobia because they are required to fly for work and their career depends on it. For others, an airplane flight stands between them and a vacation that they’ve wanted to take for a long time, a family visit, a wedding or another important event. Thomas had one client whose dream was to go to Europe to visit the country of his ancestry. Eventually, he was able to make that flight and sent Thomas a postcard to commemorate the achievement.

A key aspect of overcoming aviophobia is breaking things into small pieces — both with the therapeutic preparation and with the coping mechanisms on the day of the flight, Thomas says. For instance, when clients are ready to fly, it can be helpful for them to focus only on the next bite-sized task: checking in, getting through security, finding their gate, etc. They aren’t allowed to worry about what happens in steps three or four while they’re still on step two, Thomas emphasizes.

To help her clients prepare, Thomas works with them to imagine, visualize and become accustomed to what getting on a plane involves. Videos on YouTube are one helpful tool. Thomas often watches footage taken midflight with clients so they can get used to the sights and sounds of an airplane. There is even a six-hour video on YouTube of an entire flight from the East Coast to the West Coast of the United States, Thomas says. One of her clients would put the video on his television at home, playing it in the background to expose himself to the idea of flying.

Thomas also assigns homework that will expose her aviophobia clients to some of the uncomfortable sensations they might experience on a flight. For example, individuals who don’t like feeling the G-force of takeoff could be tasked with going to a local amusement park to get more accustomed to the sensation. She would have them start with a smaller, more tame ride and work up to the bigger roller coasters, Thomas says.

For those who are afraid of being away from home, she might suggest that they ride the subway system around Washington, D.C., or take a small day trip, such as a bus trip to New York City. Similarly, those who are afraid of heights or small spaces can expose themselves, little by little, to diffuse the fear while they are close to home, such as going to the top of a tall building or riding an elevator.

When client anxiety spikes in therapy sessions, the first instinct of many well-meaning counselors may be to try to help clients calm down or make their symptoms go away. “Unfortunately, this sends a message that anxiety is a bad thing to be avoided instead of a normal physiological reaction to perceived danger,” Thomas says. “Instead, I encourage counselors to welcome anxiety in the office and encourage the client to be willing to sit with it and make room for the anxiety. I tell clients that without moderate anxiety, we would be an extinct species, because it has been advantageous for the humans to be anxious and avoid saber-toothed tigers, bears, lions, etc. The problem is not that we have anxiety. The problem is that in this modern world, there is rarely an opportunity to be faced with real dangers, so for those of us who are blessed with a strong alert system, the system gives us a lot of false alarms.”

Thomas also works with clients to internalize the concept that although flying is a risk, it is an acceptable risk. Her clients often create notecards reminding them of this and bring the cards with them when they fly.

“Being anxious [on a flight] only means that your body is paying attention. Is this discomfort, or are you actually in danger?” Thomas asks. “I tell them, ‘When the wings fall off the plane, only then are you allowed to panic.’”

She often repeats a saying from psychologist David Carbonell, author of the Fear of Flying Workbook: Overcome Your Anticipatory Anxiety and Develop Skills for Flying With Confidence: “As an airline passenger, your only job is to be breathing baggage.” You simply have to stay in one place and be transported from point A to point B, she says.

“Since loss of control is the underlying fear for most clients, this is a tough idea,” Thomas adds.

After years of specializing in this area, Thomas has developed a relationship with representatives of Southwest Airlines at the nearby Baltimore/Washington International Airport. Occasionally, she coordinates with the airline to bring groups of clients to the airport to sit in an unused airplane, talk with airline employees and try out a mock boarding process. She has also organized events at her office at which Southwest pilots or employees come to speak and answer questions.

Thomas doesn’t require her aviophobia clients to take a flight with her. But many find it helpful to have her accompany them as they take a first “practice” flight after seeking therapy.

Once a client is ready, they schedule a flight together that leaves and returns to the Baltimore airport in the same day. They choose destinations roughly a one-hour flight away that feature something fun and relaxing to do, such as the museum at the Rhode Island School of Design in Providence or the Rock & Roll Hall of Fame in Cleveland.

After completing that first flight with Thomas, she advises them to book or start planning their next flight right away — this time on their own or with loved ones. The desired treatment outcome, she says, is for clients to be able to fly regularly and to tolerate the uncomfortable feelings that may come with that experience.

 

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Stephnie Thomas’ reminders for fearful flyers

1) Flying is an acceptable risk. Remember that the statistics are in your favor.

2) Move with the turbulence. Rate it on a 1-10 scale.

3) Notice when you’re anticipating the worst-case scenario.

4) Mindfully accept your initial anxious thoughts as just “white noise.”

5) Notice when you add a second fear.

6) Be willing to accept panic when it happens.

7) Practice allowing your physiological symptoms to get stronger.

8) Mindfully let yourself be in the plane (or wherever you are physically located).

9) Practice relaxation and mindfulness coping skills before you fly.

10) Remind yourself: “It took time to get this way; it will take time to recover.”

11) Tell yourself: “Each time I take a practice flight, I can learn that I can see it through by accepting the anxiety.”

12) Book your next flight before the practice flight is completed.

Source: stephthomas.com/fear%20of%20flying%20info.htm

 

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Contact Stephnie Thomas at stephniet@gmail.com or through her website, stephthomas.com.

 

Find out more

Stephnie Thomas suggests the following resources for practitioners looking to help clients with aviophobia:

 

Related reading from Counseling Today:

When panic attacks

Living with anxiety

 

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Bethany Bray is a staff writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

When panic attacks

By Bethany Bray July 30, 2018

Kellie Collins, a licensed professional counselor (LPC) who runs a group private practice in Lake Oswego, Oregon, experienced her first panic attack when she was 14. She remembers suddenly feeling cold, losing sensation in her hands and her heart beating so rapidly that it felt like it was going to leap out of her chest — all for no readily apparent reason.

“I thought I was dying. That’s what it felt like,” Collins says. “It was the worst experience of my life up to that point. It felt like it lasted forever, even though it was just a few minutes. Afterward, I was left with a feeling that I had no control.”

When Collins subsequently experienced more panic attacks, the situation was exacerbated by a close family member who didn’t understand what was happening. The family member suggested that Collins might be having the panic attacks on purpose, to get attention.

Collins’ life changed for the better in high school, when she began seeing a counselor. She learned not only that her panic attacks were manageable but also that she wasn’t to blame for their occurrence.

“Hearing that I didn’t cause this and that it wasn’t my fault set me on the path to get better. It made all the difference,” says Collins, a member of the American Counseling Association. “The biggest thing [counselors can do] is to validate the client’s experience. What they experience is real and not under their control in that moment — and it’s terrifying.”

‘Fear of the fear’

In addition to overwhelming feelings of fear, panic attacks are usually marked by shortness of breath or trouble breathing and a rapid heartbeat. Other physical symptoms can include sweating (without physical exertion), a tingling sensation throughout the body, feeling like your throat is closing up or feeling that you’re about to pass out, explains Zachary Taylor, an LPC and behavioral health director at a health center in Lexington, Virginia. Symptoms vary, however. “I’ve never had two patients describe it the same way,” he says. (Taylor refers to patients instead of clients because he works at a medical health center.)

According to the National Institute of Mental Health (NIMH), an estimated 4.7 percent of adults in the United States experience panic disorder at some point in their lives. The past-year prevalence was higher among females (3.8 percent) than among males (1.6 percent).

Panic disorder is marked by recurring, unexpected panic attacks (or, as NIMH describes, “episodes of intense fear” that are “not in conjunction with a known fear or stressor”). People who experience panic disorder typically worry about having subsequent attacks, even to the point of changing behavior to avoid situations that might cause an episode.

“It’s such a jarring and uncomfortable experience, and it feels so much like a real medical emergency, that they begin to fear the sensations themselves. This fear of the fear is what drives panic disorder,” explains Taylor, a member of ACA. “If it gets too bad, they begin to arrange their life around trying not to experience anything that might resemble or trigger any of those feelings that are associated with a panic attack, and it becomes a vicious cycle.”

At the same time, panic attacks can occur in people who do not have a panic disorder diagnosis. Although panic attacks are often coupled with stress, trauma or anxiety-related issues, they can also occur in clients without complicating factors, says Collins, who notes that she has seen clients who experienced their first panic attack in their 50s or 60s.

“They can happen even when life is going well and have no apparent reason. … Some people have them for a period of time in life and then never have them again, while others will have them throughout life,” she says. In addition, significant life changes, such as getting married, starting retirement or having a child, can trigger recurrences in clients who previously were able to manage their panic attacks, Collins adds.

Among clients with mental illness, panic attacks can co-occur with depression, anxiety, bipolar disorder, posttraumatic stress disorder, obsessive-compulsive disorder, specific phobias (particularly emetophobia, or fear of vomiting) and other diagnoses. Taylor says they can also be associated with a medical or physical issue.

“One of the most overlooked problems that can lead to developing panic is chronic sleep deprivation or insomnia,” he says, explaining that a lack of sleep can overexaggerate the fearful thoughts related to panic. When treating panic attacks, counselors should ask clients about their sleep habits within the first few sessions, Taylor advises. Counselors can also remember the acronym CATS and ask clients about their consumption of caffeine, alcohol, tobacco and sugar — all of which can worsen the feelings associated with panic attacks, he adds.

Learning coping skills and identifying triggers

Clients who come to counseling after experiencing a panic attack may start therapy without understanding the complexity of panic attacks or harbor feelings of shame or embarrassment about succumbing to panic seemingly out of the blue, Collins says.

It is sometimes helpful to explain to clients that during a panic attack, their body is launching into the fight-or-flight mode that is part of their biological wiring, Collins says. However, in this case, there is no tiger chasing them.

“I like to say that [a panic attack] is tripping the sensor, like when a leaf falls on your car and the alarm goes off. It trips the sensor, but your car doesn’t know” that there isn’t any actual danger, she explains. Collins says it also can be helpful to assure clients that “it will never be as bad as those first few times when you didn’t know what was happening to you.”

To identify triggers, Collins suggests walking clients through the months, days and hours that led up to their first panic attack — but only when the individual is ready to relive the experience, she adds. Some triggers can be easily identifiable, such as a spike in work-related stress or the loss of a loved one. Other triggers may be less obvious, meaning more work will need to be done to unpack the experience later in therapy.

“I like to make sure clients have really solid coping skills before they work on the underlying stuff that might be contributing” to their panic attacks, such as trauma, Collins says. “Spend the first few sessions identifying what’s been going on. Once they’re confident and capable of managing and getting through an attack, then ask about what might be contributing” to the attacks occurring.

Outside of session, counselors can encourage clients to devote time to journaling, relaxation, deep breathing and counting exercises that can boost self-reflection and change negative thought processes, Collins suggests.

Counselors can also equip clients with coping mechanisms such as mindfulness to help them remain calm and feel more in control in the event of a panic attack. Collins often gives her clients a small stone to carry with them and hold in their hand when a panic attack strikes. She tells them to focus on the stone and describe it to themselves — is it rough, smooth, cold, heavy? This can help divert their attention from the panicky sensations, she explains. The same technique can be followed using car keys, a coffee mug or whatever else clients can hold in their hands that wouldn’t readily draw undue attention from others, she adds.

Clients can also develop mantras to remind themselves in the moment that even though a panic attack feels all-consuming, it is a finite experience. Among the phrases Collins suggests as being helpful:

  • “I’ve gotten through this before.”
  • “This is only temporary.”
  • “Even though this feels like it’s going to last forever, it will end; it always does.”

Collins acknowledges, however, that “once it gets to a certain point, these things don’t work. You have to accept it for what it is when you’re in the middle of an attack. You have to ride the wave, accepting that it will be temporary and it will go away.”

“Sometimes, even getting angry at the panic attack can help,” she adds. “When [people] allow themselves to accept that anger, it takes away some of the power of the attack itself. Admit that it stinks but it’s something you can get through.”

Uncomfortable but not dangerous

Thinking that a panic attack can be halted or avoided by using breathing or relaxation techniques is a misconception, according to Taylor. Those methods are often the first choice of well-meaning practitioners, but Taylor argues that “it sends a subtle message to the patient that what you’re experiencing is dangerous and we need to do something to prevent it.”

“The first thing you need to do is teach [clients] that what [they are] experiencing is uncomfortable but not dangerous,” he says. “It’s your avoidance of the uncomfortable feelings, and trying to stop it, that has unintentionally made it worse. When it comes to symptoms of panic, trying to suppress or avoid those symptoms is the exact opposite of what you want to do.”

Diaphragmatic breathing and other relaxation techniques can be helpful to manage anxiety, Taylor clarifies, but they won’t stop the symptoms of a panic attack altogether. “The only way to truly stop it is to become accustomed to the feelings” and to understand that a panic attack is not dangerous, he adds.

Taylor finds the DARE method developed by author Barry McDonagh particularly helpful. The technique focuses on overcoming panic with confidence rather than employing futile attempts to calm down, Taylor says. The four tenets of DARE are:

  • Diffuse: Using cognitive diffusion, counselors can teach clients to deflect and disarm the fearful thoughts that accompany panic attacks. The thoughts that flood people’s minds during these episodes are just that — thoughts — and are not dangerous, Taylor explains. “Teach them to say ‘so what?’ to their thoughts: ‘What if I embarrass myself or pass out or throw up? So what?’ Take the edge off that thought by not only demoting it but separating ourselves from the thought: ‘It’s not me. I didn’t put it there.’ Teach patients to say to themselves, over and over, ‘This sensation is uncomfortable but not dangerous.’ Think of it like a hiccup. It’s uncomfortable but not dangerous. There’s nothing medically wrong. The more you focus on it, the more uncomfortable it gets.”
  • Allow for psychological flexibility: It is more important that individuals allow and become comfortable with their negative associations than it is to try to get rid of them, Taylor says.
  • Run toward the symptoms: Moving toward feelings of discomfort is antithetical to human instinct, but in the case of panic attacks, it can actually be an effective tactic. Taylor teaches people who deal with panic attacks to tell their bodies to “bring it on. Ask your heart: ‘Give me more. Let’s see how fast you can beat.’ One of the fastest ways to stop a panic attack, ironically, is to ask for more and try and make it worse. It’s the resistance to the sensations that makes it stick around.”
  • Engage: Teach clients to engage in the moment once the panic attack has peaked and is starting to wind down. This is when grounding and mindful exercises can be helpful, Taylor says. “What’s important is to focus on right here and right now. That will help you continue to move forward and get unstuck,” he adds.

An attachment approach

All of the counselors interviewed for this article noted that cognitive behavior therapy (CBT) is an effective, tried-and-true method to support clients who experience panic attacks by helping them refocus the fearful and overexaggerated thoughts that accompany the experience.

Linda Thompson, an LPC and licensed marriage and family therapist in Florida, finds that using CBT through the lens of attachment theory can be particularly helpful in addressing panic attacks. That holds especially true for clients who struggle with feelings of abandonment or rejection or have experienced attachment trauma, including the loss of a loved one or caretaker. Counselors can identify clients who might benefit from attachment work by asking questions at intake regarding past relationships and loss, Thompson says.

“If they are the kind of person who is very relationship-oriented and attachment is very important to them or there is trauma there, that has to be brought into the conversation,” says Thompson, an associate professor at Argosy University with a private practice in the Tampa area.

Thompson suggests that counselors invite someone to whom the client is attached, such as a partner or a spouse, into the therapy sessions (with the client’s consent). The practitioner can prompt discussion that helps the client share some of the inherent fears that he or she is harboring. Often, Thompson says, the partner’s response to this sharing is “I had no idea you felt that way. How can I help?”

From there, counselors can introduce techniques that the client and the client’s attachment figure can use together when the client is feeling anxious, Thompson says. Eye contact, hand holding and other physical connections can be particularly helpful. “It’s making it about connecting,” she explains.

Once they understand that their loved one’s worry and panic are spurred by issues related to relationships or a fear of isolation, friends and family members can be better prepared to respond differently when the person begins to struggle. If the client is willing, counselors can play a role in training the individual’s support system to help with attachment-oriented responses. For example, if a client wakes up in the middle of the night feeling panicked, a spouse or partner could respond by rubbing the person’s back or whispering affirmations such as “You’re not alone,” “I’m here” or “We’re going to get through this together,” Thompson says.

Attachment-oriented clients may also benefit from learning to do breathing techniques with someone to whom they are attached, Thompson adds. For example, a client may start to feel the symptoms of a panic attack while driving. Relying on techniques learned in session, the client would pull the car over and focus on their child in the backseat — holding the child’s hand, making eye contact and breathing together. The physical touch will boost oxytocin, a hormone connected to social bonding and maternal behavior, Thompson explains.

Thompson also suggests that these clients try yoga to help with relaxation and self-control. She says the practice is more beneficial if it involves a social aspect, so she recommends that clients practice yoga in a class with other people instead of alone at home.

Similarly, Thompson suggests helping attachment-oriented clients build a “tribe” or circle of support beyond the counselor. This is especially important for those who have lost a spouse or partner and those who are more susceptible to isolating themselves. Counselors can guide clients in finding connections that are personally meaningful to them, whether that is through participation in spiritual or religious activities, volunteer work or other community groups such as a book club. Focusing on relationships rather than the physical symptoms of a potential panic attack can help these clients feel less vulnerable, says Thompson, a past president of both the Pennsylvania Counseling Association and the International Association of Addictions and Offender Counselors, a division of ACA.

Thompson recalls one client who struggled so acutely with panic attacks and a fear of losing her loved ones that it kept her from leaving the house for two years. CBT alone wasn’t helping, so Thompson added attachment techniques to their therapy work together.

After a substantial amount of in-session exploration, Thompson discovered that the client’s panic attacks were tied to family-of-origin issues. The physical feelings the client experienced during her panic attacks were in the same part of the body where one of her parents had experienced a significant health problem.

In addition to conducting one-on-one therapy, Thompson included the client’s husband in sessions. They worked together on attachment-focused techniques, and, eventually, the couple was able to go outside of the home for the first time in a long while to celebrate their anniversary.

To prepare, they created notecards with attachment-focused feelings and reminders, such as what their first date felt like. They referred to the notecards throughout the evening and connected consistently via holding hands and making eye contact.

After the date, the client reported to Thompson that instead of thinking of where the exits were in the restaurant, as she would have done previously, she remained focused on the man — her husband — in front of her.

Thompson urges counselors to remain open to adding attachment theory or other complementary methods on top of go-to techniques such as CBT to reach clients who are experiencing panic attacks. “Expand your toolbox,” she says. “A person’s fear, the fear that is triggering panic, can have multiple origins. Help the client to find the source of their fear, and work on that. … Broaden your perspective to recognize that human beings have to be attached with people, no matter what the disorder. Ask, ‘How do I make sure the social needs of my client are being met?’”

Controlled exposure

Taylor knows firsthand how terrifying a panic attack can feel. He began experiencing anxiety in his teens and early 20s that intensified to the point of daily panic attacks.

When things were at their worst, he would often go to the emergency room of his local hospital. He wouldn’t register as a patient but would simply sit in the waiting room, knowing that those uncomfortable, uncontrollable feelings would eventually overtake him again. “Sometimes [I would go] because I was having a panic attack, or other times it was just because I felt I might have a panic attack,” Taylor recalls.

Eventually, Taylor did check himself into the hospital, and a doctor explained that he was going to be OK. That was the life-changing encounter that put him on the path to getting help; he credits medication and therapy for helping him overcome his panic attacks. The experience also inspired him to become a counselor.

This personal history plays into his work with clients. As a specialist in treating chronic anxiety and panic, he often emphasizes to clients that feelings of fear and excitement share the same neurological pathways. “It’s just our perception that makes them different. … You have to be able to ride the waves of panic without resisting it,” he says.

In addition to teaching clients to tolerate and deflect the invasive thoughts and physical symptoms that accompany panic attacks, Taylor finds exposure therapy to be a powerful treatment for panic. In fact, Taylor believes that exposure, or intentionally bringing on a panic attack in a controlled setting (such as the counselor’s office), must necessarily play a large role in overcoming the episodes.

“Patients are not moved by information; they’re moved by what they believe is possible, and they’re moved by new experiences. Just giving them the information [that panic attacks are survivable] is about as good as baptizing a cat,” he says. “If you give them the experience of exposure work in your office, they walk out a changed person. The focus should not be on staying calm but [on knowing] that no matter how hard their heart beats or [how much] they feel a sense of doom, they’re actually safe. It’s just a brain hiccup.”

Inducing a panic attack in the safety of a counselor’s office can prove to clients that what they might experience is uncomfortable but far from fatal, Taylor says. “When a counselor is doing exposure therapy with a patient and inducing panic-like symptoms in the office with them, we as counselors need first to be confident that a panic attack truly is not dangerous to the patient,” he explains. “If they start to panic and then we get scared and try to calm them down, the exposure will fail. We have to be able to stay with it, let the panic attack fully develop and subside on its own, so the patient learns that their fear of having a heart attack, passing out or losing control won’t happen. And unless we can really allow them to go all the way through a panic attack and come out the other side, the exposure just won’t work. They will continue to believe that a panic attack is dangerous and continue to try to suppress and avoid them.”

A good amount of therapeutic work may be required before clients are ready for exposure techniques, Taylor says. Once they are, counselors should begin the experience by asking clients to verbalize the worst thing they can imagine happening to them as the result of a panic attack, he says. Fears that clients typically voice include passing out, vomiting or even having a heart attack.

Taylor says the counselor’s response could be, “OK, are you ready to test that out” in the safety of the counselor’s office?

To induce the elevated heart rate and rapid breathing that accompany panic attacks, the counselor might suggest that the client do jumping jacks, run up and down the stairs or breathe through a straw for an extended period of time. As the panic symptoms swell and peak, the counselor will remain close by to remind the client of the cognitive diffusion and other techniques previously mentioned by Taylor.

Afterward, the counselor can talk about how the things the client feared happening as the result of a panic attack did not actually come to pass. The moment clients realize that they can endure panic attacks without their worst fears materializing is the moment they can begin to overcome the attacks, Taylor says.

Conquering avoidance

Individuals who have experienced panic attacks will sometimes start avoiding situations or places where a prior attack occurred. Often, this includes public places such as shopping malls. If this inclination is left unchecked, it can spiral into the person missing work and social engagements or engaging in other isolating behaviors, Collins says. On top of that, avoidance will serve only to make things worse, she notes.

“That fear of having another panic attack can be crippling,” she says. “One of the fears a lot of people have is having an attack in front of people or being in a place where they can’t escape, such as an airplane or a meeting at work.”

When Collins broaches this subject with clients, she frames it as taking their power back and not letting panic attacks control their lives. “We talk about starting small and [taking] baby steps, especially if they’ve been terrified of a place for a while,” she says.

Counselors can begin by having clients visualize in session the place they have been avoiding. Ask them to describe it and talk about how their body feels as they think about that location, Collins suggests. This process may need to be repeated several times before clients feel comfortable and confident enough to make a plan to actually go to the places they have been avoiding, she adds.

When they do go, make sure the client takes a friend or other trusted person with them for support. Clients should also be directed to stick to the plan they have created and talked through in their counseling sessions, Collins says.

For example, if a client has been avoiding going to a shopping mall out of fear of having a panic attack, a first step in the client’s plan might be simply driving to the mall, parking the car and sitting inside it for five minutes before leaving. The client might even need to repeat that step of the process multiple times, Collins says.

After that, the client can move on to walking through the doors of the mall and then leaving immediately. On the next visit, the client might enter the mall and go into a store, and so on. The idea is to continue going until the client no longer associates that place with feelings of fear.

Often, after repeated visits, “people will say, ‘OK, I don’t need baby steps. I want to go now,’” Collins says.

Above all, compassion

Counselors can provide a holistic approach to addressing panic attacks that clients might not have experienced previously with medical professionals or other mental health practitioners. Most of all, Collins says, counselors should offer empathy to clients who are confronting such a distressing, overwhelming and, often, seemingly unexplainable experience.

“That validation is the most powerful thing I’ve seen that helps people,” she says. “Clients get better with the relationship, the validation, the compassion. Compassion: That’s the No. 1 thing to remember.”

 

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Contact the counselors interviewed for this article:

 

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Learn more:

ACA Practice Brief on panic disorder: counseling.org/knowledge-center/practice-briefs

 

Zachary Taylor recommends these resources for counselors who want to learn more about the treatment of panic attacks:

  • DARE: The New Way to End Anxiety and Stop Panic Attacks by Barry McDonagh
  • Anxious Kids, Anxious Parents: Seven Ways to Stop the Worry Cycle and Raise Courageous and Independent Children by Reid Wilson and Lynn Lyons
  • Interview, “Maximizing Exposure Therapy for Anxiety Disorders” with Michelle Craske, professor of Psychology, Psychiatry and Biobehavioral Sciences and director of the Anxiety and Depression Research Center at the University of California, Los Angeles: sscpweb.org/craske
  • Article, “Get Excited: Reappraising Pre-Performance Anxiety as Excitement” by Allison Brooks, assistant professor, Harvard Business School: apa.org/pubs/journals/releases/xge-a0035325.pdf
  • Dr. Andrew Weil’s 4-7-8 Breathing Method: drweil.com/videos-features/videos/the-4-7-8-breath-health-benefits-demonstration/

Linda Thompson recommends these resources for counselors wanting to learn more about attachment-focused responses:

 

 

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Bethany Bray is a staff writer and social media coordinator for Counseling Today. Contact her
at bbray@counseling.org.

Letters to the editorct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Five pragmatic tools to become a nonanxious presence: Tips and tricks for being a mindful counselor

By John Wheeler June 26, 2018

One of the most uplifting and powerful things counselors can do for their clients is to become a “nonanxious presence.” The term, originally coined by Jewish Rabbi and family therapist Edwin Friedman, is used to describe an individual who provides a calm, cool, focused and collected environment that empowers others to be relaxed.

This can be especially helpful for clients who have varying levels of anxiety, are in crisis or share information that could be traumatizing. By being a nonanxious presence, the counselor can model emotional regulation and invite clients to see that there is more than the anxiety or other feelings they may be experiencing.

As a counselor-in-training and certified empowerment coach, here are the five pragmatic tools that I use in my own practice.

 

1) Don’t buy in to the story; it only makes your client a victim. Everyone has a story about life. They use this story to determine who they are, where they are from, who they hope to become and all the difficulties they have overcome. As counselors, we must acknowledge the stories our clients share and the significance they assign to these stories. However, we must further consider how clients may use these stories to limit themselves and give up control in their life. If, as counselors, we allow ourselves to be swept into the story, we do a disservice to our clients and allow them to serve in the role of victim.

How does that apply to being a nonanxious presence? By not buying into the story and the role your clients have assigned themselves, you invite them to see the story from a different perspective. When you resist the urge to emotionally join their story, you are able to see all the ways in which their story is playing out in their daily lives. You, as counselor, are then free to identify patterns of behavior and gain insight into clients’ lives, thus empowering them to create something greater than they currently have.

2) Be you and trust your training. As a counselor-in-training myself, it seems the hardest thing to remember is to be yourself and to trust your training. Many times, we can be swept up in what we must “do” as counselors and fail to connect with the client. If we get caught up in the information we must gather, the treatment goals we are measuring and the skills or techniques we plan to implement, we may miss the opportunity to make a true connection, which so many people are missing in their lives.

The most influential measure of success in counseling is the client-counselor relationship. Have you ever noticed that some of your best sessions take place when you are willing to simply be present with your clients and let go of using a specific technique? How different might your practice be if you were willing to just be you, had faith that you possess the training you need and allowed yourself to meet the client in the here and now? Truly being present with yourself also invites your clients to be with themselves and to lower their barriers. In the process, you become the nonanxious presence that allows for greater change in clients’ lives.

3) Empower your clients to know that nothing is personal. Take a moment and consider a time when you experienced difficulty in a relationship, either romantically or otherwise. How differently might you have reacted to the event if you had known it wasn’t personal? This is another tool I use as a nonanxious presence with my clients. I empower them to know that nothing they have experienced or believe was done to them is personal.

This approach can be particularly helpful when dealing with abuse, trauma or relationship problems that arise in session. Clients can sometimes use their abuse or trauma as a coping skill to ensure that no one is able to get that close to them again. It is a means for them to know they have control and will not allow more abuse in the future. Reframing your clients’ perspective to “it wasn’t personal” invites them to see where they were a convenient target for the other person to release what they were experiencing. When individuals choose to abuse someone, they seldom consider who the other person is; quite frankly, they are just looking to relieve whatever level of stress, anxiety or other feeling they are experiencing.

When using this tool with your clients, it is important to have a strong rapport and relationship with them because challenging someone’s view on abuse can be difficult for the person to accept. If you are able to empower your clients to see that nothing is personal, however, it opens the door for them to separate themselves from the abuse or trauma and to begin the healing process.

4) Practice having an interesting point of view about everything. The greatest tool I have learned from my training with Access Consciousness is to practice having an interesting point of view about everything. An interesting point of view is the place where you can hear, see or become aware of anything without judgment.

As counselors, we receive training in cultural competency and learn the importance of maintaining an environment of nonjudgment with our clients. This is exactly what invites our clients to trust, share and be present with us in session.

How many times have you been judged? How did that make you feel or react? Now imagine if you were sharing the most intimate parts of your life and became aware that someone had a point of view about you? I am not saying that counselors should not be observant and make notice of things taking place in session, but we must be willing to put our points of view aside and be with our clients.

Another way to use this tool is to teach our clients that they can also have an interesting point of view in any area of their own life. This can help them detach from the high level of emotions that prevent them from going beyond the problem. What might this approach add to your daily life inside and outside of your counseling practice?

5) Ask questions, never give answers. As counselors, we can fall into the habit of dispensing advice. As someone who studied for a few years as a life coach, one of the greatest tools I used was to always ask questions and never to give answers. As a nonanxious presence, you can empower your clients by asking questions that allow them to see what is true in their lives.

Depending on your clients’ level of cognition, the use of this tool can lead to greater levels of healing and insight into their choices in life. It also helps to eliminate the possibility of setting up the counselor as the “power” in the relationship and prevents clients from developing a high level of dependency. As counselors, we must allow our clients to see their difficulties from a different light and empower them to trust in themselves.

Questions always empower clients, whereas providing “answers” disempowers clients. Acknowledge that your clients are the experts in their own lives; we, as counselors, are simply a resource they can use to gain new information.

 

Many of us who choose this profession believe we are called to serve others or have the ability to make a difference in the world. If you truly embrace your role as a nonanxious presence in the lives of your clients and the power this can have to create change, I firmly believe that you will have a rewarding career. What if you were willing to not simply diagnose and treat your clients but to empower them to live their best lives? What if you were willing to acknowledge the gift that you are and the ability you have to invite something greater to exist on the planet? We often hear that “human beings are messy.” What if you being you, as a nonanxious presence, is exactly what is required to begin untangling the mess?

 

 

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John Wheeler is a graduate student at the University of Dayton and a counselor-in-training at Riverscape Counseling in Dayton, Ohio. His focus in therapy is helping to address people’s unique needs while also assisting in facilitating a healthy, self-sustaining outlook on life. He encourages clients to take a proactive approach in fostering a lifestyle that promotes mental, emotional and physical well-being. Contact him at wheelerj7@udayton.edu.

 

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Related reading, from the Counseling Today archives: “When help isn’t helpful: Overfunctioning for clients

 

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.