Your Anxiety Toolkit - Anxiety & OCD Strategies for Everyday

Kimberley Quinlan, LMFT

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ADHD vs. Anxiety (with Dr. Ryan Sultan) | Ep. 381
4d ago
ADHD vs. Anxiety (with Dr. Ryan Sultan) | Ep. 381
Navigating the intricate landscape of mental health can often feel like deciphering a complex puzzle, especially when differentiating between conditions ADHD vs.anxiety. This challenge is further compounded by the similarities in symptoms and the potential for misdiagnosis. However, understanding the nuances and interconnections between these conditions can empower individuals to seek appropriate treatment and improve their quality of life. ADHD, or Attention Deficit Hyperactivity Disorder, is a neurodevelopmental condition characterized by symptoms of inattention, hyperactivity, and impulsivity. While commonly diagnosed in childhood, ADHD persists into adulthood for many individuals, affecting various aspects of their daily lives, from academic performance to personal relationships. On the other hand, anxiety disorders encompass a range of conditions marked by excessive fear, worry, and physical symptoms such as heart palpitations and dizziness. The intersection of ADHD and anxiety is a topic of significant interest within the mental health community. Individuals with ADHD often experience anxiety, partly due to the challenges and frustrations stemming from ADHD symptoms. Similarly, the constant struggle with focus and organization can exacerbate feelings of anxiety, creating a cyclical relationship between the two conditions. A critical aspect of differentiating ADHD from anxiety involves examining the onset and progression of symptoms. ADHD is present from an early age, with symptoms often becoming noticeable during childhood. In contrast, anxiety can develop at any point in life, triggered by stressors or traumatic events. Therefore, a thorough evaluation of an individual's history is vital in distinguishing between the two. Moreover, the manifestation of symptoms can offer clues. For example, while both ADHD and anxiety can lead to concentration difficulties, the underlying reasons differ. In ADHD, the inability to focus is often due to intrinsic attention regulation issues. In anxiety, however, the concentration problems may arise from excessive worry or fear that consumes cognitive resources. Understanding the unique and overlapping aspects of ADHD and anxiety is crucial for effective treatment. For ADHD, interventions typically include medication, such as stimulants, alongside behavioral strategies to enhance executive functioning skills. Anxiety disorders, meanwhile, may be treated with a combination of psychotherapy, such as cognitive-behavioral therapy (CBT), and, in some cases, medication to manage symptoms. The integration of treatment modalities is paramount, particularly for individuals experiencing both ADHD and anxiety. Addressing the ADHD symptoms can often alleviate anxiety by improving self-esteem and coping mechanisms. Similarly, managing anxiety can reduce the overall stress load, making ADHD symptoms more manageable. In conclusion, ADHD and anxiety represent two distinct yet interrelated conditions within the spectrum of mental health. The complexity of their relationship underscores the importance of personalized, comprehensive treatment plans. By fostering a deeper understanding of these conditions, individuals can navigate the path to wellness with greater clarity and confidence. This journey, though challenging, is a testament to the resilience and strength inherent in the human spirit, as we seek to understand and overcome the obstacles that lie within our minds. TRANSCRIPT Kimberley: Welcome, everybody. We are talking about ADHD vs anxiety, how to tell the difference, kind of get you in the know of what is what.  Today, we have Dr. Ryan Sultan. He is an Assistant Professor of Clinical Psychiatry at Columbia University. He knows all the things about ADHD and cannabis use, does a lot of research in this area, and I want to get the tea on all things ADHD and anxiety so that we can work it out. So many of you listening have either been misdiagnosed or totally feel like they don’t really understand the difference. And so, let’s talk about it. Welcome, Dr. Sultan. ADHD vs. ANXIETY  Ryan: Thank you. I really like doing these things. I think it’s fun. I think psychiatrists, which is what I am, I think one of the ways that we really fail, and medical doctors in general don’t do well at this, which is like, let’s spend some time educating the public. And before my current position, I did epidemiology and public health. And so, I learned a lot about that, and I was like, “You know how you can help people? We have a crisis here. Let’s just teach people things about how to find resources and what they can do on their own.” And so, I really enjoy these opportunities.  WHAT IS ADHD vs. WHAT IS ANXIETY?   I was thinking about your question, and I was thinking how we might want to talk about this idea of ADHD versus anxiety, which is a common thing. People come in, and they see me very commonly wanting an evaluation, and they think they have ADHD. And I understand why they think they have ADHD, but their main thing is basically reporting a concentration or focus issue, which is a not specific symptom. Just like if I’m moody today, that doesn’t mean I have a mood disorder. If I’m anxious today, it doesn’t mean I have an anxiety disorder. I might even feel depressed today; it doesn’t mean I have a depression disorder. I could even have a psychotic symptom in your voice, and it does not mean that I have a psychotic disorder. It’s more complicated than that.   I think one of the things that the DSM that we love here in the United States—but it’s the best thing we have; it’s like capitalism and democracy; it’s like the best things that we have; we don’t have better solutions yet—is that it describes these things in a way that uses plain language to try to standardize it. But it’s confusing to the general public and I think it’s also confusing to clinicians when you’re trying to learn some of these conditions.  WHEN IS ADHD vs. ANXIETY DIAGNOSED?  And certainly, one of the things that have happened in my field that people used to talk a lot about is the idea that, is pediatric, meaning kid diagnosis of ADHD, which often in my area here in the United States will be done by pediatrician, are they adequately able to do that? Because poor pediatricians have to know a lot. And ADHD, psychiatric disorders are complicated. Mental health conditions are super complicated. They’re so complicated that there are seven different types of degree programs that end up helping you with them. PsyD, PhD, MD, clinical social worker, mental health counselor, and then there’s nurse practitioner. So, like super complicated counseling. So, how do we think about this?  The first thing I try to remind everyone is, if you’re not sure what’s going on with you, please filter your self-diagnosis. You can think about it, that’s great. Write your notes down, da-da-da, but I would avoid acting purely on that. You really want to do your best to get some help from the outside. And I know that mental health treatment is not accessible to everyone. This is an enormous problem that existed before the pandemic and still exists now. I say that because I say that all the time, and I wish I had a solution for you. But if you have access to someone that you think can help you tease this throughout, you want to do that.  SYMPTOMS OF ADHD vs. ANXIETY  But what I would like us to do, instead of listing criteria, which you can all Google on WebMD, let’s think about them in a larger context. So, mental health symptoms fall into these very broad categories. And so, some of them are anxiety, which OCD used to be under, but it’s now in its own area. Another one, would be mood. You can have moods that are really high, moods that are really low. Another one you could take ADHD, you could lump it in neurodevelopmental, which would mix it with autism and learning disorders. You could lump it with attention, but the problem with that is it would also get lumped with dementia, which are processes that overlap, but they’re occurring at different ends of the spectrum.   So, let’s think about ADHD and why someone might have ADHD or why you might think someone has ADHD, because this should be easier for people to tease out, I think. ADHD is not a condition that appears in adulthood. That’s like hands down. Adult ADHD is people that had ADHD and still have ADHD as adults. And most people with ADHD will go on to still have at least an attenuated version, meaning their symptoms are a little less severe, maybe, but over 60% will still meet criteria. It’s not a disorder of children. Up until the ‘90s, we thought it was a disorder of kids only. So, you turned 18, and magically, you couldn’t have ADHD anymore, which didn’t make any sense anyway.   So, to really get a good ADHD diagnosis, you got to go backwards. If you’re not currently an eight-year-old, you have to think a little bit about or talk to your family, or look at your school records. And ideally, that’s what you want to do, is you want to see, is there evidence that you have, things that look like ADHD then? So, you were having trouble maintaining your attention for periods of time. Your attention was scattered in different ways. Things that are mentally challenging that require you to force yourself to do it, that particularly if you don’t like them, this was really hard for you. You were disorganized. People thought that things went in one year and out the other.   Now this exists on a spectrum. And depending on the difficulty of your scholastic experience and how far you pushed yourself in school, these symptoms could show up at different times. For example, it’s not uncommon for people to show up in college or in graduate school. Less so now, but historically, people were getting diagnosed as late as that, because now they have to write a dissertation. For those of you guys who don’t know, a dissertation is being asked to write a book, okay? You’re being asked to write a book. And what did you do? You went to college. Okay, you went to college, and then you had some master’s classes, and then you get assigned an advisor, and you just get told to figure out what your project is. It is completely unstructured. It is completely self-sufficient. It is absurd. I’m talking about a real academic classic PhD. That is going to bring it. If somebody has ADHD, that’s going to bring it out because of the executive functioning involved in that, the organization, the planning. I got to make an outline, I got to meet with my mentor regularly, I got to check in with them, I got to revise it, I got to plan a study or a literature review. There’s so many steps involved. So, that would be something that some people doesn’t come up with then.   Other kids, as an eight-year-old boy that I’m treating right now, who has a wonderful family that is super supportive, and they have created this beautiful environment for him that accommodates him so much that he has not needed any medication despite the fact that there’s lots of evidence that he is struggling and now starting to feel bad about himself, and he has self-esteem issues because he just doesn’t understand why he has to try so hard and why he can’t maintain his attention in this scenario, which is challenging for him.   So, ADHD kids and adults, you want to think of them as their brains as being three to five years behind everyone else in their development, okay? And they are catching up, but they’re more immature, and they’re immature in certain ways. And so, this kid’s ability to maintain his attention, manage his own behaviors, stay organized, it’s like mom is sitting with this kid doing his homework with him continuously, and if she stops at all, he can’t hold it together on his own. So, when we think about that with him, like, okay, well, that’s maybe when it’s showing up with him. That’s when it’s starting to have a struggle with him.   But let’s relate it to anxiety. One problem would be, do you have ADHD or do you have anxiety? Well, there’s another problem. Another problem is having ADHD is a major risk factor for developing an anxiety disorder, okay? So now I’m the eight-year-old boy, and this eight-year-old boy does not have the financial resources to get this evaluation, or the parents that are knowledgeable enough to know that, it might even have been years ago where there was less knowledge about this. And he’s just struggling all the time, and he feels bad about himself, and he’s constantly getting into trouble because he is losing things because he can’t keep track of things because he’s overwhelmed. And now he feels bad about himself. Okay. He has anxiety associated with that. So now we’re building this anxiety. So he might even get mood symptoms, and now we have a risk for depression.   So, this is just one of the reasons why these things are like these tangled messes. You ever like have a bunch of cords that you have one of the dealies, you keep throwing them in a box, and now you’re like, “What do I do? Do I just throw the cords out or entangle them?” It’s a very tangled mess. Of course, it takes time to sort through it. The reason I started with ADHD is that it has a clear trajectory of it when it happens. And in general, it’s a general rule, symptomatology, meaning like how severe it is and the number of symptoms you have and how impairing it is. They’re going to be decreasing as you get older. At least until main adulthood, there’s new evidence that shows there might be a higher risk for dementia in that population.   But let’s put geriatric aside. There’s a different developmental trajectory. Whereas anxiety, oh God, I wish I could simplify anxiety that much. Anxiety can happen in different ways. So, let’s start with the easy thing. Why would you confuse them in this current moment? If I am always worried about things, if I’m always ruminating about things, I’m thinking about it over and over again, I’m trying to figure out where I should live or what I should do about this, and I just keep thinking about it over and over again, and I’m in like a cycle. Like, pop-pa-pa pop-pa pop-pa-pa-pa. And then you’re asking me to do other things. I promise you, I will have difficulty concentrating. I promise you, I can’t concentrate because it’s like you’re using your computer and how many windows do you have open? How many things are you running? I mean, it doesn’t happen as much anymore, but I think most of us, I meant to remember times where you’re like, “Oh, my computer is not able to handle this anymore.” You’re using up some of your mind, and you can call that being present.   So, when people talk about mindfulness and improving attention, one of the things that they’re probably improving is this: they’re trying to get the person to stop running that 15, 20% program all the time. And it’s like your brain got upgraded because you can now devote yourself to the task in front of you. And the anxiety is not slowing you down or intruding upon you, either as an intrusive thought in an OCD way or just a sort of intrusive worry that’s probably hampering your ability to do something concentration-intensive. And then if you have anxiety problems and you’re not sleeping right, well, now your memory is impaired because of that. So, there’s this cycle that ends up happening over and over again.  IS HYPERACTIVITY ANXIETY OR ADHD? Kimberley: Yeah, I think a lot of people as well that I’ve talked to clients and listeners, also with anxiety, there’s this general physiological irritability. Like a little jitteriness, can’t sit in their chair, which I think is another maybe way that misdiagnosis can -- it’s like, “Oh, they’re hyperactive. They’re struggling to sit in their chair. That might be what’s going on for them.” Is that similar to what you’re saying?  Ryan: Yeah. So, really good example, and this one we can do a little simpler. I mean, the statement I’m going to say is not 100% true, but it’s mostly true. If you are an adult, like over 25 for sure, and you are physically jittery, it is very unlikely that that is ADHD. Because ADHD, the whole mechanism as we understand it, or one of the mechanisms causing the thing we call ADHD, which of course is like a made-up thing that we’re using to classify it, is that your prefrontal cortex is not done developing. So, it needs to get myelinated, which is essentially like -- think about it like upgrading from dial up to some great, not even a cable modem. You’re going right to Verizon Fios. Like amazing, okay. It’s much faster, and it’s growing. And that’s the part of you that makes you most human. That’s the most sophisticated part of your brain. It’s not the part that helps you breathe or some sort of physiological thing, which, by the way, is causing some of those anxiety symptoms. They’re ramped up in a sympathetic nervous system way, fight or fight way. It’s the part that’s actually slowing you down. That’s like, “Whoa, whoa, whoa, whoa, whoa, calm down, calm down, calm down.” This is why, and everyone’s is not as developed. So, we’re all developing this thing through 25, at least ADHD is through 28.   Car insurance goes down to 25 because your driving gets better, because your judgment gets better, because you can plan better, because you are less risk-taking. So, your insurance has now gone down. So, the insurance company knows this about us. And our FMRI scans, you scan people’s brains, it supports that change. These correlate to some extent with symptomology, not enough to be a diagnosis to answer the person’s question that they’re going to have that. I wish it was. It’s not a diagnosis. We haven’t been able to figure out how to do that yet.   So, by the time you’re 25, that’s developed. And the symptoms that go away first with ADHD are usually hyperactivity, because that’s the inability to manage all the impulses of your body, not in an anxious, stressed-out way, but in an excited way. You think of the happy, well-supported, running around ADHD kid is kind of silly and fun. It’s a totally different mood experience than the anxiety experience. Anxiety experience is unpleasant for the most part. Unless your anxiety is targeting you to hyper-focus to get something done, which is bumping up some of your dopamine, which is again the opposite experience of probably having ADHD, it’s a hyper-focus experience, certainly, the deficit part of ADHD, you’re going to be feeling a different physiological, the irritability you talked about 100%. You’re irritable because you are trying so hard to manage this awful feeling you have in your body. You physically feel so uncomfortable. It is intolerable.   I have this poor, anxious young man that has to do a very socially awkward thing today. Actually, not that socially awkward. He created the situation, which is one of the ways we’re working on it with him in treatment. And I’m letting him go through and do this as an exposure because it’ll be fine. And he’s literally interacting with another one of our staff members. But he finds these things intolerable. He talks about it like we are lighting him on fire. So, he’s trying to hold it together, or whatever your physiological experience is. It may not have been as dramatic as I described. You’re irritable when people are asking things of you because you don’t have much left. You’re not in some carefree mood where you’re like, “Whatever, I’m super easygoing. I don’t care.” No, you’re not feeling easygoing right now. You’re very, very stressed out.   Stress and anxiety are very linked. Just like sadness and depression are very linked, and like loneliness and depression are linked, but they’re not the same thing. Stress and anxiety are very, very linked, and they’re similar feelings, and they’re often occurring at the same time and interacting with each other. ADD vs. ADHD  Kimberley: Right. One question really quick. Just to be clear, what about ADD vs. ADHD?  Ryan: We love to change diagnostic criteria. People sit around. There’s a committee, there’s a whole bunch of studies. And we’re always trying to epidemiologically and characterologically differentiate what these different conditions are. That’s what the field is trying to do as an academic whole. And so, there’s disagreements about what should be where. So, the OCD thing moving is one of them.   The ADD thing, it’s like a nomenclature thing. So, the diagnosis got described that the new current version of the diagnosis is attention deficit hyperactivity disorder, and then you have three specifiers, okay? So, that’s the condition you have. And then you can have combined, which is hyperactive and inattentive. Just inattentive, just hyperactive. And impulsive is built in there. So, it’s really not that interesting. People love to be like, “No, no, I have ADD. No, I don’t have the hyperactive.” And I’m like, “I know, but from a billing point of view, the insurance company will not accept that code anymore. It doesn’t exist.” DOES ADHD OR ANXIETY IMPACT CONCENTRATION?  Kimberley: Yeah. So, just so that I know I have this right, and you can please correct me, is if you have this more neurological, like you said, condition of ADHD, you’ll have that first, and then you’ll get maybe some anxiety and some depression as a result of that condition. Whereas for those folks, if their primary was anxiety, it wouldn’t be so much that anxiety would cause the ADHD. It would be more the symptoms of concentration are a symptom of the anxiety. Is that what you’re saying? Ryan: Yes, and every permutation that you can imagine based on what you just said is also an option. Like almost every permutation. Like how are they interacting with each other? How are they making each other worse? How are they confusing each other? Because you can have anxiety disorders in elementary school. I mean, that is when most anxiety disorders, the first win, like the wave of them going up is then. And you think about all the anxiety you have.   I got a friend of mine who’s got infants. And it’s fun to see like as they’re developing, when they go through normal anxiety, that that is a thing that they’re going to pass. And then there’s other things where, at some point, we’re like, actually, now we’re saying this is developmentally inappropriate, which means, nope, we were supposed to have graduated from this and it’s still around.   And so, one of the earlier ways that psychiatric conditions were conceptualized, and it’s still a useful way to conceptualize them, is the normal behavior version of it versus the non-normal behavior version of it. And again, I hate non-normal, I don’t want to pathologize people, but non-normal being like, this is causing problems for you. And if you think about it from an evolutionary point of view, all of these conditions have pretty clear evolutionary bases of how they would be beneficial. Anxiety is going to save your ass, okay? Properly applied anxiety, it’ll save your tribe. You want someone who’s anxious, who’s going to be like, “We do not have enough from this winter.” An ADHD person was like, “It’ll be fine. I’m just going to go find something else.” And you’re like, “No.” And then when that winter’s really bad and you save that little bit of extra food, that 30% that the anxious person pushed for, maybe you didn’t eat all 30% of it, but you know what, it probably benefited you and it might’ve actually made the whole tribe survive or more people survive or better health condition. So, it’s approving everyone’s outcomes.   The ADHD individual, you get them excited about something—gone. They’re going to destroy it. They’re going to find all the berries. They’re going to find all the new places. They’re going to find all the new deer. They’re going to run around and explore. It’s great. Great, great, great.   Depression is like hibernation. And if you look at hibernation in a mammal, like what happens, there’s a lot of overlaps. Lower energy, maybe you store up some food for the winter. It’s related to the seasons. You’re in California, right? This is not a problem you have, but for those of us in New York, where we have seasonality, seasonal depression is a thing. It’s very much a thing. It’s very noticeable, and it’s packed on top of these conditions everyone else is having.  But the idea is that the hibernation or the pullback is like something happens to you that upsets you, which is the psychosocial event that’s kicking you in the face that might set off your depression. That’s why people always say, “Oh, depressions just don’t come out of nowhere. This biochemical thing isn’t true.” What they’re saying is something has to happen to start to kick off the depression, but that’s not enough. It’s that you then can’t recover from it.   And so, a normal version of it is that you get knocked out and you spend a week or two, you think about it. Rumination is a part of depression for many people. You reevaluate, and you say, “You know, I got kicked in the face when I did that. That was not a good plan for me. I need a new plan. I either need to do something different or I need to tackle that problem differently.” And so, that would be the adaptive version of a depressive experience. Whereas the non-adaptive version is like, you get stuck in that and you can’t get out.  Kimberley: Or you avoid.  Ryan: The avoiding doing anything about it, and then that makes it worse. So, you started withdrawing. I mean, that’s the worst thing you can do. This is a message to everyone out there. The worst thing that you can do is withdraw from society for any period of time. Look, I’m not saying you can’t have a mental health day, but systematic withdrawal, which most of us don’t even realize is happening, is going to make you worse because the best treatment for every mental health condition is community. It is really. All of them. All of them, including schizophrenia.   I used to work in Atlanta. I did my residency. There’d be these poor guys that have a psychotic disorder. They hear voices. The kinds of people that, here in New York City, are homeless, they’re not homeless there. Everyone just knows that Johnny’s just a little weird and his mom lives down the street. And if we find Johnny just in the trash can or doing something strange, or just roving, we know he’s fine, and someone just takes him back to his mom’s house and checks on him. Because there’s a community that takes care of him, even though he’s actually quite ill from our point of view. But when you put him in an environment where that community is not as strong, like a city, it does worse, which is why mental health conditions are much higher rates in urban areas. Probably why psychiatry and mental health in general is such a central thing in New York City. TREATMENT FOR ADHD vs. ANXIETY  Kimberley: Yeah. Okay, let’s talk quickly about treatment for ADHD. We’re here always talking about the treatment for anxiety, but what would the research and what’s evidence-based for ADHD if someone were to get that clinical diagnosis?  Ryan: So, you want to think about ADHD as a thing that we’re going to try to frame for that person as much as how is it an asset, because it historically has made people feel bad about themselves. And so, there are positive aspects to it, like the hyper focus and excitability, and interest in things. And so, trying to channel into that and then thinking about what their deficits are. So, they’re functional deficits. If you’re talking adult population, functional deficits are going to be usually around executive functioning and organization planning. Imagine if you’re like a parent of small children and you have untreated ADHD, you’re going to be in crazy fight-or-flight mode all the time because there’s so many things to keep track of. You have to keep track of your wife and their life. Kimberley: I see these moms. My heart goes out to them. Ryan: And they’re probably anxious. And the anxiety is probably protecting them a little bit. Because what is the anxiety doing? You think about things over and over and over again, and you double check them. You know what that’s not a bad idea for? Someone who’s not detail-oriented, who’s an ADHD person, who forgets things, and he gets disorganized. So, there’s this thing where you’re like, “Okay, there may actually be a balance going on. Can we make the balance a little bit better?” So, how do you organize yourself?  MEDICATIONS FOR ADHD Right now, there’s a stimulant shortage. Stimulants are the most effective medication for reducing ADHD symptoms. They are the most effective biological intervention we have to reduce the impact of probably any psychiatric condition, period. They are incredibly effective, like 80, 90% resolution of symptoms, which is great. I mean, that’s great. That’s great news. But you also want to be integrating some lifestyle changes and skills alongside of that. So, how do you organize yourself better? I mean, that’s like a whole talk, but like lists, prioritizing lists, taking tasks, breaking them down into smaller and smaller pieces. Where do you start? What’s the first step? Chipping away. You know what? If you only go one mile a day for 30 days, you go 30 miles. That’s still really far. I know you would have gone 30 miles that day, especially if you have ADHD, but you’re still getting somewhere.  And so, that kind of prioritization is really, really important. And so, you can create that on your own. There are CBT-based resources and things to try to help with that. There are ADHD coaches that try to help with that. It’s consistency and commitment around that. So, how do you structure your life for yourself? That poor PhD candidate really needs to structure their life because there is no structure to their life.  The other things we want to think about with that, I mean, really good sleep, physical exercise. People with ADHD, we see on FMRI scans when you scan someone’s brain, there’s less density of dopamine receptors, less dopamine activity. You want to get that dopamine up. That’s what the medications are doing, is predominantly raising the dopamine. So, physical activity, aerobic exercise, in particular, is going to do that. Get that in every day, and look, it’s good for you. It’s good for you. There is no better treatment for every condition in the world other than exercise, particularly aerobic. It basically is good for everything. If you just had surgery, we still want you to get out and walk around. Really quickly, that actually improves your outcome as fast as possible. So, those are the things I like people to start with if they can do that, depending on the severity of what’s going on, the impact, what other things have already been tried. Stimulant medications or non-stimulant medications like Wellbutrin, Strattera, Clonidine are also pretty effective. Methylphenidate products, which is what Ritalin is. Adderall products mixed in amphetamine salts, Vyvanse, these are very effective medications for it. There’s a massive shortage of these medications that people are constantly talking about, and is really problematic and does not appear to have an endpoint because the DEA doesn’t seem ready to raise the amount that they allow to be made because they are still recovering from the opioid crisis, which is ongoing. And so, they’re worried about that. Really, they want to be very thoughtful about this. These medications have a very low-risk potential for misuse. In fact, people with ADHD, they appear to reduce the risk of developing a substance use disorder. It’s the most common thing that people worry about. So, treatment actually reduces that.  That said, the worst -- I mean, I don’t want to say the worst thing. I mean, people hate me. The really not great way to get psychiatric treatment is to show up to someone once and then intermittently meet with them where they write a prescription for a medication for you that’s supposed to help you, and stimulant medications are included on that. So, that’s probably why I didn’t lead with that, even though there’s actually more science to support them, is that by themselves, it’s really going to limit how much help you’re going to get. Kimberley: Can you share why? Ryan: Because you need to understand your condition, because you need to spend time with your clinician learning about your condition and understanding how it’s affecting your life, and understanding how the medication is actually meant to be a tool. It should be like wearing glasses. It doesn’t do the work for you. It doesn’t solve all your problems, but it’s easier to read when you put your glasses on than without it. It supports you. You still need to figure out how to get these things done. It lowers the activation energy associated with it. But you also want to monitor it. You can’t take these medications 24 hours a day and just be ready to go and work, which is things that people have tried. It doesn’t work because you need to sleep, because you will die. They’ve tried this. We know that you will literally die, like not sleeping. And in the interim, you are damaging yourself significantly. So, taking it and timing it in an appropriate way, still getting sufficient sleep, prioritizing other things—they are like a piece of a puzzle, and they are a really powerful piece. But you really don’t want that to be the only thing driving your decision-making, or that be what the interaction is really about. And by the way, the same thing is true for all psychiatric medications. Kimberley: I was going to say that’s what we know about
Is Faith Helping Or Hindering Your Recovery (With Justin K Hughes) | Ep. 380
Apr 5 2024
Is Faith Helping Or Hindering Your Recovery (With Justin K Hughes) | Ep. 380
Exploring the relationship between faith and recovery, especially when it comes to managing Obsessive-Compulsive Disorder (OCD), reveals a complex but fascinating landscape. It's like looking at two sides of the same coin, where faith can either be a source of immense support or a challenging factor in one’s healing journey. On one hand, faith can act like a sturdy anchor or a comforting presence, offering hope and a sense of purpose that's invaluable for many people working through OCD. This aspect of faith is not just about religious practices; it's deeply personal, providing a framework that can help individuals make sense of their struggles and find a pathway towards recovery. The sense of community and belonging that often comes with faith can also play a crucial role in supporting someone through their healing process. However, it's not always straightforward. Faith can get tangled up with the symptoms of OCD, leading to situations where religious beliefs and practices become intertwined with the compulsions and obsessions that characterize the disorder. This is where faith can start to feel like a double-edged sword, especially in cases of scrupulosity, where religious or moral obligations become sources of intense anxiety and compulsion. The conversation around integrating faith into recovery is a delicate one. It emphasizes the need for a personalized approach, recognizing the unique ways in which faith intersects with an individual's experience of OCD. This might involve collaborating with religious leaders, incorporating spiritual practices into therapy, or navigating the complex ways in which faith influences both the symptoms of OCD and the recovery process. Moreover, this discussion sheds light on a broader conversation about the intersection of psychology and spirituality. It acknowledges the historical tensions between these areas, while also pointing towards a growing interest in understanding how they can complement each other in the context of mental health treatment. In essence, the relationship between faith and recovery from OCD highlights the importance of a compassionate and holistic approach. It's about finding ways to respect and integrate an individual's spiritual beliefs into their treatment, ensuring that the journey towards healing is as supportive and effective as possible. This balance is key to harnessing the positive aspects of faith, while also navigating its challenges with care and understanding. Justin K. Hughes, MA, LPC, owner of Dallas Counseling, PLLC, is a clinician and writer, passionate about helping those impacted by OCD and Anxiety Disorders. He serves on the IOCDF's OCD & Faith Task Force and is the Dallas Ambassador for OCD Texas. Working with a diversity of clients, he also is dual-trained in psychology and theology, regularly helping anyone to understand the interaction between faith and mental health. A sought-after writer and speaker, he is currently mid-way through writing his first workbook on evidence-based care of OCD for Christians. He is seeking a collaborative agent who will help secure the best publishing house to help those most in need. Check out www.justinkhughes.com to stay in the loop and get free guides & handouts! Kimberley: Welcome, everybody. Today, we’re talking about faith and its place in recovery. Does faith help your recovery? Does it hinder your recovery? And all the things in between.  Today, we have Justin Hughes. Justin is the owner of Dallas Counseling and is a clinician and writer. He’s passionate about helping those who are impacted by OCD. He is the Dallas ambassador for OCD Texas and serves on the IOCDF’s OCD and Faith Task Force, working with a diversity of clients. He’s also dual-trained in psychology and theology, regularly helping anyone to understand the interaction between faith and OCD, most commonly Christians. But today, we’re here to talk about faith in general. Welcome, Justin. Justin: Kimberley Jayne Quinlan, howdy. Kimberley: You said howdy just perfectly from your Texas state.  Justin: Absolutely. Kimberley: Okay. This is a huge topic. And just for those who are listening, we tried to record this once before, we were just saying, but we had tech issues. And I’m so glad we did because I have thought about this so much since, and I feel like evolved a little since then too.  So, we’re here to talk about how to use faith in recovery and/or is it helpful for some people, and talk about the way that it is helpful and for some not. Can you share a little bit about your background on why this is an important topic for you? Justin: Absolutely. So, first of all, as a man of faith, I’m a Christian. I went to a Christian college, got my degree in Psychology, and very much desired to interweave studies between psychology and theology. So, I went to a seminary. A lot of people hear that, and they’re like, “Did you become a priest?” No, it was a counseling program at a seminary, Dallas Theological Seminary. I came here and then found my wife, and I stayed in Dallas.  And it’s been important to me from a personal faith standpoint. And I love the faith integration in treatment and exploring that with clients. And of course -- or maybe I shouldn’t say of course, but it’s going to be a lot of Christians, but I work with a lot of different faith backgrounds. And there are some really important conversations happening in the broader world of treatment about faith integration and its place. And we’re going to get into all those things and hopefully some of the history and psychology’s relationship to faith, which has not been the greatest at different points. For me personally, faith isn’t just an exercise. It’s not something that I just add on to make my day better. In fact, a lot of times, faith requires me to do way more difficult things than I want to do, but it’s a belief in the ultimate object of my faith in God and Christ as a Christian. I naturally come across a lot of people who not only identify that as important but find it as very essential to their treatment. And let’s get into that, the folks that find it essential, the people who find it very much not, and the people who don’t. But that’s just a little bit about me and why I find this so important. Kimberley: Yeah. It’s interesting because I was raised Episcopalian. I don’t really practice a lot of that anymore for no reason except, I don’t know, if I’m going to be really honest.  Justin: So honest. I love that.  Kimberley: Yeah, I’ve been thinking about it a lot because I had a positive experience. Sometimes I long for it, but for reasons I don’t know. Again, I’m just still on that journey, figuring that piece out and exploring that.  Where I see clients is usually on the end of their coming to me as a client, saying, “I’m a believer, but it’s all gotten messed up and mushed up and intertwined.” And I’m my job. I think of my job as helping them untangle it. Justin: Yeah. Kimberley: Not by me giving my own personal opinion either, but just letting them untangle it. How might you see that? Are you seeing that also? And what is the process of that untangling, if we were to use that word? Justin: It’s so broad and varied. So, I would imagine that just like with clients that I work with and folks that come to conferences and that I talk with, the listeners in your audience, hi listeners, are going to have a broad experience of views, and it’s so functional. So, I want people to hear right away that I don’t think that there’s just a cookie-cutter approach. There can’t be with this. And whether we’re treating OCD, anxiety disorders, or depression, or eating disorders, or BFRVs, fill in the blank, there are obviously evidence-based treatments which are effective for most, but even those can’t be a cookie cutter when it comes down to exactly what a person needs to do or what is required of them in recovery.  So, yes, let me just state this upfront for the folks that might be unduly nervous at this point. First of all, the faith piece, religious piece, does not have to enter into treatments for a lot of people to get the job done. In fact, actually, for a lot of people, it was much more healing for them, including many of my clients. I have friends and family members that sometimes look at me as scant. So like, “Wait, you went to seminary, and sometimes you don’t talk about God at all.” And it’s like, “Yeah, sometimes we’re just doing evidence-based treatment, and that is that.” And as an evidence-based practitioner, that’s important to me.  So, when people come in, I want to work with what their goals are, their values. And a lot of people have found themselves, for any number of reasons, stuck, maybe compulsions or obsessive thoughts or whatever, are stuck in all things belief, religion, or faith or whatever else. And sometimes actually, the most healing thing for them to do is sometimes get in, get out, do the job clinically, walk away, experience freedom, and then grow and develop personally.  But then I’ve also discovered that there’s this other side that some people do not find a breakthrough. Some people stay stuck. And maybe these are the people that hit the stats that we see in research of 20% or so just turn down things like ERP, (exposure and response prevention) with OCD when they’re offered. And then another 20 to 30% drop out. And we have great studies that tell us that most people who stick with it get a lot of benefits, but there’s all the other folks that didn’t. And sometimes it’s because people -- no offense, you all, but sometimes people just don’t want to put in the work and discipline.  However, we can’t minimize it to that. Sometimes it’s truly people that are willing to show up, and there’s a complex layer of things. And the cookie-cutter approach is not going to work for them. Maybe they have the intersection of complex health issues, intersection of trauma, intersection of even just family of origin things where life is really difficult, or even just right now, a loneliness epidemic that’s happening in the world.  And by the way, I’m a huge believer in the evidence base. There’s a lot in the evidence base that guides us. And as I’m talking today, I want to be really clear that when I work with folks, even when we get into the spiritual, I’m working with the evidence base. Yeah, there’s things that there’s no specific protocol for, but a lot of folks, I think, can hopefully be encouraged that there’s a strong research base to the benefits and the use and the application and also the care of practicing various spiritual practices through treatments.  So, to come back to the original question, it depends so much. It’s like if somebody asked me a question like, “Hey, Justin. Okay, so as a therapist, do you think that --” and I get these questions all the time, “Is it okay for me to...? Like, I am afraid of this.” I got this question at one point. Somebody was curious if I thought it was okay for them to travel to another city. And it’s like, it depends. It’s almost always an “it depends.”  So, that’s where I’m going to leave it, that nice, squeaky place that we all just want a dang answer, but the reality is, it is going to massively depend on the person and where they are, and what their needs are. Kimberley: Yeah, I mean, and I’ll speak to it too, sometimes I’ve seen a client. Let’s give a few examples of a client with OCD. The OCD has attacked their faith and made it very superstitious or very fear-based instead of faith-based. And I think they come in with that, “Everything’s so messy and it used to make so much sense, and now it doesn’t.”  For eating disorders, I’ve had a lot of clients who will have a faith component where there are certain religions that have ways in which you prepare foods and things, and then that has become very sticky and hard for them. The eating disorder gets involved with that as well.  And let me think more just from a general standpoint, and I’ll use me as an example, as just like a generally anxious person. I remember this really wonderful time, I’ll tell you a funny story, when my daughter was like five, out of nowhere, she insisted that we go to every church. Like she wanted to go to a Christian and a Catholic and Jewish temple and Muslim and Buddhist. She wanted to try all of them, and we were like, “Great, let’s go and do it.” And I could see how my anxious brain would go black and white on everything they said. So, if they said something really beautiful, my brain would get very perfectionistic about that and have a little tantrum. I think it would be like, “But I can’t do it that perfect,” and I would get freaked out, but also be able to catch myself. So, I think that it’s important to recognize how the disorder can get mixed up in that. Justin: Yeah, absolutely. Kimberley: Right? Let’s now flip, unless you have something you want to add, to how has faith helped people in their recovery, and what does that look like for you as a clinician, for the client, for their journey? Justin: Yeah, absolutely. Well, on the clinical side of things, the starting place is always going to be the assessments and diagnosis and treatment plan. And then the ethics of it too is going to be working with the person where they are and their beliefs and not forcing anything, of course. And so folks are naturally -- I get it, I respect it. I would be nervous of somebody of a different belief background that’s overt about things. Some people come in, they look at the wall, they see Dallas Theological Seminary, they’ve studied a few things in advance. So, yeah, the starting places, sitting down, honest, building rapport, trust, assessing, diagnosing. So, for the folks where the faith piece is significant, I’ll put it into two categories. So, one is sometimes we have to talk about aspects of faith just from a pure assessment sample. So, a common example of that is scrupulosity in OCD. So, I have worked with even a person on the, believe it or not, Faith and OCD Task Force who is atheist. And so, why in the world do we need to talk about faith? Why is that person even on the Faith and OCD Task Force? Well, they’re representing a diversity of views and opinions on the role of faith and OCD.  Kimberley: Love it. Justin: And it’s so interesting to look at it at a base level with something like OCD. But frankly, a lot of mental disorders or even just challenges in life, if clinicians, one, aren’t asking questions about, hey, do you have any religious views, background, even just in your background? Do you have spiritual practices that are important to you? We’re missing a massive component. And here’s the research piece. We know from the research that, actually, a majority of people find things of faith or spirituality important, and secondarily, that a majority of people would like to be able to talk about those things in therapy. Straight-up research. So, a couple of articles that I wrote for the IOCDF on this reference this research. So, it is evidence-based to talk about this.  And then when we get into these sticky areas of obsessions and anxiety disorders, of course, it’s going to poke on philosophy, worldview, spirituality. And so, it could be even outside of scrupulosity, beliefs that at first it just looks like we need some good shame reduction exercises, self-compassion, and so forth, but we discover that, oh, the person struggling with contamination OCD has a lot of deeper beliefs that they think that somehow, they are flawed because they’re struggling. They’re not a good enough, fill in the blank, Christian. They’re not good enough. Because if so, surely God would break through in a bigger way. If so... Wouldn’t these promises that I’m told in scriptures actually become true?  And the cool thing is, there’s a richness in the theology that helps us understand the nuance there, and it’s not that simple. But if we miss that component, and it’s essential for treatment, it’s not just like, “Oh, I feel bad about myself. And yeah, sometimes I’m critical with myself.” And if we don’t go at that level of core fear, or core distress, or core belief, oftentimes we’re missing really a central part of the treatment, which we talk about in any other domain. People just get nervous sometimes, thinking about spirituality. It’s like politics and religion, right? Nobody talks about those things. Well, if we’re having deeper conversations, we usually are. And as clinicians, those of you that are listening to the podcast as clinicians, you know that you have to work with people of different political leanings, people of different faith leanings, people who actually live in California versus [inaudible]. I love California.  So, the first category is, if we’re doing good clinical work, we’re going to be asking questions because it matters to most people. If we don’t, we’re missing a huge piece. It doesn’t mean you’re a bad therapist, but hey, start asking some questions if you’re not, at a minimum.  But then there’s the second piece that most people actually want to know, and most people have some aspects of practice or integration, or even the most religion church-averse type of person will have any number of things come up such as, “Yeah, I pray occasionally,” or “Yeah, I do this grounding exercise that puts me in touch with the universe or creation or whatever it is.”  So, there’s the second category of when it is important to a person because it’s part of the bigger picture of growth, it’s part of the bigger picture of breaking free from challenges that they have, and, frankly, finding meaning. And I’ll just make one philosophical comment here, because I’m a total nerd. Psychology can never be a worldview. Psychology tells us what. Psychology is a subset of science. And by worldview, I mean a collective set of beliefs, guidance, direction about how life should be lived. We can only say, “Hey, when you do this, you tend to feel this way, or you tend to do these behaviors more or do these behaviors less.” At the end of the day, we have to make interpretations and judgments about right and wrong, how to live life, the best way to live life. These are in the realm of interpretation.  So, surprise, surprise, we’re in the realm of at least philosophy, but we very quickly get into theology. And so back to the piece that most people care about it, most people have some sort of spiritual practice that they’ll resonate with and connect with. And then most people actually want to integrate a little bit into therapy. And then some people find that it is essential. They haven’t been able to find any lasting freedom outside of going deeper into a bigger purpose, `bigger meaning. Kimberley: You said a couple of things that really rang true for me because I really want to highlight here, I’m on the walk here as well as a client. And I love having these conversations with clients, not about me, about them, but them when they don’t have a spiritual practice, longing for one. I’ve had countless clients say, “I just wish I believed.” And I think what sometimes they’re looking for is a motivator. I have some clients who have a deep faith, and their North Star is that religion. Their North Star is following the word of that religion or the outcome of it, whether it be to go to heaven or whatever, afterlife or whatever. They believe like that’s the North Star. That’s what determines every part of their treatment. Like, “Why are we doing this exposure today?” “Because this is my North Star. I know where I’m heading. I know what the goal is.” And then I have those clients who are like, “I need a North Star. I don’t have one. I don’t get the point.” And I think that is where faith is so beautiful in recovery.  When I witness my clients who are going to do the scary thing, they don’t want to do it, but they’re so committed to this North Star, whatever it might be. And maybe there’s a better language than a North Star, again, whatever that is for that person. Like, “I’m walking towards the light of whatever that religion is.” I feel, if I’m going to be honest, envious of that. And I totally get that some people do too.  What would you say to a client who is longing for something like that? Maybe they have spiritual trauma in some respects or they’ve had bad experiences, or they’re just unsure. What would you say to them? Justin: Yeah, that’s really great. And first of all, I just want to really say that it takes a lot of vulnerability and strength to talk as you do. And one of the ways that I admire you, KQ, is through your ability to have these vulnerable conversations. So not just like the platform of expert, because at the end of the day, we’re all just people and on a journey for sure. And so thanks for being honest with that.  And I’m on a journey as well. And certainly, I realized jumping on podcasts, these things put us in the expert role and we speak at conferences and things like that. But I think that’s a bit of the answer right there, is that being where we are to start with is so huge. And I mean, you’re so good with the steps to take around acceptance and compassion. That’s it. It’s like fear presses towards a thousand different possibilities, and none of them come true exactly that way. And it can lead towards people missing a lot of personal growth stuff, spiritual growth stuff. And one of those things, I think, that we do is we sit with that. Clinically, I’m going to assess, ask a lot of questions, Socratic questions as a subset of the cognitive therapy side of doing that. Let me just come back to the simplicity. I think we get there. We sit in it for a second. And otherwise, we miss it. We’re rushing to preconceived solutions or answers, but we’re saying that we don’t necessarily have an answer for that. So, what if we take some time to actually notice it and to be with that and to actually label it and be like, “I’m not sure. I’m yearning. I’m envious. I’m wanting something, but I don’t know. So, put me in, coach.” I’ll sit with people. That’s really the first thing.  Kimberley: Yeah. What I have practiced, and I’ve encouraged clients is also being curious, like trying things out if that lines up with their values, going to a service, reading a book, listening to a podcast, and just trying it on. For me, it’s also interesting with clients, is if they’re yearning for it, try it on and observe what shows up. Is it that black-and-white thinking or perfectionism? Is it your obsessions getting involved? Is it that it just doesn’t feel good in your body? And so forth. Again, just be where you are and take it slow, I think.  I have a few other areas I want you to look at in terms of giving me your professional thoughts. If somebody wants to incorporate faith into their treatment, what can that look like? Can it look like praying together? What does that look like? Justin: You’re asking all the good questions. Yeah, absolutely. And also, one other thing to reference, I know you’re friends with Shala Nicely and Jeff Bell. And so they wrote a book. And for those that are on that, I would say, more “I’m seeking journey,” it’s When in Doubt, Make Belief: An OCD-Inspired Approach to Living with Uncertainty. And I love Shala and Jeff. They’re so great, and they’ve been really pivotal people in my own life, not just as friends, but just as personal growth too. And so, that’s an example specifically where Shala talks about the throes of her suffering. Is Fred in the Refrigerator? is her basically autobiography that goes into the clinical piece too, where at the end of the day, there was a bit of a pragmatic experience that she couldn’t -- the universe being against her, she basically always had that view and she needed something that was different. And so she got there, I think. I hope I’m reflecting her sentence as well, but got there pragmatically. “The universe is friendly” is something that she said.  Now, I just know that my Christian brothers and sisters, if they’re listening to this, they’re probably like, “What the heck is Justin talking about? The universe is friendly?” Because that’s very, very different from the language that we’ve used, but it’s just such a great example to me of just one step at a time, a person on the journey. They’re looking at those things and assessing, okay, what is obsessive, what is compulsive, what is this thing that I can believe in and I ultimately do, but maybe I’m not. I don’t want to or I’m not ready, or it doesn’t make sense to me to make a jump into an organized religious plea for whatever else. And so, how does it look for clients?  So in short, do I pray with clients? Yeah, absolutely. Do I open up the Bible? Yes, absolutely. Actually, it is a minority of sessions, which again, on my more conservative friends and family side of things are almost shocked and scratching their heads. Like, “You’re a Christian, you do counseling, and you’re not doing that.” We’re a bunch of weirdos. We’re in that realm of the inter-Christian circle in a good sense. We believe so deeply that God loves us and God has interceded and does intercede, and interacts with our present, not just a historical event here and there, and we’re left on our own, the deistic watchmaker, to use a philosophical reference there. That because we believe that so strongly, we’re not going to take no for an answer in the sense of the deeper growth and deeper faith.  So, sometimes that backfires though, especially getting into the superstitious, like, “Well, God’s got to be in everything, and I’m not feeling it,” as opposed to like, “Okay. Is it possible that I could just have a brain that gives me some pretty nasty thoughts sometimes and it doesn’t necessarily reflect that I’m in a bad state, that I can be curious about what a person getting mangled by a car might look like mentally and then be terrified by that?” And then like, “Thanks, brain, for giving me the imagination. Glad I can think through accidents so I can maybe be a safer driver.” Yeah, absolutely. But I will say that’s one of those sticky points a lot of times for Christians because we believe that thoughts matter and beliefs matter. And so there can be this overinterpretation of everything is always something really big and serious about my status and my heart, and something that’s really big and serious about spiritual things or demonic stuff, or fill in the blank.  So, the faith integration piece, I do carefully, but I’m not scared of it. I’ve done it so often. It’s through a lot of assessments. It has to be from the standpoint of the client’s wanting that. Usually, the client is asking me specifically, like, “Hey, would you pray at the end of the session?” Sure, absolutely, in most cases.  And this, such a deep topic. I’m fully aware that there are those in the camp that view faith integration as completely antithetical to what needs to happen in treatments. And they argue their case, they’re going to argue it really strongly, but the same exists on the other side as well. And I try and work in that realm of, okay, what’s good for the clients? And are there some things that I don’t do? Yeah, but I’m not really asked to do them.  I’ve had a number of Muslim clients throughout the year. I don’t join in with Ramadan with clients in various practices or fasting with a client, for example. That’s not my faith practice there. But can I walk with the client who is trying to differentiate between the lines of fasting and I had water at this point, and the sun was going down and I thought. And other people were having water, but I’m getting stuck on assessing, like, was it too early, and did I actually violate my commitment, my vow? Did I violate what I was supposed to be doing?  I can absolutely work with that person, and I need to. I can’t really work with OCD or anxiety disorders if I wanted to turn that person away at the door and be like, “Oh, well, I’m not Muslim, so I’m sorry.” No, we’re going to jump into it and be like, “Okay, so tell me about this thought and then this behavior that came up at this time, and you’re noticing that that’s a little different from your community, that other people are starting to drink water, eat food. And so, you mentioned that it was right at sunset, but what time was that?” “Well, actually, it was like 10:30 p.m. It’s two hours dark.” It’s like, “But I think I saw a glow in the distance.” And it’s like, “Okay, now we’re into a pretty classic OCD realm.” And so the simplest way that I can say that faith integration can be done in therapy is carefully, respectfully, with good assessments. Kimberley: Do you have them consult with their spiritual leader if you’re stuck on that? And does that involve you speaking with them, them speaking with them, all three of you? What have you done? Justin: Yeah, absolutely. So, there is a collaboration that goes in a number of different ways. Most of the time, people can speak with their clergy member or faith leader pretty directly, pretty separately, and that is going to work just fine. I would say in most cases, people don’t need to, especially if I’m working with OCD. A lot of folks usually have a pretty good general sense of, “Okay, I know what my faith community is going to say about this is X, but I’m scared because it feels like it’s on shaky ground, I’m obsessing,” et cetera.  So, the clarification with the clergy, for instance, or a leader is more from the standpoint of if there’s not a defined value definition practice, and that does come up for sure. So, helping that person to even find who that might be, especially if they’re not a part of that, and/or maybe a good article to read with some limits, like, okay, three articles max. Check out a more conservative view, a more liberal view, a more fill in the blank.  And then my friend and colleague Alec Pollard up at St. Louis Behavioral Medicine Institute, he’s been on scrupulosity panels with me. He uses this excellent form called the PISA, (Possibly Immoral or Sinful Act). And it’s just a great several-question guide. That or any number of things can be taken to clergyperson, leader in Christian circles a lot of times, like a Bible study or community group. Maybe flesh those things out just a little bit, maybe once, maybe twice max.  And so, back to how much others are integrated, yeah, it’s a mix and match, anything, everything. For me, with direct conversations with clergy, it’s actually because I’m pretty deep into this realm, I have pretty easy access to a lot of folks, so I don’t really need to so much talk directly or get that person on a release. But a lot of people do, especially if they don’t know that religious belief or faith traditions approach on certain topics.  Kimberley: Yeah. It’s so wonderful to talk about this with you.  Justin: Thanks, Kimberley. Same here. Kimberley: Because I really do feel, I think post-COVID, there’s more conversations with my clients about this. This could be totally just my clients, but I’ve noticed an increased longing, like you said, for that connection, the loneliness pandemic. Justin: Yeah, that’s statistical.  Kimberley: Such a need for connection, such a need for community, such a need for that, like what is your North Star? And it can be, even if we haven’t really talked about depression, it can be a really big motivator when you’re severely depressed, right? Justin: Absolutely.  Kimberley: And this is where I’m very much like so curious and loving this conversation with my clients right now in terms of, where is it helpful? Where isn’t it helpful? As you said, do you want to use this as a part of your practice here in treatment, in recovery? And what role does it play? I know I had mentioned to you, I’d even asked on Instagram and did a poll, and there were a lot of people saying, “It gave me a community. It immensely helps. It does keep me focused on the goal,” especially if it’s done intentionally without letting fear take over. Is there anything you wanted to add to this conversation before we finish up?  Justin: Yeah, I guess two things. So, one is you talked about that, and we talked about a couple of those responses before we jumped on to recording. So, in summary, the responses were all across the board, like, “Ooh.” Let me know if I’m summarizing this well, but, “I have to be really careful. That can be really compulsive or not so much. I don’t like to do that. I don’t think it’s necessary.” And then like, yeah, absolutely. This is really integral and really important. Is that a fair summary? Kimberley: Very much. Yep.  Justin: Okay. And so, I’m building this talk, Katie O'Dunne and Rabbi Noah Tile, ERP As a Spiritual Practice. We’re giving here at the Faith and OCD Conference in April, if this is out by then. And in my section that I have, I’m covering the best practices of treatments, specifically ERP (exposure and response prevention) for OCD, and clinically, but then also from a faith standpoint, what do we consider with that? And there’s this three-prong separation that I’m making. I’m not claiming a hold on the market with this, but I’m just observing. There’s one category of a person who comes into therapy, and it’s like, yeah, face stuff, whatever. It doesn’t matter, or even almost antagonistic against it. Maybe they’ve been burnt, maybe they’ve been traumatized or abused with faith. Yeah, I get it. So, that first camp is there. But then there’s also a second camp that people like to add on spiritual practices. They might mix and match, or they might follow a specific system, belief system. And whether it gets into mindfulness or meditation practices or fasting or any number of things, they find that there’s a lot of benefit, but it’s maybe not at the heart of it.  And then there’s this third prong of folks that it is part and parcel of everything they do. And I work with all three. They come up in different ways. And sometimes people cycle between those different ones as well in treatments in the process.   Kimberley: I’m glad you
Fix this Error in Thinking (if you want to be less anxious) | Ep. 379
Mar 29 2024
Fix this Error in Thinking (if you want to be less anxious) | Ep. 379
Now fix this one error in thinking if you want to be less anxious or depressed, either one. Today, we are going to talk about why it is so important to be able to identify and challenge this one error in your thinking. It might be the difference between you suffering hard or actually being able to navigate some sticky thoughts with a little more ease. Let’s do it together. Welcome back, everybody. My name is Kimberley Quinlan. I’m an anxiety and OCD specialist, and I am so excited to talk with you about this very important cognitive error or error in thinking that you might be engaging in and that might be making your life a lot harder. This is something I catch in myself quite regularly, so I don’t want you to feel like you’re wrong or bad for doing this behavior, but I also catch it a lot in my patients and my students. So, let’s talk about it.  The one error you make is black-and-white thinking. This is a specific error in thinking, or we call it a cognitive distortion, where you think in absolutes. And I know, before you think, “Okay, I got the meat of the episode,” stay with me because it is so important that you identify the areas in your life in which you do this. You mightn’t even know you’re doing it.  Again, often we’ve been thinking this way for so long, we start to believe our thoughts. Now, one thing to know, and let’s do a quick 101: we have thoughts all day. Everybody has them. We might have all types of thoughts, some helpful, some unhelpful. But if you have a thought that’s unhelpful or untrue and you think it over and over and over and over again, you will start to believe it. It will become a belief. Just like if you have a lovely, helpful thought and you think that thought over and over and over again, you will start to believe that too.  And what I want you to know is often, for those with mental health struggles, whether that be generalized anxiety, panic disorder, depression, eating disorders, OCD, PTSD, social anxiety, the list goes on and on, one thing a lot of these disorders have in common is they all have a pretty significant level of errors in thinking that fuel the disorder, make the disorder worse, prevent them from recovering. My hope today is to help you identify where you are thinking in black and white so we can get to it and apply some tools, and hopefully get you out of that behavior as soon as possible.  Here are some examples of black-and-white thinking that you’re probably engaging in in some area of your life.  The first one is, things are all good or they’re all bad. An example might be, “My body is bad.” That there are good bodies and bad bodies. There are good people and bad people. There are good thoughts and bad thoughts. That’s very true for those folks with OCD. There are good body sizes and bad body sizes, very common in BDD and eating disorders. There are people who are good at social interaction and bad at social interaction. That often shows up with people with social anxiety. That certain sensations might be good, and certain sensations might be bad. So if you have panic disorder and you have a tight chest or a racing heart rate, you might label them as all bad. And this labeling, while it might seem harmless, is training your brain to be on high alert, is training your brain to think of things as absolutes, which does again create either anxiety or a sense of hopelessness, helplessness, and worthlessness specifically related to depression. So we’ve got to keep an eye out for the all good and the all bad.  The next one we want to keep an eye out for is always and never. “I always make this mistake. I never do things right. I will always suffer. I will never get better.” These absolutes keep us stuck in this hole of dread. “It’ll always be this way. You’re always this way.” And the thing to know here is very, very rarely is something always or never true. We can go on to talk about this here in a little bit, but I want you just to sit with that for a second. It’s almost never true that almost never is the truth. How does that sound for a little bit of a tongue twister?  Next thing is perfect versus failure. If you’re someone who is aiming for that is either perfect or “I’m a failure,” we are probably going to have a lot of anxiety and negative feelings about yourself. This idea that something is a failure. I have done episodes on failure before, and I’ll talk about that here in a second. But the truth is, there is no such thing as failure; it’s just a thought. And all of these are just thoughts. They’re just thoughts that we have. And if we think that our thoughts are facts, we can often again get into a situation where we have really high anxiety or things feel really icky.  Another absolute black-and-white thinking that we do is that this is either easy or it’s impossible. There’s only those two choices. It should be either really easy or it’s not possible at all. Again, it’s going to get us into some trouble when we go to face our fears because facing fears is hard. We’ve talked about, it’s a beautiful day to do hard things. And the reason I say that is to really challenge this idea that things should be easy. And just because they’re hard doesn’t mean they’re impossible. Often people will say, “I can’t.” Again, just because they’re hard doesn’t mean that you can’t do it. It just might take some practice.  So, these are common ways that black-and-white thinking shows up. And by now, if you’re listening, you’re probably thinking, “Oh yeah, I’ve been called out.” And that’s okay. We all do this type of thinking. But let’s talk about now tools and what you can do to target this.  Let me tell you a story. Recently, I found myself managing what I would consider a crisis, a family crisis. It took several months for us to navigate this very, very difficult time. And I often leave voice recordings to my best friend. We communicate that way quite regularly. And every now and then, I listen back to what I’ve said to her just to hear myself and what I’m saying and where my head is. And I was shocked to hear me saying, “It’s always going to be this way. It’ll never get better. This is so bad. I failed. This is impossible. I can’t do this anymore.” I was doing all of the things. And for me, that awareness is what clicked me into like, “Oh, no wonder I’m panicking. No wonder I feel dread the minute I wake up in the morning because my story about this is exacerbating and making this harder on me. It’s creating more suffering.” So the first thing I did is what I would tell my patients as well—to start with just a simple awareness training. Just being aware of when you do it. We don’t have to change anything. We’re not going to judge ourselves, but we’re just going to write down on a sticky note or an app on your phone every time you get caught in a black-and-white thinking, and we’re going to jot it down. “I always will feel this way. I will never get better. This will forever be a failure.” We want to just jot it down. And that is, in and of itself, a huge part of the work—just being aware when you catch it. We’re not here to come down hard on you for doing it. Sometimes it’s just a matter of going, “Oh, okay, Kimberley, I see that I’m doing black-and-white thinking.” And that might be all that we do.  Often, with my patients, I will have them log this for homework because, in CBT, we do a lot of homework. And so I will say, “I want you to write it down and come back to me next week because next week, we’re going to work on the next tool.”  Now this may be a little different depending on the condition, and I want to make sure I’m really thorough here. If you have GAD (generalized anxiety disorder) or panic, we do a lot of cognitive restructuring. We do a lot of cognitive restructuring about how you cope with your discomfort. And in some cases, we might even restructure the content of your thought.  However, if you have OCD, it’s a little tiny bit different. We would still correct your thoughts about your ability to tolerate discomfort or your thoughts about yourself. But we want to be careful because sometimes when we start looking too close at the thought and trying to make sense of it and trying to correct it too much, we can actually start to be doing a little nuanced, subtle compulsion where we’re getting reassurance, we’re confessing, we are reinforcing the whole importance of this by going over it and correcting it, correcting it and correcting it. So just keep an eye out for that. If you’re in therapy, bring it up with your therapist just to make sure that you’re not using this skill today in a way that could become compulsive. Sometimes it does, sometimes it doesn’t, depends on the person.   For eating disorders, I know as my recovery from eating disorder, I did a lot of this, really examining, is my body all good or all bad? Is there such a thing as a perfect body or a failed body? This food or this body size, how do we determine its goodness or its badness? And looking at how extreme it can be.  Now, another really important piece here is with depression. In depression, we use a lot of black-and-white thinking. “I’m all that. They’re all good. I’m a failure. I’ll never get better. It’ll never get better. Things will never look up. It’ll always be this way.” Depression loves to use black-and-white thinking.  And so when we talk about cognitive restructuring, what we’re not talking about is just making it all positive. So here are a couple of examples. If you have depression, and for those of you, if you have depression and you don’t have access to a therapist, we have a whole online course called Overcoming Depression, where we go through this in depth of the common errors, not just black and white thinking, but the common errors in depression. And we work at coming up with helpful ways to respond. But one of the tools and skills that we use is, we don’t want to just come up with positive thoughts. It’s going to feel crappy to you. It’s going to feel fake. It’s not going to land. But what we want to do is find corrections or rebuttals to that thought that are more evidence-based, more rational, more logical, more helpful—things that might feel truer to you, even if it’s still somewhat distorted. It’s better than thinking in these absolutes because, like I said before, if you’re thinking in absolutes, you can guarantee you’re going to feel crummy.  Another example is with GAD (generalized anxiety disorder) or with panic disorder. A lot of it is catching our appraisal of sensations and feelings in our body. Now, again, we actually have a whole course on this as well called Overcoming Anxiety and Panic. Again, we go through a whole module of cognitive restructuring where we identify the specific thoughts that people with generalized anxiety and panic have. And it will be looking for where you make these black-and-white, all-or-nothing statements that “It would be bad if that happened. I will always again feel this way. I’ll never amount to anything. This panic attack will never end. I’m not handling it well. I’m handling it all bad,” or that “This sensation is impossible, and I can’t tolerate it.” So we go through it and really look at what are the things that you’re worrying about, and how are you really bringing in black and white thinking?  There are other distortions. In fact, there are 10 other distortions which we’re not covering today. Those are all in those courses as well. But again, for today, I wanted to really double down on this one. This one is particularly pesky and problematic.  The other thing to remember as we’re looking at black-and-white thinking is to remember that usually, 99.999 % of the time, things happen in the middle, in the gray. I often will hear me say to clients, “Can you be a little more gray about that?” Not to say a little more dark and depressive. I’m saying gray in that, “Is there somewhere in the middle that is more true and factual? Is it all good or all bad or is it a little of both? Or is it none of either? Where in the middle does it land? Oh, you’re having the thought that you’re either successful or a failure? Where is everybody else in this continuum?” Most likely, they’re in the gray. Can you learn to be more comfortable accepting the gray of the world and not going to these absolute black-and-whites?  The beauty is in the gray. We know this. The beauty is being kind to yourself in the gray, which brings me to the last point here, which is to practice self-compassion. We are in the gray. This podcast episode in and of itself is neither all bad nor all good. It’s going to be a variation, and a lot of that’s going to be dependent on people’s opinion, where they are, what they’re thinking, their mood, that things are really black and white. And can we be gentle with ourselves and humble enough to allow ourselves to see that this is neither good, bad, success, failure, always, never? These skills and the awareness of when we’re thinking this way can reduce a significant amount of our suffering, especially when you catch them, label them, and redirect in a kind, compassionate way.  One thing I don’t want you to do is identify how you’re thinking in this black-and-white way and respond to that with black-and-white thinking by saying, “You’ll always think this way. You’ll never ever stop doing this.” Ironic, but we do it all the time. Almost always, when people criticize themselves, they’re using one of the two areas in thinking black and white thinking and labeling, which is like name calling. And again, we want to identify these areas in thinking.  Again, if you want to go back and take a look at those courses, we go through this immensely in depth because there’s such an important part of Overcoming Anxiety and Panic and Overcoming Depression. And again, that’s the names of the courses. You can head over and look into that in the show notes, or go to CBTSchool.com. We have all of our courses listed there.  All right, folks, that’s it. Please fix this error in thinking if you want to be less anxious. Black-and-white thinking will create so much suffering in your life. And my hope is that these episodes and the work we do here at Your Anxiety Toolkit make you suffer a little bit less each week.  Have a great day, everyone, and I’ll see you next week.
11 Things I Tell My Patients in Their First Session of OCD Treatment | Ep. 378
Mar 22 2024
11 Things I Tell My Patients in Their First Session of OCD Treatment | Ep. 378
Obsessive-Compulsive Disorder (OCD) is a challenging condition, but the good news is that it's highly treatable. The key to effective management and recovery lies in understanding the condition, embracing the right treatment approaches, and adopting a supportive mindset. This article distills essential guidance and expert insights, aiming to empower those affected by OCD with knowledge and strategies for their treatment journey. YOU ARE BRAVE FOR STARTING OCD TREATMENT Taking the first step towards seeking help for OCD is a significant and brave decision. Acknowledging the courage it takes to confront one’s fears and commit to treatment is crucial. Remember, showing up for therapy or seeking help is a commendable act of bravery. YOU CAN GET BETTER WITH OCD TREATMENT OCD treatment, particularly through methods like Exposure and Response Prevention (ERP) and Cognitive Behavioral Therapy (CBT), has shown considerable success. These evidence-based approaches are supported by extensive research, indicating significant potential for individuals to reclaim their lives from OCD’s grasp. The path may not lead to a complete eradication of symptoms, but substantial improvement and regained control over one’s life are highly achievable. OCD TREATMENT IS NOT TALK THERAPY OCD therapy extends beyond the realms of conventional talk therapy, involving specific exercises, homework, and practical worksheets designed to confront and manage OCD symptoms directly. These tools are integral to the treatment process, allowing individuals to actively engage with their treatment both within and outside therapy sessions. THERE IS NO SUCH THING AS “BAD” THOUGHTS A pivotal aspect of OCD treatment involves changing how individuals perceive their thoughts and their control over them. It's essential to recognize that thoughts, regardless of their nature, do not define a person. Attempting to control or suppress thoughts often exacerbates them, which is why therapy focuses on techniques that allow individuals to accept their thoughts without judgment and reduce their impact. YOU CAN NOT CONTROL YOUR THOUGHTS, BUT YOU CAN CONTROL YOUR BEHAVIORS You will have intrusive thoughts and feelings. This is a part of being human, and it is not in your control. However, you can learn to pivot and change your reactions to these intrusive thoughts, feelings, sensations, urges, and images.  YOU HAVE MANY OCD TREATMENT OPTIONS While medication can be a valuable part of OCD treatment, particularly when combined with therapy, it's not mandatory. Decisions regarding medication should be made based on personal circumstances, preferences, and professional advice, acknowledging that progress is still possible without it. In addition to ERP and CBT, other therapies such as Acceptance and Commitment Therapy (ACT), mindfulness, and self-compassion practices have emerged as beneficial complements to OCD treatment. These approaches can offer additional strategies to cope with symptoms and improve overall well-being. The accessibility of OCD treatment has expanded significantly with the advent of online therapy and self-led courses. These digital resources provide valuable support, particularly for those unable to access traditional therapy, enabling individuals to engage with treatment tools and strategies remotely. For those without access to a therapist, self-led OCD courses and resources can offer guidance and structure. Engaging with these materials can empower individuals to take active steps towards managing their OCD, underscoring the importance of self-directed learning in the recovery process. TREATMENT WILL NEVER INVOLVE YOU DOING THINGS YOU DO NOT WANT TO DO I am usually very clear with my patients. Here are some key points I share I will never ask you to do something I do not want you to doI will never ask you to do something that I myself would not do I will never ask you to do something that goes against your values. RECOVERY IS NOT LINEAR Recovery from OCD is not a linear process; it involves ups and downs, successes and setbacks. Embracing discomfort and challenges as part of the journey is essential. Adopting a mindset that views discomfort as an opportunity for growth can greatly enhance one’s resilience and progress in treatment. There will be good days and hard days. This is normal for OCD recovery.  There will be days when you feel like you are making no progress, but you are. Keep going at it and be as gentle as you can SETTING CLEAR TREATMENT GOALS Clarifying treatment goals is crucial for a focused and effective therapy experience. Whether it's reducing compulsions, living according to one’s values, or tackling specific fears, clear goals provide direction and motivation throughout the treatment process. BE HONEST WITH YOUR THERAPIST The success of OCD treatment is significantly influenced by the honesty and openness of the individual undergoing therapy. Without reservation, sharing one’s thoughts, fears, and experiences allows for more tailored and effective therapeutic interventions. IT IS A BEAUTIFUL DAY TO DO HARD THINGS.  No question. You can do hard things!  OCD is a complex but treatable condition. By understanding the essentials of effective treatment, including the importance of evidence-based therapies, the role of mindset, and the value of self-directed learning, individuals can embark on a journey towards recovery with confidence. Remember, every step taken towards confronting OCD is a step towards reclaiming control over one’s life and living according to one's values and aspirations. TRANSCRIPT There is so much bad advice out there about OCD treatment. So today, I wanted to share with you the 11 things I specifically tell my patients on their first day of OCD therapy.  Hello, my name is Kimberley Quinlan. I’m an OCD specialist. I specialize in cognitive behavioral therapy, and I have helped hundreds of people with OCD over the course of the 10, 15 years I have been in practice.  Now, whether you have an OCD therapist or not, my goal is to help you feel confident and feel prepared when addressing your OCD treatment and symptoms, whether you have an OCD therapist or not. That is the big goal here at CBTSchool.com and Your Anxiety Toolkit podcast.  Make sure you stick around until the end because I will also be sharing specific things that you can remember if you don’t have a therapist, because I know a lot of you don’t. And I’ll be sharing what you need to know so that you don’t feel like you’re doing it alone.  Now, if you’re watching this here on YouTube, or you follow me on social media at Your Anxiety Toolkit, let me know if there’s anything I’ve missed or anything that you were told on your first session that was particularly helpful, because I’m sure your knowledge can help someone else or another person with OCD who is in need of support and care and advice. So let’s go. Here are the 11 things that I tell my patients on their first day of OCD therapy. Number one, I congratulate them for showing up, because showing up for OCD treatment is probably one of the most brave things you can do. I really make sure I validate them that this is scary, and I’m really glad they’re here. And I’m pretty impressed with the fact that they showed up, even though it’s scary.  The second thing I tell them is that OCD treatment is successful. You can come a long way and make massive changes in your life by going through the steps of OCD treatment, showing up, being willing to take a look at what’s going on in your life, and making appropriate changes so that you can get your life back, do things you want to do, spend more time with your family, your friends, the things you love to do, like hobbies, and that OCD treatment can be very effective. We’re very lucky that OCD is a very treatable condition. It doesn’t mean it’ll go away completely, but you can have absolute success in getting your life back.  Now, one thing to know here is, how do we know this? Well, OCD treatment research and OCD treatment articles. If you go onto Google Scholar, you will find a lot of articles that show a meta-analysis of the OCD treatments available, where it shows that ERP and cognitive behavioral therapy are the gold standard of treatment. And using a meta-analysis, that basically means that they’ve surveyed all of the large, well-done research articles and found which one shows the most results and shows that they have the most repeated results over periods of time. And that’s why it is so important that you do follow the research because there is a lot of bad information out there, absolutely.  Now, the third thing I tell my patients on their first day of therapy is that OCD treatment is not talk therapy. It’s not just talking, that it requires OCD therapy exercises and homework and lots of worksheets. I have a packet that we give our patients at the center that I own in Calabasas, California. Everyone gets a welcome manual. And in the welcome manual, it’s got worksheets on identifying obsessions and compulsions. It’s got mindfulness worksheets. It’s got logging worksheets. And I will send you home with those to do for homework. You’ll come back. Let me know what worked, what didn’t work, what was helpful, what wasn’t. And you will be doing a lot of this work on your own.  Now, again, as I mentioned at the beginning, if you do not have access to OCD therapy or you don’t have the resources to get that, we have an online course called ERP School. It is a course specifically for people with OCD, where I walk you through the specific steps that I take my patients through. And all of those worksheets are there. They have worksheets on identifying your obsessions, identifying your compulsions, mindfulness, self-compassion worksheets, things that can remind you and prompt you in the direction of setting up a plan so that you can get moving and make the steps on your own. The fourth thing that you need to know on the first day of your therapy is that there is no such thing as bad thoughts. Let’s just sit with that for a second. There is no such thing as bad thoughts. Your thoughts do not define you, nor do your behaviors, that you might have these thoughts that you think are going to really freak you out. You might have this idea, these thoughts, these intrusive, repetitive, scary thoughts, and you might think, “Well, I can’t even tell Kimberley about them yet.” I will often tell my patients like there is nothing these walls haven’t heard, and you probably won’t shock me because I haven’t been shocked in many, many, many years working as an OCD therapist. I’ve heard it all. I’ve heard the most, what people perceive as the grossest thoughts. It’s a normal part of the work that we do. And your thoughts are neither good nor bad and they do not define you. And I really make that point made because, as we move forward, I want you to know that I’ve seen a lot of cases and that “your thoughts aren’t special” in that they’re not something that I would be alarmed by.  The fifth thing that I would tell my patients is that you cannot control your thoughts. And I bet you believe it because you’ve probably tried over and over again, and all you found is the more you try and control it, the more thoughts you have. The more you try to suppress your thoughts, the more thoughts you have. There are, as we’ve already discussed, OCD treatment options that will really solidify this concept. Now, the most important one is exposure and response prevention, which is the type of treatment that we use for OCD and is the type of treatment that all of those research articles I discussed before show and direct to as a really successful treatment for OCD.  Now, in addition, there are other OCD treatment options. One of those treatment options is OCD treatment with medication. Now, again, when you do that meta-analysis, we have found that a combination of CBT and ERP with medication is the most successful. Now, that doesn’t mean you have to take medication, though. I’m never going to tell my patients that they have to take medication.  So we can have OCD treatment with medication. We can have OCD treatment without medication. In fact, some of my most difficult cases, the clients, for medical reasons or for personal values reasons, chose not to go on medication. You can still get better. It might make it a little more difficult. You may want to speak with your therapist, or if you’re doing this alone, you might need to put in a little extra homework, have a team of support, and people who are really there holding you accountable. Absolutely. But medication is another treatment option that you may want to consider as you move through this process. Now there are also new treatments for OCD recovery. They might include acceptance and commitment therapy, mindfulness practices, self-compassion. We even have some research around dialectical behavioral therapy as other OCD treatment interventions. I will be implementing those as we go, depending on what roadblocks show up. And again, if you’re doing this on your own, there are amazing resources that can also help you, and I’ll share about those here in a bit. Again, as we’ve talked about, there is also OCD treatment online. Since COVID-19, we’ve done a lot of growing in terms of being able to utilize CBT via the internet, via our computers, via our smartphones. A lot of people come to us because they’ve looked for OCD treatment in Los Angeles, which is where we are. And even though they only live a few miles down the street, they’re still doing sessions online because it’s so convenient. They can do it at home between sessions with their work or between getting their kids to school. So, OCD treatment online has become a very popular way to also access treatment. And I give these to my clients as we go, because sometimes they’re going to need a little extra help.  Now, as I’ve mentioned to you earlier in there, if you don’t have access to OCD treatment, there are tons of self-led OCD courses. Again, one of the ones that we offer is ERP School. Now you can go to CBTSchool.com, or you can click the link below in the show notes, where we have all of these courses for OCD and other anxiety disorders. But there are others as well—other amazing therapists who have created similar products.  When we’re really looking at treatment depending on your age, the treatment does look very similar for OCD treatment for adults and OCD treatment for children. They are very, very similar. With children, we might play more games, have more rewards, use those strategies, but to be honest with you, adults are just big kids in adult bodies. So I really believe that we want to make this as fun as we can. Have rewards. Have there be something that you’re working towards. Make it fun. Make it a part of a game. I use a lot of games in treatment and a lot of ERP games because why do we want to make everything boring all the time? Why not make it a little bit fun if we can? Number seven, the main thing I’m going to tell you here, and this is really, really important, is I will not ask you to do something that you don’t want to do. I have this in our welcome manual. We don’t ask people to do things that go against their values, and we don’t ask people to do things that I myself would not do. There are a lot of TV shows that sort of use ERP and exposure work as sort of like doing your worst, worst, worst, worst, worst case. And that’s fine. But often we’re not doing that. We’re doing exposures, we’re facing your fears so that you can get back to functioning, so you can get back to doing the things you want to do. So again, I’m not going to have you do anything you don’t want to do. You’re in charge. If you’re taking ERP School, we do the same thing. You create your own plan. You create a hierarchy of what you want to start with, and we work our way up. And we do the same thing in therapy as well.  Now the eighth thing that I will tell you, and by then you’re probably getting a little tired and overwhelmed. We might take a little tea break really quick, but I would tell you that recovery is not linear. While we do have effective treatment for OCD, it will be an up-and-down process. You’ll have really good days, and you’ll have some hard days. And those hard days don’t mean that you’re doing anything wrong. It doesn’t mean that your treatment’s not successful. It just means we have to take a look here and see what’s going well, what’s not going well, what do we need to tweak, do we need to make a pivot here. Or do we need to reassess something and maybe apply some additional tools—mindfulness tools again, self-compassion skills, some distress tolerance skills, maybe? But just remember, your recovery will not be linear, and that is okay.  Now the ninth thing I’m going to tell you is that your OCD treatment goals must be clear. You are going to get really clear on why you’re here, what you want to do, why you’re doing this treatment because it is hard work. Again, there’s homework. I’m going to be giving you some things to do at home, and they’re going to be a little bit difficult. They’re going to cause you to feel some feelings that maybe you don’t want to feel, some sensations you don’t want to feel.  And so, really again, I will ask them, like, what are your goals for treatment? Now, some common OCD goals for OCD therapy is to reduce compulsions. “I want to be able to not be doing these compulsions for hours and hours.” Other people say, “I want to live my life according to my values. I don’t want to let fear constantly be telling me what to do.” Other people will say, “I want to learn how to tolerate this discomfort and this uncertainty because every time I try and run away from it, it just gets worse. It makes it worse. And now I’m stuck in this cycle.” So it’s important that you get really clear.  Sometimes people will come in and they’ll say, “I’ve never been to Paris. I want to be able to go to Paris with my family. And so, that’s the goal.” That’s fine too. You could have a large goal like that, or you could have a really simple goal like, “I just want to have more space in my life to paint,” or “I don’t want to feel like I’m on edge all the time, like the scariest thing is going to happen all the time.” And that’s fine too.  Now, the 10th thing that you’re going to need to know and need to remember is, our recovery is really dependent on how open and honest you are. As I said at the beginning, some people don’t feel yet like they can trust to tell me the depth of their intrusive thoughts, and that’s okay. But throughout therapy, I’m going to need you to be really honest with me and really honest with yourself, because if you’re not disclosing what’s going on and the thoughts you’re having, we can’t actually apply the skills to it. And then it puts a wrench in the success of your treatment.  So we want you to be as open, honest as you can. And I often will say to them, there is nothing I haven’t heard. In fact, if you have taken ERP School already—a lot of you have—we actually play a couple of games where we play a game called One Up, which is where no matter what thought you have, you make it a little worse or little more scary. And I give some demonstrations and show like I’m not afraid to go there. I will go to the scary, yucky place just to show you that that’s what I want you to do as well. Again, it doesn’t have to be all serious. We’re allowed to play games, and we do that in therapy as well.  Often people will ask like, how do I tell my therapist about these horrible thoughts I’m having? Like, how do I share? If you’re having a specific type of thought that you feel is particularly taboo or very scary to share, or you’re afraid of the consequences of sharing, what I would encourage you to do is do a very quick Google search. There are some amazing websites and articles online of your obsession. Print it out and bring it to your therapist, and say, “Hey, this is what I’m dealing with. I’m too scared or I’m too vulnerable to share. It’s so horrendous in my mind, but this is what I’m going through.” And chances are, again, the therapist, if they’re a trained OCD specialist, will go, “Ah, thank you for letting me know. I’ve treated that before. I’m good to go.” Again, if they’re a newer therapist, it’s still okay because they’re getting the education about really common obsessions that happen a lot in our practice.  Okay. Here we go—drum roll to the last one. And I know you guys are probably already guessing what it is. It’s something I say to my patients and to you guys all the time, and it’s this: It’s a beautiful day to do hard things.  We have been taught that life should be easy, shouldn’t be scary, shouldn’t be hard, and that you should be Instagram-ready all the time. But the truth is, life is hard. And today is a beautiful day to do those hard things. I have found that those who recover the fastest and the most successful over time are the ones who see discomfort as a challenge, something that they’re willing to have. They’ll say, “Bring it on, let’s go. Bring my shoulders back. I know it’s going to be here.” And they’re really gentle with themselves when they have this discomfort. And I want you to really walk away feeling empowered that you too can handle some pretty uncomfortable things because you already are. So again, it’s a beautiful day to do hard things.  All right, let’s round it out because I know I promised you some extra things here. Now, what have we covered? We’ve covered the mindset shifts that you need for OCD therapy, behavioral changes that you’re going to need to make. We’ve talked about complementary tools, the most important being self-compassion. And also, guys, you can also follow Your Anxiety Toolkit because we have over 380 episodes of tools and core concepts, and everything like that.  Now, for treatment, just so that you get an idea of what this would look like, I share with my patients what treatment looks like. So usually, once I’ve told them all of this, I send them home with their welcome manual, and I’ll say, “The next two to three sessions, I’m going to be training you for this treatment. And a lot of that is going to involve psychoeducation, me giving you tools, giving you strategies, putting a plan together.” And again, for those of you who don’t have therapy, we do exactly that in ERP School. So if you feel like you need some structure, you can go to CBTSchool.com and access ERP School. We can go through that.  Now, for those of you, again, who don’t have an OCD therapist, does OCD therapy and treatment work for you too? Yes. We actually have some early research to show that self-led programs can be very successful for people with OCD and with other anxiety disorders. So, if you don’t have access to therapy, you could take ERP School. You could buy some workbooks that you buy from Amazon or your local bookstore. There are a ton of workbooks out there. Shameless plug, I also wrote one called The Self-Compassion Workbook for OCD. You can get it wherever you buy books. There are also online groups. I’m a huge, huge proponent of online groups. So if there are support groups in your area, by all means, use those because just knowing other people who are struggling, what you’re struggling with can be so validating and inspiring because you’re seeing them do the hard thing as well.  But either way, treatment requires a lot of homework. So, as I say to patients, showing up here once a week isn’t going to get you better. You’re going to have to practice the skills. And if you don’t have a therapist, you’re going to be doing that anyway. So I want to really hope that you leave here with a sense of inspiration and hope that you can get better even if you don’t have OCD therapy at this time. So there you go, guys. There are the 11 things I tell my patients on the very first session. I will usually end the session by encouraging them and, again, congratulating them for coming in and doing this work with me. Let them know I’m so excited for them.  I hope that this was helpful for you, and my hope is that you too will then go on to learn all the tools that you need in your tool belt and go on to live the life that you want to live because that’s the whole mission here at Your Anxiety Toolkit.  Have a wonderful day, everybody, and I’ll talk to you next week.
Stop Doing These Things if You Have Panic Attacks | Ep. 377
Mar 15 2024
Stop Doing These Things if You Have Panic Attacks | Ep. 377
In the realm of managing anxiety and panic attacks, we often find ourselves inundated with advice on what to do. However, the path to understanding and controlling these overwhelming experiences also involves recognizing what not to do. Today, we shed light on this aspect, offering invaluable insights for those grappling with panic attacks.  Stop doing these things if you are having panic attacks, and do not forget to be kind to yourself every step of the way.  1. DON'T TREAT PANIC ATTACKS AS DANGER It's a common reaction to perceive the intense symptoms of a panic attack—rapid heartbeat, dizziness, or a surge of fear—as signals of immediate danger. However, it's crucial to remind ourselves that while these sensations are incredibly uncomfortable, they are not inherently dangerous. Viewing them as mere sensations or thoughts rather than threats can create a helpful distance, allowing for more effective response strategies. 2. DON'T FLEE THE SCENE The urge to escape a situation where you're experiencing a panic attack is strong. Whether you're in a grocery store, on an airplane, or in a social setting, the instinct to run away can be overwhelming. However, leaving can reinforce the idea that relief only comes from escaping, which isn't a helpful long-term strategy. Staying put, albeit challenging, helps break this association and builds resilience. 3. DON'T ACCELERATE YOUR ACTIONS During a panic attack, there might be a tendency to speed up your actions or become hyper-vigilant in an attempt to alleviate the discomfort quickly. This response, however, can signal to your brain that there is a danger, perpetuating the cycle of panic. Slowing down your breath and movements can alter your brain's interpretation of the situation, helping to calm the storm of panic. 4. AVOID RELIANCE ON SUBSTANCES Turning to alcohol or recreational drugs as a quick fix to dampen the intensity of a panic attack can be tempting. Nonetheless, this can lead to a dependency that ultimately exacerbates the problem. It's important to let panic's intensity ebb and flow naturally, without leaning on substances that offer only a temporary and potentially harmful reprieve. 5. STOP BEATING YOURSELF UP Self-criticism and judgment can add fuel to the fire of anxiety and panic. It's vital to adopt a compassionate stance towards yourself, recognizing that experiencing panic attacks doesn't reflect personal failure or weakness. Embracing self-kindness can significantly mitigate the added stress of self-judgment, creating a more supportive environment for recovery. SEEKING SUPPORT Remember, you're not alone in this struggle. Whether through therapy, online courses, or community support, reaching out for help is a sign of strength. Resources like "Your Anxiety Toolkit" are there to remind you that it's possible to lead a fulfilling life, despite the challenges panic attacks may present. Lastly, embrace the notion that it's a beautiful day to do hard things. Facing panic with acceptance rather than resistance diminishes its hold over you, opening the door to healing and growth. TRANSCRIPT:  Stop doing these things if you have panic attacks. I often, here on Your Anxiety Toolkit, talk about all the things you need to do—you need to do more of, you need to practice skills that you can get better at. But today, we’re talking about the things you shouldn’t do if you are someone who experiences panic attacks, panic disorder, or any other disorder that you also experience panic attacks in. Let’s get to it. Let’s talk about the things not to deal. Welcome back. Stop doing these things if you have panic attacks. When I say that, in no way do I mean that the things we’re going to discuss you should beat yourself up for. If you’re doing any of the things that we talk about today, please be gentle. It is a normal human reaction to do these things. I don’t want you to beat yourself up. Please feel absolutely zero judgment from me because even I am someone who needs to keep an eye out for this, keep myself on check with these things when I am experiencing panic attacks as well. Let’s go through them.  The number one thing to stop doing if you’re having a panic attack is to stop treating them like they are dangerous. If you experience symptoms of panic or you experience panic disorder, you know that feeling. You feel like you’re going to die. You feel like your heart is going to explode or implode, or your brain will explode or implode. You’ll know that feeling of adrenaline and cortisol rushing around your body. You get it; I get it. It feels so scary. But we must remind ourselves that it’s not dangerous, and we can’t treat them like they’re dangerous. We can’t respond to these symptoms as if they’re dangerous. We want to instead treat them like they are, which is sensations in the body or thoughts that appear in your brain. Once we can do that, then we have a little bit of distance from them and we can respond effectively.  Now, the second thing I want you to stop doing if you have panic attacks is to never leave. If you are at the grocery store and you’re having a panic attack, do not leave the grocery store. If you’re on an airplane, boarding an airplane, and you’re having a panic attack, do not leave the airplane. If you’re in a room and you’re experiencing panic, don’t leave.  Now, I know in that moment, it can feel so dangerous, as we just discussed, and so scary, but when we leave, we will associate relief with running away, and we actually don’t want that. Instead, with panic, we want the relief to be that we wrote it out and we were able to tolerate that feeling and navigate that feeling effectively and compassionately and not from the place of running away and escaping. If you can do one thing, the most important thing to do is to not leave where you’re at.  Now, does that mean that you can’t take a minute to step away for a second? That’s fine. Does it mean that you can’t, if you’re in a conversation, just say, “Can I have a few minutes? I just need to run to the restroom,” or whatever it be, take some time to get yourself back together? That’s okay. We’re not here to win any races or anything, but do your best not to leave the actual environment or place that you are having the panic attack.  Now, the third thing you can not do if you’re having a panic attack is don’t speed up your actions. We talk a lot about this in our online course called Overcoming Anxiety and Panic. How you respond to a panic attack can really determine how your brain interprets the event. If you’re having a panic attack and you really speed up and you start to act frantic or in an urgent way, and you’re sort of like hypervigilant looking around or trying to urgently frantically change something, your brain will interpret that high-paced activity or that speeding up of your actions as if it is a danger, and it will keep sending out hormones like cortisol and adrenaline, which will keep the panic attack and the anxiety going. What we want to do instead is slow it down, slow your breath down, slow your actions down, really get in tune. If you can just slow it down a little and change how you respond. And what we want to do here—and we do this in Overcoming Anxiety and Panic, if you’re interested in taking this course and you don’t have access to therapy or you’re wanting a step-by-step way of working through generalized anxiety and panic, go ahead and take a look. It’s at CBTSchool.com. You can go and check it out there, but if not, you can also do this with your clinician or by yourself—is do an inventory of how you respond when you are panicking. What safety behaviors do you engage in to try and get it to go away? What do you do to respond to it as if it is dangerous? Do you leave? Do you speed up? Do you become hypervigilant? Do you seek reassurance? Do you do mental compulsions?  We can go through and do an audit of those behaviors and see what you’re doing to sort of control and manage that anxiety. And we want to really work hard at reducing those behaviors. Do an inventory and get very clear so that next time you are having a panic attack, you can instead change those behaviors or replace them with more effective behaviors. If you’re interested again in that course, you can go to CBTSchool.com/overcominganxiety.  Now, the fourth thing you need to stop doing if you have panic is to not rely on substances. And when I say substances, I mean alcohol or recreational drugs. There is a massive overlap between people with panic attacks and panic disorder and substance use, and I get it. Having a quick drink of alcohol can sometimes take the edge off a panic attack. However, once again, if that is your way of coping, you will build a reliance and a dependence on that behavior. And we want to work instead at allowing that discomfort to rise and fall on its own without intervening with ineffective behavior. And recreational substances are a really big no-no if you’re someone who is experiencing a panic attack.  Now, that is different from prescribed medications. If you have been prescribed a psychiatric medication and you’re following the doctor’s orders, that is a different story. And please do go and speak to your doctor about those specific directions. What I’m speaking about right here is substances like recreational drugs or alcohol to help manage that panic attack.  Now, the last thing you need to stop doing if you have panic disorder or panic attacks is you have to stop beating yourself up. Beating yourself up will only make it worse. In fact, we have research to show that the more you criticize yourself, beat yourself up, judge yourself, the more likely you are for your brain to release more anxiety hormones and increase the experience of anxiety and panic. And so, that goes against everything that we want and need. We don’t need to add more anxiety to the mix if you’re already experiencing a panic attack.  And so, what we want to do here is work at not beating yourself up, not criticizing yourself for having this because it’s not your fault. It doesn’t mean there’s anything wrong with you. It’s a normal human reaction to want to run away and do everything you can to make it go away, including drinking substances and doing recreational drugs. We don’t want to beat ourselves up, whether you’ve done those in the past or if you’re currently doing them. If you’re struggling, reach out for help. There are clinicians around the world who can help. We have, again, online courses, if you haven’t got access or you can’t afford those services. There are books, there are podcasts like this one that are free. Do what you can to get support and get help so that you’re not doing this alone.  You aren’t alone. Thousands and millions of people around the world struggle with panic attacks. Again, they do not mean that there’s anything wrong with you. And there are important, very effective skills you can use to manage them, and go on and live a very, very, very, very wonderful, successful, fulfilling life.  Of course, I’m always going to end with this because I always do, but do also remind yourself it is a beautiful day to do hard things. The more you can willingly have panic and allow it to rise and fall on its own, the less power it has over you. So, do remember today is a beautiful day to do hard things.  Thank you so much for being here with me. I look forward to seeing you next week on Your Anxiety Toolkit, and I’ll see you there.
20 Phrases to Use when you are Anxious | Ep. 376
Mar 8 2024
20 Phrases to Use when you are Anxious | Ep. 376
Anxiety can often feel like a relentless storm, clouding your thoughts and overwhelming your sense of calm. It's during these turbulent times that finding the right words can be akin to discovering a lifeline amidst the chaos.  To aid you in navigating these stormy waters, we've curated a list of 20 empowering phrases based on expert advice. These phrases are designed to validate your feelings, soothe your inner critic, fill you with encouragement, and help you respond proactively to anxiety. Here's how you can incorporate them into your life to foster resilience, kindness, and self-compassion. VALIDATE THE DIFFICULTY "This is hard, and it's okay that it's hard for me." Acknowledge the challenge without judgment."I'm doing the best I can in this moment." Remind yourself of your effort and resilience."My feelings are valid and understandable." Affirm the legitimacy of your emotions."I am human, and having a difficult day is okay." Normalize the ups and downs of human experience."I give myself permission to feel this while being kind to myself." Embrace your feelings with compassion. SOOTHE THE CRITICAL VOICE "This is not my fault." Release unwarranted guilt and blame."It’s okay that I’m not perfect." Celebrate your humanity and imperfections."It's okay to make mistakes." View errors as opportunities for growth."My challenges do not define my worth." Separate your worth from your struggles."May I be gentle with myself as I navigate this difficult season?" Practice self-compassion and kindness. FILL YOURSELF WITH ENCOURAGEMENT "It's a beautiful day to do hard things." Empower yourself to face challenges."I can tolerate this discomfort." Recognize your strength and resilience."This anxiety or discomfort will not hurt me." Acknowledge your capacity to withstand anxiety."Humans are innately resilient." Remind yourself of your inherent ability to overcome adversity."I am more than my worst days." Focus on the breadth of your life’s narrative. GET CLEAR ON YOUR RESPONSE TO ANXIETY "I REFUSE to lead a life based on fear." Commit to acting on your values."I choose to speak to myself with understanding and patience." Cultivate a compassionate inner dialogue."I have already chosen how I'm going to respond, and now I'm going to honor that decision." Preemptively decide on positive actions."I will treat myself with the same kindness that I offer others." Extend your empathy inward."I’m going to honor my journey and respect my own pace." Accept your unique path and timing. BONUS PHRASE FOR CONTINUOUS SUPPORT "We are just going to take one step at a time." Focus on the present moment to manage overwhelm. These phrases, thoughtfully designed to address different facets of anxiety, are tools at your disposal. Use them to navigate through moments of anxiety, to remind yourself of your strength, and to cultivate a kinder relationship with yourself. Remember, it's not about employing all of them at once but finding the ones that resonate most with you. Anxiety is a complex and deeply personal experience, and thus, your approach to managing it should be equally personalized. Let these phrases be your guide as you continue on your journey toward a more peaceful and empowered state of being. TRANSCRIPTION:  Here are 20 phrases to use when you are anxious. Now I get it, when you’re anxious, sometimes it’s so hard to concentrate. It’s so hard to know where you’re going, what you want to do, and it’s so easy just to focus on anxiety and get totally stuck in the tunnel vision of anxiety or feel completely overwhelmed by it.  Today, I want to offer you 20 phrases that you can use when you’re feeling anxious or experiencing OCD. These are yours to try on and see if you like them. You don’t have to use all of them. They’re here for you to use as you wish, and hopefully, they’re incredibly helpful. All right, my loves, let’s talk about the 20 phrases you can use when you’re feeling anxious. Now, I have prepared these in four different steps. You can actually go through and pick one or several of these and go through these, write them down, and have them in your pocket or in your wallet, or whatever you want, a sticky note on your fridge to use as you need. These are to help guide you towards a life where you lean into your fear. You treat yourself kindly. You encourage yourself. You champion the direction you want to go in. And my hope is that you can use these in many different scenarios, and they can help you get to the life that you want. Let’s go and do it.  The first category is validate the difficulty. Most people, when they’re anxious, they get caught up in this wrestle of, “I shouldn’t have this. Why do I have it? It’s not fair,” and I totally get it. But what we want to do is first validate the difficulty. If you can say that, and you can do that by using one of these five phrases: Number one, “This is hard, and it’s okay that it’s hard for me.” Again, let’s say it together. “This is hard, and it’s okay that it’s hard for me.” The second phrase that I’m going to offer to you is, “I’m doing the best I can in this moment.” The truth is, you are doing the best you can with what you have and given the circumstances. I want you to remember that as best as you can as well.  Number three, “My feelings are valid and understandable.” If anybody else was in this exact situation, they’d probably be thinking, feeling, and acting in the same way. The fourth one is, “I am human, and having a difficult day is okay.” Not only is it okay, it’s normal. Humans have difficult days. This is a total normal part about being human. You might be having an immense amount of anxiety, but please do remember the millions of other human beings around the globe who are having a very similar experience to you. It doesn’t mean there’s anything wrong with you.  And then the fifth way I want you to validate the difficulty is to say, “I give myself permission to feel this while being kind to myself.” Remember I said “while.” I give myself permission to feel this way while being still kind to myself.  Let’s move on to the second category, which is soothing the critical voice. I know when we have anxiety, we can be really, really hard on ourselves. The phrase I want you to practice or trial is, number one, “This is not my fault.” And it’s not your fault. You did not ask for this. You can’t stop the fact that your brain sometimes gets hijacked and throws a bunch of anxiety or thoughts, or feelings towards your urges. It is not your fault.  The second one is, “It’s okay that I’m not perfect.” Nobody is. We want to remember that this is our first time being a human and we’re not going to get it right the first time. It’s okay that you’re not perfect, nobody is.  You might also want to try the phrase, “It’s okay to make mistakes.” That is how I learn and grow. Remember here of all the people who have succeeded in their recovery, or all the people who are succeeding in other areas of their life, they didn’t get there because of easy, breezy times. They got there by making mistakes, and they’d keep going and they keep trying, and they’d go again and they go again and they learn and they grow. The next thing you may want to try on, and another phrase you can use is, “My challenges do not define my worth.” You’re not either better or worse for having this anxiety. You’re not less than or more than depending on whether you have a mental illness or not. Your worth is not something that’s up for discussion, and it’s not up for measurement. We all have equal worth. And this challenge that you’re experiencing or this anxiety you’re experiencing does not define your worth.  Now, the last one I want you to practice here, you can actually practice more from a meditation or a meditation practice, which is a practice of loving kindness. We could call it a metta meditation or a loving-kindness meditation. And the goal from this is to actually meditate on sending yourself loving kindness.  Now, if you’re someone who wants to learn how to do this, we have an entire meditation vault called the Meditation Vault, where I have created over 30 different meditations for people, specifically with anxiety, to help you practice meditation and learn how to practice loving kindness. You can go to CBTSchool.com to learn more about that. I would, again, need to spend a whole other episode talking to you about that. But if you want to practice the art of sending yourself loving kindness, you can go there to learn more.  But for right now, to finish out this category, what we want to do is practice one of those meditations, which is to offer yourself the phrase, “May I be gentle with myself as I navigate this difficult season?” What we are doing here is we’re offering ourselves a promise per se of saying, “May I be gentle with myself?” In a true loving-kindness meditation, often what we do say is, “May I be happy? May I be well? May I live with ease?” And if you particularly like my voice and it feels very soothing to you, all of those meditations are there in the meditation vaul, and we go through that extensively.  The next section is to fill yourself up with encouragement. Now, when we are anxious, it’s easy to feel very discouraged and just want to run away and change every part of our plans for the day. But what we want to do is we want to fill yourself up with encouragement. Here are some phrases that you can use to help with that goal.  Number one, you know I’m always going to say this, “It’s a beautiful day to do hard things.” We can do hard things. We have to keep repeating this to ourselves. You may even want to add some sass to it and add a little swear word. A lot of my patients have said, “It’s a beautiful day to blank hard things.” Now that’s okay too. You can sass it up, whatever feels most empowering to you.  Another way you can fill yourself up with encouragement is to offer yourself the phrase, “I can tolerate this discomfort,” because you can, and you have, and you will. “I can tolerate this discomfort.” Another thing you can offer is, “This anxiety or this discomfort will not hurt me. I am stronger than I could ever know.” And the truth is, anxiety does not hurt you. It’s uncomfortable, and it’s painful. I understand that. But it won’t hurt you. It won’t damage you. It won’t destroy you, that we’re stronger than we could ever, ever believe we could be.  The next thing you may offer to yourself, and this is one that I particularly love, is that humans are innately resilient. They do most of their growing through hard things. And I’ve already mentioned this to you before. Most of the really successful people got there, not because it was easy and breezy; it’s because we are resilient, and that’s how we grow, and that’s how we learn, that we can get through very, very difficult things. And then the last thing is, “I am more than my worst days.” That this might be a difficult day, but I am more than this difficult day. There’s a bigger story here for me. This uncomfortable moment or this uncomfortable day is just a part of that story. But the bigger picture is that I am much more than these hard, difficult days.  And then the last category, which you have to also include, is to get very clear on how you are going to respond. This is where we get a little more firm with ourselves in the phrases. You will hear, I get a little sassy myself in this, and we get a little more decisive or confident. Even if you don’t feel confident, we want to speak in this confident, assured way.  Number one is, “I REFUSE,” and I’ve written refuse in capital letters. “I REFUSE.” And I say this to myself, I want you to say this to yourself. “I REFUSE to lead a life based on fear.” I will move forward, acting on my values and my beliefs, and who I want to be. That’s the first phrase. And we want to emphasize, “I refuse to act out on this fear.” The second is, “I choose to speak to myself with understanding and patience.” I’m choosing that because it’s so easy to fall back into criticism and blame and humiliation and critical self-punishing words. I choose to speak to myself with understanding and patience.  Now, the third one involves you being very proactive. Now, I’ll give you the phrase first, and then I’ll explain it to you. The phrase is, “I have already chosen how I’m going to respond, and now I’m going to honor that decision.” What I want you to do, if you are someone with anxiety, is to create a plan ahead of time—to have a plan on how you are going to respond to anxiety.  Now, if this is difficult for you, we have two courses that I want you to rely on. Number one is Overcoming Anxiety and Panic, and the other one is ERP School. And that’s for people with OCD and health anxiety. If you’re someone who struggles with generalized anxiety or panic or OCD, you are going to need a plan ahead practice. You’re going to need to know what fear and obsessions and thoughts and fear and all the things get you to do normally. And then you’re going to have to be able to break that cycle with a specific plan on attack on how you’re going to handle that. And we go through those steps in those two courses or any of our courses. We break it down so that you have a specific plan on how you’re going to handle this, what you’re going to do, what you’re not going to do, how you’re going to treat yourself, and so forth.  If you haven’t got a therapist and you want to learn how to do that, head over to CBTSchool.com. Those courses, there is low cost as we could make them, and they’re there for you to help you have a plan so that you can say to your anxiety when you’re struggling, “I’ve already chosen how I wish to respond, and now I’m going to honor that decision. “ Now, the reason that I say that phrase that way is when you have a plan up ahead head, that’s one part of it, but then you have to honor your plan. And what often happens is, when we have a plan and we don’t honor that plan, that’s often when we start to feel like we distrust ourselves. We feel like we’ve let ourselves down.  And so what we want to do is we want to make a plan, and then we want to choose to honor that plan. And by honoring the plan that you set out -- and I’m not going to tell you what that plan should be. The cost isn’t going to tell you what you have to do. You get to decide that for yourself based on your own core values. But once you do that, and when you follow through by honoring that decision that you made ahead of time, that’s when you start to trust yourself. That’s when you start to really feel empowered. That’s when you start to break that cycle of anxiety because you’ve stood firm on the ground on what your plan was and how you’re going to show up.   I’ll repeat it again. “I have already chosen how I want to respond, and now I’m going to honor that decision because I matter, and this is my life, and I want to follow through in the way I said I would.” Now, the fourth one is, “I will treat myself with the same kindness that I offer others in this situation.” Again, we’re speaking firmly and kindly with conviction to ourselves. “I will treat myself with the same kindness that I would offer to others.”  And then the last one is, “I’m going to honor my journey and respect my own pace.” This doesn’t have to be a straightforward, linear process. In fact, it won’t be. And we have to honor our own journey and our own pace, because sometimes it takes longer for us than it does for others. And that’s okay. We’re going to honor our journey. We’re going to respect our own pace.  And I will offer you a bonus phrase, which is, “We are just going to take one step at a time.” Just focus on one step at a time. Because if you’re looking too far ahead, it will get overwhelming. You are handling a huge, huge discomfort. And so we want to be as gentle as we can. We want to honor our values. We want to lead with our values, not lead with fear. And my hope is one or many of these phrases will help you get there. I hope this has been helpful.  Again, I want to remind you, some of these won’t land for you, and that’s entirely okay. Just practice and try the ones that you feel will be helpful, and leave the rest. This is your journey. You get to choose it. I just hope that some of these skills and tools that we talk about on Your Anxiety Toolkit are helpful. And I hope you have a wonderful, wonderful day.
Why teen depression is at an all-time high (with Chinwe Williams) | Ep. 375
Mar 1 2024
Why teen depression is at an all-time high (with Chinwe Williams) | Ep. 375
THE RISING TIDE OF TEEN DEPRESSION: UNDERSTANDING AND ADDRESSING A MODERN CRISIS In recent times, the specter of teen depression has loomed larger than ever before, casting a long shadow over the lives of young individuals across the globe. With reports indicating a significant upsurge in cases of depression among adolescents, the need to unravel the complexity of this issue and explore effective strategies for intervention has never been more urgent. At the heart of the matter is the alarming statistic that suicide rates among teenagers aged 15 to 19 have surged by 76% since 2007, with a particularly distressing increase observed in teen girls. The rates of suicide have doubled among female teens compared to their male counterparts, underscoring a gendered dimension to the crisis. Moreover, the youngest demographic, children between the ages of 10 and 14, has witnessed the highest rate of increase in suicide across all age groups, a fact that underscores the severity and early onset of mental health challenges in today's youth. This escalation in teen depression and suicidal ideation can be attributed to a myriad of factors, ranging from societal pressures and the rapid pace of cultural shifts to the unique challenges posed by the digital age. The omnipresence of social media and technology, while offering new avenues for connection, has paradoxically fostered a sense of isolation and disconnection among adolescents. The digital landscape, with its relentless comparison and instant feedback loops, has exacerbated feelings of inadequacy, anxiety, and despair among young people. Furthermore, the impact of depression is not confined to any single demographic. Contrary to previous beliefs that African-American families were less likely to experience suicidal ideation, recent research has unveiled an elevated risk among African-American boys aged five to 11. This revelation challenges preconceived notions about the protective factors supposedly inherent in certain communities and underscores the indiscriminate nature of mental health challenges. The narrative surrounding teen depression and despair is further complicated by the conflation of despair with clinical depression. While depression is a diagnosable condition characterized by a specific set of symptoms persisting over time, despair can embody similar feelings of hopelessness and sadness without necessarily meeting the criteria for a clinical diagnosis. This distinction is crucial for understanding the breadth and depth of the emotional turmoil experienced by adolescents, which may not always fit neatly into diagnostic categories. Addressing this burgeoning crisis requires a multifaceted approach, centered around the power of connection and the cultivation of resilience. Building resilience in young people involves fostering internal coping mechanisms as well as providing robust external support systems. Parents, educators, and mental health professionals play a pivotal role in modeling healthy coping strategies and offering unwavering support to adolescents navigating the tumultuous waters of mental health challenges. One of the key strategies for combatting teen depression involves nurturing meaningful connections between young people and their caregivers. The act of showing up for adolescents in both significant moments and the mundane details of daily life can have a profound impact on their sense of belonging and self-worth. Consistency in presence and support, coupled with genuine engagement in activities that resonate with the interests of young people, can fortify their emotional resilience and counteract feelings of isolation and despair. In the digital realm, it is imperative to strike a balance between leveraging technology for connectivity and mitigating its potential negative impacts on mental health. Encouraging responsible and mindful use of social media, fostering face-to-face interactions, and emphasizing the importance of digital detoxes can help alleviate the pressure and anxiety associated with online environments. As society grapples with the escalating crisis of teen depression, it becomes increasingly clear that a collective effort is required to address the underlying causes and provide a supportive framework for adolescents. By prioritizing mental health education, advocating for comprehensive support services, and fostering an environment of openness and understanding, we can begin to turn the tide against teen depression. In doing so, we not only alleviate the immediate suffering of young individuals but also lay the groundwork for a healthier, more resilient generation. TRANSCRIPTION Kimberley: Welcome, everybody. I am so delighted to have our guest on today, Dr. Chinwé Williams. Welcome, Dr. Chinwé Williams. I’m so happy to have you here. Chinwé: Oh, I’m so excited to be here. Thanks so much for having me. Kimberley: As I said to you, several months ago, I was having a massive influx of cases of teens, my teen clients and my staff’s teen clients reporting really strong waves of depression, including not just my clients, but also my pre-teen, also reporting that that’s what some of our friends are reporting. I think it’s everywhere. And I really feel that, even though we always talk about anxiety here, I really wanted to make sure we’re addressing the really high rates of depression and despair in teens. So, thank you for writing the most wonderful book. As I went to research that, I found your book, it’s called, Seen: Despair and Anxiety in Kids and Teenagers and the Power of Connection. So, thank you for writing that book.  Chinwé: Thank you so much for reading it. Yes.   Kimberley: Yes, I actually listened to it. So, I actually got to hear your voice, which I thought was really beautiful because you and Will Hutcherson, who wrote it, it was lovely. You bounced back and forward between the two of you. Chinwé: Yes, we did. We did.  Kimberley: What made you decide to write this book? Chinwé: I started my career as a high school counselor, my goodness, probably now 18 years ago, which is so weird for me to admit that, or even wrap my mind around that. And I loved working with adolescents. And in the particular high school that I was working at, we were really, really able to do the work of promoting and supporting the mental and emotional well-being of students, not just the academic well-being. And a lot of my school counselor friends at other schools, they were really focused on the schedule and post-secondary options, and SATs. So, I was really fortunate to be at a school where I saw students almost like how I’m seeing clients clinically, 10 o’clock, 11 o’clock, 11:15, 11:30. And so, that was such a great experience for me, especially early in my career.  The reason we wrote the book is because, back then, 18 years ago, I saw a little bit of self-harm. I saw anxiety. I saw depression. I certainly saw despair. I saw kids, students struggling with relationships, struggling with, what is my future going to look like? However, what we are seeing today, what I am seeing in my clinical practice, I still work with adolescents, but I do work with a great deal of adults. I work with parents and families, and I have conversations with just my friends and people that I’m doing life with. The episodes or experiences of anxiety and depression has really just increased significantly. Kimberley, I am sure that you are so aware of just the stats that are out there that really point to the shift that’s occurred in our culture, specifically as it relates to youth mental health.  Just for example, and this seems like such a long time ago, but I think it really gives us an idea of how much has changed, a good bit has changed in a relatively short period of time. But the stats are pointing to the fact that since 2007, suicide rates have increased a whopping 76% for teenagers between the ages of 15 and 19. So 76%. So the bulk of that number really is pointing to how our teen girls are struggling. Suicide rates are double in teen girls versus our boys. The highest rate of increase in suicide among all age groups—and this is where I always have to take a deep breath still—is in kids. These are kids between the ages of 10 and 14 is what the research is showing.  The alarming part of this whole thing is that we’re seeing younger and younger kids impacted by what we sometimes think of as, yes, adolescence is tough. There are hormones. There’s social pressures. There are academic pressures. Kids are worried about the future. Well, younger and younger kids are also being impacted by feelings of hopelessness and discouragement.  And the other thing—you and I talked about this before we started recording. The other thing that’s been really shocking for a lot of people to learn is when I started my career, way back in the day, we were told that families of color, specifically African-American families, were really the least likely to take their own lives. But what we have learned recently, and this is a stat that has really shocked, but also confused and confounded a lot of clinicians, as well as mental health researchers, is that there’s an elevated risk of suicidal thoughts for African-American boys between the ages of five and 11. So once again, just younger and younger kids are experiencing really hopeless feelings, but we are seeing the most anxiety, the most despair, and depression among adolescents and young adults. So that’s why we wrote the book.  Kimberley: I get teary just hearing about it. My heart aches, and I feel like it’s a crisis. It’s a crisis that they’re experiencing and parents. I think what was really also very beautiful that you talked in the book about how, I think, even as clinicians, we perceive kids who are struggling with, “Oh, they must have gone through a trauma.” But also, it’s just kids who haven’t been through a trauma. I mean, I think the COVID in and of itself and all of the unrest of our world is traumatic for everybody. But it was also very validating to see that this is also for reasons that we yet don’t really understand. Do you want to speak to that at all?  Chinwé: Yes, absolutely. So in the book, I wrote about clients that I’ve experienced throughout the years. I’ve changed factors and variables that would easily identify them. But many people will point to some of the illustrations in the book that are of kids who come from really supportive families. Many of them are high achieving. Many of them have a lot of resources that they just have access to, and yet they still experience levels of anxiety, sadness, even are self-harming, even espouse suicidal thoughts, or we call it suicidal ideation.  What that tells us, again, I think just sort of zooming out, is the bigger picture of just so many things that have shifted in our culture, so many things that have shifted from a societal perspective where young people are feeling disconnected, they’re feeling more anxious, they are more resourced. The research tells us that Gen Alpha and Gen Z are the most diverse, more resourced, tech-savvy. They’re so connected to the technological and global world, but they feel so disconnected oftentimes from themselves, from their family members, and also their friends. And so, I think it really is so interesting that it really speaks to, regardless of the walk of life or where you or your family falls from an income perspective, none of us are immune.  I try to be pretty transparent. My daughter has given me permission to share. She is 20 years old. She’s in college. She is brilliant and kind and thoughtful and highly sensitive and gifted and has a mother who’s a mental health professional. And at 13, she experienced high, high anxiety and high levels of despair. And again, she’s given me permission to share, and I do share this when I talk to parents and educators across the country, and I’m so grateful that she’s given me that permission. But just to show that she had resources. She was in private school. She’s my bonus daughter. She had support from me, her dad, and also her biological mom, and her grandparents, and she still experienced what a lot of kids across the country are experiencing.  Kimberley: I’m so grateful you share that. I think that that’s it too. We would assume that if your bonus mom is a therapist and you have all the resources, it just wouldn’t happen to you. But it doesn’t discriminate, does it? It can affect any family. As a clinician, I don’t think I was really trained to really understand that either. I was trained to think like, okay, there must be something wrong with the family, they must be fighting at home, or there must be discord at home, or so forth. So I’m so grateful that you share that. And thank you to her. How brave and wonderful that she struggled and obviously came through on the other side, absolutely.  In the book, this blew my mind, really, honestly. I’m almost embarrassed to say, but it blew my mind that you described that there is a difference between despair and depression. Can you share what that is all about?  Chinwé: Yes. As you know, depression is a clinical term. It’s a diagnosis that has a set of symptomology that’s connected to it. So, we as clinicians are looking for certain symptoms that exist more days than not over a two-week period of time, right? At that two-week mark, I’m starting to pay a lot of attention when parents are sharing what’s happening with their kids. Because when you’re an adolescent, we know that hormones will shift your mood, you’ll be high on something that you’re watching on TV. Not high literally, because we got to make that distinction. You’re not vaping or using marijuana, but you’re feeling euphoric and you’re elated about something maybe you’re seeing on television. And then you look down at your phone, or your mom asks you to clean your room or do your work. And then you can look like you have a level of despair. But that may not be the case, right? We know with adolescents, there are just normal ups and downs that are just a part of that stage of development.  So it’s important to really share that in order to get a diagnosis of depression. You want to see a number of symptoms for a period of time that really impact your child’s level of functioning in a persistent and pervasive way. Maybe they’re not functioning as well as they normally would at school or if they have an after-school job or an extracurricular activity or you’re noticing that some things at home. So those are some things that we look at from a clinical perspective.  Now, despair is something different, but not by a whole lot. There’s a whole lot of overlap, and we do go into it with pretty great in-depth in the book, but essentially, despair really has a lot of those same symptoms of depression where you’re feeling lethargic, perhaps low energy. You struggle with thoughts that tell you maybe that you’re not enough, you’re inadequate, or inferior. Sometimes you don’t feel like doing those things that you normally love to do. In clinical terms, we call it anhedonia, right? Those things that you typically enjoy that make you happy—playing with your pet, going for a walk, hanging out with your friends. If you’re not doing those things, we do start to wonder about some mood issues, some internalizing disorders. So, anxiety, mood issues such as depression, but with despair, and we make this distinction on purpose with intentionality, and here’s why.  Despair does share a lot of the symptoms as depression, but it doesn’t need to meet the criteria for major depression for us to really know that is a tough place to be. And many of us, especially young people, we may not be able to just relate or connect to having major depression or bipolar, but many of us on this earth can relate to having an experience of loss or grief or deep disappointment, or pain that we just continue to stuff and we rally and we show up for the next thing and we show up for the next thing. But that pain is still there, and it doesn’t really have a place to go because we haven’t really shared with people that we were going through this pain. We just kept going with our routine.  Despair can make you feel the exact same way, but it doesn’t necessarily rise to the level of a mental health diagnosis. And it’s important to point out because young people right now are going to social media outlets like TikTok, and they’re hearing from social media influencers—I put that in quotation marks—that are saying, “If you have this symptom, then you have this diagnosis.” And so, young people are attaching to those labels, and we did not want that in this book. This book is for anyone who has a child, a student, someone that you’re coaching, leading, guiding, that is struggling with a mental health issue, or just struggling emotionally, but it doesn’t necessarily lead to a criteria that indicates that there’s some sort of diagnosis.  Kimberley: Thank you for differentiating that, because that was really cool for me to hear from a clinician diagnostically. That was really cool to know. Let’s talk about solutions. So we know this is happening. You talk about, and I am too is going to say, like we’re sending all the love to the parents who are navigating this. We’re sending all the love to the clinicians and the teachers and the school counselors and the guidance counselors who are navigating this with their teens. What can we do for our teens, or how can we help them?  Chinwé: Excellent question. As a mental health practitioner and a parent of three kids, I know how difficult it can be to sort of see the big picture when your child is struggling. We all can relate to feeling overwhelmed, again, even as a professional. I’ve talked to my pediatrician friends and my medical doctor friends. It’s the same thing when it’s your kid. You have all the head knowledge, but sometimes it can still be difficult.  I think for all of the families that are listening right now, I want you to remember a really important word that’s actually overused. That word is resilience. We’re hearing a whole lot about resilience. We’re hearing a whole lot about emotional resilience, mental resilience. In the book Seen, we call it grit. We acknowledge because I’m talking to educators across the country that are seeing this and parents and even employers that are feeling this. We acknowledge that in a lot of ways, the younger generation, they have lost their grit. They don’t appear to be as resilient as the older generations.  But where I want to step in is by saying that we don’t shame them or blame them. And how many times have we turned on the news and we heard, “Oh, these kids are snowflakes,” or “These kids are weak,” or “They’re not tough, and they just need to pull their pants up,” and whatever the saying is. Kimberley: Pull them up by the bootstraps. Chinwé: Thank you. And your big girl panties—I’ve heard that too. And I was traveling the other day, someone said, “Yeah, my dad always said, ‘Just put some mud on it, put some dirt on it, and keep it going.’” And the older generation, we have a tendency to blame the younger generation for experiencing this mental health crisis, and that just isn’t fair.  We do want to help them to develop grit and build grit, but the way that we help them with resilience is remembering that a key element of resilience is internal coping resources with external support. That external support is key. When young people are facing any sort of mental health challenge, again, it doesn’t have to be depression; it could just be a period of high anxiety or sadness that’s just gone on for too long. They need to know that they have what it takes, but they need people to remind them and people to walk alongside them because life will be full of difficulty, of course. But we want to teach our young people that they can face this, anything that overwhelms them. They can experience that overwhelm, but also know that they have the ability to pull on those internal coping resources, assuming that they’ve been taught those resources, and also access the support of families.  The first thing that I want to tell parents is to model exactly what you want to see. And this is big, and this could be its own episode, and maybe you’ve already done an episode. But the way that we help young people when they’re having a tough time is to model good mental health even—and this is important—even when you’re struggling. Because I struggle sometimes, and I have the coping resources. Life can feel really overwhelming and can test us. But do we pretend like we don’t struggle just because we’re parents or adults or because I’m a licensed professional? Well, how’s that going to help my child?  So, it’s important for parents to know that the very first lesson around mental and emotional wellness has to come from you. When your kids are able to see how you, first of all, identify that you’re having a challenge and then respond to the challenge, that helps them. That helps them know that, okay, I can go through a tough situation or feel a level of distress, but I don’t have to sit with it and rally, or I don’t have to pretend like it hasn’t happened or whatever’s happening hasn’t affected me.  So, what a parent can do is when you get home from work or your day or a meeting with a friend that just was hard and heavy, acknowledge that. We don’t want to weigh kids down, and I get that. We don’t want to put our problems onto them, but it’s okay to say in a very general or conversational way it has been a really long day. Or, “I met with mommy’s friend, Cindy. Oh, she’s had a lot going on in her family. Oh, I just need a moment. I think what I’m going to do is before I get dinner started, I’m going to go for a walk, or I’m going to just take a couple of deep breaths, or I’m just going to have a seat. I’m going to rest.” How many of us—Kimberley, I’m guilty of this—come home, we’ve had a hard day, we heard something heavy, and we go straight to cooking and cleaning and checking homework and all the things. So, what happens to that energy? So, I feel like this is just a really good opportunity to show kids the value of acknowledging that every day isn’t going to be great and it’s not supposed to be, but what can you do about it?  Kimberley: Yeah. That is so important, I think. And I think it’s easier said than done. I think that parents are exhausted too, right? They’re struggling at high rates too, I’m assuming. I don’t know the research on that. So, I think we also need to wrap everyone in compassion in that we’re doing the best we can.  You also talked about social media before and about how much connecting to social media disconnects them from the family. And I think that as parents, sometimes we let them be on tech because parents need a break, you know what I mean? I know I’ve caught myself with that with my nine-year-old of, “I’m just going to let him have some tech time because I need a break,” but then that’s disconnecting them. Can you speak to the impact of social media for teens?  Chinwé: Yeah. I think the first thing that would really highlight this topic is to mention that just so recently, I want to say probably a couple of months ago, we learned that the federal government, along with at that time 13 separate states—I’m sure it’s more at this point—sued the social media giant, Meta, which many of your listeners will recognize Meta as the parent organization for Facebook and Instagram. Now, we use Facebook and Instagram to promote mental health. And so, there are benefits to social media 100%, and I think it’s important to highlight that for parents because some kids really are getting information about causes that they want to support. They are getting information about mental health. Sometimes it’s in the bite-size way where we want them to dig in a little bit more, right? But they’re good aspects to mental health.  But the reason for the lawsuit was because the social media giant was being accused of creating intentionality features that are causing addiction to social media, which is one of the things that has been identified as fueling this mental health crisis among youth. So, there are real stats that are -- we probably have always had a sense that being connected or over-connected to technology wasn’t good. During COVID, what the heck else were we supposed to do as parents? We were doing Zoom school. I’m sure you had your own podcasts at that point. I was doing podcasts. I was doing telehealth. So I appreciated technology, but like you said, a lot of parents really leaned on technology during that time because we didn’t have a whole lot else going on and kids still needed to stay connected, and so did we. But I think that balance is so key.   I’m going to tell you, when I travel and people ask me, what’s the thing that worries you the most about young people as a former high school counselor, someone who works with adolescent mental health? And I say very quickly, without hesitation, that I am really concerned about the fast-paced nature of our culture. We are moving, I think, at lightning speed as a culture. We’re becoming increasingly more digitally connected, which means that we’re becoming more and more less physically connected. So how does that impact our young people? And we’re so quick to point to these things (I’m holding my phone right now) and ask young people, especially teenagers, to do less of this. But if we’re honest, aren’t we just as guilty as parents?  I have a colleague, and I don’t know if you would agree with this at all. I’m still kind of wrapping my mind around it because I like to see hard stats. But I had a colleague that said that he believes that most adults have some level of digital addiction. I don’t know. I don’t know that for a fact, but I know again that we are very much so attached to our phones. And so, the younger generation sees that. And if they’re going through despair, if they’re having thoughts of self-harming, if they’re having anxious thoughts, and they see that we are super duper connected to our phones, where then do they go? Are we essentially modeling the same thing?  So again, I’m not here to say that technology doesn’t have its utility. It’s not all bad. But when our world is moving so fast that our nervous systems can’t keep up, what do we need to do? The answer is to slow down and have more face-to-face connections. Kimberley: Yeah. I think that without the research, I can say for myself, it’s interesting. I actually had a colleague of mine, we both agreed we would track how many times we picked up our phone. And when I tracked it, it was always like, “Oh, I’m overwhelmed. I’ll just watch Instagram for a minute,” or “I’m feeling sad. I’ll just watch Instagram for a second.” And it was like, that’s my first coping skill. This is not good. That’s not good. So I totally agree with what you’re saying.  I have one more question for you. So, the real word that felt so yummy to my whole body when I read your book was the word connection and how important that is for our teens but also for, I think, all humans. How might we connect better with our teens? Chinwé: Oh gosh, can I throw a stat that’s sticking in my head? Can I throw that out right now?  Kimberley: Please. Chinwé: From birth to graduation, I still get goosebumps, and I’ve been saying this for about a year now. From birth to graduation, we have 936 weeks with our kids. 936 weeks and roughly 3,000 hours in one year. So, just depending on where you are in your parenting phase, depending on just who you are and the makeup of your nervous system, that’s going to land differently for you. But I know the first time, and even today when I hear that, I’m like, “There’s not enough time. Am I doing enough? Should I not be on this podcast? Should I be with her in school?” So it’s fine.  But I think that, like, am I spending enough time? Am I connecting? And I don’t know one parent that I’ve counseled or that I do life with that doesn’t want to be a good parent. And I always remind parents that it’s not this whole connection piece that we’re seeing in the attachment research and the neuroscientific research. It’s not about being a perfect parent. It really is about being an intentional parent and showing up undistracted. So that whole conversation about before we check our kids, let’s see if we’re modeling the behavior we want them to see as it relates to technology. And again, tons of compassion. I’m a huge proponent on giving yourself the kindness that you would give someone else who might be struggling. So, that’s really important. But showing up undistracted, but also showing up when it’s not convenient.  We know through brain research that connection can help bring down all of that energy that happens on the right side of the brain when an individual is highly activated, high anxiety for far too long, a state of despair for far too long, which can actually end up feeling like just numbness, like I feel nothing.  So, what helps individuals to begin to heal, promote that healing is connection with another human being that they feel loved and cared for, that they feel respected, someone that respects them, someone that values who they are, not just what they do. “I love you just for who you are.” That’s something that I say.  I’m actually being reminded of a Valentine’s Day card that my third grader made for me. And he wrote the sweetest thing, and I’m not going to read all of it, but at the very end, he said, “Thank you for loving me even when I’m unlovable.” And I sort of chuckled, and he read it to me and we laughed at the same time because that’s something I say to him all the time. Regardless of the behavior, regardless of what we are facing right now, the correction or the challenge, or you’re not getting along with your brother, I love you no matter what.  So, even just hearing that, even just hearing that as adults that someone is going to be by our side and going to help us through a tough time, even when maybe we’re not acting lovable or “acceptable” from society’s perspective, what’s better than that?  One of the very first tools that we talk about in our book Seen, we have five connection tools. The very first tool is showing up and showing up when it’s not convenient. As mama bears and papa bears, we have that instinct to swoop in and protect our kids when they’re struggling. And we also show up during those huge milestone moments—the concerts, the graduations, the big sporting events. And by the way, kids want to look up and see us and see grandparents in the stands. That’s important. But the kids that I’ve been counseling throughout the years, they want their parents to show up in the seemingly insignificant and mundane moments of life, just to do basic things. Not to check the homework, not to talk about the boy that texted last night, but go for a coffee to just connect. Go in the front yard and play basketball. Go fishing.  The key is whatever is meaningful and valuable to your child, those are the things that we want parents to engage in. And consistency really matters. And we’re talking about teenagers. This is what I’ve learned throughout the years, especially when I was a school counselor—the tendency is to think that as our kids get older, they need us less and less. And this is what my teenagers in therapy are telling me—I find that when they hit 13, 14, and 15, ooh, they are making huge life decisions. And even though there’s sometimes that conflict that happens between parents and teenagers or parents and preteens that can cause parents to sometimes disconnect because we get our feelings hurt sometimes and disengage, that’s when our kids are making really tough life decisions, so that’s when they need us the most.  Consistency matters. So, it’s not showing up here and there. No knock on people who have busy lives and busy jobs, but the research shows that consistency builds trust. So, we show up, we show up undistracted, and we show up before they ask us to. Kimberley: So beautiful. For me, it’s been a constant reminder of like, look them in the eyes. It’s so easy to be talking while chopping vegetables or checking email. It’s like, “Kimberley, stop and look at them in the eyes. That’s what they need to be seen.” So, I love that so much.  I understand that you have a new book out. Please tell us all about where people can find you and learn about you. And you have a new book out. Tell us all the things. Chinwé: Oh, thank you so much. Yes, our first book was Seen, which is really a book for connecting with a young person, if you’re a parent, educator, coach, regardless of mental health diagnosis. However, as we were traveling and sharing about the contents of Seen, everywhere we would go, parents would say, “Oh, this is awesome. I’m going to give this to my teenager.” And Will and I would be like, “No, this is not for your teenager; this is actually for you and another caring adult.” And then they would say, “Well, where’s the book for teenagers or is there a workbook?”  And so, we wrestled with this for about a year, and we decided, looking at the stats, that’s really pointing to anxiety being super high, very rampant among all of us, including adults, 28% of adults have an anxiety disorder. We also are seeing that young people, adolescents, and young adults are struggling with anxiety. So we wrote a book that’s specifically for strategies to help with anxiety, and it’s called Beyond the Spiral: Why You Shouldn’t Believe Everything Anxiety Tells You. And it’s really going over six different lies that anxiety tells you. And here’s a sneak peek: Anxiety tells you that you have no control. Anxiety tells you that you’re going to miss out. Anxiety tells you that you should just ignore it, and anxiety tells you that you’re not safe. And there are two more. But then every single chapter, we talk about
What it is REALLY like to be an Anxiety Therapist | Ep. 374
Feb 16 2024
What it is REALLY like to be an Anxiety Therapist | Ep. 374
In the realm of mental health, the role of an anxiety therapist is often shrouded in mystery and misconceptions. To shed light on this crucial profession, Joshua Fletcher, also known as AnxietyJosh, shares insights from his latest book, "And How Does That Make You Feel?: Everything You (N)ever Wanted to Know About Therapy," in a candid conversation with Kimberley Quinlan on her podcast. Joshua's book aims to demystify the therapeutic process, offering readers an intimate look behind the therapy door. It's not just a guide for those struggling with anxiety but an engaging narrative that invites the general public into the world of therapy. The book's unique angle stems from a simple yet intriguing question: Have you ever wondered what your therapist is thinking? One of the book's key revelations is the humanity of therapists. Joshua emphasizes that therapists, like their clients, are complex individuals with their own vices, flaws, and inner dialogues. The book begins with a scene where Joshua, amidst a breakthrough session with a client, battles an array of internal voices—from the biological urge to use the restroom to the critical voice questioning his decision to drink an Americano right before the session. This honest portrayal extends to the array of voices that therapists and all humans contend with, including anxiety, criticism, and analytical thinking. Joshua's narrative skillfully normalizes the internal chatter that professionals experience, even as they maintain a composed exterior. The conversation also touches upon the diverse modalities of therapy, highlighting the importance of finding the right approach for each individual's needs. Joshua jests about "The Yunger Games," a fictional annual event where therapists from various modalities compete, underscoring the passionate debates within the therapeutic community regarding the most effective treatment methods. A significant portion of the book delves into the personal growth and challenges therapists face, including dealing with their triggers and the balance between professional detachment and personal empathy. Joshua shares an anecdote about experiencing a trigger related to grief during a session, illustrating how therapists navigate their emotional landscapes while maintaining focus on their clients' needs. The awkwardness of encountering clients outside the therapy room is another aspect Joshua candidly discusses. He humorously describes the internal turmoil therapists experience when meeting clients in public, highlighting the delicate balance of maintaining confidentiality and acknowledging the shared human experience. Joshua's book, and his conversation with Kimberley, paint a vivid picture of the life of an anxiety therapist. It's a role filled with challenges, personal growth, and the profound satisfaction of facilitating others' journeys toward mental wellness. By pulling back the curtain on the therapeutic process, Joshua hopes to demystify therapy, making it more accessible and less intimidating for those considering it. In essence, being an anxiety therapist is about embracing one's humanity, continuously learning, and engaging in the most human conversations without judgment. It's a profession that requires not only a deep understanding of mental health but also a willingness to confront one's vulnerabilities and grow alongside their clients. Through his book and the insights shared in this conversation, Joshua Fletcher invites us all to appreciate the intricate dance of therapy—a dance that, at its best, can be life-changing for both the therapist and the client. Transcript:  Kimberley: I’m very happy to have back on the show Joshua Fletcher, a dear friend of mine and quite a rock star. He has written a new book called And How Does That Make You Feel?: Everything You (N)ever Wanted to Know About Therapy. Welcome back, Josh. Joshua: It’s good to be back. Thanks, Kim. When was the last time we spoke together on a podcast? I think you were on The Disordered podcast not so long ago. That was lovely. But I remember my guest appearance on Your Anxiety Toolkit was lovely. HOW DOES THAT MAKE YOU FEEL?  Kimberley: I know. I’m so happy to actually spend some time chatting with you together. I’m very excited about your new book. It’s all about therapy and anxiety and what it’s really like to be an anxiety therapist and the process of therapy and all the things. How did this book come about? Joshua: I wanted to write a book about people who struggle with anxiety, but in the mainstream, because a lot of the literature out there is very self-help, and it’s in a certain niche. One of my biggest passions is to write something engaging with a nice plot where people are reading about something or a storyline that they’re interested in whilst inadvertently learning without realizing you’re learning. That’s my kind of entertainment—when I watch a show and I’ve learned a lot about something or when I’ve read a book and I’ve inadvertently learned loads of things because I’m taking in the plot.  With this book, I wanted to write a book about therapy. Now, that initially might not get people to pick it up, might not interest you, might not interest you about anxiety therapy, but I wanted to write something that anyone could pick up and enjoy and learn lots because I want to share our world that we work in with the general public. And so, the hook that I focused on here was, have you ever wanted to know what your therapist is thinking? And I thought, well, I’m going to tell people what I’m thinking, and I’m going to invite people behind the therapy door, and you’re going to see what I do and what’s going on in my head as I’m trying to work with people who struggle with mental health.  I wrote the pitch for it. People went bananas, and they loved it because it’s not been done before. Not necessarily a good thing if it’s not been done before. And here we are. I love it. I’m really proud of it. I want people to laugh, cry, be informed. If you go on a journey, learn more about therapy, learn more about anxiety. All in one book. THERAPISTS ARE HUMANS TOO Kimberley: Yeah. I think that one of the many cool things about it is, as a therapist, people seem to be always very curious or intrigued about therapists, about what it’s like and what it’s like to be in a room with someone who’s really struggling, or when you’re handling really difficult topics, and how to be just a normal human being and a therapist at the same time. Joshua: Yeah. What I want to write about is to remind people that therapists are humans. We have our vices and flaws. I’m not talking on behalf of you, Kim. I’m sure you’re perfect.  Kimberley: No, no. No, no. Flawed as flawed could be. Joshua: Yeah, but to a level that it’s like, even our brains have different voices in them all the time, different thought processes as part of our rationalization. And I want people to peer inside that and have a look. So, one of them is like the book opens with me and a client and it’s going really well, and this person’s talking, this character’s talking about where they’re up to, and celebrating on the brink of something great. And then there’s the voice of biology that just pops into the room, into my head. And it’s the biology of you need to go to the toilet. Why did it? And then the voice of critic comes in and says, “Why did you drink an Americano moments before this client?” Now you’re sat here, and you can leave if you want, but it would be distasteful. And you’re on this brink of this breakthrough.  And so, I’ve got this argument going on in my head, going, “You need the toilet.” “Yeah, but this person’s on a breakthrough.” And then I got empathy, like, “Yeah, but they feel so vulnerable. They want to share this.” And then you’ve got analytical and all the chaotic conversations that are happening as a therapist as I’m sat there nodding and really wanting the best for my client. THE VOICES IN OUR HEAD Kimberley: Exactly. That’s why I thought it was so brilliant. So, for those of you who haven’t read it, I encourage you to, but Josh really outlines at the beginning of the book all of these different voices that therapists and all humans have. There’s the anxiety’s voice and there’s biology, which you said, like, “I need to go to the restroom,” or there’s the critic that’s judging you, or there’s the analytical piece, which is the clinical piece that’s making sense of the client and what’s going on and the relationship and all the things. And I really resonated with that because I think that we think as clinicians, as we get better and more seasoned, that we only show up with this professional voice we’re on the whole time, but we’re so not. We’re so not on the whole time. This whole chatter is happening in the background. And I think you did a beautiful job of just normalizing that. Joshua: Thanks, Kim. It’s a book that therapists will like, but do you know what? People will identify their own voices in this, particularly the anxiety. You and I talk about anxiety all day every day, always beginning with what if—that voice of worry that sits around a big table of thoughts and tries to shout the loudest and often gets our attention. And I tried to show that this happens to a lot of people as well. It’s just the what-if is different. So, for some people, it’s, “What if this intrusive thought is true?” For some people, it’s, “What if I have a panic attack?” For some people, it’s, “What if this catastrophe I’ve been ruminating on for so long happens?” For therapists, it’s, “What if the worst thing that happens here, even in the therapy room?”  I’m an anxiety therapist that has been through anxiety, and I still get anxiety because I’m human. So, I celebrate these voices as well. Also, because I’m human, I can be critical almost always of myself in the book. So, I’m not just criticizing the people I’m working with. Absolutely not. But that voice comes in, and it’s about balancing it and showing the work and what a lot of training to be a therapist is. It’s about choosing the voice. And I didn’t realize how much training to be a therapist actually helps me live day-to-day. Actually, I’m more rational when making more life decisions because I can choose to observe each voice, which was integral to me overcoming an anxiety disorder, as well as just facing life’s challenges every day. WHAT IS IT LIKE TO BE A THERAPIST?  Kimberley: Right. Because we’re really today talking a lot about what it’s ACTUALLY like to be a therapist—and I emphasize the word ‘actually’—what is it actually like to be a therapist, if we were to be really honest? Joshua: One thing I mentioned is that I talk about the therapeutic hour, which is how long, Kimberley? Kimberley: Fifty minutes. Joshua: Yeah. The therapy took out and I explained what we do in the 10 minutes that we have between clients on a busy day. And people imagine us doing meditation or grounding ourselves or reflecting or whatever. Sometimes I do do that. Sometimes I just scroll Reddit, look at memes, eat candy, and do nothing. And it’s different each time. That’s what I’m doing. I’m not some mystic sage in my office, sitting sinisterly under the lamplight waiting for you to come in. No, I’m usually faffing around, panicking, checking that I don’t look like a scruff, putting a brush through my hair, trying to hide the stains of food I’ve got on my shirt because I overzealously consume my lunch.  And there’s obviously some funny stories in there, but also there’s dark stuff in there as well. When I trained to be a therapist, I went through grief, and I made some quite unethical decisions back when I was training. Not the ones I’m proud of, but it actually shows the serious side of mental health and that a lot of therapists become therapists because of their own journeys. And I know that that applies to a lot of therapists I know. Kimberley: For sure. I have to tell a story. A few months ago—I’m a member of lots of these therapist Facebook groups—one of the therapists asked a question and said, “Tell me a little bit what your hour looks like before you see a client. What’s your routine or your procedure pre-clients?” And all these people were saying, “I journal and I meditate and all of these things.” Some people were like, “I water the plants and I get my laptop open.” And I just posted a meme of someone who’s pushing all the crap off my table and screeching into the computer screen and being like sitting up straight. And all of these people responded like, “Thank God,” because all the therapists were beautifully saying, and I just came in here honestly, “Sometimes I literally sit down, open the laptop, and it is a mess. But I can in that moment be like, ‘Take a breath,’ and be like, ‘Tell me how you’re doing.’” Like you said, how does that end? We start the therapeutic hour. And I think that we have to normalize therapists being that kind of person. Joshua: Definitely. I think one of the barriers to people seeking therapy is that power dynamic, that age-old trope that someone stood leaning against a mahogany bookcase. You’ve probably got a mahogany bookcase. Your practice is really nice. I certainly have. I’ve got an Ikea KALLAX unit full of books I’ve never read.  Kimberley: Exactly. Your books aren’t organized by color because mine are not. Joshua: No, no. There’s just some filler books in there. Just like, why is Catcher in the Rye? Why is Catcher in the Rye? I don’t know, I just put it on there. I just want to look clever. Anyway, it’s like people are afraid of that power dynamic of some authority figure going in there about to judge them, mind-read them, shame them, or analyze them. And no, I think dispelling that myth by showing how human we are can challenge that power dynamic. It certainly did for me. I would much rather open up to someone who isn’t showing the pretense that they have all of life together. Don’t get me wrong, professionalism is essential, but someone who’s professional and human, because going to therapy is some of the most human experiences you’ll ever do. I don’t want someone who isn’t showing too scared to show that sign or certain elements of being human, but obviously professionally. And it’s a fine balance to get. But when you do find a therapist like that, for me personally, one who’s knowledgeable, compassionate, empathetic, has humility, I think beautiful things can happen. Kimberley: Yeah. I think you use the word that I exactly was thinking of, which is, it’s such a balancing act to, as a therapist, honor your own humanity from a place of compassion. Like, yeah, we’re not going to have it all together and it’s not going to be perfect, and we won’t say the right thing all the time. But at the same time, be thoughtful and have the skills and the supervision to balance it so that you are showing up really professional and from that clinical perspective.  DO THERAPISTS GET CONSULTATION?  Tell me a little bit about consultation as a clinician. I know for me, I require a lot of consultation for cases, not because I don’t know what I’m doing, but I’m always going to be honest with the fact that maybe I’m seeing it from a perspective that I hadn’t thought of yet. What are your thoughts on that kind of topic? Joshua: Therapy’s got to work for both people as well, because the therapeutic connection, I believe, is one of the drivers that promotes therapeutic growth and change. It promotes trust. I will consult with clients and my supervisor and make sure it’s right. I’m not everyone’s cup of tea, but for people, particularly with anxiety disorders, I think they like to know and come to therapy. I think I’ve used self-disclosure on my public platforms tastefully in the sense that I know what it’s like to have gone through an anxiety disorder, whether it’s OCD or panic disorder or agoraphobia, and come out the other side.  But also, it’s balancing that with, “Actually, I’m your therapist here. I will help you in a therapeutic setting and use my training.” You know I’m not someone who’s got everything worked out, but you do know that someone who can relate that can step into your frame of reference, something I talk about a lot in the book frame of reference and empathy. If you feel like a therapist has done that and is in your frame of reference and it’s like, “Ah, yeah, they get it or they’re at least trying,” and we as therapists feel like there’s a connection there too on a professional and therapeutic level, I think magic can happen. And I love therapy for that. Not all therapy is great and beautiful and wonderful. Some of it is messy, and some of it just doesn’t work sometimes. And I do talk about that too, but it’s about when you get that intricate dance and match between therapist and client, I think it’s life-changing. WHAT TYPE OF PERSON DO YOU NEED TO BE TO BECOME AN ANXIETY THERAPIST? Kimberley: Yeah. What do you think about the type of person you would have to be to be an anxiety specialist, especially if you’re doing exposure and response prevention? The reason I ask that is I have a private practice in California. I have eight clinicians that work for me. Almost every time I have a position that’s open, and when I’m interviewing people to come on to my team, I would say 60% come in, and they’re good to go. They’re like, “I want to do this. I love the idea of exposure therapy.” But there is often 40% who say, “I’m not cut out for this work. This is not how I was trained. It’s not how I think about things.” After I’ve explained to them what we do and the success rate and the science behind it, they clearly say, “This isn’t for me.” What are your thoughts about what it takes or what kind of person it takes to be an anxiety specialist? Joshua: That’s a great question. First of all, you’ve got to trust and believe in the modality that you’re trained in. You and I use the principles a lot of cognitive behavioral therapy and exposure response prevention. I’ve got first-hand experience of that. You’ve got to trust the science and what we know about human biology, which is really important. It’s about what you’re trading in that modality. What I talk about -- again, see how I’m segueing it back to the book. Brilliant. I’ve done my media training, Kim. It’s like, “Always go back to the book. Come on, Josh.” One of my favorite chapters in the book is explaining about modalities because a lot of people just think therapy is one big world where you see a therapist, they wave a magic wand, you feel better, and suddenly our parents love us again. No, that’s not how it works.  Kimberley: It’s not? DIFFERENT TYPES OF ANXIETY THERAPISTS Joshua: No, it’s not. Mental health has different presentations, and a modality is a school of thought that approaches difficulties in mental health. So, the first modality I go to is person-centered, which is counseling skills, listening, empathy, unconditional positive regard.  The Carl Rogers way of thinking—I think I love that. Is that good for OCD, intrusive thoughts, exposure therapy, and phobias? Not really. It’s nice to have a base of that because there’s more chance of a therapist being understanding, stepping in your frame of reference, and supporting you through that modality. But I wouldn’t say it’s equipped for that.  Whereas in CBT, a lot of it is psychoeducation, which I love. And that’s a different modality. Cognitive behavioral sciences, whether it’s third wave, when you’re looking at acceptance commitment, where are you looking at exposure response prevention. There’s lots of song and dance about I-CBT at the moment and things like that. They’re all different modalities and skills of thought.  Then you’ve got psychodynamic, which is the mahogany bookcase, lie on the sofa, let’s play word association. Oh yeah, you want to sleep with your mom, Josh? No, I don’t. That’s nothing to do with why I keep having panic attacks in the supermarket. Stop judging me. But that’s a different type of approach. Jungian approach can be quite insightful, but it’s got to match what the presentation is for you.  I think CBT is my favorite, but it sucks for stuff like grief. When I was grieving, I did not want CBT. I did not want my grief formulated. I did not want to see that my behaviors were perpetuating discomfort. I was like, “Yeah, that’s just part of my grieving process.” And in this chapter, I just talk about the different modalities. Therapists are very passionate about the modality of the school that they train in because you have to give part of yourself to it. You have to go through it yourself. And I’m very passionate about the modalities I’m trained in. And so, I play on this in the book. There’s a chapter called The Younger Games or The Yunger Games, a play on words. And basically, it’s once-a-year therapists from every modality, whether it’s hypnotherapy, transactional analysis, CBT, person-centered, the trauma-informed. All of these, they all meet up in a field, and we all fight to the death. And the last remaining person is crowned the one true modality. Now last year, it was hypnotherapy. And what I also say is that a betting tip for next year is the trauma-informed. So, every year, I’ll keep you updated on The Yunger Games. And basically, it’s a narrative device to explain that.  Within the world of therapy, there are different types of therapists. You and I, we love CBT. We’ll bang the drum for that. We feel that there’s not enough ERP out there that certainly isn’t, particularly with the evidence and the points towards it and mountains of evidence. But other therapists may not feel the same. So, when people come to work at CBT School and they realize that Dumbledore, aka Kim Quinlan, is like, “No, we do ERP here; we’ve got to get down and dirty and do the horrible work,” they’re like, “That’s not conducive to the softer step-back approach that I’ve trained in, in my modality.” Kimberley: Yeah. I’m always so happy that they just are honest with me. I remember as an intern at OCD Center in Los Angeles very clearly saying, “Are you okay talking about really very sexual, very, very graphic topics?” He listed off. Like, “Here is what you’re going to need to be able to talk about very clearly with a very straight face. You can’t have a wincing look on your face when you talk about intrusive, violent sexual thoughts. You’re going to have to be up for the game.” And I think that was a big thing for me. But what I think is really cool about your book, and you see now I’m bringing it back to your book, is it doesn’t mean the voice isn’t in your head sometimes questioning you. As I was reading it, I’m like, there is an imposter in therapists all the time saying, like you said, the critic that’s like, “You don’t know what you’re doing. You’re a failure. You’re a flake. You’re a complete fraud. You haven’t got it together. Maybe you haven’t even worked on the thing yourself yet.” That’s going to be there. Joshua: Yeah, and I still get that. I can’t speak for you. But I think what makes a good therapist is a therapist who self-doubts. You don’t want to go and see a therapist who thinks that they’ve got it all worked out. That’s a red flag in itself. A good therapist is one that always wants to improve and uses that doubt and anxiety to make themselves a better therapist. Don’t get me wrong, I’m pretty confident in my ability to be a therapist now, but there are challenges. In the book, the voices that come up, there’s 13 of them. One of them is escapist, which is, “I just want to get the hell out of you,” or “Maybe I want to get rid of this client. I’m not equipped for it.” And then the other voices come in and they’re like, “But maybe this is just you being critical,” or “The evidence suggests that actually you are trained for this,” and navigating that doubt, the anxiety that your therapist has. And I think it’s a beautiful thing.  A lot of therapists are very harsh on themselves, but I think it’s a gift to have that inner critic. Because if you stand there like one of these therapists, and these therapists do exist, unfortunately, I have completed all my training. I know everything inside out. My word is gospel. I worked out what the problem was with this person within 10 minutes. You don’t want to talk to that person. What a close-minded moron. And there’s a judgmental voice from a therapist. Kimberley: No, but I think that’s informed. Joshua: So, it celebrates the vulnerability. You want a therapist who’s not got everything worked out. Absolutely. I do anyway. Kimberley: Yeah, for sure. I’m wondering, how often have you had to work through your own shit in the room with a client? Meaning—I’ll give you a personal example—the very first time I ever experienced derealization for myself was with a client, and I was sitting across from them. They were just talking, and all of a sudden, I had this shift, like everything wasn’t real. Their head looked enormous and their body looked tiny. Like they were this tiny little bobbly head thing on the couch. And I knew what was happening. Thankfully, I knew what it was like. I knew what it was. Otherwise, I probably would have panicked, but I had to spend the rest of the session being as level and mindful as I could as I watched their head just bubble around in this disproportionate way. I got through it. I can say confidently I think I pulled it off really well, but it was hard. And I left the session being like, “What the heck just happened?” Has there been any experiences for you like that? Joshua: Yeah, all the time. I mean, first of all, I’d question if you did have derealization. I was your client with a giant head and a tiny body. I was like, “What’s going on here?” There wasn’t derealization. That’s my body, Kim. Kimberley: No, that’s just how I look, Kimberley.  Joshua: It’s just how I look.  Kimberley: “Stop judging.” Joshua: But in general, no, it’s true. And again, one of the voices in my book, And How Does That Make You Feel?, it’s called trigger because therapists, they have to give a lot of themselves and they’re living a life and have had stuff in their past. One of the voices is trigger. One of the things I get asked a lot is, I don’t know about you, Kim, “If you’ve had anxiety, how can you work with it all day?” I’m like, “Because I’m all right with it. It’s okay now.” Sometimes it creeps in, though, if I’m tired or have not slept well. There’s stress in my personal life that you can’t avoid. Maybe I’ve not eaten too well. Maybe it’s just ongoing things. Sometimes trigger can happen, and it can be a stress-induced trigger or it could be a literal trigger from a traumatic event.  So, in the book, I explain when people bring grief and death, that sometimes makes me feel vulnerable because of my own experiences with grief and death. No spoilers, but the book throughout, one of the themes is why I became a therapist. Not only because of my passion for anxiety disorders and to be self-righteous around other therapists, train different modalities, but also because it’s a very grief-informed decision to want to help people.  And there’s several traumatic stories. One traumatic story around grief, that trigger, the voice of trigger will come up. So, a client could be talking about their life, like, “I’ve lost this person; I’m going to talk about it.” And of all these 13 voices around the table, what your therapist is thinking, trigger then shouts loudest. It goes, “Ah, trigger.” There’s some pain that you’ve not felt for a while and I’ve got to navigate it. You navigated the derealization, the dissociation. You’ve got to navigate it somehow by pulling on the other voices. And not only do therapists do this, but people do this as well sometimes, whether you’ve got to be professional or you don’t want to turn up to your friend’s birthday and just listen to trigger and anxiety and start crying all over your friend’s birthday cake. You might do. It’s quite funny, but not funny.  Kimberley: I was going to say, what’s wrong with that?  Joshua: Have you done it again? I thought you stopped that.  Kimberley: Yeah. You haven’t done that?  Joshua: It’s part of the interview at CBT School. You need to do really hard, tricky things. Go to your best friend’s birthday and make it all about you.  Kimberley: Exactly. Joshua: But yeah, it’s one of those. It crops up. The book’s funny a lot, but it’s good. It takes some really serious turns, and it shows you a lot of stuff can creep in and how I deal with it as a therapist. And I’m sure you related to it as well, Kim, because we do the same job, but you just do it in a sunnier climate. SEEING CLIENTS IN PUBLIC  Kimberley: Right. What I can say, and this will be the last thing that I point out, is you also address the awkwardness of being a therapist, seeing your clients in public and the awkwardness of that, or the, “Oh crap, I know this person from somewhere.” Again, no trigger. I don’t want to give the fun parts of the book, but as a therapist, particularly as someone who does exposure therapy, I might go across the road and take a client to have coffee because they’ve got to do exposures. We very often do see people, our clients, our friends in our work. How much does that impact the work that you do? Joshua: If you ever bump into your therapist, just know that you have all the power there. Your therapist is squirming inside, “I don’t know what I’m doing. I don’t know. Do I completely blank this person?” But then I look like a dick. “Do I give a subtle nod? Oh, you’re breaking confidentiality. They’re out with loved ones.” It’s up to you. You can put your therapist out of their misery by just saying, “Hey, Kim.” “Hey, Josh.” And then I will say hi back because that shows that you’re okay with that.  There is a very extreme shocking version of this story, of this incident in the book where, when I’m at my lowest, I do bump into a previous client. On a night out, when I’m off my face on alcohol. Oh, if you want to find out more about that... Media training’s really paid off. Get him on the hip.  Kimberley: I didn’t want to give it all away, and you just did. Joshua: No, no, not giving any more away. A media training woman said, “Entice them, then leave it, because then they’re more likely to read it.” So, I have listened to that media woman because my previous tactic of just begging and screaming into a camera doesn’t work. It’s like... Kimberley: But going back exactly—going back, we are squirming. I think that is true that there is a squirm factor there when you see clients, and it happens quite regularly for me. But I think I’ve come to overcome that by really disclosing ahead of time. Like if I see you outside, you’re in the place of power, you decide what to do, and I’ll just follow your suit. It’s a squirm factor, though. Joshua: See, that’s clever, good therapy stuff because you do it all part of the contracting and stuff. Actually, I told all my clients this is okay. But also, when you’re a new therapist or sometimes you forget, you’re like, “Oh no.” I used to run a music night in Manchester as part thing I did on the side. Enjoy it, love music, I was the host. One week I was on holiday, so a friend organized all the lineup of people to come down. Headline Act was a band name. Went along, and when I’m there, I’m having fun.
Living with Depression: Daily Routines for Mental Wellness | Ep. 373
Feb 9 2024
Living with Depression: Daily Routines for Mental Wellness | Ep. 373
In the realm of mental health, the significance of structured daily routines for depression cannot be overstated. Kimberley Quinlan, an anxiety specialist with a focus on mindfulness, Cognitive Behavioral Therapy (CBT), and self-compassion, emphasizes the transformative impact that Daily Routines for Depression can have on individuals grappling with this challenging condition. Depression, characterized by persistent feelings of sadness, hopelessness, and a lack of interest in once-enjoyable activities, affects every aspect of one's life. Quinlan stresses that while professional therapy and medication are fundamental in the treatment of depression, integrating specific daily routines into one's lifestyle can offer a complementary path toward recovery and mental wellness. THE POWER OF MORNING ROUTINES FOR DEPRESSION Starting the day with a purpose can set a positive tone for individuals battling depression. Quinlan recommends establishing a consistent wake-up time to combat common sleep disturbances associated with depression. Incorporating light physical activity, such as stretching or a gentle walk, can significantly boost mood. Mindfulness practices, including meditation, journaling, or gratitude exercises, can help foster a healthier relationship with one's thoughts and emotions. Additionally, a nutritious breakfast can provide the necessary energy to face the day, an essential component of "Daily Routines for Depression." DAYTIME ROUTINES FOR DEPRESSION Throughout the day, setting realistic goals and priorities can help maintain focus and motivation. Quinlan advocates for the inclusion of pleasurable activities within one's schedule to counteract the anhedonia often experienced in depression. Techniques like the Pomodoro Method can aid in managing tasks without becoming overwhelmed, breaking down activities into manageable segments with short breaks in between. Exposure to natural light and ensuring a balanced diet further contribute to improving mood and energy levels during the day. EVENING ROUTINES FOR DEPRESSION As the day draws to a close, engaging in a digital detox and indulging in relaxation techniques become crucial. Limiting screen time and investing time in hobbies or skills can provide a sense of accomplishment and fulfillment. Establishing a calming bedtime routine, including activities like reading or taking a bath, can enhance sleep quality, an essential factor in "Daily Routines for Depression." WEEKLY ACTIVITIES TO OVERCOME DEPRESSION Quinlan also highlights the importance of incorporating hobbies and community engagement into weekly routines. Finding a sense of belonging and purpose through social interactions and new skills can offer a much-needed respite from the isolating effects of depression. NAVIGATING TOUGH DAYS WITH COMPASSION Acknowledging that the journey through depression is fraught with ups and downs, Quinlan advises adopting a compassionate and simplified approach on particularly challenging days. Focusing on basic self-care and seeking support when needed can provide a foundation for resilience and recovery. In conclusion, Daily Routines for Depression are not just about managing symptoms but about rebuilding a life where mental wellness is prioritized. Through mindful planning and self-compassion, individuals can navigate the complexities of depression and move towards a more hopeful and fulfilling future. PODCAST TRANSCRIPT If you’re living with depression today, we are going to go through some daily routines for your mental wellness.  Welcome. My name is Kimberley Quinlan. I’m an anxiety specialist. I talk all about mindfulness, CBT, self-compassion, and skills that you can use to help you with your mental wellness.  Let’s talk about living with depression, specifically about daily routines that will set you up for success. My goal first is to really highlight the importance of routines. Routines are going to be the most important part of your depression recovery, besides, of course, seeing your therapist and talking with your doctor about medication.  This is the work that we do at home every day to set ourselves up for success, finding ways that we can manage our depression, overcome our depression by tweaking the way in which we live our daily life because the way we live our lives often will impact how severe our depression can get. There are some behaviors and actions that can very much exacerbate and worsen depression. And there are some behaviors and routines that can very much improve your depression. So, let’s talk about them today. DEPRESSION SYMTPOMS Let’s first just get really clear on depression and depression symptoms. Depression is a common and can be a very serious mental illness and medical condition that can completely negatively impact your life—the way you feel, the way you think, the way you act. It often includes persistent feelings of sadness, emptiness, hopelessness, worthlessness that can really impact the way you see yourself and your own identity. It often includes a lack of interest in pleasure in the activities that you once enjoyed.  Depression symptoms can vary from mild to very severe. They can include symptoms such as changes in appetite, sleep disturbances, loss of energy, excessive guilt, difficulty thinking or concentrating. Sometimes you can feel like you have this whole brain fog. And again, deep, overwhelming feelings of worthlessness and hopelessness.  Now, it is important to recognize that depression is not just a temporary bout of sadness. It’s a chronic condition. It’s one that we can actually recover from, but it does require a long-term treatment plan, a commitment to taking care of yourself, including therapy and medication. So, please do speak to your medical professional and a mental health professional if you have severe depression or think you might have severe depression.  It can also include thoughts of wanting to die and not feeling like you want to live on this earth anymore. Again, if that’s something that you’re struggling with, please go to your local emergency room or immediately seek out professional mental health or medical health care.  It is so important that you do get professional help for depression because, again, depression can come down like a heavy cloud on our shoulders, and it tells a whole bunch of lies. We actually have a whole podcast episode about how depression is a big fat liar. And sometimes when you are under the spell of those lies, it’s hard to believe that anything else might be true. So, it’s very important that we take it seriously. And as we’re here today to talk about, it’s to create routines that help really nurture you and help you towards that recovery.  TREATMENT FOR DEPRESSION Before we move into those routines, I want to quickly mention the treatment for depression. The best treatment for depression is cognitive behavioral therapy. Now there is often a heavy emphasis on mindfulness and self-compassion as well. Cognitive behavioral therapy looks at both your thoughts and your behaviors. And it’s important that we look at both because both can impact the way in which this disorder plays out.  If you don’t have access to a mental healthcare professional, we also have an online course called Overcoming Depression. Overcoming Depression is an on-demand online course where I teach you the exact steps that I use with my clients to propel them into setting up their cognition so that they’re healthy, their behaviors, so that they bring a sense of pleasure and motivation, and structure into their daily lives. And then we also very heavily emphasize self-compassion and that mindfulness piece, which is so important when it comes to managing highly depressive and hopeless thoughts. So, that’s there if you want to go to CBTSchool.com/depression, or you could go to CBTSchool.com, and we have all the links right there.  DAILY ROUTINES FOR DEPRESSION All right, so let’s talk about daily routines for depression. Research shows that, specifically for depression, finding a routine and a rhythm in your day can greatly improve the chances of your long-term recovery. And so, I really take time and slow down with my patients and talk to them about what routines are working and what routines are not. I’m not here to tell you or my patients, or my students how to live their lives and what to do specifically. I’m really interested at looking at what’s working for you and what’s not. Let’s first start with morning routines.  What often very much helps—and maybe you already have this, but if not, this is something I want you to consider—is the importance of a consistent wake-up time. When you’re depressed, as I mentioned before, a common depression symptom is sleep disturbance. Often, people lay awake all night and sleep all day, or they sleep all night and they sleep all day, and they’re heavily overwhelmed with this sleepy exhaustion. It is really important when it comes to morning routines that you set a time to wake up every morning and you get up, even if it’s for a little bit, if that’s all you can handle. Try to set that really consistent wake-up time.  What I want to emphasize as we go through these routines for depression is I don’t mind if you even do tiny baby steps. One thing you might want to start from all of the ideas I give you today, you might just want to pick one. And if that’s all you can do, that is totally okay.  What we also want to do is we want to, if possible, engage in some kind of light movement, even stretching, to boost mood. There’s a lot of routine, even just stretching or gentle walks outside. It doesn’t have to be fast. It doesn’t have to be for an hour. It could be for a quarter of a block to start with. But that light exercise has been shown to boost mood significantly. And then if you’re able, maybe even to do that multiple times throughout the day.  Another morning routine that you may want to consider is some type of mindfulness practice. Again, we cover this in overcoming depression and with my patients in CBT, but some kind of mindfulness practice. It might be journaling, it could be a gratitude practice, it could be preferably some kind of meditation. Often, what I will encourage my clients to do is just listen to a guided meditation, even if you don’t really follow along exactly. But you’re just learning about these concepts. You’re learning about the tools. You’re getting curious about them if that’s all you can do. Or if you want, you could even go more into reading a book about mindfulness, starting to learn about these ideas and concepts because they will, again, help you to have a better relationship with your thoughts and your feelings.  Another morning routine I want you to maybe consider here is to have some type of nutritious breakfast, something that supports your mental health. We want to keep an eye out for excessive sugar, not that there’s anything wrong with sugar, but it can cause us to have another energy dump, and we want to have something that will improve our energy. With depression, usually, we don’t have much energy at all. So, whatever tastes yummy, even if nothing feels yummy, but there’s something that maybe slightly sounds good, have that. If it’s something that you enjoy or have good memories about, or if it’s anything at all, I’m happy just for you to eat anything at all if it’s not something that you’ve been doing.  Let’s now move over to work-day or daytime strategies or routines. The first thing I want you to consider here throughout the day is setting realistic daily goals and priorities. We have a course at CBT School called Optimum Time Management, and one of the core concepts of that course, which teaches people how to manage their time better, is we talk about first prioritizing what’s most important.  If you have depression, believe it or not, one of the most important things you can do to prioritize in your daily schedule is pleasure. And I know when you have depression, sometimes nothing feels pleasurable. But it’s so important that you prioritize and schedule your pleasure first. Where in the day can you make sure that you do something enjoyable, even if it’s this enjoyable, even if nothing is enjoyable, but you used to find it enjoyable? We want to prioritize your self-care, prioritize your eating, having a shower, brushing your teeth. If nothing else gets done that day, that’s okay. But we want to prioritize them depending on what’s important to you.  Now, if you’re someone who’s depressed because you’re so overwhelmed with everything that you have to do—again, we talk about this in the time management course—we want to really look at the day and look at the schedule and say, “Is this schedule nurturing a mental health benefit to me? Is it maybe time for me to reprioritize and take things off my schedule so I can get my mental health back up to the optimum level?”  I have had to do this so many times in the last few years, especially as I have suffered a chronic illness, really separate like an hour to really look at the calendar and say, “Are these things I’m doing actually helping me?” Sometimes I found I was doing things for the sake of doing them to check them off the list, but I was getting no mental benefit from them. No real value benefit from them either.  Another daytime strategy you can use is a technique or a tool called the Pomodoro Technique or the Pomodoro Method. This is where we set a timer for a very short period of time and we go and we do the goal and we focus on the thing for a short period of time. So, an example might be I might set a timer for 15 minutes, and all I’m going to do during that 15 minutes is write email. If 15 minutes is too much for you, let’s say maybe you need to tidy up your dishes, you might set a timer for 45 seconds and just get done with what you can for 45 seconds and then take a short break. Then you set the timer again. All I have to do is 45 seconds or a minute and a half or three minutes or five minutes, whatever is right for you, and put your attention on just getting that short Pomodoro little bout done.  This can be very helpful to maintain focus. It can be very helpful to maintain the stress of that activity, especially if it’s an activity that you’re dreading. And so, do consider the Pomodoro technique. You can download free apps that have a Pomodoro timer that will set you in little increments. It was actually, first, I think, created for exercise. So, it sets it like 45 minutes on, 20 seconds off, 45 seconds on. And so, you can do that with whatever task you’re trying to get done as well.  Another daytime routine I want you to consider is getting some kind of natural light or going outdoors. There is so much research to show that going outside, even if it’s for three minutes, and taking in the green of the earth or the dirt under your feet, really getting in touch and grounding with some kind of nature, or being in the sunlight, can significantly improve mood. So, consider that as well. And again, I’m going to mention, make sure you eat lunch. Eat something that boosts your mood and boosts your energy levels.  Now let’s talk about evening or wind-down routines for depression or practices. Now, number one, one of the things that we often do the most, which we really need to be better about, and this is me too, is doing some kind of digital detox in the evenings. Try your hardest to limit screen time before bed because we know screens before bed actually disturb our sleep. We also know that often we spend hours, hours of our day scrolling on social media. And even though that might feel pleasurable, it actually removes us from engaging in hobbies and things that actually make us feel good about ourselves.  One of the best ways to feel good about who you are and to feel accomplished is to be learning something or mastering something. I don’t care if it’s something that you’re starting and you’re terrible at. We have a lot of research that even moving and practicing a skill will improve and boost your mood so much more than an hour of sitting and watching funny TikTok videos.  Now, again, if all you want to do is that for right now, that’s fine. Maybe spend five minutes doing some hobby or task—something that you enjoy or used to enjoy—that you feel like you’re getting better at. Maybe you learn Spanish, you learn to crochet, you learn to knit, you do paint by number. It doesn’t matter what it is. Just pick something and work at something besides looking at a screen, especially in the evenings.  Another evening routine I want you to consider is some kind of relaxation technique for depression—reading, take a bath, maybe do again some stretching or some light yoga, maybe dance to one song. Anything you can do to, again, move your body. Again, we have so much research to show that moving your body gently, especially in the evening, can help with mood.  Another thing here is to find a comfortable sleep routine and bedtime routine. So, if you can, again, go back to your scheduling, and if you’re not good at this—we do have that online course for time management—create a nighttime routine that feels yummy in your bones. Maybe it’s reading a book, a lovely warm blanket, the pillow you love, a scent—sometimes an oil diffuser would be lovely for you. Dim the lights, close the blinds, create a nice, warm, cozy nook where you can then ease into your sleep.  Overall, weekly activities and routines that you may want to consider for your mental wellness include again finding hobbies. It doesn’t have to be grand. You don’t have to sign up for a marathon. You don’t have to become an amazing artist. You can just pick something that you suck at. That’s okay.  I always tell my patients to do paint by number. It requires very little mental energy, but you do have this cool thing that you did at the end that you can gift somebody, or you can even scrap it at the end, it doesn’t matter. Put it up on your wall—anything to get you out of your head and out of the mood piece—and really get into your body, moving your hands and thinking about focusing on other things.  One of the most important things that you can do to help boost mood and decrease depression is to find a community of like-minded people. The social interaction and improving and maintaining connections between people are going to be so important. In fact, in some countries, the treatment per se for depression, no matter how depressed somebody is, the community go and get them, bring them out, they have a party for them, they cook for them, they surround them, they dance with them. And that’s how those communities and tribes help people get through depression. And we in our Western world have forgotten this beautiful, important piece of community and being a part of a big community family.  Now, if you have struggled with this and it’s been difficult, I encourage you to reach out to support groups. There are so many ways—meet-up groups, local charities, volunteering, maybe finding again a hobby, but a place where you go and you’re with other people, even just doing that. You don’t have to spend a lot of time, but being around people. Even though when you’re depressed, I know it doesn’t feel like that’s a helpful thing. We do know that it does connect those neural pathways in our brain and does help with the management and maintenance of depression recovery.  Now, what do we do, and how can we maintain these routines on the really tough days? When it comes to handling the tough days, I understand it can feel overwhelming. All of this can feel like so, so much. But what I’m going to encourage you to do is keep it really simple. Just doing your basic functioning is all that’s required on those really tough days. It doesn’t matter if you don’t get all the things done on your list. Be compassionate, be gentle, encourage yourself, look at the things you did do instead of the things you didn’t get to do, and also seek support. Reach out to your mental health professional or a support group or your medical doctor or family or a friend or a neighbor if you’re really needing support.  There will be hard days. Depression is not linear. Recovery for depression is not linear. It’s up and down. There will be hard days. So, be as gentle as you can. Keep it as simple and as basic as you can. Do one thing at a time. Try not to focus at the whole day and all the things you have to do. That’s going to help you feel less overwhelmed and, again, help you get through one thing a day.  Let me do a quick recap. The importance of routine is huge. Routines are going to be probably one of the most important parts of your long-term recovery, besides, of course, treatment and medication. It will help you to get through the hard and stressful days and will also allow you to slowly make steps into the life that you want, and often, because we have depression, depression can take away the life that we want. So, that routine can help you slowly build up to the things that you want to do and get back to the life that you do really value.  I encourage you all to play around with this. Remember, look at the routine you have already, and maybe add one thing for now. Take what works for you, but if some of the things I mentioned today, don’t leave them. Please don’t feel judged or embarrassed if some of these aren’t really working for you. We have to look at what works for us and be very gentle with ourselves with that as well. I hope this has been helpful. The routines have really saved me in my mental health. And so, I hope it helps you just as much as it’s helped me.  Have a great day, and I’ll see you guys next week.
Increasing Distress Tolerance (with Joanna Hardis) | Ep. 372
Feb 2 2024
Increasing Distress Tolerance (with Joanna Hardis) | Ep. 372
In the insightful podcast episode featuring Joanna Hardis, author of "Just Do Nothing: A Paradoxical Guide to Getting Out of Your Way," listeners are treated to a deep dive into the concept of distress tolerance and its pivotal role in mental health and personal growth. Joanna Hardis, with her extensive background in treating anxiety disorders such as panic disorder, OCD, and Generalized Anxiety Disorder, shares her professional and personal journey toward understanding and teaching the art of effectively managing internal discomfort without resorting to avoidance or escape tactics. The discussion begins with an exploration of the title of Joanna's book, "Just Do Nothing," which encapsulates the essence of her therapeutic approach: the intentional practice of stepping back and allowing thoughts, feelings, and sensations to exist without interference. This practice, though seemingly simple, challenges the common impulse to engage with and control our internal experiences, which often exacerbates suffering. A significant portion of the conversation is dedicated to "distress intolerance," a term that describes the perceived inability to endure negative emotional states. This perception leads individuals to avoid or escape these feelings, thereby increasing vulnerability to a range of mental health issues including anxiety, depression, and substance abuse. Joanna emphasizes the importance of recognizing and altering the self-limiting beliefs and thoughts that fuel distress intolerance. Practical strategies for enhancing distress tolerance are discussed, starting with simple exercises like resisting the urge to scratch an itch and gradually progressing to more challenging scenarios. This gradual approach helps individuals build confidence in their ability to manage discomfort and makes the concept of distress tolerance applicable to various aspects of life, from parenting to personal goals. Mindfulness is highlighted as a crucial component of distress tolerance, fostering an awareness of our reactions to discomfort and enabling us to respond with intention rather than impulsivity. The podcast delves into the importance of connecting with our values and reasons for enduring discomfort, which can provide the motivation needed to face challenging situations. Joanna and Kimberley also touch on the common traps of negative self-talk and judgment that can arise during distressing moments, advocating for a more compassionate and accepting stance towards oneself. The idea of "choice points" from Acceptance and Commitment Therapy (ACT) is introduced, encouraging listeners to make decisions that align with their values and move them forward, even in the face of discomfort. The episode concludes with a message of hope and empowerment: everyone has the capacity to work on expanding their distress tolerance. By starting with small, manageable steps and gradually confronting more significant challenges, individuals can cultivate a robust ability to navigate life's inevitable discomforts with grace and resilience. EPISODE HIGHLIGHTS:  The Concept of "Just Do Nothing": This core idea revolves around the practice of intentionally not engaging with every thought, feeling, or sensation, especially when they're distressing. It's about learning to observe without action, which can reduce the amplification of discomfort and suffering. Understanding Distress Intolerance: Distress intolerance refers to the belief or perception that one cannot handle negative internal states, leading to avoidance or escape behaviors. This concept highlights the importance of recognizing and challenging these beliefs to improve our ability to cope with discomfort. Building Distress Tolerance: The podcast discusses practical strategies to enhance distress tolerance, starting with simple exercises like resisting the urge to scratch an itch. The idea is to gradually expose oneself to discomfort in a controlled manner, thereby building resilience and confidence in handling distressing situations. Mindfulness and Awareness: Mindfulness plays a crucial role in distress tolerance by fostering an awareness of our reactions to discomfort. This awareness allows us to respond intentionally rather than react impulsively. The practice of mindfulness helps in recognizing when we're "gripping" distressing thoughts or sensations and learning to gently release that grip. Aligning Actions with Values: The podcast emphasizes the significance of connecting actions with personal values, even in the face of discomfort. This alignment can motivate us to face challenges and make choices that lead to personal growth and fulfillment, rather than making decisions based on the urge to avoid discomfort. These concepts together form a comprehensive approach to managing distress and enhancing personal well-being, as discussed by Joanna Hardis in the podcast episode. TRANSCRIPTION:  Kimberley: Welcome, everybody, today. We have Joanna Hardis. Joanna wrote an amazing book called Just Do Nothing: A Paradoxical Guide to Getting Out of Your Way. It was a solid gold read. Welcome, Joanna. Joanna: Thank you. Thank you for having me. Thank you for reading it, too. I appreciate it. Kimberley: It was a wonderful read and so on point, like science-backed. It was so good, so you should be so proud. Joanna: Thank you. Kimberley: Why did you choose the title Just Do Nothing? Joanna: I mean, it’s super catchy, but more importantly than that, it is really what my work involves on a personal level and on a professional level—learning how to get out of my own way or our own way by leaving our thoughts alone, learning how to leave uncomfortable feelings alone, uncomfortable sensations alone, uncomfortable thoughts alone. Because that’s what creates the suffering—when we get so engaged in them. Kimberley: Yeah. It’s such a hard lesson. I talk about this with patients all the time. But as I mentioned to you, even my therapist is constantly saying, “You’re going to have to just feel this one.” And my instinct is to go, “Nope. No thanks. There has to be another way.” Joanna: A hundred percent. Yes. I mean, it really is something on a daily basis. I have to remind myself and work really hard to do. Kimberley: It is. But it is such powerful work when you do it.  Joanna: Mm-hmm.  Kimberley: Early in the book, you talk about this term or this concept called ‘distress intolerance.’ Can you tell us what both of those are and give us some ideas on why this is an important topic? Joanna: Sure, and this is what got me interested in the book and everything. Distress tolerance is a perception that you can handle negative internal states. And those internal states can be that you feel anxious, that you feel worried, you feel bored, vulnerable, ashamed, angry, sad, mad, off. There’s an A to Z alphabet of those unpleasant and uncomfortable emotional states. And when we have that perception that we can handle it, our behavior aligns, so we tend to do things.  When we are distress-intolerant, we have a perception—often incorrect—that we cannot handle negative internal states. So then we will either avoid them or escape them or try to figure them out or neutralize them or try to get rid of them, make them stop—all the things that we see in our work every day.  Before I had my practice in anxiety disorders, I worked over a decade in an eating disorder treatment center, and we know that when someone has really low distress tolerance, they are more vulnerable to developing eating disorders, anxiety disorders, depressive disorders, substance use disorders. So, it’s a really important concept. Kimberley: It’s such an important concept. And you talk about how the thoughts we have which can determine that. Do you want to share a little bit about that? Because there was a whole chapter in the book about the thoughts you have about your ability to tolerate distress. Joanna: Sure, and I didn’t answer the second part of your question., I just realized, which will tie into that, which is how it sounds. How it sounds is, “I can’t bear to feel this way, so I’m going to avoid that party,” or “I’m having too good of a day, so I can’t do my homework,” or “I can’t bear if my kids see me anxious, so we’re not going to go to the playground.” And so, what drives someone’s perception are their thoughts and these thoughts and these self-limiting stories that we all have, and that oftentimes we just buy into as either true, or perhaps at one point, they may have been true, but we’ve outlived them. Kimberley: Yeah. We’re talking about distress tolerance, and I’m always on the hunt to widen my distress tolerance to be able to tolerate higher levels of distress. And I think what’s interesting is, first, this is more of a question that I don’t know the science behind it, but do you think some people have higher levels of distress which makes them more intolerant, or do you think the intolerance which is what makes the distress feel so painful? Joanna: I don’t know the research well enough to answer it. Because I think it’s rare that you see -- I mean, this is just one construct. So it’s very hard to isolate it from something like emotional sensitivity or anxiety sensitivity or intolerance for uncertainty, or something else that may be contributing to it. Kimberley: Yeah. No, I know. It’s just a question I often think about, particularly when I’m with patients. And this is something that I think doesn’t really matter at the end of the day. What matters is—and maybe this will be a question for you—if our goal is to increase our distress tolerance, how might somebody even begin to navigate that? Joanna: Sure. I love that question. I mean, in the book, I take it down to such a micro level, which is learning how—and I think you’ve talked about it on podcasts—itch serve. So, one of the exercises in the book is learning how you set your timer for five minutes and you get itchy, which of course is going to happen. And it’s learning how to ride out that urge to scratch the itch. So, paying attention to. If you zoom in on the itch, what happens?  What happens when you zoom out? What else can you pay attention to?  And so when someone learns that process, that is on such a micro level. I often tell patients it’s like a one-pound weight. Kimberley: Yes. Joanna: And then what are some two-pound weights that people can use? So then, for many people, it’s their phone. So, it’s perhaps not checking notifications that come in right away. They begin to practice in low-distress situations because I want people to get confident that they know how to zoom in, they know how to zoom out. They know if they’re feeling a sensation, the more that they pay attention to it, the worse it’s going to feel. And so, where else can they put their awareness? What else can they be doing?  And once they get the hang of it, we introduce more and more distress. So then, it might be their phone, then it might be them intentionally calling up a thought. And we work up that way with adding in, very gradually, more distress or more discomfort. Exercise is a great way, especially if it’s not married to anxiety, to get people interacting with it differently. Kimberley: Yeah. We use this all the time with anxiety disorders. It’s a different language because we talk about an ERP hierarchy, or your exposure menu, and so forth. But I love that in the book, it’s not just specific to that. It could be like you talked about. It’s for those who have depression. It’s those who have grief. It’s those who have eating disorders. It’s those who have anger. I will even say the concept of distress tolerance to me is so interesting because there’s so many areas of my life where I can practice it. Like my urgency to nag my kids another time to get out the door in time, and I have to catch like, “You don’t need to say it the third time.” Can you tolerate your own discomfort about the time it’s taking them to get out the door? And I think that when we have that attitudinal shift, it’s so helpful. Joanna: Yes. I find parenting as one of the hardest places for me, but it was also a reminder like the more I keep my mouth shut, the better. Kimberley: Yeah. And I think that’s really where I was talking before. I found parenting to be quite a triggering process as my kids have gotten older, but so many opportunities for my own personal growth using this exact scenario. Like your fear might come up, and instead of engaging in that fear, I’m actually just going to let it be there and feel it and parent according to my values or act according to my values. And I’ve truly found this to be such a valuable tool. Joanna: Yes. And I have found what’s been really interesting, when my kids were at home, that was where my distress was. Now that the two of the three are out of the house, my distress is when we’re all together and everyone have a good time. And so, it morphs, because what I tell myself and my perception and the urgency, it changes. It’s still so difficult with them, but it changes based on what’s happening. Kimberley: Yeah. And I think this is an opportunity for everyone, too. How much do you feel that awareness piece is important in being aware that you are triggered? For the folks listening, of course, you’re on the Your Anxiety Toolkit podcast. Most are listening because they have anxiety. Do you encourage them to be aware of other areas? They can be practicing this.  Joanna: Yes. Kimberley: Can you talk to me about that? Joanna: 100%, because I feel like -- what is that metaphor about the onion? It’s like the layers of an onion. So, people will come, and they’ll think it’s about their anxiety. But this is really about any uncomfortable feeling or uncomfortable sensation. And so. It may be that they’re bored or vulnerable or embarrassed or something else. So, once someone learns how to allow those feelings and do what is important to them or what they need to do while they feel it, then yes, I want them to go and notice where else in their life this is showing up. Kimberley: Talk to me specifically about how in real-time, because I know that’s what listeners are going to ask.  Joanna: Of course. Kimberley: I have this scary thing I want to be able to do, but I don’t want to do it because I’m scared, and I don’t want to feel scared. How might someone practice tolerating their distress in real-time? Joanna: I’m going to answer two ways. One, I would say that might be something to scale. Sometimes people want to do the thing because doing the thing is like the goal or the sexy thing, but if it’s outside of their window of tolerance, they may not be able to do it. So, it depends on what they want to do. So, I might say, as just a preface, this might be something that people should consider scaling.  Kimberley: Gradual, you mean? Joanna: Yes. So, for instance, they want to go to the gym, but they’re scared of fainting on the treadmill or something. Pretty common for what we see. It would be like, scale it back. So it might be going to the parking lot. It might be taking a tour. It might be going and standing on the treadmill. It might be walking on the treadmill. But we have to put it in smaller pieces.  In the moment that we’re doing something that is difficult, first, we have to notice if we’re starting to grip. I use this “if we’re starting to grip” something. If we’re starting to zoom in on what we don’t like, if we’re starting to zoom in on a sensation we don’t like, a thought we don’t like, a feeling we don’t like, I want people to notice that and you get better at noticing it faster.  The first thing is you got to notice it, that it’s happening, because that’s going to make it worse. So, you want to be able to notice it. You want to be able to loosen your grip on it. So, that might be finding out what else is going on in my surroundings. So, I’m on the treadmill, I’m walking maybe at a faster pace, and I’m noticing that my heart rate is going up, and I’m starting to zoom into that. What else am I noticing, or what else am I hearing? What else do I see? What else is going on around me? Can we make something else a louder voice? And so, every time that my brain wants to go back to heart focus, it’s like, no, no. It’s taking it back to something else that’s going on. And it helps to connect with why is this important to do? So, as I’m continuing to say, “I’m okay. I am safe. I’m listening. I’m focusing on my music, and I’m looking out the window," This is really important to do because my health is important. My recovery is important. It becomes that you’re connecting to something that’s important, and the focus is not on what we don’t like because that’s going to make it bigger and stronger. Kimberley: Right. As you’re doing that, as we’ve already mentioned, someone might be having those can’t thoughts, like I can’t handle it, even if it’s within their window of tolerance, right? It’s reasonable, and it’s an appropriate exposure. How might they manage this ongoing “You can’t do this, this is too hard, it’s too much, you can’t handle it” kind of thinking? Joanna: I like “This may suck, and I can do it.” Kimberley: It’s funny. I will tell you, it’s hilarious. In the very beginning of the book, you make some comments about the catchphrases and how you hate them, and so forth. I always laugh because we have a catchphrase over here, but it’s so similar to that in that we always talk about, like it’s a beautiful day to do hard things. And that seems to be so hopeful for people, but I do think sometimes we do get fed, like over positive ways. You have a negative thought, so we respond very positively, right? And so, I like “This is going to suck, and I’m going to do it anyway.” Joanna: Yes. So you’re acknowledging this may suck, especially if you’re deconditioned, especially if you’re scared. It may suck AND—I always tell people not the BUT—AND I can do it. Even in 30-second increments. So, if someone is like, “I can’t, I cant,” I’ll say, “You can do anything for 30 seconds.” So then we pile on 30 seconds. Kimberley: Yeah. And that’s such an important piece of it too, which is just taking a temporary mindset of we can just do this for a little tiny bit and then a little tiny bit and then a little tiny bit.  Joanna: Yes, I love that. I love that. Kimberley: Why do we do this? What’s the draw? Sell me on why someone wants to do this work. Joanna: To do...? Kimberley: Distress tolerance. We talk about this all the time. Why do we want to widen our distress tolerance? Joanna: Oh my goodness. Oh my gosh. I think once you realize all the little areas that may be impacting one’s life, it just blows your mind. But in a practical sense, people can stay stuck. When people are stuck. This is often a piece. It’s absolutely not the whole reason people are stuck, but this is such a piece of why people get stuck. And so I think for anyone that might feel stuck, perhaps they want a different job or they want to show up differently as a parent or they feel like they are people-pleasers, or they’re having trouble dating because they get super controlling. It can show up in any area of one’s life. Kimberley: Yeah. For me, the selling point on why I want to do it is because it’s like a muscle—if I don’t continue to grow this muscle, everything feels more and more scary. Joanna: Oh, sure. Yeah, hundred percent. Kimberley: The more I go into this mindset of “You can’t handle it and it’s too much, it’s too scary” things start to feel more scary. The world starts to feel more unsafe, whereas that attitude shift, there’s a self-trust that comes with it for me. I trust that I can handle things. Whereas if I’m in the mindset of “I can’t,” I have no self-trust. I don’t trust that I can handle scary things, and then I’m constantly hypervigilant, thinking when the next scary thing's going to happen. Joanna: Right. Another reason to also practice doing it, if you never challenge it, you don’t get the learning that you can do it. Kimberley: Yeah. There’s such empowerment with this work. Joanna: Yes. And you don’t have to do big, scary things. You don’t have to jump out of an airplane to do it or pose naked, because I see that on Instagram now, people who are conquering their fears by doing these. Very Instagram-worthy tasks, which could be very scary. We can do it, just like you say, with not nagging our kids, by choosing what I want to make for dinner versus making so many dinners because I am so scared that I can’t handle it if my kids are upset with me. Kimberley: Right. And for those who have anxiety, I think from the work I do with my patients is this idea of being uncertain feels intolerable. That feeling. You’re talking about these real-life examples. And for those who are listening with anxiety, I get it. That feeling of uncertainty feels intolerable, but again, that idea of widening your tolerance or increasing your ability to tolerate it in 10-second increments can stop you from engaging in compulsions that can make your disorder worse or avoiding which can make your disorder worse. Do you have any thoughts on that? Joanna: I 100% agree with you. I always say, let’s demote intolerable to uncomfortable. Because I feel sometimes like I have to know I can’t stand it, I’m crawling out of my skin. But if I’m then able to get some distance from it, that’s the urgency of anxiety. Kimberley: Yeah. It’s such beautiful work. Joanna: Yes, and especially the more people do, they’re able to say, “You know what? I can do things.” It may feel intolerable. That diffusion, it may feel intolerable. It’s probably uncomfortable. So, what is the smallest next step I can take in this situation to do what I need to do and not make it worse? That’s a big thing of mine—not making a situation worse. Kimberley: Yes. And that’s where the do-nothing comes in. Joanna: Yes. That’s the paradoxical part.  Kimberley: Yeah. Is there any area of this that you feel like we haven’t covered that’s important to you, that would be an important piece of this work that someone may consider as they’re doing this work on their own? Joanna: I think and I know that you are a big proponent of this too. I think it’s very hard to do this work without some mindful awareness practice. And I talk about it in the book. It’s just such an enhancer. It enhances treatment, but it also enhances our daily life. So, I can’t say strongly enough that it is so important for us to be able to notice this pattern when we are saying, “Oh my gosh, I can’t take this,” or “I can’t do this.” And then the behavior and to think about what’s the function of me avoiding. But if we’re going so fast and our gas pedal is always to the floor, we don’t have the opportunity to notice. Kimberley: Yeah, the mindfulness piece is so huge. And even, like you’re saying, the mindfulness piece of the awareness but also the non-judgment in mindfulness. As you’re doing the hard thing, as you’re tolerating distress, you’re not sitting there going, “This sucks and I hate it.” I mean, you’re saying like it will suck, and that's, I think, validating. It validates you, but not staying in “This is the worst, and I hate it, and I shouldn’t be here.” That’s when that suffering does really show up.  Joanna: Yes. The situation may suck. It doesn’t mean I suck. That was a hard lesson to learn. The situation may, but I don’t have to pour gas on it by saying, “How long is it going to last? Oh my gosh, this feeling’s never going to end. Do I still feel it? Oh my gosh, do I still feel it as much?” All the things that I’m prone to do or my clients are prone to do that extend the suffering. Kimberley: Make it worse. Joanna: Yeah, exactly. Kimberley: It’s a great question, actually. And I often will talk with my patients about it, in the moment, when they’re in distress. Sometimes writing it down, like what can we do that would make this worse? What can we do that will make this better? And sometimes that is doing nothing at all. And you do talk about that in the book. Joanna: Yeah. Kimberley: The forward and the backward.  Joanna: The choice points. Yes. Kimberley: Can you share just a little bit about that? Joanna: It’s a concept from ACT (Acceptance and Commitment Therapy) that says, when we have a behavior, a behavior can either move us toward or forward what’s meaningful in our values or can move us away from it. And so, as we’re thinking about doing whatever the hard thing maybe or it may not even be a hard thing; it just may be something you don’t want to do. Thinking about what your why is, what’s the forward move? Why is it meaningful to you? What do you stand to get? What’s on the other side? Because most of us are well versed, and if we give in, that’s an away move. And we have to be able to do this non-judgmentally because some days it’s just not in us, and that’s totally fine. But I want people to be honest with themselves and non-judgmental about whatever decisions they make. But it does help to have a reason that moves us forward. Kimberley: Absolutely. I think that’s such an important piece of the work. Again, that’s the selling point of why we would want to be uncomfortable. There’s a goal or a why that gets us there. Joanna: Yeah. And it’s amazing how much pain we will put up with. I mean, think about all the things people like—waxing and some of these exercise classes. It’s amazing because it’s important to someone. Kimberley: Exactly. And I think that’s a great point too, which is we do tolerate distress every day when we really are clear on what we want. And I think sometimes we have these things like I can’t handle it, but you might even ask like, what are some harder things that I’ve actually tolerated in my lifetime? Joanna: Yes, exactly because there’s a lot of things you’re so right that we do that are uncomfortable, but it’s worth it because, for whatever reason, it’s worth it. Kimberley: Yeah, I love this. I have loved chatting with you. I know I’ve asked you this already, but is there any final words you want to share before we learn more about you and where people can get in touch with you? Joanna: I just want people to know that anybody can do this. It may be that it’s just creating the right scale—a small enough step forward—but anybody can work on this. There are so many areas and ways in which we can strengthen this muscle. And so there is hope. No one is broken. It may be that people just don’t know the next best move. Kimberley: I love that. Thank you. Where can people hear more about you and get in touch with you? Joanna: My website is JoannaHardis.com and my Instagram is the same thing, @JoannaHardis. And excitingly, the book just came out in audio yesterday.  Kimberley: Congratulations.  Joanna: Thank you. Thank you.  Kimberley: That’s wonderful. And we can get the book wherever books are sold.  Joanna: Wherever books are sold, yes. Kimberley: I really do encourage people to buy it. I think it’s a book you could pick up and read once a year, and I think that there’s messages. You know what I’m saying? There are some books where you could just revisit and take something from, so I would really encourage people to buy the book and just dabble in the many concepts that you share. Joanna: Wonderful. Thank you. Kimberley: Yeah. Thank you so much for being on the show. This is such a concept and a topic that I’m really passionate about, and for myself too. I think it’s something I’ll be working on until I’m 99, I think. Joanna: Me too. I’m with you right there. Kimberley: There’s always an opportunity where I’m like, “Oh okay. There’s another opportunity for me to grow. All right, let’s get on board. Let’s go back to the school.” So, I think it’s really wonderful. Thank you so much for being here. Joanna: Thank you so much for having me.