“Key Aspects of Treating Anxiety . By Michael Yapko. · Hello this is Dr. Michael Yapko, I’m a clinical psychologist and an author and I will be spending the next hour or so speaking

Transcript from “Key Aspects of Treating Anxiety”. By Michael Yapko.

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Dr. Michael Yapko

“Key Aspects of Treating Anxiety”

Original Audio: http://www.hypnosis4anxiety.org/ Hello this is Dr. Michael Yapko, I’m a clinical psychologist and an author and I will be spending the next hour or so speaking to you on the topic of anxiety my lecture's title is “Key Aspects of Treating Anxiety”. Anxiety is the most common presenting problem that clinicians are asked to treat and I think the average therapist is in practice for about twenty seconds before the see their first anxious client. Even when anxiety isn't the predominant presenting complaint, whatever problem somebody comes in with, their anxious of that problem. They want to know whether it's going to be resolvable and how and when it's going to be resolvable. But it's important to appreciate that anxiety is highly responsive to good psychotherapy as a research clearly indicates. And so in this lecture, I'm going to describe some of the key considerations in treating anxiety and describing some of the factors that contribute to anxiety. What causes anxiety?

http://www.hypnosis4anxiety.org/


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Well, let's start at the very beginning with the question: What causes anxiety? How you answer this question, is the single most important determinant of how you will design and deliver treatment (if you happen to be a clinician) or whether and what type of treatment you will pursue if you happen to be someone suffering anxiety. So I'm hoping to give you insight into what anxiety about and what we can do about it. Where do you focus? But in answering this question you can appreciate that anxiety is a complex phenomenon and consequently it invites many different viewpoints, many different perspectives, across clinicians and researchers. So you have some individuals who focus more on the physiology of anxiety and they address questions of genetics and biochemistry. And others will focus more on cognitions - the quality of your thoughts and find patterns that might give rise to anxiety or contribute to it. Others will focus more on the behaviors associated with the development of anxiety and how people cope with that. Others will focus on the emotional side of the equation and how people feel when they're anxious and how they express their feelings, whether they express their feelings and what they do emotionally in terms of responding to the anxiety. Well, as you can appreciate anxiety is a multi-dimensional phenomena it has many different contributing factors and the best advice that I can give to a clinician or a client is that the treatment has to be as multi-dimensional as the anxiety disorder itself: just focusing on one aspect of the anxiety is really not going to be enough. Anxiety certainly can and does exist by itself. It's also true however that anxiety is very frequently found along with other disorders. When people are suffering medical conditions they are very likely to feel anxious; “What's going to happen? Am I going to be treatable? Is this going to resolve?” People have all the kinds of anxiety provoking questions. When people are depressed not only they are depressed but most the time they also suffer a co-existing or what's called a co-morbid anxiety. And these overlapped symptoms actually complicate the picture quite a bit. So it's very important to appreciate at the outset that because anxiety so often found with other conditions - again - it points you in the direction of making sure that as many different factors are being considered to address in an intervention as possible. So that when we look at the most common symptoms of anxiety certainly the most common symptom is some form of sleep disturbance and because that it's such a critical issue I'm going to address sleep in depth in just a little while. But it can also lead to people feeling irritable, people feeling like they want to just crawl out of their skin, people end up


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devising all kinds of self management strategies that can and actuality makes things worse. So the fact that anxiety can lead people to drink alcohol as a means of calming themselves or take drugs obviously complicates the picture, I can only say in the most general of ways that using any kind of substance to manage anxiety may make you feel better in the short run but it actually complicates the picture in the long run for reasons that I'll get into. But I will say in a general way now what we most want to do is empower people, give people the tools that they need to be able to manage their anxiety naturally to think about it in ways that are realistic so that they don't have the unrealistic expectation that they shouldn't feelings anxiety anytime anyplace to any degree, some people just want to feel numb inside which is why the end of abusing alcohol or drugs. Childhood Anxiety What's particularly interesting to me and where I think I'm going to start is with childhood anxiety. By the time somebody develops an anxiety disorder as an adult or becomes aware of it as an adult, they might well have been suffering anxiety literally all through their adolescence all through their childhood and really didn't have the language to describe what was happening. And people around them might have known that they were anxious to some degree but didn't really know what it was about. Well, anxiety in childhood is becoming increasingly common and it's also why we're seeing higher rates of depression in adolescence and young adulthood. Anxiety happens to be a very strong risk factor for depression. In a statistical sense the kids who are anxious stand a much greater chance of also becoming co-morbidly depressed adolescents and young adults. So it's particularly important to watch and recognize anxiety as early as possible and part of what we're considering then is the number of anxiety disorders that are present in childhood, the persistence of anxious avoidance behavior and the degree of psycho social impairment. These are the strongest risk factors associated with the eventual onset of depression or the eventually worsening of anxiety. The fact that anxiety precedes depression is one of the prevention opportunities that we have available now. How important it is if you're the parent of young children to really notice how is this child coping with situations that make him more anxious? The more that you see that child's going into avoidance, not wanting to face things that are anxiety provoking, the more concerned you really should be.


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And the same is true if you happen to be a therapist working with children. If we look at it in a statistical sense, we know that somewhere in the neighborhood of eight to ten percent of children here in the United States are seriously troubled by anxiety - more than three million children suffer one or more of the eight anxiety disorders that are listed in the diagnostic manual. Anxiety is the most prevalent psychiatric diagnosis in those sixteen and younger and as I've already alluded to, anxious children are much more likely - in fact to the top two to four times more likely - to develop depression later in life. Now the interesting thing is that these patterns for thinking about life experience that become evident in childhood are actually persistent. They are what are called attributions. So when we look at the qualities of attributions or the explanations that kids give themselves or when they're asked to give adults explanations for their reactions to things - their interpretations of situations that they face - there are certain patterns that are highly evident and highly predictable in kids who are prone to anxiety. Anxious children are far more likely to interpret ambiguous situations negatively. Now, what do I mean by an ambiguous situation? I'll give you an example of some of the research that has been done. Kids are asked to imagine how they would fare in a certain type of situation – an ambiguous or anxiety provoking situation - so for example a child is given the vignette you are shopping with your mother in a town far away from where you live and you enter a crowded department store to buy a new jacket for yourself. You run over to a rack of jackets and pull one off the hanger, put it on and turn around to show your mother what you look like and your mother's gone. What do you do? Well kids who are not prone to anxiety say “Well I guess I would find a sales person and put out a message over the public address system to have my mother meet me at the sales base” or some similar kind of problem solving answer. In contrast - stark contrast - the kids who are prone to anxiety immediately start to get highly anxious and say things like “Oh my god I’m never going to see my mother again what if I get adopted ou,t what if I never see my family again,” and they work themselves up into a frenzy just imagining themselves in that kind of ambiguous situation: “What does it mean? And what should I do?” And it tells us something again from a preventive point of view, how important it is to teach children how to be effective problem solvers. You know the American humorist Mark Twain once said “life is one damn thing after another,” and I think that he's absolutely right about that. Life is one damn thing after another and why it's so important to teach kids how to be effective problem solvers. And if you put it in a larger cultural perspective, one of the things that we've seen happen over the last generation is the emergence of what many call the “helicopter moms”, the parents who hover over their kid to make sure that their child doesn't experience anything anxiety provoking or scary or challenging. So instead of kids having failures and learning


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from them, they're being protected, instead of kids being taught how to solve their own problems ,parents step in and solve problems for them. And again, in the short run it seems like in caring and loving thing to do, but what it serves to do is disempower the child. So that when the child faces a challenge, instead of being an effective problem solver and moving into problem solving mode, instead, this child spins off into his fears and doubts and anxieties. And instead of solving the problem, he or she just gets anxious and emotional. So it's an important point that I'm making, that at any age but especially in childhood we are establishing the templates of how important it is to teach kids to be problem solvers. Cognitive Distortions So that's one aspect: The attributions of kids when they face ambiguous situations and they interpret them reflexively in negative ways that when they face uncertainty. Their projection is that something terrible is going to happen, and of course that scares them and raises their anxiety level. We also have seen in the studies of cognitions of anxious children that they report more dysfunctional cognitions, more cognitive distortions and so they will take things personally that really aren´t personal. Or they will jump to conclusions that really aren't justified. And that is why cognitive therapy has been so highly effective in treating anxiety. Because there is no doubt that how you think about things is going to make a big difference. Tolerate Ambiguity And the third factor that is evident in the cognitions of anxious children was how they judge ambiguous situations as more dangerous than other kids who aren't prone to anxiety. So the ambiguity invites projection, and by that I mean that when you face a situation it's uncertain - it requires an interpretation - you have to form some kind of judgment, “what does this mean?” “What am I supposed to do in reaction to this?” And when someone faces uncertainty and their projection is a negative one or their projections sugest that something dangerous is about to happen anxiety will naturally arise. So other things that we have learned in studying anxious kids is that becomes the template for adult anxiety. Kids find it harder - the anxious kids find it harder - than other children do to calm themselves when they're in a stressful situation. Now, this is one of the most important things that we can teach kids to do as well as adults, self-soothing strategies, calming strategies. When I was growing up, many of you might remember we used to have “mat time” as it


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was called and it was a time during the day when everybody would roll out of rubber mat to lay on them for twenty minutes or thirty minutes. Kids would just lay down and calm themselves. There would be a “calming point” during the day where people could just mellow out. That kind of a self-help strategy is more important than we realized. Developing the ability to calm yourself is an empowered way of managing anxiety - preventing it from escalating out of control. And that's why a little bit later on I'm going to talk about the merits of experiential processes like hypnosis, like mindfulness, that have a great potential to help with the calming of the self. The kids who are prone to anxiety may well be above average in creativity but interestingly they seldom use their creative abilities when making plans to cope with their anxiety. It's like all of a sudden whatever creative problem solving abilities they might have are unavailable to them. They get so focused on what makes them anxious that they start focusing on how to go about solving the problem creatively. And interestingly as well even if they do come up with some kind of creative plan for problem solving they tend to become very discouraged with it if it doesn't work instantly. This is what's called “low frustration tolerance.” And this is something that persist into adulthood. Anxious adults tend to have little frustration tolerance as well. If you provide them with a solution of some kind and it doesn't work instantly there is an ambiguous situation. And the person asks “Why isn't this working right away?!” And the person reads failure into it, reads danger into it. And consequently what could have been a potential solution if it was applied patiently, is given up on quickly, interpreted as more evidence of a failure…and so the anxiety level then continues to rise. Another interesting factor is that even when kids start to make progress in reducing their anxious feelings, when you can tell visibly that this child is starting to calm down and then you say something to them about it like “gee you seem to be doing better” or “I'm really proud of you that you've really managed to cope with this well” and “it's obvious that your anxieties are reduced,” they fail to recognize their own successes. They don't attribute it to themselves. Consequently they can’t own it. They can't feel it. They can't feel like this is empowering them in any way; and so there is a, what I will call the cognitive cornerstone of the anxiety, the foundation. It's been implied in what I've said so far but now let me repeat it very clear, very explicit for the people who are prone to anxiety. It is as if there is a firm and unwavering formula and the formula is a two part formula to people who are most prone to anxiety do two things reliable:

1. Number one they overestimate the dangers that they face, they see personal threats to their wellbeing in all kinds of places that other people don't and so it increases their anxiety increases their fear level.

2. The second factor that is quite reliable, is they underestimate their own abilities to cope with whatever threats that they might be facing.


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Now this is true for both adults and children, again a two part formula: over estimating danger, under estimating your abilities to cope. Now if we pick that apart a little bit it tells you something about what kinds of skills of somebody would need to have in order to be able to manage anxiety well. Assess Risk Realistically One particular skill is the ability to assess risk realistically, to overestimate danger means seeing risk in places where risks really don't exist. And you can appreciate that risk is in the eye of the beholder. There are people who will jump out of an airplane with a parachute strapped across her back and they don't particularly feel like that's a risky thing to do. They think it's exciting, they think it's exhilarating. So for them they take what many people view as highly risky behavior and they see it in a way that minimizes the risk altogether. And then there are other people who think it is really risky to try a new pizza place. So risk is in the eye of the beholder. And that becomes one of the most important skills that you can master, how can you learn to assess risk realistically? What is risky? How do you determine level of risk? If someone faces an uncertain situation and they think about all the potential hazards but they're not able to think in terms of probabilities and real risks, they can make anything seem dangerous. They can make it seem dangerous to sit in a chair, because they start to wonder “what if the manufacturer didn't manufacture the chair properly? “What if the wood is rotten and I don't know it and I sit in the chair and the chair falls apart and I fall and hurt myself?!” And literally they can make sitting in a chair seem risky.

So it's one of the things to really seriously consider, both as a clinician and a client, what are your skills of risk assessment? How do you know what's risky? How do you distinguish a genuine risk from an imagined risk? Overestimating Danger The other side of the equation from overestimating danger is the under estimating of abilities. It's really a critical thing to be able to know what your skills are, to be able to talk to yourself through your thoughts in a way that help you remind yourself that you can solve the problem. And if you can't solve the problem, you can talk to somebody who can help you solve the problem. That you can assess risk more realistically, that you can calm yourself, that you can take preventive steps to keep things from escalating out of control. And having that ability to manage your anxieties is priceless. And the reason it is priceless


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is because anxiety can't be avoided. You know in the simplest of ways, any time that you take the risk you will experience some anxiety. And of course the bigger the risk the more anxiety you're likely to feel. So when somebody is going to give a speech in public let say, that has to be one of the most anxiety provoking situations, there are some surveys that suggest public speaking is the number one form of anxiety. Well understandable, if you're going to get up in front of a room with people whether it's a small group or a large group, you're taking a risk. You´re taking a risk of being judged negatively. OK so there is some anxiety that goes along with that, so, how do people speak in public? Because they have the ability to focus not on the risk (that´s in the background), what's in the foreground is they have a message they want to deliver, they have something they genuinely want to say. They have a message that they want to get across, they believe in the importance of the message and that's their focal point. And they understand that when they put their message out there - as important as they think it is - they can't make other people agree that it's important. And so yes, when you give an address, when you give a talk – just like the the way that I'm giving to talk right now there might – there will be people who listen this and go, “so what?” And there will be other people who say “wow that's an enormously valuable piece of information and boy am I glad I listened to this” and I can't control the reactions that people have. All I can do is put out what I think of as being good information, timely information, well researched information, sensible information, and what people do with it after that is beyond me. But I believe in the importance of the message. I believe in the value of the information that I am presenting and so that is what has to guide me through the anxiety-provoking situation of talking into a recorder, to give this lecture. But it's an example of what I mean when I talk about the coping skills, is for me to remind myself that I can't control how people react to this, all I can do is make sure that I've done my homework and I organized it well and presented it clearly and then hope that it's of value to people. And obviously I do hope that it's of value to you as you listen to that. Where To Begin Treatment Well I have made the point that anxiety and depression most often are found together so it raises the question of where to begin treatment. Well, even if you're not experiencing depression, even if you're experiencing anxiety alone, you have to answer the same question: Where should you aim your interventions? What should you be paying attention to? Cognitive Style Well when you focus on just the anxiety side of the equation there are key patterns that you're going to want to focus on. One of those patterns I already addressed which is


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cognitive style and its causing attribution style, what you tell yourself, how do you think about these situations that you face. Another one I just alluded to is called the locus of control. One of the things that's typical for people who feel anxious is they feel like they're not in control of what's happening and that requires a very important distinction, “what is controllable and what is not controllable?” And if you give up prematurely because you think nothing's in your control, you're missing something very important in actuality even when you face circumstances that are out of your control. What is in your control is how you interpret those and how you react to those. Expectancy Another factor is expectancy and so the issue of expectancy speaks to what kind of expectations you have about how you're going to react. If you tell yourself you're going to fall apart you will. If you tell yourself you're never going to be able to handle this, then you won't. So the quality of your expectations is a really important factor in why it's a really useful exercise is what's called “success imagery,” of being able to sit quietly close your eyes and do - whether you call it a meditation or you call it a self hypnosis or you call or a mindfulness exercise - doesn't really matter to me. But the common denominator of those kinds of approaches is that you're using some very powerful images that you create in your mind to be able to see yourself methodically, step by step, handling a difficult situation with some skill with some finesse, taking some steps that make sense and can help you move through whatever the situation is. And that leads to another point. If you don't know how to handle something. If you´re not sure what the best response is, that uncertainty is going to raise your anxiety. You can't be confident you're going to handle something if you don't know how to handle it. And so it's an invitation to you to discover that, if and when you don't know how to handle something, talk to somebody who does. There are other people out there in the world who handle the kinds of situations that concern you routinely, what do they do? What do they tell themselves? Where is their focus? So much of what I've learned over the last thirty odd years of being a clinician and researcher and writer, is I am compelled to grill people and by grill people, I mean going up to people who handle situations well and asking them:

“What are you doing in there? Where is your focus? What is your internal dialogue like? What are you telling yourself while you face this situation? How do you explain this situation to yourself? How do you decide how you're going to handle it in advance? What do you do when you're just thinking on your feet? How do you determine whether this is really a risk or not?”

And by asking all kinds of questions - it's how I've learned so many strategies over the years for handling routine situations, situations that are anxiety provoking to be sure. But having the skills, the resources, the strategies to be able to move through those situations


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in a step by step fashion. So I have never hesitated for a moment when I see people handling difficult situations well, asking if I can interview them, talk to them and find out what they're doing and how they approach it. And it really teaches you what the huge differences are between people who flip into high levels of anxiety, scare the hell out of themselves and try and run away from things, to the people who roll up their sleeves, move through it and handle it. And of course the most interesting thing is they can tell you they're anxious and they do it anyway. Now that's one of the key differences and what falls into the realm of what's called a coping skill. Coping Skill One of the things that I mentioned just in passing earlier that I'll focus on now for just a moment is what's called “coping skill.” The coping skill is how you deal with the things that create anxiety. What anxious people tend to do is employ a mechanism called avoidance. I'm sure you've heard that term before. You know what avoidance is. By definition it is avoiding what is anxiety provoking. The problem of course is us that if you avoid the situations that scare you, that create anxiety in you, by avoiding them you will never learn to manage them. And by never learning to manage them the anxiety level actually increases over time. So that literally month after month, year after year, what used to be mildly anxiety provoking now becomes hugely anxiety provoking. And virtually every form of anxiety treatment I am aware of involves what is called “exposure” that eventually armed with new skills and new perspectives the person will need to face what was scary to them and that is how people develop mastery, that once you go through the experience and when you go through the experience multiple times and you survive them and you discover that the anxiety wasn't justified, that it wasn't the risk that you thought it was. That's how people become empowered. And for me it's the most compelling part of being a clinician frankly is when people say to me some variation of, This used to scare the heck out of me and now I'm managing it really well. Yes it still creates some anxiety for me but now nearly enough to make me avoided it or stay away from it and so I'm able to do the things I want to do." Well, I'd say the same thing: I'm routinely facing situations, I'm sure you are too, that are anxiety provoking. And you recognize that doing those things is more important than avoiding them. That being able to go where you want to go and do what you want to do and feeling the power to do that, is one of the most important things that you can have in life - that confidence in yourself that, even though you don't know exactly what's going to happen, you trust yourself that you're going to be able to manage it. That is what self-confidence is about. Self-confidence isn't knowing everything or having every contingency covered, but it is something that arises from observing yourself being able to problem solve, that you trust yourself that whatever situations you face you'll find a reasonably effective way of managing it.


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All right, so coming back to the patterns I've talked about; cognitive style, the quality of your thinking. I've talked about attributional style, the explanations that you make the locus of control and expectancy. I've talked about risk assessment and being able to assess risk realistically and being able to tolerate risk. Discrimination Skills There's another factor that I want to mention that are called discrimination skills. A discrimination skill is the ability to make a distinction between various options you know. There was an old experiment that was done in the 60s that has come to be known as the executive monkey studies where they would take rhesus monkeys and they would basically secure them in a chair where they couldn't escape. And they were shown pictures of circles and squares and when the monkey touched the circle it was given a food reward. When the monkey touched the square it was given an electric shock. So the monkeys, being very smart, very quickly learned to touch the circle get this food reward. Don't touch the square and avoid the electric shock. Well in rounds one, two, three the circle was clearly a circle the square was clearly a square and the monkey was able to avoid punishment and get the food reward but then the researchers did something really interesting. They started round by round of presentations of these cards with a circle and square on it. They started to take these circles and progressively make them a little squarer and they started to take the squares and progressively make them a little rounder. In the early rounds even though the circle was now a little bit more squared it was so clearly a circle and even though the square was clearly still a square it was now a little rounder looked a little bit closer to a circle but you could distinguish them and the monkey did and still managed to get the food rewards and avoid the electric shock. But little by little, round by round, as the circles became squarer and the squares became more circular after a while they became indistinguishable and the monkey could no longer tell what was the circle what was the square and the monkey had absolute panic attacks. Well, that's the kind of research that fortunately can't be done now, it is certainly a rather harsh way to treat an animal, but let's take the learning point from the experiment that when you are faced with a potentially very great choice something that has the potential to either bring you reward or punishment and you can no longer distinguish what the right thing is to do, anxiety levels go through the roof. Well if you think about it this is what daily life is about and certainly a smaller version in most cases but we're always having to make big decisions not knowing whether we're going to get rewarded for it or punished. Should I take this new job? Should we buy this house? Or should I go to this particular school? Or should I take on this particular client? Should I affiliate with this particular group? Should I, should I should I? And here you are


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not being able to metaphorically tell what's the circle and what's the square, what's the what's the thing to do that's going to get me the reward and help me avoid the punishment. And so when somebody can't make discrimination their anxiety level goes through the roof. One of the tools that I'm really offering you now in talking about this is highlighting how important it is to formalize the statement: what I am trying to distinguish between here is this and put it in words. So let me give you some examples of discrimination strategies. Earlier I talked about the locus of control. Is this in my control or isn't it? Well when somebody can't make the discrimination is this controllable or isn't it, people will act as if they don't have any control when in fact they really do. That's typical of anxious people. Or at the other side of the continuum, they'll act as if they do have control when they really don't. So it's a very repetitive and common theme in therapy to help people who don't see where the control is to find the controls. A lot of what goes on in therapy is a therapist telling the client, "Here you have more control over this than you realize." And when you say that to a client who's feeling victimized, who's feeling disempowered, they typically look at you like you are speaking Martian. They don't really get it and it really is a learning process of how to learn to discriminate where the controls are in a given situation. I will just say in a general way people have more control than they realize. Now I can talk about it in a more academic away and talk about what's called primary control and what's called secondary control. Primary control is the question of whether you actually control the circumstances. Is there something that you can do to change the situation? And if there is, that's usually plan A. First choice is to do something to actually change the circumstances. But in reality there are a lot of situations that we all face every day that we really can't do anything about. I can't do anything about the fact that this is the person who's the C.E.O. of the company or this is the person who is my supervisor or this is the person who I have to deal with in this situation. So then we move into the realm of secondary control that if I can't change the circumstances some way how do I change my reaction to it. So, for example, at the time that I'm recording this it's a late December 2010, there have been blizzards all over the East Coast of the United States. Airports have been shut down for days people have been stuck in airports for days waiting to get a flight out and literally some of the people are going to be in the airport for five, six, or even seven days. They can't leave the airport, there is nowhere for them to go, so they're literally sleeping, eating, living, at the airport. So on the news they're interviewing people and people are naturally bemoaning the fact that they're stuck, that Mother Nature has dealt them this terrible card that has ruined their holiday plans and ruined their Christmas and New Years and all of that. And then they interview one woman who smiles for the camera and she says, "Well I've decided I'm just going to look at it as an adventure and it's going to be a great story to tell people for years to come." Now that is a very sophisticated response and it's a great example of secondary control. She literally decided there's


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nothing I can do about the situation I don't have any primary control over the weather or how the airlines function so she exercised her secondary control to decide what frame of mind she wanted to be in in order to handle the situation with as little stress and distress as possible. That is a really sophisticated response. Now I'm sure there are some people who would criticize and say, "Oh that's so Pollyanna, sure that's so ridiculous." But the reality is when it's all over she's not going to remember this as a traumatic episode the way other people will. She's going to say that it was a drag but there were some things about it that were interesting and I found some abilities in myself I didn't know I had and I coped with it and it really wasn't so bad: I survived and hey here's a story and that's really a great thing. Global Cognitive Style Well, the last pattern that I want to talk about is what's called “global cognitive style.” If we ask the question WHO is most prone to anxiety, the people who have a global cognitive style are the ones who are most likely to react with higher levels of anxiety. By global style I mean the person who tends to think in over general terms, the person who will see the forest metaphorically but they really won't see the trees that comprise the forest. That's called a global cognitive style. So when you hear people make statements like "I just want to be happy," or "I just want to feel normal," or "Well I'm a phobic that's my nature." or "I just get so overwhelmed, I get so bad I just can't think," "The anxiety just happens to me, I don't do anything to cause it, it just happens to me," those are all examples of over general or global thinking. The more global someone is, the more general they are in their quality of thought, the more it precludes their ability to contain the anxiety. Containing the anxiety presupposes the ability to set boundaries, the ability to establish limits. It's a skill called compartmentalization. It's what allows people to put the anxiety aside instead of it being their global focus and just focusing on how anxious they feel. The ability to compartmentalize means as if you're building a wall or putting anxiety in a compartment so that you can focus on the other things, like problem solving, that really need to be done. Well, the ability to compartmentalize is a very very important skill and needs to be worked on to be developed. It's one of the most important skills there is in anxiety management and that's what allows you to maintain good boundaries. It's what allows you to set aside the anxiety long enough to think and make good discriminations. Is it in my control or isn't it in my control? Is this a good choice or isn't it a good choice? Do I have enough information or don't I have enough information to make a good decision? Is now a good time to talk about my feelings or is now not a good time? That all requires discriminations and you can't make discriminations if you're global, the ability to think through should I choose A or should I choose B.


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That's the heart of making discriminations which is predicated on the ability to compartmentalize. Well, when we talk about global thinking and the ability to be more specific what I have already suggested as another strategy is something I'm going to repeat now because it bears repeating. How important it is to learn to think linearly, sequentially so that instead of reacting to the entire of the anxiety how important it is to do what I was describing earlier: the success imagery of picturing yourself visualizing yourself moving through the situation. Skillfully one step at a time and laying it out for yourself ahead of time what is the strategy what is the sequence. Well, learning how to think linearly is a skill and it's typically not a skill that people prone to anxiety have but here's a way for you to learn this skill. Here's another strategy. It's a strategy that I call of flow of steps. If you take simple everyday things, everyday activities like going grocery shopping or taking a shower or driving a car. Well, we represent those kinds of experiences globally with the phrase driving a car, taking a shower, or going grocery shopping but in actuality you don't just drive a car. In reality you follow a series of steps that when all of those steps are run together they globally form the experience of driving a car. You don't just take a shower you follow a series of steps that culminate in you being clean. You don't just go grocery shopping you follow a series of steps that culminate in you being able to put groceries into your refrigerator uncovered. And so the exercise is taking these kinds of everyday experiences and identifying the steps that go into it. This is a training your brain exercise. Take things that you do every day and break them down into the steps: step one, step two, step three, step four, and you'll know that you have done this well when anybody, anybody could follow the sequence that you've laid out and they will have accomplished that task successfully. Now the important point that I've been making all through here is that how you think makes a difference, how you behave makes a difference, how you manage your anxiety physically makes a difference, how you manage it emotionally makes a difference. But earlier I mentioned that this ability to recognize and tolerate ambiguity so that you can assess risk realistically, so that you can take the ambiguity out of a situation by developing linear sequence; the flow of steps that I just talked about, all of that makes a huge difference. But one of the things that I mentioned in passing that I want to focus on for just a moment now is the issue of sleep. Sleep disturbance is the most common symptom of anxiety and it typically takes one form that's called primary insomnia or initial insomnia where the person goes to bed and they lay there and they lay there and they toss and they turn and they have difficulty falling asleep. So maybe that applies to you maybe it doesn't apply to you now but in a purely statistical sense it applies to most individuals suffering anxiety, which is why I'm talking about it. Well, the need to sleep well is obvious; certainly one of the things that we know is how important deep sleep is to good mental health. And the interesting thing is that when people can't sleep it's what leads them to do things like


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drink alcohol as a way of helping themselves fall asleep and I should point out that drinking alcohol will help you fall asleep and it will practically guarantee that two or three hours later you will be wide awake. It's what's called middle insomnia and it's going to impair the quality of sleep so it's not going to be a restorative sleep. Again, I can't emphasize enough that if you can stay away from alcohol and drugs you will be doing yourself a huge huge favor. So what keeps people awake? What keeps people awake is what is known as rumination. Rumination is spinning ideas around, thoughts around and around and around and around over and over again. And rumination has been highly correlated with anxiety. The more someone ruminates the more anxiety symptoms they have. The more someone ruminates the less effective they feel as a person. And it affects their self-esteem, increases the likelihood as well of depressive symptoms not just of anxious symptoms, and so one of the things that I'm suggesting in talking about this is how important it is to make a key discrimination. Here's the discrimination: when is it useful analysis and when is it useless rumination. I'm making the point clearly that there is a danger in thinking too much and bedtime isn't the time to think about your life. Bedtime is not the time to analyze your problems. Bedtime is the time to go to sleep and so here is another great reason to learn self-soothing strategies. I am a huge fan of hypnosis, Clinical Hypnosis. Clinical Hypnosis is a vehicle for focusing your thoughts, relaxing your body, relaxing your mind. So contrary to the popular misconception that somehow hypnosis is going to diminish someone's sense of control the reason I'm so enamored with hypnosis is because of how much it increases someone's sense of control. So learning self-hypnosis or using parallel processes like mindfulness or visualization or meditation, any of these things that teach you how to focus your thoughts in ways that are relaxing, to be able to use your thoughts to calm yourself physically and calm yourself emotionally at bedtime. It's one of the things that you really want to take seriously, how valuable it is to reduce the amount of time that it takes to fall asleep. Now what is normal? Well the National Sleep Foundation does a survey every year of looking at people's sleep habits and in the most recent data that they released they show that it takes the average person somewhere around twenty minutes to fall asleep. Now if somebody scares themselves and they make themselves anxious thinking that they should be able to go to bed and just fall asleep right away, obviously that's a misconception that drives anxiety. But whether it takes you fifteen minutes, twenty minutes or thirty minutes isn't the issue as much as it is being able to use that time to calm yourself physically so that you can fall asleep, stay asleep and wake up feeling refreshed. So now that I have been talking in a general way about rumination let me reiterate a key point. What we want to be able to do is convert from rumination to action. Bear in mind the discrimination question that I just asked was: "How do you know when it's useful analysis, how do you know wanted to useless rumination?" I'm going to answer the question for you. The answer is if the analysis does not give rise to action then it's useless


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rumination. So here's another tip when you're contemplating, when you're thinking, when you're analyzing, when you're ruminating insert the question, "What does this mean I should actually do, what is the course of action that arises from this ruminative thinking or this analysis?" The idea is to take affective action as soon as you possibly can. Now the fact that you think about things that are anxiety provoking, isn't that the problem? You know one of the characteristics of people prone to anxiety is that they routinely ask the question, "What if?" " What if I lose my job?" "What if my spouse leaves me?" "What if my kid gets into drugs?" "What if we run out of money?" Asking the "what if" question is not the problem. There's no doubt it raises anxiety, but one of my most esteemed colleagues is a psychologist at Boston University named David Barlow. He is one of the most well-known anxiety experts on the planet Earth and David said something to me once that has always stuck with me and I hope it'll stick with you as well. He said Michael, one of the ways to think about anxiety is simply this: Anxiety is the price tag for planning. Anxiety is the price tag for planning! I love that phrase because it really speaks to how important it is to think ahead but when you think ahead how it's naturally going to create some anxiety. So that when we ask a question like, "What if I lose my job?” OK that's a scary thought but it helps you start to plan what would I actually do. So that when we look at it in terms of civil engineering and I live in Southern California we have earthquakes here. The civil engineers ask the question, "So what if we have seven point two magnitude earthquake?" Well, that's an anxiety provoking thought. Nobody wants to live through a seven point two magnitude earthquake but by asking the question, "What if they design bridges to withstand earthquakes?" they design buildings that can sway to withstand earthquakes. By asking the "what if" question it allows us to develop realistic coping skills. So the problem isn't asking "what if", the problem is when you don't answer the question. By answering the question, "Here's what I would do," that doesn't mean you want it, that doesn't mean you would like it but what it does is it takes the thing that seems so formidable and so impossible to cope with and it reduces it to unpleasant but manageable. Unpleasant but manageable. I wouldn't like it if my spouse left me but I could cope with that. I wouldn't like it if I lost my job but I could cope with it. And that's why the what's the worst that can happen question that cognitive therapists often ask is such a good one. It helps people prepare that even though something unpleasant could happen that it would be manageable. Well there is really my final point in all of this, in all the different skills that I have described during the course of this lecture I have been talking about being able to problem solve. Being able to cope effectively, being able to find in yourself the resources to manage the inevitable unpleasant things in life. I have made a point as well that avoidance is a very poor coping mechanism that makes things worse. If you were to look at all of the symptoms that people developed, they are all symptoms that come about from people trying to avoid the unpleasant. Well, I understand that. I understand the importance of


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wanting to avoid the unpleasant and at the same time what makes people better is learning how to manage and learning how to cope with that. Learning to trust themselves that they can manage whatever is going to come their way and that's really one of the reasons why I've been such a huge fan of hypnosis as a vehicle for managing anxiety, that by learning relaxation it can certainly replace feelings of anxiety with comfort and the fact that the hypnosis targets anxiety producing patterns of thought. Targets anxiety producing patterns of behavior this is one of the most compelling reasons to learn self-hypnosis as a vehicle of managing your anxiety. So the various kinds of imagery that people can use of relaxation spots like a beautiful garden, or floating on a cloud or being on some spectacular island or simply using deep breathing exercises such as you learn in mindfulness meditation strategies. But when I talk about the other skills that I've mentioned; learning to increase your ability to assess risk realistically, learning to make discriminations skillfully, learning to answer the question when you ask yourself what if something bad happens, the ability to break overwhelming things into their components when I was talking about going from global to specific. Well, I have created a CD program called "Calm Down". In fact it is four CDs with seven different hypnosis sessions each one targeting a basic pattern of anxiety and so many of the patterns that I've talked about are addressed in this "Calm Down" CD program and you should know that it is an enormously valuable self-help program it's extremely popular and people write to me all the time about what a huge difference it's made in their lives so I'm just letting you know that "Calm Down" CD program is available. It's on my website yapko.com and so you can find it there. Likewise for those of you who are professionals you might be interested in a DVD called "The Case of Susan", a woman I treated who had a phobia about driving on the California freeways. The California freeways admittedly can be intimidating. People are zipping along at pretty fast rates and weaving in and out of traffic so she had had a negative experience something like twenty-eight years earlier and on the basis of that she had formed a phobia, hadn't driven in all those years. I did one session hypnosis intervention with her and it was highly successful and it illustrates these various points that I've been talking about, the various patterns that give rise to anxiety problems like the driving phobia. So the "The Case of Susan" is a DVD. It is also on my web site that you might be interested in, but in all of this I hope that I have drawn your attention to the various things that matter the most in dealing with anxiety and that includes how childhood anxiety sets up both anxiety and depression in adults why it's so important to know where to focus your attention. I've talked about sleep disturbances being a very important diagnostic consideration. I've talked about the relationship between ambiguity in life experiences and the onset of anxiety. I've talked about how important the coping styles are which can serve to either increase or decrease your anxiety. Avoidance increases anxiety, learning to deal with it


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directly reduces it. Why it's so important then for therapists to encourage clients to be active in learning the skills that help them cope with their anxiety. And I've mentioned how hypnosis can be valuable in that regard. So I hope that you have found this lecture helpful. I want to thank you for your kind attention and again if you want any additional information you can go to my website yapko.com. That's http://www.yapko.com/ and if for any reason you want to contact me you'll find my contact information there as well. So again I hope you found this lecture helpful thank you so much for your kind attention.

http://www.yapko.com/

Documents

“Key Aspects of Treating Anxiety . By Michael Yapko. · Hello this is Dr. Michael Yapko, I’m a clinical psychologist and an author and I will be spending the next hour or so speaking