Posted by: Dr. Jennifer Fee | October 29, 2010

Can Psychotherapy Help People with Social Anxiety Disorder?

Social Anxiety Disorder (S.A.D.) is painful, isolating, and destructive to people’s lives.  The person who made this video is obviously deeply familiar with what it’s like to suffer from S.A.D.:

How can psychotherapy help someone who is suffering in this intensely?  Here’s three ways therapy can help:

1.  Therapy helps address Fears, Worries and Negative Beliefs:  This person talked about being afraid of being judged and talked about behind his/her back.  If these are your thoughts, doesn’t it make sense that you would avoid people?  Who wants to be judged!  I don’t!  And, if you avoid social situations all or a lot of the time, there’s little to no opportunity to challenge those thoughts and belief systems….hence staying stuck in the problem.

Therapy can help challenge those thoughts a little bit at a time, by helping you to consider alternatives. However,  it’s not nearly as simple as “Don’t think that,” or “That’s not true,” or “Here, think this other, more positive thought.”

Instead, therapy can be a bit like putting some of your beliefs on trial in a courtroom.  There’s a “prosecuting attorney” presenting all of the evidence that your belief is not true.  Then there’s a “defense attorney” presenting all of the evidence  that the belief is true!  Interestingly the belief is often not found to be “true” or “untrue,” but rather that’s there often a morsel of truth mixed in with a whole lot of untruth.  The two sides reach a “settlement” or middle ground and come up with an “alternative” or more “balanced” belief.

2. Help with Taking Risks:  The person in the video mentioned that he/she tries to take risks, but that he/she “can’t handle the pressure.”  Risk taking is extremely important with all forms of anxiety, because the only way to conquer fears is to eventually face them.  However, going at that alone without help can be very overwhelming.  Many people who I’ve talked to who try to take risks on their own make some very key mistakes such as:  taking too large a risk, taking risks with “unsafe” people, and take risks before addressing their negative beliefs, so the results are evaluated through that grid.  All of these mistakes can make for a “no-win” situation.

So–a therapist can be somewhat like a coach, preparing you in every way possible to achieve success.  To explain, a therapist can help you plan out risks or “experiments,” in a safe, slow, and manageable manner.  Your therapist can help you identify your beliefs before you take a risk, and point out how you might be filtering the results of your risk through that grid. If a risk or an “experiment” doesn’t go well, a therapist can help you to figure out why, and what adjustments to make.

3.  Relationship with the Therapist:  Your relationship with your therapist is a key, important social “situation.”   Your therapist is going to be concerned about building a safe, trusting relationship with you.  When you have a good relationship with a therapist, then you can allow your fears to arise within the safety of that relationship, and you can take risks to address some of those fears.  I’ll give you an example:

Some of the people who I work with who have Social Anxiety Disorder are afraid of writing in front of other people.  Therefore, these clients always have their checks ready before coming into session so that they don’t have to write in front of me.  So–it’s a big deal when a person with this fear sits in front of me and writes out their check!  It might be a healing moment, or it might be a chance for us to process in the “here and now,” what it’s like to take that risk with me.

You can probably guess that therapy is a lot of hard work, and it certainly is.  However, the payoff can be tremendous.

Thanks for reading!  –Dr. Jennifer Fee

©2010. You may repost if you include the entire post with byline. This blog is for educational purposes a substitute for professional diagnosis and treatment.
Posted by: Dr. Jennifer Fee | October 27, 2010

Top 3 Ways to Vaporize the Scary “What if…….?” Thoughts

Let’s face it, “What if……” thoughts are nasty.  They can be scary, persistent, and at times, seemingly insurmountable.  Here’s a great video of Shel Silverstein narrating his famous “Whatif” poem:

Some of the What if’s….. in the poem are silly (“What if  my head starts getting smaller”), but some are lifted right out of our thoughts  (“What if no one likes me?”), and can zap up all of our energy, keep us awake at night, and lead to us avoiding people or situations where the “What if….?” might come true.  So what can you do if “What if….?” thoughts are haunting you?  Here’s 3 ideas to try:

1.  Consider that “What if…? thoughts are generally an overestimation of the danger present and an underestimation of your ability to cope even if they come true:   

In other words, we can tend to think that the consequence of our fears coming true is worse than it is, and we also think that our ability to handle difficult/bad things is not as good as it is!  Sally* constantly worried, “What if my car breaks down on the freeway?”   She believed that if her car broke down, she would not be able to cope.  A few months after telling me her fear, Sally go! a flat tire while driving on the freeway!  “It wasn’t nearly as bad as I imagined,” she reported, “I felt go flat and just pulled over to the shoulder. I called AAA with my cell phone and just waited for them.  They came, put on the spare, and I was on my way!  It was inconvenient, but I handled it just fine.”

Our ability to cope is generally much better than we imagine–even for the really tough, hard things that happen in life. 

 2. Talk Completely Through the Danger–be specific and consider the worst scenario

The most effective way to kill the “What ifs….?” is to actually have some of them happen and see that you handle the situation just fine.  But—wouldn’t if be better to handle some of those “What ifs……?” without having to have bad stuff happen?  Yes!  One way to kill or vaporize the “What if…..?” thoughts is to directly face them and respond to them.  This often requires you to think through more slowly and deliberately if your “what if’s…”” really happen.  Here’s an example:

Joe* wanted to go on more dates, but he had a lot of social anxiety.  He worried, “what if (insert name of woman here) rejects me?”  That’s a valid fear, it might happen!  But, this “what if” thought was helping Joe to avoid asking women out on dates.  Here’s an abbreviated version of one of our conversations:

Me: “OK,  let’s pretend Susie does turn you down.  What happens next?”  

Joe: “I don’t know–I guess I would be embarrassed.”

Me:  “OK, what would it be like to be embarrassed?  What would happen?”

Joe:  “I don’t know–it just wouldn’t be good.”  (Notice that Joe is vague here.  This is not helpful–it will keep him stuck in the “what if…  will be just by horrible” mode)

Me:  “I want you to think specifcially what it would look like to be embarrassed.  Does Susie point her finger at you, laugh, and run away from you?”

Joe:  “No (laughing).  She’s very sweet, and gentle.  If she turns me down, it will probably be in nice, polite way.  I would just feel bad, embarrassed.”

Me:  “And that’s the worst that would happen, you’d have an uncomfortable feeling? Would she treat you differently later?”

Joe:  “Yeah.  That would be it.  I’m sure she’d continue to be nice to me.

That’s an oversimplified version of our actual conversation–it can actually take much  longer to specifically flush out the bottom line.  For Joe it was that he feared embarrassment, but his conclusion was that while that would be a very uncomfortable feeling, it would not kill him.  He decided that the possibility of having a date with the woman he is interested in was worth the risk of having an uncomfortable feeling.

3.  Keep a Worry Log and see the actual outcome of your worries

A worry log is simply a record of your worries, your prediction of what will happen, and then the actual outcome.  I recently worked with a woman who had a lot of worries about what it would be like to have a newborn baby.  A few months after the baby was born she remarked, “I don’t even remember what I was worried about,”  but I did–and repeated a list of her worries back to her.  She laughed.  “Having a baby for the first time is not easy, but none of those things I was worried about came true! ”

I challenge you to keep a worry log for awhile.  It’s not that difficult, painful things don’t happen in our lives, they do!  However, what we worry about often does not happen.  And, what actually happens in life is not necesarily what we worry about!

Thanks for reading!  –Dr. Jennifer Fee

*””Sally” and “Joe” are made up names, and their situations are common to many, many clients with whom I have worked!

©2010. All rights reserved. This blog is for educational purposes and should not be considered a  substitute for professional diagnosis and treatment.
Posted by: Dr. Jennifer Fee | October 25, 2010

Good Scary vs. Bad Scary? It’s a Matter of Interpretation.

Pumpkin carved by Artist Anthony Lewis

My son will avoid bees but not the scene in The Sorcerer’s  Stone where Voldemort takes up residence in the back of one of Harry Potter’s teacher’s heads (which creeps me out a bit). My daughter loves the giant Ferris Wheel but won’t step outside of the house alone after dark (I’ll take the dark over the Ferris Wheel any time!).  The Harry

Scary Pumpkin Carved by Artist Anthony Lewis

Potter movie is a bit scary to my son as the Ferris Wheel is to my daughter, but they enjoy that kind of “scary.”   For them, some kinds of scary are “fun,” whereas other kinds are upsetting.

It’s the same with adults.  I’ve had numerous clients who love roller coasters but are afraid of the symptoms associated with anxiety –rapid heartbeat, shaky limbs, dizziness, etc.  When I ask them to describe what happens in their bodies when they ride a roller coaster, they tell me the same bodily sensations as anxiety:  “my heart beats faster as the roller coaster reaches the top of the first drop,” “my muscles tense up ,” and “I feel a little dizzy and woozy afterwards.”  However these same people who love rollercoasters will describe the identical physical sensations of panic attacks and high anxiety to be “horrible,” “terrifying,” and “intolerable.”

The difference?  One really important and critical difference is the interpretation of the body sensations.  If you love rollercoasters and ascribe the physical sensation associated with riding them as “fun,” the feelings won’t be intolerable.  Also, there’s an obvious cause to the symptoms, people who ride roller coasters do so on purpose, whereas a lot of panic attacks appear to come “out of the blue.”

Maybe the roller coaster example doesn’t work for you.  Do you like movies where there is some suspense and tension?  If so, think about (or pay attention) to what happens in your body the next time you’re watching a suspensful movie.  How is it similar to feeling anxious?  Why is not as upsetting/scary as being anxious? 

There are reasons other than interpretation of bodily symptoms that contribute to how we might describe a situation.  I’ll discuss those in future posts.  Meanwhile, pay attention to what happens in your body in various situations and the meaning you ascribe to those feelings.  Often similar feelings are given vastly different interpretations.

Thanks for reading!  –Dr. Jennifer Fee

Posted by: Dr. Jennifer Fee | October 24, 2010

Anxiety Devotional: Joy & Anxiety Together?

18 When I said, “My foot is slipping,”
       your love, O LORD, supported me. 

19 When anxiety was great within me,
your consolation brought joy to my soul. Psalm 94:19 NIV

In 1997 my husband Richard got a dangerous bacteria in his eye.  His extended wear contact lenses helped hold it in, so that by the time he exhibited some symptoms, the situation was serious.  When I took him to the emergency room and we were told there was a 50% chance he would lose all vision in his eye.

He spent two weeks in the hospital, and another three and a half months recovering, unable to work.  I was extremely anxious about a lot of things, but the most anxiety provoking thought that he would lose his eye forever.

As difficult as that four months was, like the Psalmist, I felt the love and consolation of the Lord.  At times, that consolation brought me a little bit of joy.  Like the check that came out of the blue to cover our rent while Richard was unemployed.  It reminded me that the Lord always provides what we need. 

I always connect with God by being out in nature–and there was no opportunity for that while Richard was sick.  I think that’s why I bought a little turtle, and named him “Flash.”  Flash kept me company during the 30 minute freeway commute to the hospital, cheered up Richard (I snuck him in), and he kept me in touch with the Creator. Finally, there were friends who diligently prayed for and asked about how Richard was doing. Their love supported us and reminded us that the Lord loves us and that we are in His care.

It was not an easy time.  I had a lot of anxiety about many different things.  However, there were many events and moments that brought “joy to my soul.”  You do not have to be lost in your anxiety, you can seek Him in the middle of it.  The Lord is unchanging and faithful. Look for the love and comfort that He provides.  It is possible to have joy and anxiety and the same time!

Thanks for reading!  –Dr. Jennifer Fee

Posted by: Dr. Jennifer Fee | October 23, 2010

Anti-Anxiety Method Bar None: The Here and Now

Do you remember that the definition of anxiety is the anticipation of danger that might happen in the future?  Since that’s the case, one of the most effective ways to combat anxiety is to stay in the present.

So do not worry about tomorrow, for tomorrow will bring worries of it’s own. Today’s trouble is enough for today.” (Matthew 6:34, RSV)

  How can you stay in the present?  Grounding yourself is one way to bring yourself back into the present moment.  Abdominal breathing can also help you focus on present awareness.   However, I think the verse above gives us another method for staying in the present, which is to focus only on “today’s trouble.”

The common advice for tackling an overwhelming task is to break it down into small, manageable steps.  The same advice applies to focussing only on “today’s trouble.”   Do you write down your schedule for the day?  If you don’t, that’s a great starting point.  A schedule is a helpful aide for staying on one task/issue/event at a time.

It’s normal for  thoughts or worries enter our minds about other things when we’re trying to focus on something.  The best way to stay here and now focussed is to talk back to those thoughts.  A statement like, “I’m not dealing with the problem yet, I need to finish this task,” is a good way to push the thought aside.  Notice that you are not dismissing the thought, problem or worry, you are merely postponing it until it’s time to deal with it.  The goal is to address one thing at a time–whatever is in the present moment.

Thanks for reading!  –Dr. Jennifer Fee

Posted by: Dr. Jennifer Fee | October 21, 2010

Don’t Dismiss the Value of Breathing!

 Lots of people dismiss the effectiveness of abdominal breathing for anxiety and say, “I tried that, it doesn’t really work.” The problem is that many of these people are not breathing properly–they are breathing from their chest (which is shallow breathing and can increase anxiety) rather than from their stomachs.  Proper breathing takes practice–sometimes weeks of practice before it is effective for lowering anxiety and stress levels.

The guidelines below were first written in 1995 by myself and my colleague, Dr. Diana Walcutt, who is now in Towson, Maryland.

4X4 Breathing

This is called the 4 by 4 breathing exercise because you should practice it for 4 minutes 4 times a day to learn to do it well.  If you are able, do this with your eyes closed, imagining a pleasant place.  This is calming and designed to help you manage stress.  There are two important things to learn about breathing:

 1.  Learn how to breathe from your diaphragm (from your tummy area) and make that pattern a part of your daily life.

2.  Become skilled at shifting to diaphragmatic breathing whenever you begin to feel stressed.

 Natural Breathing

 1.  Gently and slowly inhale a normal amount of air through your nose, filling only our lower lungs.    Place your hands on your tummy so that you can feel it rising and falling with each breath.   Count to 5 slowly as you do it.

 2.  Exhale slowly through your lips, counting to 5 as you do so.

 3.  Continue this slow, gentle breathing with a relaxed attitude, concentrating on filling only your  lower lungs.

 4.  As you breathe, slowly repeat the word “relax” or “calm” or some other word which means the same to you.

 If you have difficulty following the above instructions:

 1.  Lie down on a rug or your bed, with your legs relaxed and straight, a book on your tummy and  your hands by your side.

 2.  Let yourself breath normal easy breaths.  Notice what part of our upper body rises and fall with  each breath.  Rest a hand on that spot.  If that place is your chest, you are not taking full  advantage of your lungs. If the book is moving up and down, then, congratulations, you are doing it right!

 Deep Breathing

Deep breathing is an extension of this normal process. With one hand on your chest and one on your abdomen, take a slow, deep breath, filling your lower lungs, then your upper lungs.  When you exhale, let your upper lungs go first (causing your upper hand to drop), then your lower lungs (causing your lower hand to drop).

 Reminder: Too many deep breaths, instead of natural breaths in a row, will produce a sense of lightheadedness. This is not harmful; just return to natural breathing.

 Practice

Natural slow breathing and the deep slow breathing several times each day. Practice natural breathing for a period of at least 4 minutes, 4 times a day.  The object is to train yourself to breathe from your diaphragm most of the time.

You can purchase an audio copy of this breathing exercise (10 minute track) for $4.95 USD by contacting me. 

Thanks for reading!      —Dr. Jennifer Fee

Posted by: Dr. Jennifer Fee | October 20, 2010

High Anxiety: Too Much or Too Little Going On?

What goes on around us in our external environment can trigger anxiety, especially the extremes of having too much going on or not enough. 

Too Much Stimulation:  (aka “overstimulation”):  This occurs when there’s too much going on for us to handle.  The level of overstimulation that can trigger anxiety is going to vary greatly from person to person, so it’s good to think about how much stimulation that you can handle.  Picture this scene:  You are at a large amusement park (such as Disney Land, Lego Land, Magic Mountain).  It’s a hot day and you are sweating.  There’s a large school on a field trip with over two hundred 8 year olds who are running and screaming with joy.  You have been standing in line for a ride and there’s a family with a crying toddler behind you, a bunch of the school trip children are in front of you playing a game where they try to hit each other.  You are tired and hungry.  Are you anxious?

For some the answer is yes.  For others, the answer may be no, but a different setting where there is a lot of noise, a crowd, or certain types of lighting might be overstimulating.  What type of setting triggers your anxiety?

Too Little Stimulation:  (aka “understimulation”) Did you know that boredom can trigger anxiety?  Some people get anxious standing in line, sitting at a doctor’s office, or being stuck in traffic.   Why?  Because there is time and space to think/worry about other things, or focus on bodily sensations that can trigger anxiety.  When people are busy (but not too busy), there’s sometimes less “room” for anxiety to occur in this way.

Do you have anxiety at work?  Maybe you have a job where you have too much or too little stimulation. 

So What to Do? One approach that’s gaining popularity is the “mindfulness” approach where one pays attention to the feelings in their mind and body and accept them as part of the present experience.  I talked about grounding as part of bringing oneself back into the “here and now” and away from anxiety.  That can be very effective, especially if combined with some relaxation such as abdominal breathing or Progressive Muscle Relaxation (PMR) –I’ll write about these later.

Another approach is too keep occupied –a relational way of doing this would be to talk to people in your environment (such as someone in line or at the DMV).  It does not have to be superficial, idle chatter, it’s possible to have meaningful conversations with complete strangers!  I once commented about a little Christmas tree that a woman was buying in the grocery store.  The woman then told me that she was buying the plant for her very ill brother, who she was very worried about.  She seemed to really appreciate having someone to talk to, even if it was just for a few minutes while standing in line.

If you’re more introverted, you might prefer to read while you are waiting.  If you’re in an overstimulating situation, you might want to remove yourself, even for just a few minutes.  Simply excusing yourself to go to the restroom or step outside might help you to enable yourself to calm down.

In summary, the first step is to become aware of what situations are either “too much” or “too little” for you.  Then you can think more specifically about how to better cope with those situations.

Thanks for reading!  –Dr. Jennifer Fee

Posted by: Dr. Jennifer Fee | October 14, 2010

5 Easy Ways to Ground Yourself While Anxious

When we are anxious, we are not focussed on the present moment, we are anticipating danger (See Close Cousins: Anxiety, Fear & Worry) .  One really helpful way to lower your anxiety when it starts to rise (See 3 Critical Reasons for Rating Your Anxiety) is by “grounding” yourself or bringing yourself back into the present moment.   The 5 “easy” ways to ground yourself are simply to use your five senses:

1. Sight:  Use your eyes and name what you see in your environment.  I have a big window in my office and some clients look out the window and name everything they can see:  mountains, a church steeple, birds, etc.  You can also name things around you by going in alphabetical order (“A” is for apple computer, “B” is for bench, etc.).

2. Sounds:  Same idea as sight, but name all the sounds that you hear –people talking (try to focus on what they are saying), train noise, airplane noise, a radio.  Again the point is to bring yourself back to the environment and have your thoughts/body sensations be less powerful.

3. Smell:  Smell is a great sense to use for grounding because you do not have to simply observe what’s in your environment, you can create it!  You can make some tea, use some hand lotion, or light a candle.

4. Taste:  Another sense that you can control.  Breath mints, hard candy,  and gum are all things that you can carry in your pocket or purse and use to bring yourself back into the present moment.  Focus as intensely as you can on what you are tasting–sweet?  sour? salty? etc.

5.  Touch:  I’ve had lots of clients who pet their cats and dogs to lower their anxiety.  However, there’s all kinds of things you can touch to bring yourself into the present–even if it’s just a smooth countertop!  Whatever you are touching pay close attention to how it feels–is it smooth, rough, soft, hard, fuzzy, etc?  The point is to focus on the texture and sensation and remind yourself where you are.

Grounding can take practice and patience in order to be helpful, but for many it is an essential tool for making the sensation of anxiety less intense.

Thanks for reading!  –Dr. Jennifer Fee

Posted by: Dr. Jennifer Fee | October 10, 2010

A Day of Rest. Do You Take One?

It’s Sunday.  I am looking forward to going to church, watching my son play baseball, and watching both baseball and football on TV.  There’s no work in my schedule (In case you are wondering, I am writing this post on Saturday night)!  I do everything I can to make Sunday a day of rest.

The focus of my day will be on family, friends and God.  All major religions have a Sabbath and the commonality that they all share is that the purpose is to get you to stop what you normally do and focus on something else! 

Some of that focus is physical rest and some of that focus is mental rest.  Obviously some of it is for spiritual reasons–to take dedicated time to focus on one’s relationship with God, which can be difficult to do if one does not rest physically and mentally!

Stress is cumulative.  In other words, the more stress you experience in a given year, the more likely you are to experience a stress-related illness.  Therefore, it is essential that we develop a lifestyle designed to alleviate the effects of stress.  Taking a regular, weekly day of rest is one of the best ways to combat the effects of our stressful lives. 

In addition to resting, a sabbath can help us build healthy relationships.  When we are busy with work and “tasks” we have little time for relationship.  Healthy, supportive relationships with people and with God help tremendously to combat the effects of stress.

So, what are you doing today? 

–Dr. Jennifer Fee

Posted by: Dr. Jennifer Fee | October 9, 2010

3 Critical Reasons for Rating Your Anxiety

Quick (meaning don’t think too hard)–right now on a scale from 0 to 10 where a “0” is completely relaxed and a “10” is a full-blown panic attack, how anxious are you right now?

So whatever your rating is, what do you think it was an hour ago? Lower?  Higher? The same?  Are you wondering why I’m asking?  Well, I’m asking for 3 really important reasons:

1.  So You Can Catch it Early!  If you are going to learn how to control your anxiety, you need to develop a keen awareness as to when it starts to escalate.  Granted, sometimes anxiety escalates at break-neck speed, but the more sensitive you become to your changing level of anxiety, the better you’ll be able to “catch it” before it becomes a panic attack. 

The higher our emotions (any emotion, not just anxiety), the more difficult it is to think.  You are going to be able to calm yourself down from a “6” much more easily than from an “8” or “9.”  And if your anxiety reaches a “10”?  A ten for most people is the “point of no return,” meaning that it is a panic attack.  If you reach this point, just remember that panic attacks don’t last forever, they last 10-15 minutes.  You can try again to calm yourself once the panic attack is over. 

2. So You Can Find  Your Trigger!  Once you become more aware of the changing experience of anxiety in your body and mind, you can start to look for the things that trigger it.  I’ve written about triggers extensively before (and will do so again here), but for now keep in mind that there’s innumerable things that trigger anxiety and some of them are very subtle.  Subtle triggers might range from merely being too hot, hungry, or tired all the way to thoughts, images, and memories that are floating in our mind just outside of our awareness.  Sometimes triggers are linked together–meaning a body sensation might lead to a memory which leads to a thought that raises anxiety.

It may sound complicated, but with a little detective work most people can pinpoint most of the triggers that are leading to their rising anxiety.  But first things first, you cannot look for triggers unless you are aware that you are anxious.  This is why rating your anxiety is so important!

3. So You Can Do Something!  OK, so if you know your anxiety is rising and what might be triggering it, it’s time to untrap yourself from that trigger!!   Anytime your anxiety reaches a “5” it’s time to do something–you want to bring it down below a “5.”  Even if you can only bring it down to a “3” or a “4” that’s an awesome start, it’s movement in the right direction!

So what can you do?  What normally calms you down?  Or, what would “untrap” you from the trigger?  If you’re too hot, take off your jacket.  If you are hungry, eat.  If you are agitated while standing in line at the grocery store, talk to the person behind you or read the magazine covers.  Other things such as abdominal breathing, prayer, visualization, and self-talk are all effective for lowering anxiety—and I’ll write about all of these things later.

So now that you’re done reading, what’s your anxiety rating now?  Is it higher (sometimes thinking about anxiety can raise it)?  Is it lower (maybe you have hope that you can take control of your anxiety)?  Or is it the same?

Thanks for reading!  –Dr. Jennifer Fee

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