Anxiety Management

Learning to deal with distressing thoughtsDealing with Troubling ThoughtsSection ContentsUnderstand why attempts to control our emotions failLearn about willingness to experienceLearn about thinking about thinkingUnderstand the link between thoughts and symptomsIdentify ways we can deal with troubling thoughtsBackground - Stoic PhilosophyEpictetus, about 55 - 135 AD Man is disturbed not by things, but by the views he takes of them

Stoicism is a school of Hellenistic philosophy, founded by Zeno of Citium in Athens in the early third century BC. It proved to be a popular and durable philosophy, with a following throughout Greece and the Roman Empire from its founding until all the schools of philosophy were ordered closed in AD 529 by the Emperor Justinian I, who perceived their Pagan character to be at odds with his Christian faith.

Epictetus was a Greek Stoic philosopher. He was born a slave and lived in Rome until his exile to Nicopolis in north-western Greece, where he lived most of his life.

So far as is known, Epictetus himself wrote nothing. All that remains of his work was transcribed by his pupil Arrian. The main work is The Discourses, four books of which have been preserved (out of an original eight).

Psychologist Albert Ellis, the founder of Rational Emotive Behaviour Therapy, credited Epictetus with providing a foundation for his system of psychotherapy.

Stoicism teaches the development of self-control and fortitude as a means of overcoming destructive emotions; the philosophy holds that becoming a clear and unbiased thinker allows one to understand the universal reason, or 'logos'.

The word stoic has come to mean unemotional or indifferent to pain, because Stoic ethics taught freedom from passion by following reason. But the Stoics did not seek to extinguish emotions, only to avoid emotional troubles by developing clear judgment and inner calm through the practice of logic, reflection, and concentration.

Marcus Aurelius was a student of the writings of epictetus: "Because your own strength is unequal to the task, do not assume that it is beyond the powers of man; but if anything is within the powers and province of man, believe that it is within your own compass also.

Other Stoic philosophers include: Antipater of Tarsus, Cato the Younger Diodotus (teacher of Cicero), Diogenes of Babylon, Marcus Aurelius, Musonius Rufus and Rubellius Plautus.

3Background - ConstructivismConstructivism is a perspective in philosophy that views all of our knowledge as constructed, i.e. it doesnt necessarily reflect any external absolute realities; rather depending on convention, human perception and social experienceExperiment with the views in this section, take and use what seems right or useful for youThere is no one size fits all solution!Constructivism is a perspective in philosophy that views all of our knowledge as "constructed", under the assumption that it does not necessarily reflect any external absolute realities; it is contingent on convention, human perception, and social experience. Therapists are mostly interested in how people construct their realities, rather than pursuing some absolute universal truth. In effect, we co-construct our realities in relation to one another!

Constructivism in Psychology considers how human beings create systems for meaningfully understanding their experiences. In psychotherapy, for example, this may mean a therapist asking questions that help elucidate a client's world-view in an effort to make clear his or her meaning-making habits. The assumption here is that clients encounter problems not because life is inherently problematic, or because they have a mental illness, but because of the way the client languages their problems.

Piaget served as Professor of Psychology at the University of Geneva from 1929 to 1975 and is best known for reorganizing cognitive development theory into a series of stages. These four stages of development correspond roughly to (1) infancy, (2) pre-school, (3) childhood, and (4) adolescence. Each stage is characterized by a general cognitive structure that affects all of the child's thinking. Each stage represents the child's understanding of reality during that period, and all but the last is an inadequate approximation of reality.

The four development stages are described in Piaget's theory as:

1. Sensorimotor stage: from birth to age 2 years (children experience the world through movement and senses) 2. Preoperational stage: from ages 2 to 7 (acquisition of motor skills) 3. Concrete operational stage: from ages 7 to 11 (children begin to think logically about concrete events) 4. Formal operational stage: after age 11 (development of abstract reasoning).4Individual DifferencesThe way we perceive things is determined in part by the map of the world we carry inside our headsOur map is drawn up in childhood - it tells us about ourselves, life, and about other peopleOur map is a rough guide to lifeSometimes our maps are inaccurate!

To Deny the Map is to Follow the Map

Complete the following

Men are ...Women are ...Life is ...I am ...Thoughts are both Consequences & CausesOur thoughts are triggered by events around us, by our behaviour and by our feelings and emotions, as well as by other thoughts

We all have thoughts of which were unaware (unconscious)We have relatively little control over thoughts which enter our minds Although our thoughts may be irrational we often believe them Unpleasant emotions and feelings often accompany negative thoughts7Which Comes First - Thoughts or Feelings?Whats important, from a purely practical point of view, is that its usually much easier to change our thinking (what we think) and our behaviour (what we do), than it is to change our emotionsTherefore we can make useful changes simply by assuming that thoughts come first!

Some Anxiety is Useful - Yerkes-DodsonOur abilities improve with anxiety, up to a point Anxiety interferes with complex tasks more than simple ones

In Summary...Our minds are sensitive danger warning systemsSome of our thoughts are inaccurate, unhelpful or out of timeNegative and inaccurate thoughts often seem as though theyre trueThey also feel true, so we tend to give them a high credibility ratingNegative thoughts can give rise to painful moods, emotions and physical sensationsRelational Frame theory (RFT) suggests that one reason for human suffering is the development of language!

Caution!You might want to look away if you have arachnophobiaSPIDERConscious Thoughts are LexicalLexical means made of wordsIf were afraid of spiders, the word SPIDER can evoke thoughts, emotions and physical feelingsThoughts (words) evoke emotions - to a greater or lesser degree, just as though a real spider were actually presentTheres a picture of a spider on the next slide ...

Careful What You Say!Why taking about horrible things at dinner time isnt a good ideaThe word vomit can have similar stimulus effects as real vomitTransfer of Stimulus FunctionsRelational Frame Theory (RFT) talks about the way that the stimulus function of an object or an event tends to get transferred to the word used to describe itIf youre afraid of spiders, the fear, the urge to run away and the physical effects of seeing a spider can all be evoked just by the word spiderWords as Noxious StimulantsOur use of language can underlie a great deal of suffering as a result of the transfer of stimulus functions from referents to the language used to describe themWords can become noxious stimulantsWords as Sources of PainHearing someone talk about their relationship break-up, or about a bereavement can be very painful, especially if we have suffered something similar ourselvesAll we are exposed to is words, yet the words can evoke thoughts and feelings, as though a relationship break-up or bereavement were happening here and nowTelescopingWhen I remember past events which went badly, or when I anticipate things that make me scared, I telescope the past and the future into the presentWithout language, could we evoke a negative past or anticipate a negative future?Why Worry?Worry primarily involves thinking or self-talk (Borkovec & Inz, 1990)This kind of internal verbal behaviour is one of the most highly evolved systems characterising human beings, allowing us to experiment with ideas, consider alternative choices, evaluate our motives and consider the likely consequences of each possible choice before acting on one of them, without fearing that the environment might, in some way, punish us for considering them20Chronic WorryHowever, chronic worry has an avoidant function (Borkovec, 1994; Borkovec, Alcaine, & Behar, 2004). Chronic worriers often believe worrying will help them prepare for, problem-solve, or superstitiously avoid negative future events (Davey, Tallis, & Capuzzo, 1996) despite evidence to the contraryBorkovec and Roemer (1995) found that GAD worriers reported engaging in worry to distract themselves from even more emotional things. The next few slides show common unhelpful thoughts and beliefs

Tom Borkovec, Professor of Psychology, University of Illinois. Worry does not reduce the likelihood of negative outcomes, increase the likelihood of effective coping (Borkovec, Hazlett-Stevens, & Diaz, 1999), or result in effective, concrete problem-solving (Stober, 1998). The strategy of avoidance utilized by GAD worriers is negatively reinforced in the short term by a reduction of psychological distress; and in the long term by the nonoccurrence of catastrophic events which precipitated the worrying.

21Difficulty Tolerating Doubt &UncertaintyProblems can arise if we believe...That uncertainty is stressful and upsettingThat uncertainty is unfairThat unexpected events are to be avoidedThat uncertainty interferes with our ability to functionCertainty seeking is a problem e.g. having a heart attack 1 in 10,000,000 chance, but so long as theres a chance, I worryConsider - of what can we be absolutely certain?Cognitive Style 2 - Unhelpful BeliefsProblems can arise if we believe...That worry helps us find solutions to problemsThat worry increases our motivationThat worrying in advance helps us feel better if bad things happenThat worrying prevents bad things happening (thought-action fusion)That worrying shows we are responsible and caring peopleHaving positive beliefs about worry are a problem23Cognitive Style 3 Problem AvoidanceSolving problems gives us a sense of mastery and pleasureProblem solving = problem orientation + problem solving skillsProblem orientation = (perceptions of problems) + (perception of self as effective) + (realistic expectations)Problem solving skills = (defining the problem) + (identifying goals) + (identifying alternative solutions) + (choosing a solution) + (implementing a solution)Cognitive Style 4 Ineffective Self-SoothingWorry is lexical theres often little imagery involved, worry dampens our autonomic arousal and emotional processing without emotional richness we cant identify our needsGAD worry reduces hyperventilation and tachycardia a form of self-soothing which is painful and only partially effectiveWorry reduces the likelihood of full network activation i.e. behavioural, cognitive, emotional and physiological arousal (which is required for panic response)Common CharacteristicsEarly role-reversed or caretaking relationshipsInsecure attachmentsPredominance of overly-nurturing personality styleConscientiousnessPositive social evaluation preoccupation people pleasing style

Avoiding ProblemsAlthough acting directly on painful things in the outside world can work well (it helps us feel effective), focussing on negative thoughts and feelings doesnt help in the same wayAvoiding things which make us afraid means we continue to fear fear itselfOur willingness to experience reduces the likelihood of panicAn example...A person with a fear of heights wants to take her family up the Eiffel tower, and shes not willing to experience anxietyShe thinks:I hope I dont have a panic attackIm not even going to think about having a panic attackThe anxiety spiralThe very phrase Im not even going to think about having a panic attack, whether spoken aloud or thought, can be a noxious stimulus for feelings of anxietyThe thoughts I must not feel X contain the very words likely to evoke feelings associated with XTry this - shut all thoughts of Uri Geller out of your mind...How Do You Get Out of a Chinese Finger Trap?

Getting Rid of Feelings Doesnt WorkWhen we struggle to get rid of a thought, emotion or feeling, we end up with the original pain, plus more caused by our failing attempts to get rid of the experience (more suffering)We sometimes call this the anxiety spiral fear and anxiety breed even more fear, which can, in turn, lead to panicIn a sense, we get (intensify) what we noticeSo we need to notice what we want to get!What can happen if we feed one stray cat?

Thinking positively, negativelyWhen we think a negative thought and try to get rid of it, we are thinking positively, negativelyThinking is like breathing: It goes on night and day and you cant stop it. But you can change it. You can breathe slowly and deeply or shallowly and quickly. You can breathe any way you want. But you cant stop.Getting rid of fails because we are intensifying the experience by attending to it

Whats the Best Thing to do in Quicksand?Emotions Come in WavesRecognise that an emotion begins, peaks, then ebbsThink about how long horrible feelings and emotions usually lastDont become preoccupied by the time though...Think about how confident swimmers deal with wavesDont splash about!Intrusive ThoughtsIntrusive thoughts - thoughts which just seems to pop into our mind without warning and which are upsetting or which stop us from getting on with things.Thought suppression studies, (Wegner, Schneider, Carter & White, 1987) show that the very act of trying to suppress a thought only results in more unwanted thoughts. This has been termed the rebound effect. The more you try to suppress a thought, the more the thought keeps popping up (rebounding)Dealing with Intrusive ThoughtsIf you are troubled by thoughts which intrude, try the following techniques: Thought stopping Creative fantasies boxing your worries Making worry time Surreal VisualisationDistractionGuilt and regret a special case?

Thought StoppingThought ReplacementYelling StopThought disputationThought Replacement: when an unwanted thought enters, immediately replace the thought with a healthy, rational one.Yelling Stop on thinking the unwanted thought, immediately yell STOP. The yell can be out loud or only in the mind. Continue to yell STOP until the unwanted thought ceases.Substituting a Healthy Thought Pattern: if you have a tendency to think irrationally due to irrational beliefs, you can develop a rational pattern of thinking by challenging every thought that comes to mind, asking: Is this a rational thought? If not, what is irrational about it? What would be a rational replacement for this thought?Replacement Visual Image: if you have a tendency to visualize negative images, replace these negative images by positive, healthy images.

39Creative Fantasies - Boxing

Paradox - Worry TimePut aside time each day to worry incessantlyParadoxically, it can be very difficult to consciously hold a worrySurreal Visualisation

Re-voicing our worries to disempower them ...Give your worries a different voiceClick the speaker icon aboveDistractionThoughts have charm that which draws our attention to themThe challenge is to find something more charming than our worriesWhat can you think of that is more attractive or interesting than worry?Guilt and Regret a Special Case?Consider your values and personal philosophy, would most people with your philosophical outlook feel guilt or regret in your circumstances?Is it possible for you to forgive yourself, even if others wont?When the whole picture is taken into account, people always do the best they can do you believe this?To what extent is personal pride or anger preventing you from moving on? (guilt is sometimes based on anger)What reparations or amends might you be prepared to make?These may be to heal the past, or to improve the futureSummaryUnderstand why attempts to control our emotions failLearn about willingness to experienceLearn about thinking about thinkingUnderstand the link between thoughts and symptomsIdentify ways we can deal with troubling thoughts

ReferencesBorkovec, T.D. (1994). The nature, functions, and origins of worry. In G.C.L. Davey & F. Tallis (Eds), Worrying: Perspectives on theory, assessment, and treatment (pp. 5-34). New York: Wiley.Borkovec, T.D., Alcaine, O.M., & Behar, E. (2004). Avoidance theory of worry and generalized anxiety disorder. In R.G. Heimberg, C.L. Turk, & D.S. Mennin (Eds). Generalized anxiety disorders: Advances in research and practice (pp. 77 108). New York: Guilford.Davey, G. C. L., Tallis, F., & Capuzzo, N. (1996). Beliefs about the consequences of worrying. Cognitive Therapy and Research, 20, 499-520.Borkovec, T. D., & Roemer, L. (1995). Perceived functions of worry among generalized anxiety disorder subjects: Distraction from more emotionally distressing topics? Journal of Behavior Therapy and Experimental Psychiatry, 26, 25-30.Borkovec, T. D. & Inz, J. (1990). The nature of worry in generalized anxiety disorder: A predominance of thought activity. Behaviour Research & Therapy, 28, 153 - 158.Wegner, Schneider, Carter & White, 1987