Tag Archives: stress & anxiety

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.

The most wonderful time of the year?

By Bethany Bray October 23, 2017

Counselors can help clients prepare for the pressures that come during the holiday season, from a barrage of parties and social events to the temptation to compare themselves with the happy, near-perfect holiday scenes in movies, advertisements or friends’ social media posts.

For clients with seasonal depression, it can all be overwhelming — just at a time when people are expected to be happy and joyful, says John Ballew, a licensed professional counselor (LPC) with a private practice in Atlanta. Financial stresses, relationship concerns, grief over the loss of a loved one and other life challenges can feel more intense.

“This can be exactly the time that’s going to press on an old wound,” says Ballew, a member of the American Counseling Association.

Cindy Gullo, an ACA member and licensed clinical professional counselor in O’Fallon, Illinois, says she also notices an uptick in depression symptoms in her teen clients during the unstructured weeks of school break for the holidays, as well as anxiety over the return to school in the new year. She coaches clients to create and maintain structure over holiday breaks, including getting up at the same time in the morning and keeping up with the tasks they normally do while in school, such as completing reading assignments or practicing a musical instrument.

For Ballew’s adult clients, setting boundaries — from limiting their party RSVPs and holiday overeating to avoiding toxicity on social media — is often key to navigating the holidays. He also talks about the difference between self-care and self-indulgence with clients when preparing for the season.

“The adage that ‘No is a complete sentence’ is very applicable here,” Ballew says. “Especially if they have social anxiety, three hours at a party can feel totally overwhelming. Plan to go for 20 minutes, say hello to at least three people, then leave and admit you’ve done something difficult.”

On the flipside, clients who don’t receive any holiday invitations can sink into isolation or self-pity. Ballew says he works with clients to challenge themselves. Are they sitting at home waiting for the phone to ring? If so, they can be the one to call friends and initiate get-togethers. They can volunteer. They can choose to attend concerts and other local events on their own.

The holidays — from Thanksgiving to Valentine’s Day — can also be a struggle for clients who are single and unhappy about it. Again, Ballew says he challenges these thought patterns with clients. “For people who are alone, it’s learning to love being alone and make peace with it,” he says. “Reassess old patterns and beliefs and let go of things that aren’t working. What activities can you do alone? What beliefs do you have that keep you from enjoying things alone?”

Conversations with clients about setting boundaries can also be helpful in preparing for the family pressures and get-togethers that crop up during the holidays. For clients with particularly toxic or unhealthy family situations, this may mean limiting their involvement or staying away altogether, Ballew says. It may even be helpful to create their own new traditions during the holidays.

Sometimes, Ballew coaches clients to think of family visits as a trip to the zoo: What behavior might you see? What can you expect? What responses can you have ready for when family members make inappropriate or triggering comments?

When appropriate, he will create a “family bingo” board with clients, listing predictable patterns and negative behaviors that they can track in their minds. Although they wouldn’t bring the board to family gatherings, its creation is a way to prep for managing potentially challenging situations, Ballew explains.

“Approaching things with a sense that it doesn’t need to be that serious can be helpful,” he says. “With other folks, if the family is seriously dysfunctional, they just need to set boundaries. For example, if dad gets drunk, they don’t need to wait around to be berated. Have a [plan and] a place to go so you aren’t as vulnerable as when you were younger.”

Marcy Adams Sznewajs, an ACA member and LPC with a private practice in Beverly Hills, Michigan, specializes in working with teenagers and emerging adults. Like Ballew, she works with clients to prepare for family interactions over the holidays, with focus placed on empathy and listening skills.

“We do a lot of role-play in anticipation of family events,” she says. “What would happen if your uncle goes down this path and you respond in this way? How might that end? How would you like it to end? What are some different ways you can approach the situation? Teens don’t always have the ability to step back and say, ‘Just because someone doesn’t understand me doesn’t mean that I need to spout off my opinion at all times or respond.’”

“We also talk about understanding other people’s perspectives and life experiences,” she continues. “If they can look at a [family member’s] actions and behaviors from a place of empathy, sometimes it’s easier to sit through a conversation. Or, sometimes, it’s so horrible that all they can do is take a deep breath and get through it. Then we talk about management, mindfulness and ‘this too shall pass.’

“I tell them, ‘I can’t always help fix this, but I can help you cope, and you are strong enough to deal with this.’”

 

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READ MORE about supporting clients through seasonal depression in the article, “A light in the darkness” in Counseling Today‘s November magazine: https://wp.me/p2BxKN-4V1

 

From the Counseling Today archives: “Unhappy holidays: Helping clients through the ‘holiday blues’

 

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Bethany Bray is a staff writer 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.

 

High anxiety

By Laurie Meyers August 29, 2017

Licensed professional counselor (LPC) Keri Riggs, an American Counseling Association member with a private practice in Richardson, Texas, started noticing the pattern about eight months to a year ago: clients reporting a sharp increase in anxiety. And it wasn’t only her existing clients who were expressing discomfort; new clients were seeking her out, surprised and distressed by the symptoms they were experiencing.

“I had [new] clients coming in who would say, ‘I went to the ER because I had chest pain, and they told me I was having a panic attack,’” she says.

Others told Riggs that although they had always had some anxiety, they had been able to handle it previously. Now they felt that they needed help and a place to talk about what they were feeling.

What is the impetus for this ongoing surge of stress and anxiety? Riggs believes that a confluence of terrorist events — ranging from multiple attacks in Paris to the Pulse nightclub shootings in Orlando, Florida, to the more recent bombing at an Ariana Grande concert in Manchester, England — have combined with the drama and divisiveness of the current political climate to leave many people feeling fearful and uneasy.

A substantial number of Riggs’ clients belong to groups — including immigrants, women and members of the LGBTQ community — that feel specifically singled out and threatened by the inflammatory rhetoric that has increasingly taken center stage over the past year-plus. Those who care particularly about the people in these groups or the issues affecting them also find themselves susceptible to a lingering sense of anxiety and dread.

Anxious atmosphere

Of course, it is not just people in “targeted” populations who are experiencing rising anxiety. In February, the American Psychological Association released a report, “Stress in America: Coping With Change,” that found two-thirds of Americans are stressed about the future of the nation.

Gerald Brown, an ACA member and LPC with a private practice in Statesville, North Carolina, didn’t need a survey to tell him that Americans are more stressed. “In both [my] new intakes and established clients — especially in the last four to six months — anxiety levels have increased tenfold,” he says.

Brown says that uncertainty about the future and the lack of cohesion in America’s political and social landscape have left many people living in a state of hypervigilance and suspicion, distrustful of those around them and prone to looking over their shoulders. He adds that this atmosphere of anxiety is affecting how people feel about themselves and making them question whether they can trust their own instincts about “outsiders.” Brown says he has witnessed an increased level of suspicion for anyone who might be considered “other,” which is serving to create a substantial societal divide.

ACA member Peter D. Ladd, a licensed mental health counselor who specializes in existential counseling and mediation, agrees, saying that what he calls a negative “emotional climate” is taking its toll on many people in the United States. He believes that this climate — filled with talk of revenge, resentment and hatred — is encouraging violence and harming people’s mental health.

Ladd, who sees primarily families and children in his private practice in Clayton, New York, says that many of his clients are displaying significant apathy. “I believe their sense of hopelessness comes from the climate of chaos presently dominating our government and society,” says Ladd, coordinator of the mental health counseling program at St. Lawrence University and the author of numerous books on conflict resolution and relationships. “In the same way that adolescents may feel apathetic from a chaotic family system, many adults, I believe, are feeling a sense of hopelessness from a chaotic government and society. Chaos wears people out, leaving in its wake a sense of hopelessness.”

Brown says more of his clients have been reporting relationship troubles, problems sleeping, unhealthy eating habits and a general sense of malaise. “A lot of new clients have been gaining weight, snacking a lot more, and it’s unconscious snacking. They didn’t even realize they were eating,” he says. “What I find is that people are watching the news too much and too often. … It impacts how they eat, how they sleep and their levels of anxiety.”

Balancing act

Riggs says that helping clients determine how much news to take in when they are feeling anxious is a delicate balance. “We walk that line [of], ‘How do I stay informed about what is happening in my world without becoming paralyzed?’” she says. “And that’s a very individual path, because what works for me might not work for someone else.”

Brown is a big advocate of turning off the news and getting off of social media, but he acknowledges that not everyone can or wants to turn away from reporting and opinions on current events. However, he does think that clients need to find a way to disconnect and wind down at the end of the day. He observes that many people arrive home from a day of work — which may have been anxiety-producing in and of itself — and put down their devices to have dinner, only to be drawn back in by a headline alert or a social media notification. Hours later, it’s time for bed, and they have spent zero waking hours being disconnected.

“I don’t think it’s healthy. You need to find a balance,” Brown emphasizes. He recommends that clients start the winding down process at least two hours before bedtime by dimming the lights, reading something light or listening to relaxing music. And although he isn’t anti-television, Brown recommends that clients not watch violent or intense shows at night. “Those images are hard to get out of our heads, and it impacts a lot of people’s sleep patterns,” he explains.

Riggs agrees that getting enough sleep is essential and one of the most important parts of self-care, particularly for those struggling with anxiety. At the same time, she says, self-care doesn’t come with a one-size-fits-all prescription. The key is cultivating pleasure and joy, she emphasizes. Some people seek solace in faith or work out their tensions through exercise. Others seek enjoyment — and perhaps seek meaning — through art, literature or music.

Riggs also helps clients build resilience by having them identify the sources of personal support in their lives and encouraging them to look back on the difficult times they have gone through in the past and survived.

Brown finds that spending dedicated time with each of his young daughters helps him maintain his personal equilibrium. “I think another thing that is missing [in modern society] is not getting one-on-one time with loved ones,” he says. “Everyone goes to their own corners at home and does their own thing.”

As restorative as spending time with loved ones may be for some, it can be a particular source of stress for others in these politically divisive times, Riggs observes. Some of her clients have mentioned that their friends and family members have minimized or dismissed their fears and anxiety. Others have struggled with loved ones who want to steamroll them into agreeing with a certain point of view. In those cases, Riggs says, “We talk a lot about assertive communications strategy. ‘What would you like to say [to this person]? What’s appropriate?’”

Sometimes those on opposite sides simply can agree to disagree by acknowledging that they will still love and respect one another despite their different viewpoints, Riggs says. However, it’s not uncommon for people to get pushback. “I’ve had clients who have had to hang up on people because [those people] refuse to respect the boundaries,” Riggs says.

Indeed, cutting off or limiting communication may be the only way for some clients to effectively deal with friends or family members who repeatedly cross boundaries and raise the clients’ stress levels. In certain instances, clients may have to unfriend people on Facebook or specify the terms under which they can meet or the topics that they can discuss.

Unfortunately, sometimes even that isn’t enough. “Really aggressive people can be toxic, and clients need to evaluate, ‘What value does this person bring to my life?’” Riggs says.

Seeking solace

Avoiding Facebook, scary movies and irate relatives is all well and good, but how do those who are feeling stressed and depressed get through the day?

Katie Gurwell, a Seattle-based licensed mental health counselor whose specialties include grief and life transitions, tells clients to build a “first-aid kit” with 3-by-5-inch cards that have helpful suggestions written on them such as “go eat something right now” or “put this song on.” She also urges them to start noticing when something makes them feel good — including small events such as seeing a beautiful flower, spotting a bird or hearing a specific song — and taking 10 to 20 seconds to savor and absorb the moment rather than just moving on.

When clients are overcome by stress, Riggs recommends using cognitive behavior techniques such as naming five things that they see or thinking of five countries that start with the letter “S.” She says these simple exercises can draw people away from their anxious sensations and into the cognitive, which is calming. One grounding technique that Riggs recommends to clients is to stop and observe what they hear in their environment, such as voices in the next office, birds outside the window or a clock ticking.

Brown likes to employ a simple breathing technique that he also recommends to clients: Inhale for four seconds through the nose, hold the breath for seven seconds and slowly breathe out for eight. He is also a devotee of the song “Weightless,” which the British group Marconi Union and sound technicians created to be the “most relaxing sound ever” (available on YouTube). A British neuromarketing research firm, Mindlab International, conducted a study and found that listening to the song produced a greater state of relaxation than any other music tested to this point.

Re-establishing control

We may not be able to change the world — or other people — but it’s still possible to regain a sense of personal control. That’s one message that counselors can communicate to clients who are anxiety-ridden over the current state of the world.

Brown helps clients envision a new future by creating a “vision board.” He asks them to fill a blank white poster board with images, words or phrases related to personal growth, such as self-improvement ideas, relationship goals or career prospects. Examples might include a desired job title or position or even a place that the client wants to visit. Brown believes that looking at and reflecting on these words and images every day can help people envision the steps that they need to take to achieve their goals.

Another way to re-establish personal control is for clients to understand the elements that trigger their anxiety, Riggs says. “What’s the story [clients are telling themselves] about what is going to happen? So many clients are saying, ‘What if? What is this going to mean for my children?’”

Clients often fear that if something bad happens, they won’t be able to handle it, Riggs says. So she asks, “What is your worst fear? What’s important to you, and what are you afraid of, and what do you want to do about it?”

She notes that part of anxiety is being effectively frozen, meaning that the antidote often involves taking action. Riggs first helps her clients identify what is within their control and what is not. She then helps them learn to let go of what is outside their control but to take action on the things that are.

“Taking action” can mean anything from getting involved in local politics to making a symbolic gesture (such as boycotting particular businesses or brands) to finding a community of
like-minded individuals so the client doesn’t feel alone in his or her struggles, Riggs explains.

One of Riggs’ clients decided that she wanted to become more active in helping refugees, so they spent a session talking about steps the client could take to do that. The discussion involved questions that helped the client define the level of involvement that would be personally meaningful. “What’s my next step? Am I a person who can just write a check, or do I need to be grass-roots and have refugees come live in my home?” Riggs says.

At the same time, clients don’t necessarily need a “cause” to make a difference or take action, Brown says. He says that bringing meaning and purpose to others through volunteering — such as by visiting a retirement home and playing games with the residents as he and his family do — can give clients a sense of control. “Despite what is happening politically,” he says, “you can begin to effect change in positive ways.”

 

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

Living with anxiety

By Bethany Bray May 24, 2017

Anxiety disorders are the most common mental illness in the United States, affecting 18 percent of the adult population, or more than 40 million people, according to the National Institutes of Health. Among adolescents the prevalence is even higher: 25 percent of youth ages 13 to 18 live with some type of anxiety disorder.

Anxiety disorders are often coupled with sleeplessness, depression, panic attacks, racing thoughts, headaches or other physical issues. Anxiety can run in families and be a lifelong challenge that spills over into all facets of life, from relationships and parenting to the workplace.

The good news is that anxiety disorders are manageable, and counselors have a plethora of tools to help clients lessen the impact of anxiety. Caitlyn McKinzie Bennett, a licensed mental health counselor, says she regularly talks this through with her clients at her private practice in Orlando, Florida. She often uses an analogy of ocean waves with clients: Anxiety comes in waves, and managing the disorder means learning coping tools and strategies to help surf those waves rather than expecting the waves to disappear entirely.

“Anxiety can be a long-term thing,” says Bennett, who is also a doctoral student in counselor education at the University of Central Florida. “With clients, I try and explain that [anxiety] is the body’s response that something’s not right — based off of what’s happened to you [such as past trauma] or what’s happening currently. Then we can work to accept it, cope and be happier in your life. Some things you can’t necessarily get rid of in their entirety, and that’s OK. It’s learning to be you and have a fulfilling life with anxiety, where you’re able to feel anxious and [still] be productive and be a mother, a student, a partner. I try and normalize that [anxiety is] going to come and go. It’s OK, and it’s human.”

Anxiety doesn’t happen in isolation

Everyone experiences anxiety from time to time, such as worry over an upcoming work responsibility, school exam or first date. Anxiety disorders, however, are marked by worry and racing thoughts that become debilitating and interfere with everyday functioning.

“It’s a normal part of life to experience occasional anxiety,” writes the Anxiety and Depression Association of America on its website (ADAA.org). “But you may experience anxiety that is persistent, seemingly uncontrollable and overwhelming. If it’s an excessive, irrational dread of everyday situations, it can be disabling. When anxiety interferes with daily activities, you may have an anxiety disorder.”

A number of related issues fall under the heading of anxiety disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), including specific phobia, panic disorder, separation anxiety disorder, social anxiety disorder, generalized anxiety disorder and others. According to the DSM-5, anxiety disorders “include disorders that share features of excessive fear and anxiety and related behavioral disturbances. Fear is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat.”

Racing thoughts, rumination and overthinking possibilities — from social interactions to decision-making — are central to anxiety. In addition, people with anxiety often struggle with insomnia or sleeplessness and physical symptoms such as a racing heart, sweaty palms and headaches, says Bennett, an American Counseling Association member who is currently leading a study for her doctoral dissertation on the effects of neurofeedback training on college students with anxiety. Adolescents sometimes turn to self-harming behaviors such as cutting or hair pulling to cope with anxiety. In adults and adolescents, anxiety can manifest in physiological issues such as stomachaches or irritable bowel syndrome. Although adults may channel their anxiety into physical problems, they’re also generally much more capable than adolescents and children of identifying and articulating the anxious thoughts, ruminations and social struggles that they’re facing, Bennett says.

Bennett worked with a 14-year-old female client whose anxiety had manifested as the behaviors of obsessive-compulsive disorder (OCD), including avoiding the number six, leaving her closet door open a certain way and struggling with crossing thresholds. Bennett worked with the client to identify her triggers and find coping mechanisms, such as connecting with friends and her Christian faith.

“A big part of her improvement was creating the awareness of what was happening,” Bennett says. “Typically there’s a large, irrational fear. With her, she was afraid that her mom was going to die. She would focus on it so much that it would cause her to start the [OCD] behavior. … For her, it felt so real. It was so scary for her that she felt compelled to do these behaviors to keep her mom alive, so to speak.”

Bennett worked with the young client to confront her fears in small doses through exposure therapy, such as listening to a song at volume level six and talking through how she felt afterward. This method allowed Bennett to first address the client’s OCD behaviors and then — once trust was built and the client had progressed — move on to work through the bigger, deeper issue of her fear of her mother’s death.

“It helped her to feel safe enough and have the confidence to work through some smaller things and move on to work on bigger things,” Bennett says. “For her it was talking it out, normalizing that for her and drawing attention to [her anxious behaviors].”

Christopher Pisarik is an associate professor in the Division of Academic Enhancement at the University of Georgia and a licensed professional counselor (LPC) who works with students in need of academic support. He says that stress and irregular sleep and eating patterns — which are often ubiquitous parts of college life — can go hand in hand with anxiety.

“Sleep is a big one — if they’re just not sleeping, or sleeping too much,” says Pisarik, who also treats many college-age clients at his private practice in Athens, Georgia. “This is really, really common — clients who can’t get to bed until 4 a.m., and then they can’t get to class, and it snowballs. Their thoughts just race with worry. … Sleep seems to be a big diagnostic indicator [for anxiety], and not being able to go to bed. [I ask clients,] ‘What are you thinking about, and can you stop thinking about this? Is that what’s keeping you from getting back to sleep?’ They get tired and fatigued, and it’s perpetuated.”

In addition, anxiety is often coupled with — or is an outgrowth of — other mental illnesses, most commonly depression. Counselors will need to treat a client’s anxiety alongside other diagnoses, Bennett says. For example, a client with schizophrenia will have hallucinations that provoke extreme anxiety. If the counselor doesn’t address the client’s anxiety, those symptoms will get worse, explains Bennett.

“Depression and anxiety are like brother and sister,” she adds. “They play off of each other and exacerbate the symptoms. You need to work through both. I don’t think I’ve ever worked with anyone who solely experienced anxiety.”

Stephanie Kuhn, an ACA member and LPC at the Anxiety Treatment Center of Greater Chicago, agrees. She regularly sees client anxiety paired with other issues such as specific phobias, insomnia, chronic pain issues, depression, panic disorders and OCD.

“It’s never really one thing,” Kuhn says. “It’s never just anxiety.”

Pumping the brakes on racing thoughts

The first step for many people who struggle with anxiety is to create awareness of their thoughts and then learn to manage those thoughts with a counselor’s help. Although the strategy of identifying negative self-talk and addressing one’s thoughts is old hat to most counselors, it may be an entirely new concept for some people, especially younger clients, says Pisarik, an ACA member who uses cognitive behavior therapy (CBT) in his private practice. Clients with anxiety often polarize, exaggerate or catastrophize details in their minds as they ruminate over them, he explains.

“Even being able to identify anxious thoughts is big,” Pisarik says. “They just assume it’s normal to walk around [feeling] anxious because of these thoughts. … It gives them a language and a real usable and rudimentary skill they can use in the moment when they’re walking in [to a stressful exam]. They can identify that their inner narrative isn’t healthy.”

For example, a college student might come to a counselor expressing worry about an upcoming exam in a class that he or she needs to pass for a major in pre-med. The student might have allowed negative and catastrophic thoughts to snowball: “If I get a C on this test, I will never get into medical school, which will derail my entire career plan and make my parents angry and disappointed.”

“For … a student who is 20 years old and [still] learning to think critically, it would be easy to blow everything out of proportion and catastrophize everything,” Pisarik says. “I am really big on helping them understand negative thinking and false cognitions, and getting them to self-monitor and renarrate [their unhealthy thoughts].”

Following the CBT approach, Pisarik says he would talk such clients through their thought patterns to identify and restructure their negative thoughts about the exam. He would also suggest that they focus on and remind themselves of prior successes, such as other exams or classes in which they earned A’s and B’s.

“I would try and systematically educate the client [about] what type of thinking that is,” Pisarik continues. “There are many doctors out there who got C’s and got into medical school, and probably [who] got C’s in medical school. I will explain that they are catastrophizing this … [and] try and get them to think about it in a different way, evaluate it carefully and create a different narrative about it. Are there people who have gotten C’s and gotten into medical school? If it stops you from getting into medical school, would that be the worst thing in the world?”

“It takes a consistent effort to practice and challenge one’s thinking,” adds Pisarik, who co-authored the article “A Phenomenological Study of Career Anxiety Among College Students.” The article will be published in the December issue of The Career Development Quarterly, the journal of the National Career Development Association, a division of ACA.

CBT works well for anxiety because “it lets people see that their own thinking and their behaviors are not productive for the way they want to live or the life they’re living right now,” says Kuhn, who uses both CBT and exposure therapy with her clients at the Anxiety Treatment Center of Greater Chicago. “It’s giving people an outside perspective — getting them to look at their own thoughts and behaviors objectively rather than letting those anxious thoughts take over everything, making it harder to function.”

One way Kuhn works with clients on challenging their unhealthy thoughts is by asking them to identify the best, worst and most likely outcomes of situations they are ruminating over. “I ask, ‘Would [the outcome] matter in a week, a month or a year from now?’ Typically the answer is no,” Kuhn says. “After we go through that, we reframe the original thought [and] transform it into something more rational, more realistic.”

Both Pisarik and Kuhn encourage their clients to keep thought logs to track anxious thoughts and the situations that triggered them. This exercise increases self-awareness, helps identify triggers and creates an opportunity to discuss how the client might change the negative narrative.

“Writing helps a lot because it slows people’s minds down, and they can go back and read about it,” Kuhn says. “Creating that awareness is the only way to understand yourself, understand what you’re worried about and be able to accept it and push it away.”

In addition to using thought logs, Pisarik gives his clients a list of automatic negative thoughts, or ANTs, to check themselves against. The collection lists the most common types of unhealthy, anxious thoughts and types of thinking, including catastrophizing and either-or thinking (polarizing).

Kuhn has a particular phrase that she often repeats with clients: “Handle it.” She acknowledges that it’s not the most empathic of mantras, but it does help to focus on the manageability of anxiety. With clients, she works toward a goal of “being able to sit with the uncomfortableness [of anxious thoughts] and tolerate the stress.”

Kuhn says her style when working with clients matches her personality: “Let’s go forward and hit our fears hard instead of tiptoeing around them.”

Exposure therapy, which introduces things in small, controlled increments in session that make a client anxious, is another good way to focus on handling anxiety, Kuhn adds. Whether the scenario is a fear of speaking up in class or a fear of being rejected by a loved one, exposure therapy can help clients learn to live with the issue and the anxious feelings that come with it.

“When I talk to people about ‘handling it,’ it’s creating that awareness and understanding [of] themselves that they’re able to manage or take on more than they think they can,” Kuhn says. “Anxiety a lot of the time makes us believe that we can’t handle the tiniest things. That’s why our body has created or learned how to respond to things in an overactive or hypersensitive way.” This is most commonly experienced in our fight-or-flight response, she says.

Managing worry and taming anxiety

From CBT and mindfulness to a focus on wellness and coping strategies, professional counselors have a wide range of tools to help clients who struggle with anxiety. Here are some ideas and techniques that can be particularly useful.

> Controlling the controllables. Kuhn says it can be helpful for clients to talk through and identify what is out of their control during situations that make them anxious. “A lot of times, anxious clients want control over everything, and that’s just not realistic,” Kuhn says. “It’s important to go over what’s controllable and what’s not. That creates awareness and a pathway to reevaluate [their] own thinking and behavior. I like to call it ‘controlling the controllables.’ I talk with clients about this a lot.”

Kuhn often uses an exercise with clients in which she draws a target with concentric circles. Things that clients can control, such as their own thoughts and behaviors, go in the center circle. Things that they partially control, such as their emotions or what they focus on sometimes, go in the middle ring. Things that are out of their control, such as what other people think or do, go in the outside circle. In a simpler alternative, Kuhn draws a center line down a piece of paper and works with clients to list what is and isn’t in their control in situations that make them anxious.

> Creating common ground. Kuhn says she also talks openly with clients about how common anxiety is, alerting them that they are among literally millions of Americans who are battling the same challenge. “I let them know they are not alone. It creates a universality,” Kuhn says. “To let people know that they’re not the only ones suffering like this can help. … It does create a common ground for people not to feel ashamed of [their anxiety] or feel like they can’t talk to someone about it. Just creating that education typically makes people feel a ton better.”

> Acknowledging and naming worry. Journaling and making lists to document anxious thoughts can help clients address and reframe the everyday rumination that accompanies anxiety. Kuhn offers two variations on this intervention: worry time and the worry tree.

With “worry time,” clients set aside a dedicated amount of time (Kuhn suggests 30 minutes) every day to write down any anxious thoughts that are troubling them. Clients don’t need to engage in long-form writing to complete this exercise, Kuhn says. Making a bulleted list or jotting thoughts down on sticky notes will work just as well. When the designated time is up, clients put all the notes in a box or container that they have set aside for this purpose. This action signifies that they are leaving those thoughts behind and can move on with the day.

“They have to leave those thoughts or sticky notes there and be done with them,” she says. “Obviously more [anxious] thoughts will come, but you have to remind yourself to leave them behind.”

With Kuhn’s “worry tree” intervention, clients create a flowchart of their anxious thoughts. With each item, clients ask themselves whether their worry is productive or unproductive (see image, below). “Is it something that you can actually do something about?” Kuhn asks. “If it’s unproductive, then you need to just let it go. Do something you enjoy or focus on something else to reset [your mind].”

 

> Mind-body focus and exercise. Mindfulness, meditation and other calming interventions can be particularly helpful for clients with anxiety. Kuhn recommends the smartphone app Pacifica, which prompts users with breathing, relaxation and mindfulness exercises, for both practitioners and clients. Kuhn, who has a background in sports counseling, and Pisarik, who is a runner himself, also prescribe exercise to anxious clients. Exercise boosts serotonin, a neurotransmitter connected to feelings of well-being, and comes with a host of other wellness benefits. In addition, exercise allows a person to get outdoors or disengage from work and home activities and other people for a brief period to “have time to hear your thoughts and challenge them,” Pisarik says. “You have to hear your thoughts if you’re going to challenge them.”

> The butterfly hug. Beth Patterson, an ACA member and LPC with a private practice in Denver, teaches deep breathing exercises to anxious clients to help them become grounded, focusing on the flow of energy through the body. She also recommends the “butterfly hug” technique. With this technique, clients cross their arms across their chests, just below the collarbone, with both feet planted firmly on the floor.

Clients tap themselves gently, alternating between their right and left hands. This motion introduces bilateral stimulation, the rhythmic left-right patterns that are used in eye movement desensitization and reprocessing. “It’s phenomenally self-soothing,” Patterson says. “Doing that with deep breathing really helps with anxiety. I love the idea that you’re hugging yourself. Even just doing that helps.”

> Walk it out. Along with deep breathing and grounding, Patterson also recommends walking and movement for clients who are feeling anxious. She instructs clients to focus on the feeling of each foot hitting the ground instead of their anxious thoughts. As with the butterfly hug, this action creates bilateral stimulation, Patterson notes.

Bennett also uses walking as a way to help clients refocus their thoughts. She will take clients out of the office during a session for a “mindful walk” up and down the block. During the walk, they talk about what they’re sensing, from the sunshine to the breeze to the smell of flowers. Bennett says this allows her to work with clients “in the moment,” recognizing and refocusing anxious thoughts as they come. Afterward, they process and talk through the experience back in the office.

“It’s a lesson that [anxious] thoughts are going to come up for you, and you can refocus on your sense of touch or hearing,” Bennett says. “Thoughts will come up, and it’s really easy to attach to those thoughts and become anxious, but we can acknowledge the thought, be accepting of it in the moment and refocus. Change and connection can come that way.”

> This is not that. Clients commonly transfer anxiety-provoking personal issues onto relationships or situations in other facets of life, including the workplace, Patterson says. For example, Patterson worked with a client who had a very domineering, controlling mother, and this client felt triggered by a female boss in her workplace. Patterson introduced the client to the mantra “this is not that,” and they worked on reframing the anxiety the client experienced when she felt her boss was being controlling.

“She had to work through it in a beneficial and compassionate way for herself and really remember ‘this is not that,’” Patterson says. “Our minds are brilliant, but they’re binary computers. When something happens, it will immediately associate it with something else it knows. If a co-worker is being overly competitive, it might trigger feelings about sibling rivalry. This [mantra] offers a great opportunity to work through family-of-origin issues [with clients] when you see them replicated in the workplace.”

> Abstain from negativity. Another empowering tool clients can use is to become conscious of and then avoid unhealthy or toxic situations and people who trigger their anxiety, Pisarik says. He advises clients to “stay away from groups of people or individuals who they know will engage in negative self-talk or negativity. If you’re feeling anxious already, the last thing you want to do is to go and talk to that toxic person.”

Similarly, he commonly advises anxious students to avoid waiting outside the room where they’re about to take a big exam, surrounded by 30 classmates who might be saying that they are going to fail, they didn’t study enough, they don’t feel prepared and so on. Counselors can coach anxious clients to think ahead and prepare ways to remove themselves from these types of situations, regroup and redirect their thinking, Pisarik says.

> Lifestyle choices. Counselors can also educate clients on the connection between anxiety and lifestyle choices such as sleep patterns, exercise and diet, Pisarik says. For young clients especially, this also includes social media use, he notes.

Pisarik says he frequently talks with his college-age clients about their alcohol consumption, drug use, irregular diet and other aspects of the modern university experience. “The lifestyle of a college student is absolutely conducive to generating anxiety,” he says. “While they are college students, I get that — their job is to have fun and sleep whenever [they] want. But building some sort of healthy routine is important, [including] getting enough sleep and making sure they eat well. I tell them to try and maintain the diet they had at home. … If you’re struggling with anxiety to begin with, any one of those [elements] can add to it, and those are really easy fixes.”

For Bennett, conversations with clients about lifestyle also include questions about smoking and caffeine use. Both tobacco and caffeine can make a person shaky or make his or her heart and mind race, which can trigger or exacerbate anxiety, she points out.

In addition to social media use, Pisarik also asks clients about their social engagement, such as participating in sports or other hobbies. Clients who struggle with anxiety often isolate themselves, he notes, so he works with them to identify social outlets, from volunteering to joining a school club. This sense of connection can reduce anxiety, he says.

> Narrative therapy and externalization. Patterson finds narrative therapy helpful when working with clients with anxiety because it allows them to externalize what they’re feeling. When clients uses phrases such as “I am worried” or “I am anxious,” Patterson will gently redirect them by saying, “No, you’re Susan, and you have a problem called worry.”

“Externalize the problem,” Patterson explains to clients. “Externalize it and dis-identify it. See it outside of yourself. … ‘I can deal with that because it’s not who I am.’ … If you’re carrying it around as if it’s you, you can’t do anything about it. The truth of the matter is, it’s not you.”

Counselors can also help clients with anxiety to focus on a time in their lives when they faced a similar challenge and got through it, Patterson says. She asks clients questions to help them probe deeper. For example: How did you handle that challenge? What worked, and what didn’t work?

 

Working with clients on medication

Anti-anxiety medications are commonly prescribed in the United States. Their prevalence means that counselors are likely to encounter clients who are taking medication to control their anxiety symptoms.

Regardless of their feelings about the use of psychotropic medications, practitioners must treat and support clients who are taking such medications the same as they would any other client, Kuhn says. “I never treat someone differently based on their medication. They get the same CBT therapy that anyone else would get,” she says, adding that the most important thing is to ensure that clients don’t feel judged by the counselor.

Kuhn has seen anti-anxiety medications work well for some clients. “It can take that little edge off that they need to get through the day and be able to function,” she says. At the same time, she also has clients who express a desire to be able to stop taking their medication eventually.

Pisarik notes that for anti-anxiety medication to work well, clients must remember to take it faithfully, keep track of how it makes them feel and schedule the repeated appointments needed to monitor and adjust dosage levels. Each of these elements can pose a challenge to college-age clients. “It’s a lot of work, and [college students] often lack the discipline and time to get it right,” Pisarik says.

Bennett agrees, suggesting that even though professional counselors are not the ones prescribing medications, they still need to discuss and explore medication use with their clients. She also stresses that practitioners should be knowledgeable about the different kinds of medications that clients may be taking and their possible side effects.

Bennett sometimes conducts conference calls with her clients and the medical professionals who are prescribing them medications so that she can help clients ask questions and otherwise be a support to them. “We [counselors] don’t prescribe, but at the same time it’s very important to collaborate with whoever is prescribing the [client’s] medication,” she says. “Be supportive and involve the client in conversations: How long have you taken it? Have you noticed any side effects? Has it been helping? Talk about how often they’re supposed to take it and if they’re adhering to that. There can be stigma about taking medications, so it’s important to normalize it. … It’s comforting too for the client to know that you’re on their side, and part of that is collaboration [about medication].”

 

See the person, not the anxiety

Given how common anxiety disorders are, it’s likely that any counselor’s caseload will be filled with clients presenting with symptoms of anxiety. It is important, however, for counselors to treat each client as an individual and to tailor the therapeutic approach to meet that client’s unique needs, Bennett emphasizes.

Building trust and a healthy therapeutic relationship are key in treating anxiety because clients can feel very vulnerable as they talk about what makes them anxious, Bennett points out. That is why it is critical to get to know these clients as individuals rather than through the lens of their anxiety.

“Don’t assume that because they’re anxious, they’re going to think and behave like other people with anxiety,” Bennett says. “Meet them where they are and find out what’s most effective for them based off of their interests. It can be empowering for clients to integrate their own interests and life experiences into the therapeutic process. Not only does this create buy-in for the client, but it can also help in creating a safe space to begin exploring the vulnerabilities that come along with anxiety. … Hear their story, find their strengths and give them a voice in the process. It’s important to honor them as individuals.”

 

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To contact the counselors interviewed for this article, email:

 

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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 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.