Navigating the Intersection of Work and Mental Health
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Working Better and Stressing Less

Ideas on work and mental health

Posts tagged counseling
Reducing suffering without reducing anxiety - WHAT!?

I specialize in treating anxiety and so it might be disconcerting for you to read that reducing my clients' anxiety is one of my least important treatment goals. Hear me out though please... 

The American Psychological Association defines anxiety as, "...an emotion characterized by feelings of tension, worried thoughts and physical changes like increased blood pressure. People with anxiety disorders usually have recurring intrusive thoughts or concerns. They may avoid certain situations out of worry. They may also have physical symptoms such as sweating, trembling, dizziness or a rapid heartbeat."

The problem with "treating anxiety" is that it doesn't respond well to us going straight after it. This is why so many extremely competent, smart, functional people end up in therapy offices after failing to fix their own anxiety. Anxiety is a monster fed by many factors, one of them being attention, and so the more direct attention we put on getting rid of it, the biggest and stronger it becomes. So rather than focusing on anxiety reduction, I focus on reducing the total suffering of the client at hand. Most clients have the following types of suffering:

1. Primary symptoms - In the case of anxiety, this may be physiological arousal, worrisome thoughts, and irritability. 

2. Coping mechanisms - It takes energy to cope with anxiety and anything that takes energy away from other things in our lives is stealing from us or making us suffer. Coping mechanisms become their own type of suffering. 

3. Fear of it getting worse - In all psychological disorders and especially in anxiety, sufferers fear symptoms getting worse or feeling forced to use maladaptive coping mechanisms (alcohol, drugs, self-harm, etc.)

4. Shame around the coping mechanisms, symptoms, and fear of worsening. Almost everyone with psychological suffering feels bad that they feel bad. They feel bad about what their symptoms have done to their relationships, jobs, or hobbies. They feel shame that they have turned to harmful coping strategies when the pain gets to be too much. 

The problems with targeting only the first of these four factors are that first, anxiety itself is slippery. And second, the anxiety itself often comprises a minority of total suffering patients experience. So, I go backwards. 

Let me explain using a couple of hypothetical patients that I created to represent typical courses I've observed in my practice. In the graph below, this hypothetical patient started with a total suffering level of 100. In this course of treatment, we targeted their shame around anxiety symptoms and coping mechanisms and did a bit of work on their fear of symptoms returning or having to use maladaptive coping mechanisms. We never targeted their anxiety or coping mechanisms themselves. The result was still a huge reduction in suffering - from 100 to 50. 

More typically, a course of treatment does eventually influence actual anxiety or depression symptoms and not just the ancillary shame and fear. In the graph below, this hypothetical patient and I worked on shame and fear around anxiety symptoms and coping mechanisms. Because those were a big source of their worry and anxiety, they experienced actual reduction in worry and physical anxiety symptoms.

Does this mean we don't ever work with anxiety directly? Of course not! I teach relaxation techniques, meditation and mindfulness, some simple yoga practices, and other skills to help clients work more skillfully with their anxiety. The problem is that none of the four factors above will EVER get to zero. No one walking on this earth has zero anxiety, zero coping stress, zero concern about getting "sicker," or zero shame. So if I don't teach my clients how to manage the cycle of anxiety, coping, concern, and shame and only treat their anxiety symptoms, they will eventually get worse again.  

Once clients let go of shame and begin practicing the cultivation of compassion for themselves, they feel less bad about their coping strategies, release worry about getting worse, stop needing as many coping strategies to get through the day, and have less anxiety overall. More importantly, they have a system to continue practicing throughout their lives so that after therapy is over and over time, they keep working to increase compassion and reduce shame and suffering. 

Therapists don't take you to the end - we just help you get started on the journey. 

A few of our favorite books on shame, self-compassion, and anxiety

How do therapists listen for so long?

Therapy is the only interaction I can think of (in American society, anyway) during which two people sit together for an extended period of time and the entire conversation is focused on one person. I often get the question, "don't you get bored having to listen for so long? Doesn't your mind wander?" These are two separate questions with two different answers. 

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I cannot think of a single time when I have been bored in my role as a therapist. There is so much to pay attention to in a therapy session that we do not pay attention to in daily conversations. At minimum, I have to pay attention to what was said, what my plan is with the client, and a multitude of factors that help me assess a client's state of mind including things like speech, motor activity, and mood. Because so much more is going on than would occur in a regular conversation with a friend, it is hard to get bored and still be a minimally competent therapist. 

The other question, "does your mind ever wander," requires a more complicated answer. The short answer is, "yes." The reason for my mind wandering has never been boredom, however. Therapists are only human and I assume I speak for more than myself when I say, sometimes I have a headache, get an unexpected wave of fatigue, realize mid-session that I'm coming down with a cold, or simply didn't get good quality sleep the night before. I know I really strive to show up healthy and alert and I can usually do that because I have a small practice and I can be sure to be truly "on" during the days I'm committed to my clients. But the closer to full time a therapist is, the more of a representative sample of that person's "real life" their clients are going to get. So yes my mind does occasionally wander but it is never out of lack of interest in the client. It's almost always because minds like to wander and sometimes mine takes off before I can catch it. 

Why can't I be normal, like other people?
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Why does everyone else seem to have it together while I am falling apart? I want to feel happy like everybody else but I feel sad. I wish I could relax like a normal person but I cannot stop worrying and planning for things to go wrong. Why do I keep sabotaging my relationships while other seem to have no problem? What is wrong with me?

According to the National Institute of Mental Health, 26.2 percent of all American adults will suffer from a diagnosable mental disorder, in any given year. About 9.5 percent of the population will suffer from a mood disorder while 18.1 percent of the population will qualify for the diagnosis of an anxiety disorder. 

This means that for every four people you run into, at least one was, is, or will be suffering from enough pain this year to warrant a mental health diagnosis. Remember too that these figures account for the percent that will qualify for a diagnosis THIS YEAR. Over a lifetime, the numbers are even higher. 

Given these facts, what is "normal?" It can be frightening to acknowledge suffering and even mental illness as "normal," because we confuse acceptance and acknowledgement with approval and resignation.  

Perhaps we can learn to acknowledge our suffering without approving of it. We can relieve pain without fighting it. We can live vibrantly with mental illness without curing it. We can be completely normal and completely in pain at the same time and the bright spot of hope in that is YOU ARE NOT ALONE. 

For more information on mental health statistics in the US, please visit, 

http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/index.shtm