Best Practices for Anxiety Treatment | Cognitive Behavioral Therapy

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs register@allce.com counselortoolbox you I'd like to welcome everybody to today's presentation on best practices for the treatment of anxiety. Now, not too long ago we did a presentation on strengths based biopsychosocial approaches to addressing anxiety. And while those are wonderful, you know, I thought maybe we ought to look at what's some of the current research. So I went into PubMed, which is, I don't know, it's playground for me. It's where you find a lot of the journal articles and you can sort and I sorted by articles that were done and meta analyses that were done within the past five years. So that gives us an idea about current research. I mean, there's a lot of stuff that is still the same. Like some of the medications that were known to work 10 years ago are still known to be, you know, good first line treatments. But there are also some newcomers that we'll talk about and there are also some changes that we're going to talk about. So we're going to explore some common causes for anxiety symptoms. In order to treat it. We really need to. And of course this does play into the biopsychosocial aspect. We really need to understand kind of what causes it. Because anxiety that's caused by, for example, somebody having a racing heart may be different than anxiety that's caused for somebody who has abandonment issues. So we're going to treat the two things differently. So we want to look at some of the common causes. We're going to look at some common triggers for anxiety. You know, what are some of these common themes that we see in practice? And I will ask you to share some of the themes that you see that underline or underlie a lot of your client's anxiety and identify current best practices for anxiety management, including counseling interventions, medications, physical interventions, and supportive treatments. So we care because anxiety can be debilitating and a lot of our clients have anxiety. A lot of our clients have anxiety, comorbid with depression, and they're looking at us going, how can I feel anxious and stressed out and like I can't sit still and depressed at the same time. You know, when you're depressed you're supposed to want to sleep. Well, a lot of times people who have both issues really want to sleep, but they can't. So I want to help clients understand that also sometimes anxiety, when people are anxious for long Enough. The body starts kind of holding on to the cortisol. The body actually recognizes at a certain point, this is a losing battle. I'm not going to put energy into this anymore. So it starts withdrawing some of its excitatory neurotransmitters, so to speak, and people will start to feel depressed. Basically, the brain has already said the this is hopeless. You're helpless to change the situation. So then people start feeling hopeless and helpless, which is sort of the definition, if you will, of depression. Low grade chronic stress and anxiety erodes energy and people's ability to concentrate. So if we're going to help them become their uber selves, we need to help them figure out how to address anxiety. Not just generalized, overwhelming, debilitating anxiety, but also panic, social anxiety, and those minor anxiety triggers that come along that may not meet the threshold for a diagnosis. Anxiety is a major trigger for addiction relapse. If you have a client who has self medicated before or had an addiction for some reason, anxiety is a major trigger. Increased physical pain. When anxiety goes up, people tend to tense their muscles. When they tense their muscles, they tend to feel more pain. I mean, think about when you're stressed, you tend to have more pain, like in your neck and your back. And things that already hurt may hurt more. Why? Because serotonin, which is one of our major antianxiety neurotransmitters, is also one of our major pain modulators. So when serotonin levels are too low because anxiety is high, then our pain perception is gonna be more acute and people can have sleep problems. If you're stressed out, your body thinks there's a threat. You're not going to be able to get into that deep, restful sleep. You may sleep, you may sleep a lot, but it's probably not quality sleep, which means your neurotransmitters may get out of whack, your hormones make it out of whack, and your body's going to start perceiving itself in a persistent state of stress. When we're exhausted, the body knows that we may be the weakest link in the herd. So it continues to secrete cortisol to keep, keep you on alert a little bit. So you may, again, you may be resting, kind of like when you have a new baby at home. Those first couple months that my children were home from the hospital, I slept, but I didn't sleep well. I mean, the slightest little noise and I was awake and I was looking around and, you know, I felt it. I felt exhausted and a lot of new parents. So triggers for anxiety, abandonment and rejection. And we're going to talk about ways we might want to deal with these things. But some of the underlying themes that I've seen in a lot of clients and when I do the research, what a lot of what themes that come out include low self esteem. If someone has low self esteem, they're looking to be externally validated. Oftentimes they're looking for somebody else to tell them you're lovable, you're okay. So that can lead to anxiety about not having people to tell them you're okay, which makes their relationships tenuous and can make them dysfunctional. Irrational thoughts and cognitive distortions may lead people to believe that if I'm not perfect, for example, I am not lovable. So we're going to look at some irrational thoughts and cognitive distortions. Unhealthy social supports and relationships. When you're in a relationship, it takes two to tango. And even if your client is relatively mentally and physically healthy, if they are in a dysfunctional relationship, they can fear abandonment and rejection if that other person is always saying, if you don't do X, I'm going to leave you, or if that other person is always cheating on them or whatever. So relationships can trigger abandonment anxiety and ineffective interpersonal skills can lead to relationship turmoil and social anxiety. If our clients are in relationships, even if they're not completely dysfunctional, if our clients are not able to ask for what they need and set appropriate boundaries and manage conflict effectively because conflict happens in every relationship, then they may start to argue more, which may lead to fearing, may lead to relationships ending in the past and them going, well, every relationship I get into ends, which means I must not be lovable. So they start fearing abandonment and rejection. So these are four areas that we can look at when we're assessing clients. Another issue is the unknown and loss of control. A lot of times negative self talk and cognitive distortions can contribute to that. If I don't have control of everything, then it's all going to be a disaster. Negative others when clients hang out or when people hang out with negative people, it kind of wears on you after a while. You notice that people who are tend to be more negative, pessimistic, conspiracy minded, tend to hang out with people who are also negative, pessimistic and conspiracy minded. So if you're hanging out with somebody who tends to be anxious, then the anxiety can be palpable and it can kind of permeate. Physical complaints can lead people to be anxious because they don't Know what's causing it. Like I said earlier, sometimes if your heart starts to race, if you don't know what's causing it, you can start thinking I'm having a heart attack or I'm going to die. When people have panic attacks, for example, they truly think they're having a heart attack and it's, I've had them, they are very, very unpleasant experiences. But when people start having physical complaints and it can be, you know, they have a weird rash that they can't get to go away or, you know, whatever, but when they don't know what it is and they can't control it, they can't make it go away, they start thinking about all the worst case scenarios and going online and getting on WebMD, which usually gives you all the worst case scenarios. So physical complaints are important. We need to normalize. The fact that nobody's pain free all the time. And you know, the fact that you may have an ache or a pain or a lump or a bump or a, you know, a cough, most likely, you know, when we look at probability, the probability of it being something significant is pretty small now. Do you want to get it checked out? Probably. But you know, the probability that is anything to be worried about is relatively small. And a sense of powerlessness can trigger fear of the unknown and loss of control. For somebody who doesn't feel like they have any agency in their life, if they have an external locus of control or if they felt victimized all of their life, then they may fear not being in control. They may be holding on and saying, okay, this is the one area of my life I can control. When I grew up, you know, I grew up in a very chaotic environment. I had no control. I was bounced around into foster system, yada, yada yada. Now that I'm an adult, you know, I can control these things and I am going to hold on with white knuckles. And if I can't control everything, then that terrifies me. Death and loss are other triggers for anxiety. And it can be people or pets. And pets are important. I don't want to minimize pets because you know, they are little parts of a lot of our families. So making sure we check that. My daughter's dog for example, is, it's getting old, she's getting older, she's 14 now I think and you know, she's in decent health. We took her to the vet and the vet said, yeah, she's got a little heart murmur but that's expected for a 14 year old dog. But when she goes out if she doesn't come back when I call her, I have this rush of anxiety for a second that, oh, my gosh, I hope this wasn't the day. So. Anxiety around losing people. And, you know, if she. When she crosses the bridge, she will. And, you know, I'm okay with that. I'm. I have a harder time dealing with my daughter's emotional turmoil when that happens. And because she's grown up with this dog. So, you know, those are the types of things that we want to talk about with our clients. What things are weighing on you that you may not even be thinking about? Because I know in the back of my mind, there's always that worry about one of our donkeys and her dog. Jobs and promotions can trigger anxiety. If people are afraid they're going to lose their job, if they're always afraid that, you know, they're going to walk in and get a pink slip or get fired, you know, we want to help them. Look at how realistic is that. Are you doing what you need to do in order to achieve and keep your job? And sometimes it's not easy to answer. I mean, the first thought that a lot of us have is, well, you know, if you're doing the right thing, so just do it. But there are those bosses out there, and I've had some really amazing bosses, a lot of them, and I've had two really horrendous bosses. And those two bosses, I could never. I never felt like I was able to do anything right. And so going to those jobs, there was always this anxiety about, what am I going to get in trouble for today? So you want to talk with people about, does your job cause anxiety? What can you do to moderate that anxiety? Same thing with promotions. People may get anxious about whether they're going to get promoted. Safety and security. When you lose safety and security, you can feel really anxious. So if there's a break in at the house next door or a shooting down the road, or you start watching the news, you can feel very unsafe and unsecure really quickly. So we want to help people figure out how safe and secure are you really. And a lot of it goes back to really looking at facts. When people lose their dreams and hopes or fear that they're going to lose their dreams and hopes, they can start to get anxious. You know, they have this dream that they're going to be a doctor or I just finished the presentation on helping high school students transition to college, and a lot of high school students, for example, start college with these wide eyes and hopes to save the world. And they want to be doctors and engineers and this and that. And they get into it and they realize that it's a lot harder than they thought, or they realize that, you know what? I really don't like this, but I've already committed to it, so what do I do? Or I want to help people, but I can't cut it doing this. You know, for me, I figured out in my second year that I wasn't going to medical school because I wasn't going to pass calculus. And that caused a lot of anxiety. It was like, okay, what am I going to do now? What career should I choose? Helping people figure out, do you have dreams that have maybe kind of crashed and burned and you have to find new ones? Okay, that one. Got to accept it, figure out that it's not going to be, what can you do now? People may also have dreams about relationships. They get into relationships and they see themselves with this person forever, and then this relationship ends and. Or starts to get rocky and they're like, but that's my dream. What happens if my. That's got to happen because it's my dream. I don't know how to function if that goes away. We want to help people be able to rewrite their narrative. And then sickness, spiders and other phobias kind of goes in with death. A lot of times when people get sick, they start getting anxious that, oh, my gosh, what if this is terminal? Oh, my gosh, what if this is, you know, incurable? If I get bit by a spider, it's going to kill me, which is rare. You know, there are very few spiders that are actually that poisonous. Same thing with snakes. Going over bridges. I've shared with y'. All. That is my. One of my irrational fears. You know, I am just terrified that, you know, something's going to happen and I'm going to get pushed off the side of the bridge, which is completely irrational. But we need to help people look at those and identify the thoughts that they're telling themselves about those phobias and deal with that anxiety. Failure is another trigger for anxiety, especially in this culture, our culture, American culture, in. In large part puts a high premium on success and perfectionism. So when people realize that they're not perfect, they may start to get anxious because they feel like, if I'm not perfect, then I'm a failure. You know, those cognitive distortions of all or nothing thinking, and they start with that negative self talk. You know, you can't do anything right. So those are some of the Issues that, you know, we often see in counseling sessions. So what do we do? You know, somebody comes in and they're like, I can't live this way, doc. Anxiety, depression and substance disorders, as well as a range of physical disorders, are often comorbid. So this is the first thing we need to realize. We need to realize that we're very rarely dealing with a very simple diagnosis. You know, when somebody comes in, we need to figure out, you know, if they come in and they're presenting with depression. All right, let's talk about that. And then we start realizing that their depression started to occur after a long period of being really, really anxious. Okay? So we need to deal with that, but we also need to help them with their sense of hopelessness and helplessness. We need to develop that sense of empowerment. And then substance disorders, we know that substance use is often a way of self medicating, but we also know that it monkeys with the neurochemicals in the brain and can contribute to anxiety and depression. Same thing with physical issues. Pain from physical disorders, anxiety about having physical disorders, medications you're taking for physical disorders can all contribute to, to anxiety. So we need to look at the person as a whole and go, what are all the things that are contributing to the anxiety and what are all the things that the anxiety is contributing to? So we have, we start having this big list of stuff that needs to be addressed and then we can start figuring out, okay, where do we start? So knowing that these things are comorbid helps researchers explore pathways to mental disorders so they can start figuring out, you know, what little string can we pull to unravel this blanket of anxiety so it doesn't suffocate somebody. And for us as clinicians, it provides us key opportunities to intervene. You know, sometimes clients will come in and they start talking about their anxiety and their physical issues, you know, maybe their anxieties about, you know, heart palpitations. And because that's a common one, we may want to encourage them to go see the doctor to get that ruled out. You know, rule out anything that has to do with hormone imbalances or, you know, heart conditions or anything else that might be contributing to it, which can help them address it. And if they do have physical disorders, let's go with hormone imbalances that are contributing to the heart palpitations, then they can start to treat that. If they don't start to treat that, then no amount of talk therapy we do is going to get them to the quality of life that they're looking for. Because they're still going to feel those. So we want to make sure that we're addressing them holistically. Anxiety disorder should be treated with psychological therapy, pharmacotherapy, or a combination of both. And what they found, and this is no surprise, this is kind of old news, is that counseling plus pharmacotherapy tends to have the best outcomes. But separating the two, they have similar outcomes in many cases. But that's just looking at, and I hate to call it simple anxiety, but we're just looking at anxiety symptoms here. We're not looking at full quality of life. And we want to make sure that we're also including any medical issues. Cognitive behavioral therapy is regarded as the psychotherapy with the highest level of evidence. There are a variety of cognitive behavioral approaches ranging from acceptance and commitment therapy to dialectical behavior therapy, to CBT to rebt. Any of those that deal with the thoughts and the cognitions fall in that realm, and it has been found to be effective. The current conceptualization of the etiology of anxiety disorders includes an interaction of psychosocial factors, such as childhood adversity or stressful events and a genetic vulnerability. So the psychosocial factors, and these are other things when we do our assessment, we want to pay attention to, because our approach for treatment is going to be different for people, for example, who have trauma related brain changes, maybe then for somebody who doesn't. So we want to look at childhood adversity and stressful events that may have caused basically what I, what I tell clients is like rewiring of the brain. There are trauma related brain changes in soldiers and especially in children or in people who've been exposed to extreme trauma that are designed to protect them. But it also can cause complications kind of later on in dealing with anxiety, coping skills that were learned that are ineffective. You know, sometimes people grow up in a household or an environment or a situation where they don't learn effective coping skills. So we need to kind of help them unlearn those and learn new ones, build on their strengths. And trauma issues that may still need to be dealt with, such as domestic violence. You know, if they grew up around a lot of domestic violence, they may think, you know, I'm out of that situation, it's over. I don't want to think about it. It's not bothering me anymore. Or a parental absence. And I put absence because it can be death. It can be a parent that just packed up and left. It could be a child that got put up for adoption, Whatever put the child in a position of feeling like they were rejected by a parent can be very traumatic and bullying, among other things. But there are a lot of trauma issues that people, once they're out of that situation, often say, you know, I'm out of it, it's not a big deal, I dealt with it, let's move on. And they don't realize the full ramifications and how that's contributing to their current anxiety and their current self talk and cognitions. Current stressors. If somebody has a lot of current stressors, that's also going to impact whether they develop generalized anxiety. You know, we're kind of stacking the deck here. And the current availability of social support, if they don't have effective current social support, then they're going to have difficulty bearing the weight of everything on their own shoulders. So we want to look at all these psychosocial factors when we do our assessment. Now, going back to trauma issues, if you've taken the trauma courses at all, ceus, you know that some people are not ready to acknowledge that the trauma is still bothering them or work on the trauma. And that's okay. We can educate them that it might be an issue and then let them choose how to address it. But we want to bear in mind the fact that, you know, this could be sort of an underlying force motivating some of the current cognitions and genetic vulnerability. So you take any three people and you put them, or 300 people and you put them through roughly the same psychosocial situations, they're all probably going to react a little bit differently based on their prior experiences, but also because of their genetic makeup, there are certain permutations, and they found four we'll talk about later that make the brain more or less responsive to stress and more or less responsive to serotonin, which is your calming chemical. So brains that are less responsive to serotonin aren't going to, you know, send out as much or send out serotonin as easily so people can stay kind of tensed and wired. That's really oversimplified explanation, but that's all you really need for right now. So genetic vulnerability impacts people's susceptibility to the effects and development of dependence on certain substances, which can increase anxiety. When people are detoxing from alcohol, when they're detoxing from benzos, when they're detoxing from opiates. They can feel high levels of anxiety when they take opiates. Some people find that opiates have wonderful anti anxiety properties. Not that I am advocating for the use of opiates. I'm just. Client experiences have shown that that can be true. So some people are going to be more susceptible to the anti anxiety effects of certain substances and some people are going to be prone to become dependent on substances where others may not. And that part of that is genetic vulnerability. And they estimate about 30% of the predictability of the development of anxiety disorders is genetic. And genetics also impact which medications are effective. If you have genetic makeup a, then SSRIs might be helpful. If you have genetic makeup B, then atypical antipsychotics may be more effective and SSRIs might not do anything, which is why a lot of our clients get so frustrated because there's no way to figure out exact. Well, I guess there is now that there's genetic testing out there. But up until then it was harder to figure out which medications to start with. And most physicians, matter of fact, I don't know of a single physician that actually starts out by saying, well, let's do a genetic profile to see what med to start you out with. Most will start out with a SSRI or some other anti anxiety medication, some sort of a benzo. That's been my experience. So we may want to encourage clients to consider genetic testing if they're having difficulty finding a medication regime that works for them and they are feeling like they have to have medication. Genetic vulnerability also affects what's going to make somebody more vulnerable. Now, of all of you in class today, you know, thinking about sleep, you know, sleep may not be a big deal for some of you. I know people who can go days or weeks with four or five hours of sleep and they feel fine. It's not a big deal. Not me. I need eight or nine hours of sleep. So genetically, for whatever reason, I am programmed to need a lot of sleep. So when I don't get that much sleep, I tend to be. It tends to be harder for me to deal with life on life, life's terms. And I know that that makes me more vulnerable to being irritable. So genetic vulnerability affects who can become addicted, affects what medications work best and affects what situations are going to tend to make somebody more vulnerable to anxiety. So our medications, and I know the type on here is small, but we're going to go through it. The first line Drugs are the SSRIs, selective serotonin reuptake inhibitors and the SS, NRIs, selective norepinephrine reuptake inhibitors. Now the names are a little bit deceptive because selective norepinephrine reuptake inhibitors also increase available serotonin, but the mechanism of action is different. The mechanism of action for each SSRI is a little bit different as well, which is why you can put somebody on Prozac, they have an awful experience, and you can put them on Zoloft, and they have a much better experience. Now, like I said earlier, a lot of the research pre 5 years ago had been done on medications, and Zoloft, Paxil, Luvox, Lexapro, Celexa and their generics have all been found to be effective at treating anxiety in certain people. No one medication works for everybody. In the last five years, Effexor has come on the radar, and it has been found effective according to the Hamilton Rating scale for anxiety. So that's another one to consider if clients are not successful or getting the treatment effect that they need on some of the other medications. Obviously, none of us probably are prescribers, but we do need to educate clients about why the first drug or even the third drug that the doc tries may not work, so they don't start feeling helpless and hopeless. Like I said earlier, there are at least four different genetic variations which are correlated with the development of generalized anxiety disorder. And different medications are more or less effective, depending on the genetic makeup of the person. There's a high mortality rate. Moving on to benzos, the recommendation has actually switched to really back off from the use of benzos. Now. Some doctors will prescribe an ssri, and for the first four weeks, while the SSRI is building up in the system, they will also prescribe a benzo to be taken as needed in order to moderate the anxiety. And, you know, you could argue either side of that. If somebody has a history of substance use or substance dependence, benzos are really a bad idea because they do have a high rate of dependence. But the other reasons that they are now cautioning against the use of benzodiazepines is that there's a higher mortality rate among benzo users compared with non users. There's an increased risk for dependence with use for more than six months. Now, that's a long time to be using benzos. And when we're talking about dependence and six months, we're talking about somebody who uses it like every four hours or every eight hours, depending on your benzo, every single day. Not a PRN user. If somebody's using it at night to help them go to sleep, or three or four times a week when the anxiety gets really high, the risk of dependence is relatively low. But a lot of people with anxiety, because if they find the right benzo, it makes them feel so much better, they may not want to be off of it. And for a lot of people, when that benzo reaches its half life and starts getting out of the system even more, their anxiety spikes. You know, they have rebound anxiety, which they want to medicate with more benzos, that's going to be an issue for them to discuss with their doctor. There's also an increased risk of dementia identified in long term benzodiazepine users. Again, this is for the people who use, you know, throughout the day, every day for six months or relatively every day for six months or more. And it doesn't matter if it's, you know, we're talking about somebody who's 65 or, or somebody who's 35 who's been using benzos for, you know, six months, a year, two years, the risk of later life dementia is greatly increased. According to the research. Benzodiazepines also don't treat depression. Okay, so if you've got somebody who has concurrent anxiety and depression, there's a much higher suicide risk if they're on benzodiazepines. So being aware and generally that suicide risk comes from overdosing on the benzodiazepines, but not always other treatment options. You know, if the benzos aren't something that people want to touch, you know, they, they scare the living daylights out of me. And SSRIs and SNRIs don't seem to be working, then tricyclic antidepressants can be tried. Those are your older generation antidepressants. Seroquel used a lot and there are some, there's some research that shows it can be really effective with anxiety, like some of the antidepressants and depending on the person, the benzos, Seroquel can make people very, very, very sleepy. So, you know, it may not. The side effects of the Seroquel, the weight gain and the fatigue and, you know, sleepiness may be unacceptable side effects for some clients. And buspirone is the third option. Buspirone works more like an antidepressant selective serotonin reuptake inhibitor in that it takes, you know, four weeks or so to kind of build up in the system. Studies have shown that there's really no long term benefit to taking it, but six months to 18 months of use, it has been shown to be effective in talking with clients. A lot of clients report that boost Barr when they take it. It doesn't necessarily help them stop being anxious like a benzodiazepine does, but it helps them not go from 0 to 200 in 2.3 seconds. It kind of keeps them from having this gush of a freak out reaction every time something goes wrong, which a lot of clients report helps because they feel more stable throughout the day. After remission, medication should be continued for six to 12 months. And during that last six months. First six months, keep it as is. Last six months. You know, they say that tapering is best. It's best not to stop somebody cold turkey on any of these. But it's definitely important for people once they're in remission to not just suddenly go, okay, I feel better. I don't need any of this anymore. They need to work into it and make sure they've developed the skills and tools that they need in order to deal with some of the anxiety that is going to happen in life. So physical signs and symptoms of anxiety may include fatigue, irritability, muscle tension or muscle aches, trembling, feeling twitchy, being easily startled, trouble sleeping, nausea, diarrhea, irritable bowel syndrome, headaches. So the first thing we want to do with clients when we're talking to them. Well, second thing, first thing is say, get a physical. Let's rule out physiological causes of this, but we can also help clients look at, you know, what might be causing these things that you can do to mitigate it. What might be contributing to your fatigue, what might be contributing to your irritability and your muscle tension or your muscle aches? I mean, let's look at ergonomics. Did you recently get a new bed or do you need to get a new bed? What about your desk chair? I know, you know, I get more muscle tension and muscle achy when I do a lot of mousing because I have deplorable posture. Becoming aware of that helps. And then I'm like, okay, well, I know what caused it. It's unfortunate, it's unpleasant, but it's not a big deal. Trembling or feeling twitchy, you know, that can be caused by low blood sugar, that can be caused by anxiety. That can also be caused by early onset Parkinson's symptoms. You know, there's, you know, can be worst case scenario or it can be something really benign. So we want to have people figure out, you know, when you start trembling or feeling twitchy, is there something that it's related to? You know, I know when my son gets really excited, he's. He just sits there and you can see him almost shake because he's so excited about something. So we want to have people prevent misidentification we don't want them to jump to that. Worst case scenario, we don't want them to go onto WebMD and go, oh my gosh, I've got cancer, I've got this debilitating disease and I'm going to die in six months. Probabilistically speaking, it's not going to happen. Yes, get a doctor's opinion. I'm certainly not going to tell them, it's all in your head. I definitely want them to get an evaluation, but I do want to in the meantime, help them really think about how likely is this and other things for headaches. And this is another one of those that can be frustrating. As we get older, our eyesight starts to go and you know, there was a period there I did fine. And then after I hit 45, my eyesight just started to like steadily and kind of rapidly in my mind decline. So I have to get my eyeglass prescription changed every couple of years and that can cause headaches. So instead of start starting to worry about, oh my gosh, I've got a headache all the time, maybe I've got a brain tumor. You know, I know that it's, it's probably my glasses or I'm grinding my teeth. So. Other biological interventions that have been evaluated. There's something called the flotation rest system, reduced environmental stimulation therapy. It reduces sensory input into the nervous system through the act of floating supine, which is on your back in a pool of water saturated with Epsom salt. You know, I'm looking at this going, that sounds really good. And you can't quite get the same experience in a bathtub because you're not floating, you've got pressure points and you're still hearing stuff. Clients can sort of simulate it with, you know, earplugs or whatever, but it's. If they can access this, it's been shown to be really effective. The float experience is calibrated so that sensory signals from visual, auditory, olfactory, gustatory, thermal, tactile, vestibular, gravitational and proprioceptive channels are minimized. That means you don't see, hear, taste, touch, smell, feel nothing, as is most movement and speech. So you want people to lay just like completely motionless and not talk, which can be hard for some people with anxiety. In the study, the study that I looked at, 50 participants reported significant reductions in stress, muscle tension, pain, depression and negative affect. And it was accompanied by significant improvement in mood, characterized by increases in relaxation, happiness and well being. I read the study, I'm like, where can I sign up? You Know, it sounds, in looking at some of the research, this was actually more effective for, for addressing anxiety than something like a massage. Tai Chi also produced significant reductions in anxiety. There was approximately a 20% treatment effect, 25% treatment effect in patients with anxiety and fibromyalgia who practiced twice a week for a year. Now, we want to look at the confounding things here. Is it the Tai Chi itself or is it learning to control the muscles and becoming more in tune with your body and learning to control your breathing that helps people reduce their anxiety? Either way, Tai Chi helps people do that. And it was shown that after a year, after the first six months, there was a significant treatment effect. But after a year it kept growing, and after a year it was about 25%. So Tai Chi can be really effective. Acupuncture at the HT7 meridian can attenuate anxiety like behavior induced by withdrawal from chronic morphine treatment through the meditation of the GABA A receptor system. What does that mean? That means if the acupuncture is done in very certain places, the anxiety behavior, the GABA A receptor system. GABA is your main calming relaxation, neurochemical that is triggered and it causes your body to sort of flood that receptor system. And this research was done on people who were detoxing from morphine treatment. But we can look at generalizing the results, and I would be interested to see further studies on it. Pain, other things we need to do to help people with anxiety. When people are in chronic pain, they often have anxiety that, oh my gosh, this is getting worse or it's never going to get better, or, or I just can't take this pain anymore, or they may get anxious that they're going to be rejected because they can't do some of the things they used to do because they're in so much pain. So there's a lot of guilt and anxiety that can kind of revolve around pain. What can we do to help clients? Guided imagery is generally very helpful. If we can help them imagine, you know, if they have pain in their shoulder, imagine the pain is like the color red and flowing out of their arm or other focused mindfulness. So, you know, when you think about something, you know, when I get a shot, if I don't think about it, it doesn't hurt near as much as if the nurse says, okay, now, 1, 2, 3. And, you know, she's counting down and I'm getting prepared and I'm really focused on it. I had another nurse one time who she was just talking to me and, you know, put the alcohol on my arm and just kept on talking. Didn't tell me she was getting ready to give me a shot. And before I knew it, she had given me a shot. And she was like, okay, we're done. I'm like, you didn't give me a shot yet. She said, yes, I did. I was like, oh, so not focusing on it. And next time you have an itch, for example, if you've ever been driving on the interstate and you get an itch on your. On your foot, I get those on the bottom of my foot sometimes. And I'm like, okay, I'm not going to pull over to itch my foot. Foot. If you focus on something besides the itch, eventually it goes away. I'm not saying pain is going to completely go away, but the more people focus on it, the more it hurts. Physical therapy can help, so encourage them to get a referral and encourage them to do a self evaluation, if nothing else, of ergonomics. In their car at work, where they watch TV and spend most of their time at home and they're sleeping. So those are the four places that they spend most of their time. What do their ergonomics look like? And that can help for a lot of people, mitigate a lot of pain. Hormones are another thing that we need to look at. Imbalances of estrogen and testosterone can contribute to anxiety symptoms, heart palpitations, fatigue, irritability. Having people get a physical, we can't, as clinicians, do anything about it, but doctors can. Rapid heart rate, sweating. Palpitations are not uncommon in women in perimenopause or menopause. So, you know, a lot of women start feeling like they're developing generalized anxiety and or something's going wrong when they start reaching that mid-40s to mid-50s area and they start having some of these symptoms. Again, we're not going to diagnose it, but we do want them to recognize that it may not be anything, you know, catastrophic. This is something that a lot of women experience and help them figure out how to deal with that supportive care. Biologically, now, you know, this isn't going to treat anything, but we can help them minimize their vulnerabilities, help them create a sleep routine so their brain and body can rebalance. This can help repair any adrenal issues that may be going on and improve energy level. People with anxiety don't sleep well, so helping them figure out how to get some quality sleep is important. Nutrition, minimizing caffeine and other stimulants is going to be a big help because those make people feel anxious. Encourage them to work with a nutritionist to try to prevent spikes and drops in blood sugar, which can trigger the stress response. When your blood sugar goes way up or way down, you can start getting kind of shaky and feel weird. And that can cause people anxiety because they might think, oh my gosh, I'm having a stroke or a heart attack or, you know, I don't know what these tremors are. So it's important that they don't misidentify symptoms and encourage them to drink enough water. Dehydration can lead to tachycardia, which is increased heart rate. Sunlight Vitamin D deficiency is implicated in both depression and anxiety mood issues. Vitamin D has been found in those main areas where serotonin receptors are found. Vitamin D receptors are found. So we know that serotonin and vitamin D have something going on. Sunlight prompts the skin to tell the brain to produce neurotransmitters and set circadian rhythms which impact the release of serotonin. Your calming neurochemical, melatonin, which is made from breaking down serotonin and it helps you sleep and gaba. So sunlight actually helps increase the release of gaba when it's time to start calming down and going to sleep. Exercise Studies have shown that exercise can have a relaxing effect. Encourage clients to start slowly. There's not a whole lot of new research on exercise and anxiety. Aromatherapy has been used a lot in, especially in other countries in the treatment of people with anxiety, people with hospital anxiety, people, women who are giving birth and they have some birth anxiety. They've been found to be really effective in a lot of those studies. Essential oils for anxiety include lavender rose, vetiver, Ylang ylang, bergamot, camomile, frankincense and Clary Sage. Encourage clients to just go to a health food store and, you know, sniff some of these, see if it makes them feel happy and calm and content. The aromatherapy molecules enter the nasal membranes and they will start triggering neurochemical reactions. And so you don't need to apply it, you don't need to ingest it. All you need to do is sniff it. So encourage clients, if they're open to it, to think about this. Because aromatherapy can be integrated into their bedroom, for example, with an atomizer or a Mr. It can be incorporated in a lot of different places. Again, where they're not applying it or ingesting it in any way. All they're doing is smelling it. They've used it in Diffusing aromatherapy in hospital emergency rooms. And they found that it reduces stress and irritability of the people in emergency rooms. And I've been to enough emergency rooms over the course of the years to know that people who are in ERs typically are not in the best mood. So if it can help those people, then it's probably going to have some sort of an effect. So psychologically helping clients realize that their body thinks there's a threat for some reason. That's why it triggered the threat response system, which is what they call anxiety. So they need to figure out why is there really a threat? You know, sometimes it's like the fire alarm going off in my house. It just means that the windows are open and there's a strong breeze. There is no fire, There is no problem. There's just a malfunction. It's a false alarm. A lot of times for clients, they get this threat reaction. They get the stress reaction, and it's not a big deal right now. So they can start modifying what their brain responds to. And again, those basic fears that a lot of people worry about. Failure, rejection, loss of control, the unknown, death and loss. Distress tolerance is one of those cognitive interventions that has taken center stage in the anxiety research. And it isn't about controlling your anxiety. Helping people recognize their anxiety, acknowledge it, and say, okay, I'm anxious. It is what it is. How can I improve the next moment? Instead of saying, I'm anxious, I shouldn't be anxious. I hate being anxious. I wrestling with that anxiety. Let it go. Just accept it is what it is. Have the client learn to start saying, I am feeling anxious. Okay, so distract, don't react. Because. And I explained to them the whole notion that feelings come in, crest, and go out in about 20 minutes. It's like a wave. So once they acknowledge their feeling, if they can distract themselves for 20 or 30 minutes, you know, obviously they figured out there's no real threat. If they can distract themselves for 20 or 30 minutes, those emotions can go down and then they can deal with it in their wise mind. Encourage them to use distancing techniques. Instead of saying, I am anxious or I am terrified or whatever, have them say, I am having the thought that this is the worst thing in the world. I am having the thought that I cannot handle this because thoughts come and go, and that comes from acceptance and commitment therapy. Functional analysis makes it possible to specify where, when, with what frequency, with what intensity, and under what circumstances the anxious response is triggered. So it's important that we help clients develop the ability to do functional analyses on their own. So when they start feeling anxious, they can stop and say, okay, where am I? What's going on? How intense is it? What are the circumstances? And they start really trying to figure out what causes this for them. So they can identify any common themes from there. Psychoeducation about cognitive distortions and techniques to prevent those circumstances or mitigate them can be provided. So if the client knows that they get anxious before they go into a meeting with their boss, and it's usually a high intensity of anxiety, okay, so we can educate them, help them identify what fears that may be related to techniques to slow their breathing and calm their stress reaction. Help them figure out times in the past when they've handled going in and talking to their boss. And it really wasn't the end of the world. You know, there's lots of different things we can do there for them there. But the first key, and it gives them a lot of a huge sense of empowerment to start becoming detectives in their own life and going, okay, now under what situations does this happen? Positive writing. This was another really cool study. Each day for 30 days, the experimental group, and this was high school age youth in China. But you know, the experimental group engaged in 20 minutes of writing about positive emotions they felt that day. So they're writing about anything positive that made them happy, that made them enthusiastic, that gave them hope, whatever long term expressive writing of positive emotions. So after 30 days, it appeared to help reduce test anxiety by helping them develop insight and use positive emotion words. So it got them out of the habit of using the destruction and doom words and encouraged them to get in the habit of looking at the positive things and being more optimistic. It's a really cool activity that clients can try. It's not going to hurt anything if you have them journal each day for 30 days. Mindfulness was also came up in the research and was shown to be really effective. In a meta analysis, six articles about mindfulness based stress reduction, four about mindfulness based cognitive therapy, and three about fear of negative appraisal and emotion regulation were reviewed. All of these showed that mindfulness was an effective strategy for the treatment of mood and anxiety disorders and and is effective in therapy protocols with different structures including virtual modalities. So, you know, if you're doing it via teleconference, mindfulness can still be helpful. Mindfulness helps people start learning how to observe what's going on and become aware of what's going on, more aware of those circumstances, which will help them complete their functional analysis. But it also helps them become aware of vulnerabilities and head off things at the pass. And if they're taking better care of themselves, if they're living more mindfully, then they may not experience as many situations that trigger their anxiety. Mindfulness also encourages clients to learn acceptance. That radical acceptance of it is what it is. I'm not going to fight it. I'm angry right now, I am anxious right now. However I'm feeling right now is how I feel, and that's okay. And it's hard for clients to get to that, but once they get ahold of that and they truly believe it and they can say, all right, it's fine, I'm not going to feel this way forever. I'm going to do something else. Until the feeling passes, it helps. And that's where the labeling and letting go comes in. Mindfulness can also help them identify trigger thoughts. What thought were you having right before you started feeling anxious? If people are mindful, or let's start back. When people are not mindful, they often notice or don't notice that they're getting anxious until they're like super, super anxious. When people are mindful, they become more aware of subtle cues. Address unhelpful thoughts when they say or believe. It's a dire necessity for adults to be loved by significant others for almost everything they do. Always. That ain't gonna happen. Why is it a necessity? What we can encourage them to do is concentrate on their own self respect, on winning approval for practical purposes, you know, for promotions or whatever. But it's not about me being lovable. It's about me getting a promotion and making more money and focusing on loving rather than being loved. Because when we give love, we generally get love back. Unhelpful thought number two. People feel they aren't able to stand it if things are not the way they want them to be or are not in their control. So encourage clients to focus on the parts that are in their control and other things in life which are going well and to which they're committed. Number three. Misery is invariably externally caused and is forced on us by outside people and events. Just reading that makes me feel disempowered. So encouraging clients to focus on the fact that reactions such as misery or happiness are largely caused by the view that people take of the conditions. So if you see it as a tragedy and devastating, then it's probably going to produce misery. If you see it as an opportunity and a challenge, it's probably going to produce a different emotional reaction. If something is or may be dangerous or fearsome. People should be terribly upset and endlessly obsessed about it. And a lot of people with anxiety get stuck on this. You know, if I feel like it's fearsome, I need to worry about it. Getting on a plane, for example, if I fear that that's dangerous, then I need to think about it and worry about it. That's not going to do any good. So encourage clients to figure out how to face it and render it harmless if possible. And when that's not possible, accept the inevitable. So, you know, looking at airplanes, you know, facing it means doing the research to figure out how dangerous is it really, and realizing that it's really not that dangerous. So that helps render it a little bit harmless in their own mind. It proves to them that it's not as dangerous as it could be. And when it's not possible, accepting the inevitable, you know, you gotta fly. So getting on there, figuring out how you're gonna get through it. Hurricanes are the same way. People, especially in places like Texas, Louisiana, Florida, may obsess as soon as it starts coming to hurricane season, or if a hurricane is spotted out in the Atlantic somewhere. They start checking the weather every hour or more, wondering what the path is going to be. And you know what? You can't change the path of the hurricane. So all you can do is board up your house, evacuate if necessary, deal with the fallout. Child driving is just another example I'll give. You know, my children are learning how to drive, and that's kind of scary and fearsome. You know, what's going to happen when they're out there. You know, you see crashes all the time. Well, render it harmless by making sure they've got good training on how to drive, make sure they're good drivers, and then accepting that some things are just not within my control. It's easier to avoid than face life difficulties and responsibilities. Well, running from fear is usually much harder in the long run. So encourage clients to look back at times that they've avoided difficulties and responsibilities and the eventual outcome. You know, what happened there. People believe they should be thoroughly competent in achieving in all possible respects, or they will be isolated, rejected, and failures. We need to encourage clients to accept themselves as imperfect with human limitations and flaws and focus on what makes them a lovable human being. What qualities like courage and intelligence and creativity and those things that can't be taken away? What inherent qualities do they have that make them awesome people? Because something once strongly affected people's lives, they should indefinitely fear it. If you got lost you know, when little kids get lost, it's terrifying. When you're grown up, if you get lost, you turn on the GPS and you figure out your way. But some people still, you know, freak out about getting lost if they got lost once. So we want to help people look back at past episodes that may be contributing to the current anxiety and compare the situations. You know, are you the same person or is this not a big deal? Now that you're older, wiser, stronger, encourage them to learn from past experiences, but not be overly attached to or prejudiced by them. Yeah, you could have. Maybe you got lost in the past and it was a horrible experience. Well, you were 6. I can see where that would be terrifying and a horrible experience. But it doesn't have to continue to impact you that way. Now when you're, you know, 26, getting lost, you know, could be an opportunity to try a new restaurant or something. People must have complete control over things. Well, this doesn't happen. So encourage clients to remember that the past and the future are largely uncontrollable. We can't change the past. It is what it is. We can learn from it so it doesn't repeat, but we can't change it. And the future is largely uncontrollable. I mean, there's a lot of things I can do to stay moving toward a rich and meaningful life, but life's going to throw me curveballs sometimes, and there's nothing I can do to plan for or control that. We can control our actions in the present to stay on our preferred path and general develop general skills to deal with adversity should it arise. So we want to help clients develop those general problem solving skills and the general support system so when they are thrown a curveball, you know, it doesn't knock them upside the head. People have virtually no control over their emotions and cannot help feeling disturbed by things. Well, encourage them to think about the fact that they have real control over destructive emotions. If they choose to work at improving the next moment and changing inaccurate thoughts, then they're not going to experience the destructive emotions as intensely or as frequently. When you feel an emotion, you feel how you feel. But again, you don't have to wrestle with it, fight it and nurture it. You can say, this is how I feel. How do I improve the next moment? When it comes to cognitive distortions, encourage them to find alternatives when they start to personalize things. If somebody laughs when you walk out of the room and the person starts getting anxious thinking, oh, they were making fun of me, I Wonder what they thought, I wonder if I had something, something stuck to the back of my dress, yada yada. And they start getting all panicked about it. That doesn't do any good. Encouraging them to think, you know, what are three alternate explanations that had nothing to do with you for why they laughed? Magnification of the worst thing. You know, taking something and saying, if this happens, then it's going to be a catastrophe, and minimization going along with that. A lot of times when people magnify and see a catastrophe, they minimize not only their own strengths and resources, but all the other stuff that they've got going for them. All they're seeing is this catastrophe. So encouraging them to focus on the facts, what is actually happening and what is the high probability event, and encourage them to get information and look at the broader picture. You know, yes, you got into a car crash and your car is totaled, and that is unfortunate. You know, it really sucks. But you know, that is not going to cause you to lose your job and then become homeless and penniless and yada yada, it might cause your insurance to go up. But okay, so you don't have a car, but what are the resources that you have? Who do you work with that might be able to give you a ride to work? You know, let's look at the resources you have and work around. So problem solving helps with magnification and also focusing on, you know, let's be grateful for what didn't happen. You know, you could have been killed, but you weren't. The car was totaled. It's replaceable. All or nothing. Thinking again, have them think about what else could have been happening. Like Brittany suggested, finding the exceptions. Instead of saying, she always does this, look for exceptions. When has she not done that? What else has she done? Instead of this selective abstraction and filtering. When people look for the good, the bad and the ugly, selective abstraction means you kind of see what you expect to see. So if you expect something to be devastating, you see only the devastating aspects of it, which kind of goes with the magnification and minimization. You filter out the stuff. A lot of times when people are in a bad mood or are anxious, they see the negative because that's the state of mind they're in. So encourage people to complete the picture. All right, there's all this bad stuff. Now what's the good stuff? You know, encourage them to look at the good, the bad and the ugly so they get a wide view of exactly what's going on. And encourage them to remember that hindsight is 20 20. When people have something embarrassing happen or they get anxious about something that happened, they look back and they go, I should have, or I could have, or oh, I wish I wouldn't have. When you were in that situation, you did what you did, and, you know, you may have had a reason for it, or, you know, you may have not had other options, or it may have just been a bonehead thing to do. But, okay, so you made one mistake. Hindsight's 20 20. That's gonna. That mistake is gonna stand out just like the great big letter on the eye chart, because you're thinking back and you're looking at it, and that's all you see. But encouraging clients to remember that other people are too busy worrying about themselves to really remember what you did. Jumping to conclusions. Encourage clients to remember to get all the data. If your significant other, male significant other, comes home and is smelling like perfume, don't just jump to the conclusion that he was cheating on you. Maybe he went to the. To the mall to get a new tie and walked through the perfume area and got spritzed or bought you some perfume. Or who knows, maybe the person sitting next to him at work sprayed her perfume at the desk and some of it filtered on. There's all different reasons that that might happen. So encourage people to get all the data. Mind reading. We can't do it. You know, you can't read somebody's mind. You don't know what they're thinking. So ask them if you what do you think about this? Don't assume anything. And emotional reasoning encourage people to step back from a situation and ask themselves, am I feeling anxious about this because I'm feeling anxious and I'm looking for reasons that it should be scary, or am I feeling anxious about this because it's really scary for some reason? There's actual facts to support my anxiety. A lot of times when we go into new situations, we may feel anxious because it's a new situation. But when we step back, we say, you know what? There's really nothing to be worried about here. You know, no big deal, I got this, and move on. So instead of rolling with it and trying to figure out, okay, I feel anxious, so there must be a reason, not necessarily very likely a false alarm. Other psychological interventions. Relaxation skills. Encourage people to learn how to relax, not only physically, but mentally. Diaphragmatic breathing is helpful. Encouraging them to breathe through their stomach, put their hand on their belly and feel their belly expand and contract slows breathing down, which triggers the rest and Digest reaction in the brain, which is calming. Meditation can be helpful for some people. Some people find trying to quiet their mind too frustrating because they've got too much monkey mind going on. That can be later or maybe never. For some people, we don't want to increase their anxiety with interventions. Cued progressive muscular relaxation also has a lot of research support. And remember, with cued progressive muscular relaxation, we're encouraging them to attach a cue, a cue word like relax or breathe with the relaxation response. So they tense their muscles and then they relax their muscles. And as they relax their muscles, they say their cue word like relax and they work from head to toe or from toe to head, tensing and relaxing different muscle groups so they become more aware of what a tense muscle feels like versus a react relaxed muscle. There are great scripts that are online that people have already recorded that can walk people walk clients through cpmr. I highly encourage it because once they get used to it, then they can just think that cue. They can think relax and as they exhale, they will start to feel their entire body kind of relaxing because it's trained when it hears that. Just like when you hear the word pop quiz when you were in high school, you had a stress reaction. Well, we want to use it in reverse and train the body so when it hears a cue word, it relaxes. Help them develop self esteem because fear of failure and rejection a lot of times come from needing other people's approval. Help them develop a rational idea of their real self. Develop compassionate self talk instead of saying I'm an idiot or I'm stupid or I'll never measure up to anything. Encourage them to talk to themselves like they would talk to their child or hopefully their best friend. And encourage them to spotlight strengths whenever they feel like they've got an imperfection. Identify three strengths that they have so they're, you know, balancing out the imperfections and the strengths. Cognitive restructuring. Reframe challenges in terms of current strengths, not past weaknesses. So if you're going to give a presentation in front of 60 people and you hate public speaking, instead of thinking about, you know, this is terrifying because, well, last time I went up in front of people, I forgot everything I was going to say and dropped my note cards. Well, that's a past weakness. What is your current strength? You're prepared, you know, your material, you yada yada. So encourage people to look at all the strengths and resources they currently have. Have them develop an attitude of gratitude and optimism because like I said with that the positive writing exercise, when people are In a grateful, optimistic frame of mind, they tend to see more of the good stuff. They see the bad stuff too, but they can also see more of the good stuff. And some of the bad stuff they see opportunistically instead of a devastation, acceptance and commitment. Therapy says that some of the reasons that we're miserable is fear. We get fused with our thoughts. We think, I am terrified. Well, if I am terrified, then I can't. I mean, if I am, I can't get rid of anything. I am. If I'm having the thought, then I'm terrified. Well, I can get rid of a thought. I can forget things easily. Encourage people to evaluate their experience and empower them to look at things as challenges and opportunities instead of hardships. Encourage them not to avoid their experiences. So things that are scary, gradual exposure and finding exceptions. Like for me, bridges, you know, I love public speaking, so that's not a thing. But when I go to a bridge, you know, when I drive to the bridge, you know, when I'm on the bridge, somebody else is driving. I get used to doing that when I drive over a bridge than when I drive over one of those bridges that opens up. I hate those bridges. I know y' all are just like, oh my gosh, yeah, it's an irrational fear. I realize that. But instead of going straight for the bridge that opens up, going for the little bridges first and then thinking back over times that I've gone over bridges and there's been no problem, you know, there's exceptions. Nothing happened. It wasn't a big deal. Sometimes I didn't even notice it until somebody pointed out, hey, look down there at that pretty water. And I'm like, oh, we're on a bridge. So encourage people to not avoid their experiences. Get used to them, embrace them, and learn that they have the power to deal with them and stop reason giving for behavior. Use the challenging questions. If something is fearsome, let's look for the at the evidence for and against it instead of, you know, making excuses. Social interventions improve their relationship with their self, which goes with self esteem improvement. People are going to feel less anxious about getting their needs and wants met if they know what their needs and wants are. So part of that is becoming mindful because a lot of our clients don't know what they need and want. They just, they want to feel better, but they don't know how. They don't know what they need to feel better. So helping them identify their needs and wants, encourage them to be their own best friend. You know, when they get A promotion, take themselves out to dinner, pat themselves on the back, whatever it is. Don't rely on other people to do it, because other people, it's not that they don't care, but other people are often very involved in thinking about their own stuff. They may not notice. Encourage them to develop a method of internal validation so they can feel like they are all that in a bag of chips. And they realize why they are lovable human beings, and they accept the fact that everybody is not going to like them and nobody is going to like them all the time, and that's okay. You know, my kids don't like me all the time. My husband doesn't like me all the time. I'm okay with that. I know I can be challenging, but, you know, most of the time, you know, they like me, and that's okay. And there are some people, you know, who don't like me at all, and, okay, there's nothing I can do about that. Helping our clients develop an okayness with that helps relieve a lot of anxiety because a lot of people feel like they have to be liked by everybody. And if somebody doesn't like them, it's like, what did I do wrong? Oh, my gosh. Encourage them to develop healthy, supportive relationships with good boundaries. Develop assertiveness skills so they can ask for help when they need it. Anxiety, a lot of times, you know, that's the body saying there's a threat. Well, if there's a threat, maybe you need some help, you know, dealing with it. So people need to be willing and able to ask for help and not feel. Feel like that's going to lead them to be rejected and allow them. Assertiveness will allow them to say no to requests again without feeling like that's going to result in them being fully rejected. Describe the ideal healthy, supportive relationship and encourage them to separate the ideals from the reals. You know, let's look at. If you had the best relationship, what would it look like? Okay, you know, Warden June Cleaver, we got that. Now, how realistic is that? You know, let's look at, you know, rephrasing this a little bit so it's less extreme. You know, Warden June Cleaver never fought. Their kids were perfect. You know, all those extreme words. Let's look at what's real, what happens in real relationships. Encourage people to identify who would be a good partner in supportive relationships. I'm not meaning necessarily romantic. I'm meaning friends and where they can be found. You know, where would you find people that you could be friends with and encourage them to play the what does it mean when game because a lot of times again, this goes with mind reading. You know. What does it mean when your friend doesn't return your text right away? What does it mean when your friend cancels dinner on Friday night? What does it mean when you see where I'm going with this? And a lot of times clients with anxiety and rejection issues and low self esteem will go to the worst case scenario. So encourage them going back to finding the exceptions. What else could have been happening? What else could it be that caused this? And it's not about you. So anxiety is a natural emotion that serves a survival function. Excessive anxiety can develop from lack of sleep, nutritional problems, neurochemical imbalances, failure to develop adequate coping skills, cognitive distortions, low self esteem, and a variety of other stuff. Recovery involves improving health behaviors, make sure your body's functioning and can make the neurotransmitters it needs and you know, release them as needed. Identify and build on current coping strategies, address cognitive distortions and develop a healthy, supportive relationship with self and others. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. You can attend and participate in our live webinars with Dr. Snipes by subscribing at allceus.com counselortoolbox this episode has been brought to you in part by allce.com providing 24.7 multimedia continuing education and pre certification training to counselors, therapists and nurses since 2006. Use coupon code counselortoolbox to get a 20% discount off your order this month.