Best Practices for Anxiety Treatment | Cognitive Behavioral Therapy

Best Practices for Anxiety Treatment | Cognitive Behavioral Therapy

this episode was pre-recorded 
as part of a live continuing   education webinar on demand CEUs are 
still available for this presentation AllCEUs.com/Anxiety-CEU I’d like to welcome everybody to today’s 
presentation on best practices for the treatment of anxiety I am your host, Dr. Dawn Elise Snipes now not too long ago we did 
a presentation on strengths-based biopsychosocial approaches to addressing anxiety and while 
those are wonderful you know I thought maybe we ought to look at you know what’s some of the 
current research so I went into PubMed which is I don’t know it’s playground for me it’s where 
you find a lot of the journal articles and you can sort and I sorted by articles that were 
done and meta-analyses that were done within the past five years so that gives us an idea 
about current research I mean there’s a lot   of stuff that is still the same like some of 
the medications that were known to work ten years ago are still known to be you know good 
first-line treatments but there are also some newcomers that we’ll talk about and there are 
also some changes that we’re going to talk about so we’re going to explore some common causes 
for anxiety symptoms in order to treat it we really need to and of course this does play into 
the biopsychosocial aspect we really need to understand kind of what causes it because anxiety 
that’s caused by for example somebody having a racing heart may be different than anxiety that’s 
caused for somebody who has abandonment issues so we’re gonna treat the two things differently so 
we want to look at some of the common causes we’re gonna look at some common triggers for anxiety 
you know what are some of these common themes that we see in practice and I will ask you to share 
some of the themes that you see that underline   or underlie a lot of your clients anxiety and 
identify current best practices for anxiety management including counseling interventions 
medications physical interventions and supportive treatments so we care because anxiety can 
be debilitating and a lot of our clients have anxiety a lot of our clients have anxiety 
comorbid with depression and they’re looking at us going how can I feel anxious and stressed out 
and like I can’t sit still and depressed at the same time you know when you’re depressed you’re 
supposed to want to sleep well a lot of times   people who are have both issues really want to 
sleep but they can’t so I want to help clients understand that also sometimes anxiety when 
people are anxious for long enough the body starts kind of holding on to the cortisol the body 
actually recognizes at a certain point this is a losing battle I’m not going to put energy into 
this anymore so it starts with drawing some of   its excitatory neurotransmitter so to speak and 
people will start to feel depressed basically the brain has already said this is hopeless this is 
you’re you’re helpless to change the situation so then people start feeling hopeless and helpless 
which is sort of the definition if you will of depression low-grade chronic stress and anxiety 
arose energy and people’s ability to concentrate so if we’re going to help them become their uber 
selves we need to help them figure out how to address anxiety not just generalized overwhelming 
debilitating anxiety but also panic social anxiety and those minor anxiety triggers that come along 
that may not meet the threshold for a diagnosis anxiety is a major trigger for addiction relapse 
if you have a client who is self medicated before or had an addiction for some reason anxiety is a 
major trigger increased physical pain when anxiety goes up people tend to tense their muscles when 
they tense their muscles they tend to feel more pain I mean think about when you’re stressed you 
tend to have more pain like in your neck in your   back and things that already hurt may hurt more 
why because serotonin which is one of our major anti-anxiety neurotransmitters is also one of our 
major pain modulators so when serotonin levels are too low because anxiety is high then our pain 
perception is going to be more acute and people can have sleep problems if you’re stressed out 
your body thinks there’s a threat you’re not going to be able to get into that deep restful 
sleep you may have you may sleep you may sleep a lot but it’s probably not quality sleep which 
means your neurotransmitters may get out of whack your hormones make it out of whack and your body 
is going to start perceiving your itself in a persistent state of stress when we’re exhausted 
the body knows that we may be the weakest link in the herd so it continues to secrete cortisol 
to keep keep you on alert a little bit so you may again you may be resting kind of like when 
you have a new baby at home those first couple   of months that my children were home from the 
hospital I slept but I didn’t sleep well I mean the slightest little noise and I was awake and I 
was looking around and you know I felt it I felt exhausted and a lot of new parents do so triggers 
for anxiety abandonment and rejection and we’re going to talk about ways we might want to deal 
with these things but some of the underlying   themes that I’ve seen in a lot of clients and when 
I do the research what a lot of what themes that come out include low self-esteem if someone has 
low self-esteem they’re looking to be externally validated oftentimes they’re looking for somebody 
else to tell them you’re lovable you’re okay so that can lead to anxiety about not having 
people to tell them you’re okay which makes their relationships tenuous and can make them 
dysfunctional irrational thoughts and cognitive distortions may lead people to believe that if I’m 
not perfect for example I am not lovable so we’re going to look at some irrational thoughts and 
cognitive distortions unhealthy social supports   and relationships when you’re in a relationship 
it takes two to tango and even if your client is relatively mentally and physically healthy if they 
are in a dysfunctional relationship they can fear abandonment and rejection if that other person 
is always saying if you don’t do X I’m going to leave you or if that other person is always 
cheating on them or whatever so relationships can trigger abandonment anxiety and ineffective 
interpersonal skills can lead to relationship turmoil and social exile if our clients are in 
relationships even if they’re not completely dysfunctional if our clients are not able to ask 
for what they need and set appropriate boundaries and manage conflict effectively because conflict 
happens in every relationship then they may start to argue more which may lead to fearing may lead 
to relationships ending in the past and them going well every relationship I get into ends which 
means I must not be lovable so they start fearing abandonment and rejection so these are four areas 
that we can look at one more assessing clients another issue is the unknown and loss of control 
a lot of times negative self-talk and cognitive distortions can contribute to that if I don’t have 
control of everything then it’s all going to be a disaster negative others when clients hang out 
or when people hang out with negative people it kind of wears on you after a while you notice 
that people who are tend to be more negative pessimistic conspiracy minded tend to hang out 
with people who are also negative pessimistic and conspiracy minded so if you’re hanging out with 
somebody who tends to be anxious then the anxiety can be palpable and it can kind of permeate 
physical complaints can lead people to be anxious because they don’t know what’s causing it 
like I said earlier sometimes if your heart starts   to race if you don’t know what’s causing it you 
can start thinking I’m having a heart attack or I’m gonna die when people have panic attacks for 
example they truly think they’re having a heart attack and it’s I’ve had them they are very 
very unpleasant experiences but when people start having physical complaints and it can be you 
know they have a weird rash that they can’t get to go away or it whatever but when they don’t know 
what it is and they can’t control it they can’t make it go away they start thinking about all 
the worst-case scenarios and going online and getting on WebMD which usually gives you all the 
worst-case scenarios um so physical complaints are important we need to normalize the fact that 
nobody’s pain-free all the time and you know the fact that you may have an ache or a pain or a lump 
or a bump or you know a cough most likely you know when we look at probability the probability of it 
being something significant is pretty small now do you want to get it checked out probably but 
you know the probability that is anything to be worried about is is relatively small and a sense 
of powerlessness can trigger fear of the unknown and loss of control for somebody who doesn’t 
feel like they have any agency in their life   if they have an external locus of control or 
if they felt victimized all of their life then they may fear not being in control they may be 
holding on and saying okay this is the one area of my life I can control when I grew up you know 
I grew up in a very chaotic environment I had no control I was bounced around in the foster system 
yadda yadda yadda now that I’m an adult you know I can control these things and I am going to hold 
on with white knuckles and if I can’t control everything then that terrifies me death and 
loss are other triggers for anxiety and it can be people or pets and pets are important I don’t 
want to minimize pets because you know they are little parts of a lot of our families so making 
sure we check that my daughter’s dog for example is it’s getting old she’s getting older she’s 14 
now I think and you know she’s in decent health we took her to the vet and the vet said yeah she’s 
got a little heart murmur but that’s expected for a 14 year old dog and but when she goes out if she 
doesn’t come back when I call her I have this rush of anxiety for a second oh my gosh I hope this 
wasn’t the day so anxiety around losing people and you know if she when she crosses the bridge 
she will and and you know I’m okay with that I’m I have a harder time dealing with my daughter’s 
emotional turmoil when that happens and because she’s grown up with this dog so you know those 
are the types of things that we want to talk about with our clients what things are weighing on you 
that you may not even be thinking about because I know in the back of my mind there’s always that 
worry about one of our donkeys and her dog jobs and promotions can trigger anxiety if people are 
afraid they’re gonna lose their job if they’re always afraid that you know they’re gonna walk in 
and get a pink slip or get fired you know we want to help them look at how realistic is that are 
you doing what you need to do in order to achieve and keep your job and sometimes it’s not easy to 
answer I mean the first thought that a lot of us have is well you know if you’re doing the right 
thing so just do it but there are those bosses out there and I’ve had some really amazing bosses 
a lot of them and I’ve had two really horrendous bosses and those two bosses I could never I 
never felt like I was able to do anything right and so going to those jobs there was always this 
anxiety about what I’m what am I going to get in trouble for today so you want to talk with people 
about does your job cause anxiety what can you do to moderate that anxiety the same thing with 
promotions people may get anxious about whether they’re going to get promoted safety and security 
you know when you lose safety and security you can feel really anxious so if there’s a break-in at 
the house next door or a shooting down the road or you start watching the news you can feel very 
unsafe and unsecure really quickly so we want to help people figure out how safe and secure are you 
really and a lot of it goes back to really looking at facts when people lose their dreams and hopes 
or fear that they’re going to lose their dreams and hopes they can start to get anxious you know 
they have this dream that they’re going to be   a doctor or I just finished the presentation on 
helping high school students transition to college and a lot of high school students for example 
start college with these wide eyes and hopes to save the world and they want to be doctors 
and engineers and this and that and they get into it and they realize that it’s a lot harder 
than they thought or they realize that you know what I really don’t like this but I’ve already 
committed to it so what do I do or I want to help people but I can’t I can’t cut it doing this you 
know for me I figured out in my second year that I wasn’t going to medical school because I wasn’t 
going to pass calculus and that caused a lot of anxiety it was like okay what am I gonna do now 
you know what career should I choose so helping people figure out do you have dreams that have 
maybe kind of crashed and burned and you have to find new ones you know okay that one we’ve got to 
accept it figure out that it’s not going to be and what can you do now people may also have dreams 
about relationships they get into relationships and they see themselves with this person forever 
and then this relationship ends and or starts to get rocky and they’re like but that’s my dream 
what happens if my that’s got to happen because it’s my dream I don’t know how to function if 
that goes away we want to help people be able to rewrite their narrative and then sickness spiders 
and other phobias kind of goes in with death a lot of times when people get sick they start getting 
anxious that oh my gosh what if this is terminal oh my gosh what if this is you know incurable 
if I get bit by a spider it’s gonna kill me and which is rare you know there are very few spiders 
that are actually that poisonous same thing with snakes going over bridges I’ve shared with you all 
that is not one of my irrational fears you know I am just terrified that you know something’s going 
to happen and I’m going to get pushed off the side of the bridge which is completely irrational but 
we need to help people look at those and identify the thoughts that they’re telling themself about 
those phobias and deal with that anxiety failure is another trigger for anxiety especially in 
this culture our culture American culture in in large part puts a high premium on success 
and perfectionism so when people realize that they’re not perfect they may start to get anxious 
because they feel like if I’m not perfect then I’m a failure you know those cognitive distortions of 
all-or-nothing thinking and they start with that negative self-talk you know you can’t do anything 
right so those are some of the issues that you know we often see in counseling sessions so what 
do we do you know somebody comes in and it like I can’t live this way doc anxiety depression and 
substance disorders as well as a range of physical disorders are often comorbid so this is the first 
thing we need to realize we need to realize that we’re very rarely dealing with a very simple 
diagnosis you know when somebody comes in we need to figure out you know if they come in and they’re 
presenting with depression all right let’s talk   about that and then we start realizing that their 
depression started to occur after a long period of being really really anxious okay so we need 
to deal with that but we also need to help them with their sense of hopelessness and helplessness 
we need to develop that sense of empowerment and then substance disorders we know that substance 
use is often a way of self-medicating but we also know that it monkeys with the neuro chemicals 
in the brain and can contribute to anxiety and depression same thing with physical issues pain 
from physical disorders anxiety about having physical disorders medications you’re taking for 
physical disorders can all contribute to anxiety so we need to look at the person as whole and go 
what are all the things that are contributing to the anxiety and what are all the things that the 
anxiety is contributing to so we have we start having this big list of stuff that needs to be 
addressed and then we can start figuring out okay where do we start so knowing that these things 
are comorbid helps researchers explore pathways to mental disorders so they can start figuring 
out you know what little string can we pull to   unravel this blanket of anxiety so it doesn’t 
suffocate somebody and for us as clinicians it provides us key opportunities to intervene you 
know sometimes clients will come in and they’re start talking they start talking about their 
anxiety and their their physical issues you   know maybe their anxieties about you know heart 
palpitations and because that’s a common one we may want to encourage them to go see the doctor to 
get that ruled out you know rule out anything that has to do with hormone imbalances or you know 
heart conditions or anything else that might be contributing to it which can help them address 
it and if they do have physical disorders let’s go with hormone imbalances that are contributing 
to the heart palpitations then they can start to treat that if they don’t start to treat that then 
no amount of talk therapy we do is going to get them to the quality of life that they’re looking 
for because they’re still gonna feel those so   we want to make sure that we’re addressing them 
holistically anxiety disorders should be treated with psychological therapy pharmaco therapy or a 
combination of both and what they found and this is no surprise this is kind of old news is that 
counseling Plus pharmacotherapy tends to have the best outcomes but separating the two they have 
similar outcomes in many cases but that’s just looking at and I hate to call it simple anxiety 
but we’re just looking at anxiety symptoms here we’re not looking at full quality of life and we 
want to make sure that we’re also including any medical issues behavioral therapy is regarded 
as the psychotherapy with the highest level of evidence there are a variety of cognitive 
behavioral approaches ranging from acceptance and commitment therapy to dialectical behavior 
therapy to CBT to rebt you know any of those that deal with the thoughts and the cognitions fall in 
that realm and it has been found to be effective the current conceptualization of the etiology 
of anxiety disorders includes an interaction of psychosocial factors such as childhood adversity 
or stressful events and a genetic vulnerability so the psychosocial factors and these are other 
things when we do our assessment we want to pay attention to because our approach for treatment 
is going to be different for people for example who have trauma related brain changes maybe 
then for somebody who doesn’t so we want to look at childhood adversity and stressful events 
that it may have caused basically what I what I tell clients is like rewiring of the brain there 
are trauma related brain changes in soldiers and especially in children or in people who’ve been 
exposed to extreme trauma that are designed to protect them but it also can cause complications 
kind of later on in dealing with anxiety coping skills that were learned that are ineffective you 
know sometimes people grow up in a household or an environment or a situation where they don’t learn 
effective coping skills so we need to kind of help them unlearn those and learn new ones build on 
their strengths and trauma issues that may still need to be dealt with such as domestic violence 
you know if they grew up a lot around a lot of domestic violence they may think you know I’m 
out of that situation it’s over I don’t want to think about it it’s not bothering me anymore or a 
parental absence and I put absence because it can be death it can be a parent that just packed up 
and left it could be a child that got put up for adoption whatever put the child in a position of 
feeling like they were rejected by a parent can be very traumatic and bullying among other things 
but there are a lot of trauma issues that people once they’re out of that situation often say you 
know I’m out of it it’s not a big deal I dealt with it let’s move on and they don’t realize the 
full ramifications and how that’s contributing to their current anxiety and their current self talk 
and cognitions current stressors if somebody has a lot of current stressors that’s also going to 
impact whether they develop generalized anxiety you know we’re kind of stacking the deck here and 
the current availability of social support if they don’t have effective current social support then 
they’re gonna have difficulty bearing the weight of everything on their own shoulders so we want 
to look at all these psychosocial factors when we do our assessment now going back to trauma 
issues if you’ve taken the trauma courses at all CEUs you know that some people are not ready 
to acknowledge that the trauma is still bothering them or work on the trauma and that’s okay we 
can educate them that it might be an issue and then let them choose how to address it but 
we want to bear in mind the fact that you know this could be sort of an underlying force 
motivating some of the current cognitions and genetic vulnerability so you take any three 
people and you put them or 300 people and you put them through roughly the same psychosocial 
situations they’re all probably going to react a little bit differently based on their prior 
experiences but also because of their genetic makeup there are certain permutations and they 
found four we’ll talk about later that makes the brain more or less responsive to stress and 
more or less responsive to serotonin which is your calming chemical so brains that are less 
responsive to serotonin aren’t going to you know send out as much or send out serotonin as easily 
so people can stay kind of tensed and wired that’s really oversimplified explanation but that’s 
all you really need for right now so genetic vulnerability impacts people’s susceptibility 
to the effects and development of dependence   on certain substances which can increase anxiety 
when people are detoxing from alcohol when they’re detoxing from benzos when they’re detoxing from 
opiates they can feel high levels of anxiety when they take opiates some people find that opiates 
have wonderful anti-anxiety properties not that I am advocating for the use of opiates I’m 
just client experiences have shown that that can be true so some people are going to be 
more susceptible to the anti-anxiety effects of certain substances and some people are going 
to be Cerrone to become dependent on substances where others may not and that part of that is 
genetic vulnerability and they estimates about 30% of the predictability of the development 
of anxiety disorders is genetic and genetics also impact which medications are effective 
if you have genetic makeup a then SSRIs might be helpful if you have genetic makeup be then 
atypical antipsychotics may be a more effective and SSRIs might not do anything which is why 
a lot of our clients get so frustrated because you know there’s no way to figure out exactly I 
guess there is now that there’s genetic testing out there but up until then it was harder to 
figure out which medications to start with and most physicians matter of fact I don’t know of 
a single physician that actually starts out by saying well let’s do a genetic profile to see 
what med to start you out with most we’ll start out with events as with a SSRI or some other 
anti-anxiety medication some sort of a benzo that’s been my experience so we may want 
to encourage clients to consider genetic testing if they’re having difficulty finding a 
medication regime that works for them and they are feeling like they have to have medication 
genetic vulnerability also affects what’s going to make somebody more vulnerable now of all of you 
in class today you know thinking about sleep you know sleep may not be a big deal for some of you 
I know people who can go days or weeks with four or five hours of sleep and they feel fine it’s 
not a big deal not me I need eight or nine hours of sleep so genetically for whatever reason I am 
programmed to need a lot of sleep so when I don’t get that much sleep I tend to be it tends to be 
harder for me to deal with life on life’s terms   and I know that that makes me more vulnerable to 
being irritable so genetic vulnerability affects who can become addicted affects what medications 
work best and affects what situations are going to tend to make somebody more vulnerable to 
anxiety so our medications and I know the type on here is small but we’re going to go through 
it the first-line drugs are the SSRIs selective serotonin reuptake inhibitors and the SNR is 
selective norepinephrine reuptake inhibitors now the names are a little bit deceptive because 
selective norepinephrine reuptake inhibitors also increase available serotonin but the mechanism 
of action is different the mechanism of action for each SSRI is a little bit different as well 
which is why you can put somebody on Prozac and they have an awful experience and you can put them 
on zoloft and they have a much better experience like I said earlier a lot of the research pre 
five years ago had been done on medications and zoloft paxil luvox lexapro celexa and their 
generics have all been found to be effective at treating anxiety in certain people no one 
medication works for everybody in the last five years effexor has come on the radar and it has 
been a found effective according to the hamilton rating scale for anxiety so that’s another one to 
consider if clients are not successful or getting the treatment effect that they need for on some 
of the other medications obviously none of us probably are prescribers but we do need to educate 
clients about why the first drug or even the third drug that the doc doc tries may not work so they 
don’t start feeling helpless and hopeless like I said earlier there are at least four different 
genetic variations which are correlated with the   development of generalized anxiety disorder and 
different medications are more or less effective depending on the genetic makeup of the person 
there’s a high mortality rate moving on to two benzos the recommendation has actually switched 
to really back off from the use of benzos now for some doctors will prescribe an SSRI and for the 
first four weeks while the SSRI is building up in the system they will also prescribe a benzo 
to be taken as needed in order to moderate the anxiety and you know you could argue either side 
of that if somebody has a history of substance use or substance dependence benzos are really 
a bad idea because they do have a high rate of dependence but the other reasons that they are now 
cautioning against the use of benzodiazepines is that there’s a higher mortality rate among benzo 
users compared with non-users there’s an increased risk for dependence with use for more than six 
months and that’s a long time to be using benzo and when we’re talking about dependence and six 
months we’re talking about somebody who uses it like every four hours or every eight hours 
depending on your benzo every single day not a PRN user if somebody’s using it at night to 
help them go to sleep or you know three or four times a week when the anxiety gets really high 
the risk of dependence is relatively low but a lot of people with anxiety because if they find 
the right benzo it makes them feel so much better they may not want to be off of it and for a lot of 
people when that benzo reaches its half-life and starts getting out of the system even more their 
anxiety spikes you know they have rebound anxiety which they want to medicate with more benzos 
that’s gonna be an issue for them to discuss with their doctor there’s also an increased risk 
of dementia identified in long-term benzodiazepine users again this is for the people who use you 
know throughout the day every day for six months or relatively every day for six months or more 
and it doesn’t matter if it’s you know we’re talking about somebody who’s 65 or somebody 
who’s 35 who’s been using benzos for you know six months a year two years the risk of later 
life dementia is greatly increased according to the research benzodiazepines also don’t treat 
depression okay so if you’ve got somebody who has concurrent anxiety and depression there’s a much 
higher suicide risk if they’re on benzodiazepines so being aware and generally that suicide risk 
comes from overdosing on the benzodiazepines but not always other treatment options you know if the 
benzos aren’t something that people want to touch you know they scare the living daylights out of 
me and SSRIs and SNRIs don’t seem to be working then tricyclic antidepressants can be tried those 
your older generation antidepressants seroquel is used a lot and there are some there’s some 
research that shows it can be really effective   with anxiety like some of the antidepressants and 
depending on the person the benzos seroquel can make people very very very sleepy so you know 
it may not the side effects of the seroquel the weight gain and the fatigue and you know 
sleepiness may be unacceptable side effects for some clients and boosts perón is the third option 
boost barone works more like an anti-depressive serotonin reuptake inhibitor and that it takes 
you know four weeks or so to kind of build up in the system studies have shown that there’s really 
no long-term benefit to taking it but six months to eighteen months of use it has been shown to 
be effective in talking with clients a lot of clients report that boost bar when they take it it 
doesn’t necessarily help them stop being anxious like a benzodiazepine does but it helps them not 
go from zero to 200 in 2.3 seconds it kind of you know keeps them from having this gush of a freak 
out reaction every time something goes wrong which a lot of clients report helps because they feel 
more stable throughout the day after remission medication should be continued for six to twelve 
months and during that last six months first six months keep it as is last six months you know 
they say that tapering is best it’s best not to stop somebody cold turkey on any of these but 
it’s definitely important for people once they’re in remission to not just suddenly go okay I feel 
better I don’t need any of this anymore they need to work into it and make sure they’ve developed 
the skills and tools that they need in order to deal with some of the anxiety that is going to 
happen in life so physical signs and symptoms of anxiety may include fatigue irritability muscle 
tension or muscle aches try laying feeling twitchy being easily startled trouble sleeping nausea 
diarrhea irritable bowel syndrome headaches so the first thing we want to do with clients when we’re 
talking to them well second thing first thing is   say get a physical lets rule out physiological 
causes of this but we can also help clients look at you know what might be causing these 
things that you can do to mitigate it what might   be contributing to your fatigue what might be 
contributing to your irritability and your muscle tension or your muscle aches I mean let’s look at 
economics did you recently get a new bed or do you need to get a new bed what about your desk chair I 
know you know I get more muscle tension and muscle achy when I do a lot of mousing because I have 
deplorable posture being becoming aware of that helps and then I’m like okay well I know it caused 
it it’s unfortunate it’s unpleasant but it’s not a big deal trembling or feeling twitchy you know 
that can be caused by low blood sugar that can be caused by anxiety that can also be caused 
by early onset Parkinson’s symptoms you know there’s you know it can be worst case scenario 
or it can be something really benign so we want to have people figure out you know when you start 
trembling or feeling twitchy is there something   that it’s related to you know I know when my 
son gets really excited he’s he just sits there and you can see him almost shake because he’s so 
excited about something so we want to have people prevent misidentification we don’t want them 
to jump to that worst-case scenario we don’t want them to go onto WebMD and go oh my gosh I’ve 
got cancer I’ve got this debilitating disease and I’m going to die in six months probabilistic Lee 
speaking it’s not gonna happen yes get a doctor’s opinion I’m certainly not going to tell them it’s 
all in your head I definitely want them to get an   evaluation but I do want to in the meantime 
help them really think about how likely is this and other things for headaches and this is 
one another one of those that can be frustrating as we get older our eyesight starts to go and 
you know there was a period there I did fine and then after I hit 45 my eyesight just started 
to like steadily and kind of rapidly in my mind decline so I have to get my eye glass prescription 
changed every couple of years and that can cause headaches so instead of starting starting to worry 
about oh my gosh I’ve got a headache all the time   maybe I’ve got a brain tumor you know I know that 
it’s it’s probably my glasses or I’m grinding my teeth so other biological interventions that 
have been evaluated there’s something called the floatation rest system reduced environmental 
stimulation therapy it reduces sensory input into the nervous system through the act of floating 
supine which is on your back in a pool of water   saturated with Epsom salt you know I’m looking at 
this going that sounds really good and you can’t quite get the same experience in a bathtub because 
you’re not floating you’ve got pressure points and you’re still hearing stuff clients can sort of 
simulate it with you know earplugs or whatever but it’s if they can access this it’s been shown 
to be really effective the float experience is calibrated so that sensory signals from visual 
auditory olfactory gustatory thermal tactile or tactile vestibular gravitational and preceptive 
channels are minimized that means you don’t see here taste touch smell feel nothing as is most 
movement and speech so you want people to lay just like completely motionless and not talk which can 
be hard for some people with anxiety in the study the study that I looked at fifty participants 
reported significant reductions in stress muscle tension pain depression and negative effect and it 
was accompanied by significant improvement in mood characterized by increases in relaxation happiness 
and well-being I read the study I’m like where can I sign up you know it sounds in looking at some of 
the research this was actually more effective for addressing anxiety than something like a massage 
Tai Chi also produced significant reductions in anxiety there was approximately a 20% treatment 
effect 25% treatment effect in patients with anxiety and fibromyalgia who practiced twice a 
week for a year now you know we want to look at the con founding things here is it the Tai Chi 
itself or is it learning to control the muscles and becoming more in tune with your body and 
learning to control your breathing that helps people reduce their anxiety either way you know 
Tai Chi helps people do that and it was shown that after a year after the first six months there was 
a significant treatment effect but after a year you know it kept growing and after a year it was 
about 25% so Tai Chi can be really effective an acupuncture at the HT 7 median Meridian can 
attenuate anxiety-like behavior induced by withdrawal from chronic morphine treatment through 
the meditation of the GABA a receptor system what does that mean that means if you if the 
acupuncture is done in very certain places places the anxiety behavior the the GABA a receptor 
system GABA is your main calming relaxation neurochemical that is triggered and it causes your 
body to sort of flood that receptor system and this research was done on people who were detoxing 
from morphine treatment but we can look at generalizing the results and I would be interested 
to see further studies on it pain other things we need to do to help people with anxiety when people 
are in chronic pain they often have anxiety that oh my gosh this is getting worse or it’s never 
gonna get better or I just can’t take this pain anymore or they may get anxious that they’re going 
to be rejected because they can’t do some of the things they used to do because they’re in so much 
pain so there’s a lot of guilt and anxiety that can kind of revolve around pain what can we do 
to help clients guided imagery is generally very helpful if we can help them imagine you know if 
that pain in their shoulder imagine the pain is like the color red and flowing out of their arm 
or other focus mindfulness so you know when you think about something you know when I get a shot 
if I don’t think about it it doesn’t hurt near as   much is if the nurse says okay now one two three 
and you know she’s counting down and I’m getting prepared and I’m really focused on it I had 
another nurse one time who she was just talking to me and you know put the alcohol on my arm 
and just kept on talking didn’t tell me she was getting ready to give me a shot and before I knew 
it she had given me a shot and she was like okay we’re done I’m like you didn’t give me a shot yet 
she said yes I did it’s like oh so not focusing on it and next time you have an itch for example 
if you’ve ever been driving on the interstate and you can each on your on your foot I get those on 
the bottom of my foot sometimes and I’m like okay I’m not going to pull over to each my foot if you 
focus on something besides the itch eventually it goes away I’m not saying pain is gonna completely 
go away but the more people focus on it the more it hurts physical therapy can help so encourage 
them to get a referral and encourage them to do a self-evaluation if nothing else of ergonomics in 
their car at work where they watch TV and spend most of their time at home and they’re sleeping 
so those are the four places that they spend most   of their time what do their ergonomics look like 
and that can help for a lot of people mitigate a lot of pain hormones are another thing that 
we need to look at imbalances of estrogen and testosterone can contribute to anxiety symptoms 
heart palpitations fatigue irritability having people get a physical we can’t as clinicians do 
anything about it but doctors can rapid heart weight rate sweating palpitations are not uncommon 
in women in perimenopause or menopause so a lot of women start feeling like they’re developing 
generalized anxiety and/or something’s going wrong when they start reaching that mid 40s to mid 50s 
area and they start having some of these symptoms again we’re not going to diagnose it but we do 
want them to recognize that it may not be anything you know catastrophic this is something that a 
lot of women experience and help them figure out how to deal with that supportive care biologically 
now you know this isn’t gonna treat anything but we can help them minimize their vulnerabilities 
help them create a sleep routine so their brain   and body can rebalance this can help repair any 
adrenal issues that may be going on and improve energy level people with anxiety don’t sleep well 
so helping them figure out how to get some quality sleep is important nutrition minimizing caffeine 
and other stimulants is going to be a big help because those make people feel anxious encourage 
them to work with a nutritionist to try to prevent spikes and drops in blood sugar which can trigger 
the stress response when your blood sugar goes way up or way down you can start getting kind of shaky 
and feel weird and that can cause people anxiety because they might think oh my gosh I’m having a 
stroke or a heart attack or you know I don’t know   what these tremors are so it’s important that 
they don’t miss identify symptoms and encourage them to drink enough water dehydration can lead 
to toxic Ardea which is increased heart rate sunlight vitamin D deficiency is implicated 
in both depression and anxiety mood issues vitamin D has been found in those main areas where 
serotonin receptors are found vitamin D receptors are found so we know the serotonin and vitamin D 
have something going on sunlight prompts the skin to tell the brain to produce neurotransmitters and 
set circadian rhythms which impact the release of serotonin your calming neuro chemical melatonin 
which is made from breaking down serotonin and it helps you sleep and gaba so sunlight actually 
helps increase the release of gaba when it’s time to start calming down and going to sleep 
exercise studies have shown that exercise can have a relaxing effect encourage clients to start 
slowly there’s not a whole lot of new research   on exercise and anxiety aromatherapy has been 
used a lot in especially in other countries in the treatment of people with anxiety people with 
hospital anxiety people women who are giving birth and they have some birth anxiety there they’ve 
been found to be really effective in a lot of those studies essential oils for anxiety include 
lavender rose Bedevere ylang ylang bergamot chamomile frankincense and Clary sage encourage 
clients to just go to a health food store and you know sniff some of these see if it makes them 
feel happy and calm and content the aromatherapy molecules enter the nasal membranes and they 
will start triggering neuro chemical reactions and so you don’t need to apply it you don’t need 
to ingest it all you need to do is so encourage clients if they’re open to it to think about this 
because aromatherapy can be integrated into their bedroom for example with an atomizer or a mr. it 
can be incorporated in a lot of different places again where they’re not applying it or ingesting 
it in any way all they’re doing is smelling it   they’ve used it in defusing aromatherapy in 
hospital emergency rooms and they found that it reduces stress and irritability of the people in 
emergency rooms and I’ve been to enough emergency rooms over the course of the years to know that 
people who are in ers typically are not in the best mood so if it can help those people then 
it’s probably going to have some sort of an effect so psychologically helping clients realize 
that their body thinks there’s a threat for some reason that’s why it triggered the threat response 
system which is what they call anxiety so they need to figure out why is there really a threat 
you know sometimes it’s like the fire alarm going off in my house it just means that the windows are 
open and there’s a strong breeze there is no fire there is no problem there’s just a malfunction 
it’s a false alarm a lot of times for clients they get this threat reaction they get this stress 
reaction and it’s not a big deal right now so they can start modifying what their brain responds to 
and again those basic fears that a lot of people worry about failure rejection loss of control the 
unknown and death and loss distress tolerance is one of those cognitive interventions that has 
taken center stage in the anxiety research and it isn’t about controlling your anxiety you know 
helping people recognize their anxiety acknowledge it and say okay I’m anxious it is what it is 
how can I improve the next moment instead of saying I’m anxious I shouldn’t be anxious I hate 
being anxious and slang with that anxiety let it go just accept it is what it is have the client 
learn to start saying I am feeling anxious okay so distract don’t react because and I explain to them 
the whole notion feelings come in crest and go out in about 20 minutes it’s like a wave so once they 
acknowledge their feeling if they can distract themselves for twenty or thirty minutes you know 
obviously they figured out there’s no real threat they if they can distract themselves for twenty or 
thirty minutes those emotions can go down and then they can deal with it in their wise mind encourage 
them to use distancing techniques instead of saying I am anxious or I am terrified or whatever 
have them say I am having the thought that this is the worst thing in the world I am having the 
thought that I cannot handle this because thoughts come and go and that comes from acceptance and 
commitment therapy functional analysis makes it possible to specify where when with what frequency 
with what intensity and under what circumstances   the anxious response is triggered so it’s 
important that we help clients develop the ability to do functional analyses on their own so 
when they start feeling anxious they can stop and say okay where am I what’s going on how intense 
is it what are the circumstances and they start really trying to figure out what causes this for 
them so they can identify any common themes from their psychoeducation about cognitive distortions 
and techniques to prevent those circumstances or mitigate them can be provided so if the client 
knows that they get anxious before they go into a meeting with their boss and it’s usually a high 
intensity of anxiety okay so we can educate them help them identify what fears that may be related 
to techniques to slow their breathing and calm their stress reaction and help them figure out 
times in the past when they’ve handled going in and talking to their boss and it really wasn’t 
the end of the world you know there’s lots of   different things we can do there for them there 
but the first key and it gives them a lot of a huge sense of empowerment to start becoming 
detectives in their own life and going okay now under what situations does this happen positive 
writing this was another really cool study each day for 30 days the experimental group and this 
was high school-aged youth in China but you know the experimental group engaged in 20 minutes of 
writing about positive emotions they felt that   day so they’re writing about anything positive 
that make them happy that made them enthusiastic that gave them hope whatever long-term expressive 
writing a positive emotions so after 30 days it appeared to help reduce test anxiety by helping 
them develop insight and use positive emotion words so it got them out of the habit of using 
the destruction and doom words and encouraged them to get in the habit of looking at the positive 
things and being more optimistic it’s a really cool activity that clients can try it’s not gonna 
hurt anything if you have them journal each day for 30 days mindfulness was also came up in the 
research and was shown to be really effective in a meta-analysis six articles about mindfulness 
based stress reduction four about mindfulness based cognitive therapy and three about fear of 
negative appraisal and emotion regulation were reviewed all of these showed that mindfulness 
was an effective strategy for the treatment of mood and anxiety disorders and is an effective 
in therapy protocols with different structures   including virtual modalities so you know if you’re 
doing it via teleconference mindfulness can still be helpful mindfulness helps people start learning 
how to observe what’s going on and become aware of what’s going on more aware of those circumstances 
which will help them complete their functional   analysis but it also helps them become aware of 
vulnerabilities and head off things at the past and if they’re taking better care of themselves 
that they’re living more mindfully then they may not experience as many situations that trigger 
their anxiety mindfulness also encourages clients to learn acceptance that radical acceptance of 
it is what it is I’m not gonna fight it I’m angry right now I am anxious right now however I’m 
feeling right now is how I feel and that’s okay and it’s hard for clients to get to that but once 
they get a hold of that and they truly believe it and they can say all right it’s fine I’m not gonna 
feel this way forever I’m gonna do something else   until the feeling passes it helps and that’s where 
the labeling and letting go comes in mindfulness can also help them identify trigger thoughts 
what thought were you having right before you started feeling anxious if people are mindful or 
let’s start back when people are not mindful they often notice or don’t notice that they’re getting 
anxious until they’re like super super anxious when people are mindful they become more aware of 
subtle cues address unhelpful thoughts when they say or believe it’s a dire necessity for adults 
to be loved by significant others for almost everything they do always running gonna happen 
why is it a necessity what we can encourage them to do is concentrate on their own self-respect 
on winning approval for practical purposes you know for promotions or whatever but it’s not about 
me being lovable it’s about me getting a promotion and making more money and focusing on loving 
rather than being loved because when we give love we generally get love back unhelpful thought 
number two people feel they aren’t able to stand it if things are not the way they want them to be 
or are not in their control so encourage clients to focus on the parts that are in their control 
and other things in life which are going well and   to which they’re committed number three misery 
is invariably externally caused and is forced on us by outside people and events just reading 
that makes me feel disempowered so encouraging clients to focus on the fact that reactions such 
as misery or happiness are largely caused by the view that people take of the conditions so if 
you see it as a tragedy and devastating then it’s probably going to produce misery if you 
see it as an opportunity and a challenge it’s probably going to produce a different emotional 
reaction if something is or may be dangerous or fearsome people should be terribly upset and 
endlessly upset about obsess about it a lot of people with anxiety gets stuck on this you know 
if I feel like its fearsome I need to worry about it getting on a plane for example if I fear that 
that’s dangerous that I need to think about it and worry about it that’s not going to do any 
good so encourage clients to figure out how to face it and render it harmless if possible and 
when that’s not possible accept the inevitable so looking at airplanes you know facing it means 
doing the research to figure out how dangerous is it really and realizing that it’s really not 
that dangerous so that helps render it a little bit harmless in their own mind it proves to them 
that it’s not as dangerous as it could be and when it’s not possible accepting the inevitable you 
know you got a fly so getting on there figuring out how you’re gonna get through it hurricanes 
are the same way people especially in places like Texas Louisiana Florida may obsess as soon 
as it starts coming to hurricane season or if a hurricane is spotted out in the Atlantic somewhere 
they start checking the weather every hour or more wondering what the path is going to be and you 
know what there’s you can’t change the path of the hurricane so all you can do is board up your house 
evacuate if necessary and deal with the fallout child driving is just another example I’ll give 
you know my children are learning how to drive and that’s kind of scary and fearsome you know what’s 
gonna happen when they’re out there you know you   see crashes all the time well render it harmless 
by making sure they’ve got good training on how to drive make sure they’re good drivers and then 
accepting that some things are just not within my control it’s easier to avoid than face life 
difficulties and responsibilities well running from fear is usually much harder in the long run 
so encourage clients to look back at times that they’ve avoided difficulties and responsibilities 
and the eventual outcome you know what happened there people believe they should be thoroughly 
competent in achieving in all possible respects or they will be isolated rejected and failures we 
need to encourage clients to accept themselves as imperfect with human limitations and flaws and 
focus on what makes them a loveable human being what qualities like courage and intelligence and 
creativity and those things that can’t be taken away what inherent qualities do they have that 
make them awesome people because something once strongly affected people’s lives they should 
indefinitely fear it if you got lost you know when little kids get lost it’s terrifying when 
you’re grown up if you get lost you turn on the GPS and you figure out your way but some people 
still you know freaked out about getting lost if they got lost once so we want to help people look 
back at past episodes that may be contributing to the current anxiety and compare the situation’s 
you know are you the same person or is this not a big deal now that you’re older wiser stronger 
encourage them to learn from past experiences but not be overly attached to or prejudiced by 
them yeah you could have maybe got lost in the past and it was a horrible experience well you 
were six I can see where that would be terrifying and a horrible experience but it doesn’t have to 
continue to impact you that way now when you’re you know 26 getting lost you know could be an 
opportunity to try a new restaurant or something people must have complete control over things 
well this doesn’t happen so encourage clients to remember that the past and the future are 
uncontrollable we can’t change the past it is what it is we can learn from it so it doesn’t repeat 
but we can’t change it and the future is largely uncontrollable I mean there’s a lot of things I 
can do to stay moving toward a rich and meaningful   life but life is going to throw me curveballs 
sometimes and there’s nothing I can do to plan for or control that we can control our actions in the 
present to stay on our preferred path and general develop general skills to deal with adversity 
should it arise so we want to help clients develop those general problem-solving skills and 
the general support system so when they are thrown a curveball you know it doesn’t knock them upside 
the head people have virtually no control over their emotions and cannot help feeling disturbed 
by things well encourage them to think about the fact that they have real control over destructive 
emotions if they choose to work at improving the next moment and changing inaccurate thoughts then 
they’re not going to experience the destructive emotions as intensely or as frequently when you 
feel an emotion you feel how you feel but again you don’t have to wrestle with it fight it and 
nurture it you can say this is how I feel how   do i improve the next moment when it comes to 
cognitive distortions encourage them to find alternatives when they start to personalize things 
if somebody laughs when you walk out of the room then the and the person starts getting anxious 
thinking oh they were making fun of me I wonder   what they thought I wonder if I had something 
stuck to the back of my dress and they start getting all panicked about it that doesn’t do 
any good encouraging them to think you know what   our three alternate explanations that hadn’t but 
had nothing to do with you for why they laughed magnification of the worst thing you know taking 
something and saying if this happens then it’s going to be a catastrophe and minimisation going 
along with that a lot of times when people magnify and see a catastrophe they minimize not only 
their own strengths and resources but all the other stuff that they’ve got going for them all 
they’re seeing is this catastrophe so encouraging them to focus on the facts what is actually 
happening and what is the high probability event and and encourage them to get information 
and look at the broader picture you know yes you got into a car crash and your car is totaled and 
that is unfortunate you know it really sucks but you know that is not going to cause you to lose 
your job and then become homeless and penniless and yadda-yadda it might cause your insurance to 
go up but okay so you don’t have a car but what are the resources that you have who can who do 
you work with that might be able to give you a   ride to work you know let’s look at the resources 
you have and work around so problem-solving helps with magnification and also focusing on you know 
let’s be grateful for what didn’t happen you know you could have been killed but you weren’t the 
car was totaled it’s replaceable all or nothing thinking again have them think about what else 
could have been happening like Brittney suggested finding the exceptions instead of saying she 
always does this look for exceptions when has she not done that what else has she done instead 
of this selective abstraction and filtering is when people look for the good the bad and the 
ugly a selective abstraction means you kind of see what you expect to see so if you expect 
something to be devastating you see only the devastating aspects of it which kind of goes with 
the magnification and minimization you filter out the stuff a lot of times when people are in a bad 
mood or are anxious they see the negative because that’s the state of mind they’re in so encourage 
people to complete the picture alright there’s   all this bad stuff now what’s the good stuff you 
know encourage them to look at the good the bad and the ugly so they get a wide view of exactly 
what’s going on and encourage them to remember that hindsight is twenty-twenty when people have 
something embarrassing happen or they get anxious about something that that happened they look back 
and they go I should have or I could have or oh I wish I wouldn’t have when you were in that 
situation you did what you did and you know maybe you may have had a reason for it or you know 
you may have not had other options or it may have just been a bonehead thing to do but okay so you 
made one mistake hindsight is 2020 that’s gonna that mistake is gonna stand out just like the 
great big letter on the eye chart because you’re thinking back and you’re looking at it and that’s 
all you see but encouraging clients to remember   that other people are too busy worrying about 
themselves to really remember what you did jumping to conclusions encourage clients to remember to 
get all the data if your significant other male significant other comes home and is smelling like 
perfume don’t just jump to the conclusion that he was cheating on you maybe he went to the to the 
mall to get a new tie and walked through the perfume area and got spritzed or bought you some 
perfume or who knows maybe the person sitting next to him at work sprayed her perfume at the desk 
and some of it filtered on there’s all different reasons that that might happen so encourage people 
to get all the data mind reading we can’t do it you know you can’t read somebody’s mind you don’t 
know what they’re thinking so ask them if you what do you think about this don’t assume anything and 
emotional reasoning encourage people to step back from a situation and ask themselves am i feeling 
anxious about this because I’m feeling anxious and I’m looking for reasons that it should be scary 
or am i feeling anxious about this because it’s really scary for some reason there’s actual facts 
support my anxiety a lot of times when we go into new situations we may feel anxious because it’s 
a new situation but when we step back we say you know what there’s really nothing to be worried 
about here you know no big deal I got this and   move on so instead of rolling with it and trying 
to figure out okay I feel anxious so there must be a reason not necessarily very likely a false 
alarm other psychological interventions relaxation skills encourage people to learn how to relax 
not only physically but mentally diaphragmatic breathing is helpful encouraging them to breathe 
through their stomach and put their hand on their belly and feel their belly expand and contract 
slows breathing down which triggers the rest and digest reaction in the brain which is calming 
meditation can be helpful for some people some people find trying to quiet their mind too 
frustrating because they’ve got too much monkey mind going on that can be later or maybe 
never for some people we don’t want to increase their anxiety with interventions cute progressive 
muscular relaxation also has a lot of research support and remember with cute progressive 
muscular relaxation we’re Sakura geing them to attach a cue AK you word like relax or breathe 
with the relaxation response so they tense their muscles and then they relax their muscles and as 
they relax their muscles they say their q”-word like relaxed and they work from head to toe or 
from toe to head tensing and relaxing different muscle groups so they become more aware of what a 
tense muscle feels like versus a reactive relaxed muscle there are great scripts that are online 
that people have already recorded that can walk people walk clients through CPM are I highly 
encourage it because once they get used to it then they can just think that cue they can think 
relax and as they exhale they will start to feel their entire body kind of relaxing because it’s 
trained when it hears that just like when you hear the word pop quiz when you were in high school 
you had a stress reaction well we want to use it in reverse and train train the body so when 
it hears a cue word it relaxes help them develop self-esteem because fear of failure and rejection 
a lot of times come from needing other people’s approval help them develop a rational idea of 
their real self develop compassion self-talk instead of saying I’m an idiot or I’m stupid or 
I’ll never measure up to anything encourage them to talk to themself like they would talk to their 
child or hopefully their best friend and encourage them to spotlight strengths whenever they feel 
like they’ve got an imperfection identify these   three strengths that they have so they’re you know 
balancing out the imperfections and the strengths cognitive restructuring reframe challenges in 
terms of current strengths not past weaknesses so if you’re going to give a presentation in front 
of 60 people and you hate public speaking instead of thinking about you know this is terrifying 
because the last time I went up in front of people I forgot everything I was going to say and drop 
my note cards well that’s a past weakness what is your current strength you’re prepared you know 
your material you yada-yada so encourage people to look at all the strengths and resources they 
currently have have them develop an attitude of gratitude and optimism because like I said with 
that the positive writing exercise when people are in a grateful optimistic frame of mind they 
tend to see more of the good stuff they see the bad stuff too but they can also see more of the 
good stuff and some of the bad stuff they see   opportunistically instead of as a devastation 
acceptance and commitment therapy says that we some of the reasons that we’re miserable is 
fear we get fused with our thoughts we think I am terrified well if I am terrified then I can’t 
I mean if I am I can’t get rid of anything I am if I’m having the thought that I’m terrified 
well I can get rid of a thought I can forget   things easily encourage people to evaluate their 
experience and empower them to look at things as challenges and opportunities instead of hardships 
encourage them not to avoid their experiences so things that are scary gradual exposure and 
finding exceptions like for me bridges you know I love public speaking so that’s not a 
thing but when I go to a bridge you know when I Drive to the bridge you know when I’m on the 
bridge somebody else is driving I get used to doing that when I Drive over a bridge then when 
I Drive over one of those bridges that opens up I hate those bridges um I know y’all are just like 
oh my gosh yeah it’s an irrational fear I realize that but instead of going straight for the bridge 
that opens up going for the little bridges first and then thinking back over times that I’ve gone 
over bridges and there’s been no problem you know there’s exceptions nothing happened it wasn’t a 
big deal sometimes I didn’t even notice it until somebody pointed out hey look down there at that 
pretty water and I’m like oh we’re on a bridge so encourage people to not avoid their experiences 
get used to them embrace them and learn that they have the power to deal with them and stop reason 
giving for behavior you know use the challenging questions if something is fearsome let’s look for 
the at the evidence for and against it instead of you know making excuses social interventions 
improve their relationship with their self which goes with self-esteem improvement people are going 
to feel less anxious about getting their needs and wants met if they know what their needs and wants 
are so part of that is becoming mindful cuz a lot of our clients don’t know what they need and want 
they just they want to feel better but they don’t know how they don’t know what they need to feel 
better so helping them identify their needs and   wants encourage them to be their own best friend 
you know when they get a promotion take themselves out to dinner pat themselves on the back whatever 
it is don’t rely on other people to do it because other people it’s not that they don’t care but 
other people are often very involved in thinking about their own stuff and they may not notice 
encourage them to develop a method of internal validation so they can feel like they are all 
that ‘no bag of chips and they realize why they are lovable human beings and they accept the 
fact that everybody is not going to like them and nobody is gonna like them all the time and 
that’s okay you know my kids don’t like me all the time my husband doesn’t like me all the time 
I’m okay with that I know I can be challenging but you know most of the time you know they like me 
and and that’s okay and there are some people you know who don’t like me at all and okay there’s 
nothing I can do about that helping our clients develop and okayness with that helps relieve a lot 
of anxiety because a lot of people feel like they have to be liked by everybody and if somebody 
doesn’t like them it’s like what did I do wrong   oh my gosh encourage them to develop healthy 
supportive relationships with good boundaries develop assertiveness skills so they can ask for 
help when they need it anxiety a lot of times you know that’s the body saying there’s a threat well 
if there’s a threat maybe you need some help you   know dealing with it so people need to be willing 
and able to ask for help and not feel like that’s going to lead them to be rejected and allow them a 
certif this will allow them to say no to requests again without feeling like that’s going to result 
in them being fully rejected describe the ideal healthy supportive relationship and encourage 
them to separate the ideals from the reals you know let’s look at if you had a best relationship 
what would it look like okay you know warden June Cleaver we got that now how realistic is that 
you know let’s look at you know rephrasing this a little bit so it’s less extreme you know warden 
June Cleaver never fought their kids were perfect you know all those extreme words let’s look at 
what’s real what happens in real relationships encourage people to identify who would be 
a good partner in supportive relationships I’m not meaning necessarily romantic I’m meaning 
friends and where they can be found you know where   would you find people that you could be friends 
with and encourage them to play though what does it mean when game cuz a lot of times again this 
goes with mine reading you know what does it mean when your friend doesn’t return your text right 
away what does it mean when your friend cancels dinner on Friday night what does it mean when 
you see where I’m going with this and a lot of times clients with anxiety and rejection issues 
and low self-esteem will go to the worst-case   scenario so encourage them going back to finding 
the exceptions what else could have been happening what else could it be that caused this and it’s 
not about you so anxiety is a natural emotion that serves a survival function excessive anxiety can 
develop from lack of sleep nutritional problems neuro chemical imbalances failure to develop 
adequate coping skills cognitive distortions low self-esteem and a variety of other stuff recovery 
Ambala involves improving health behaviors make sure your body’s functioning and make the 
neurotransmitters it needs and you know release them as needed identify and build on current 
coping strategies address cognitive distortions and develop a healthy supportive relationship with 
self and others if you enjoy this podcast please like and subscribe either in your podcast player 
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Dr. Dawn-Elise Snipes is a Licensed Professional Counselor and Qualified Clinical Supervisor. She received her PhD in Mental Health Counseling from the University of Florida in 2002. In addition to being a practicing clinician, she has provided training to counselors, social workers, nurses and case managers internationally since 2006 through AllCEUs.com Practical #evidencebased strategies and #bestpractices to address anxiety.
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