Anxiety (along with Depression) is one of the major presenting issues in therapy. It manifests as a preoccupation with the future (compared to depression which focuses on the past.)
“Anxiety is a lot like a toddler. It never stops talking, tells you you’re wrong about everything, and wakes you up at 3 am.”
What is Anxiety?
The Mind website defines Anxiety as:
“what we feel when we are worried, tense or afraid – particularly about things that are about to happen, or which we think could happen in the future.
Anxiety is a natural human response when we feel that we are under threat. It can be experienced through our thoughts, feelings and physical sensations.”
And it’s on the rise
Many studies and reports point to a dramatic rise in anxiety across the world, with a significant further increase as a result of the Covid 19 Pandemic (see Lancet Paper 2021).
Research by Professor Nick Freemantle in the UK identified a significant rise in anxiety in 2008, which has been attributed to increased unemployment and financial insecurity as a result of the banking crisis. Rates of anxiety in young women were and remain especially notable. Since then, anxiety has continued to rise, with contributing factors such as social media prevalence, Covid 19 and the Climate Crisis.
So how can we best support clients (and ourselves)?
Using the lens of the nervous system
Through the lens of the nervous system, anxiety and depression can be viewed as two sides of the same coin, pointing to dysregulation in the nervous system, through hyper (“on”/aroused) or hypo (“off”/shutting down) states.
Both states are important and ideally we cycle through “on” (sympathetic) and “off” (parasympathetic) states, smoothly switching between action/doing and relaxing/being, discharging trigger energies.
Diagram from p.21 Sarah Van Gogh (2018) Helping Male Survivors of Sexual Violation to Recover: An Integrative Approach – Stories from Therapy. Jessica Kingsley Publishers.* See bottom of article for 20% discount code.
Trauma, including attachment trauma, with its root in childhood and our experience of early care givers, can result in ongoing dysregulation of our nervous system. As a result we may jerk around the cycle and get stuck. Anxiety indicates a tendency to get stuck in the “on” state, while depression may point to a tendency to get stuck in the “off” state.
Therapy and counselling can be useful in addressing attachment trauma through developing a strong therapeutic alliance and the creation of a ‘safe enough’ container. This can help heal misattunement from the past.
Normalising anxiety (rather than amplifying or minimising) can also be useful, helping clients to develop self-compassion and to grieve and process what may have already happened in the past. Practical support can be offered in helping to identify triggers for anxiety, and evaluating the reality of the perceived danger, as well as finding ways for the client to self-soothe and learn to tolerate aroused states, expanding their window of tolerance (see below).
This resource list includes books and tools that therapists could use in the room with clients, and also recommend to clients to resource and regulate themselves outside of sessions. It is by no means exhaustive but hopefully provides some practical tools and support, supporting the release of a long deep sigh and a switching off:
“Almost everything will work again if you unplug it for a few minutes, including you.”
Have suggestions to add that have worked for you and your clients? Leave a comment in the comments section below or email us on email@example.com.
Join us for our one day online CPD event: Anxiety: Attachment, Neuroscience and The Body on 8th October 2022. In this one-day seminar our three speakers: Victoria Settle, Smita Rajput Kamble and Suzanne Worrica, will explore the experience of anxiety, and how we can effectively work with clients experiencing these symptoms in therapy.
We will explore the neuroscience of anxiety, the function of anxiety in everyday life and the experience of collective anxiety experienced in response to world events. The day will offer ideas about why some people become overwhelmed with anxiety and panic, including early causes around attachment rupture, and also offer some ways to work with anxiety and panic, including somatic/body-based approaches.
Helping Clients understand their Window of Tolerance
The Window of Tolerance model, attributed in its origins to Dr Dan Siegel, provides a useful model that can be shared with with clients, helping them to become more aware of when they may be hyper or hypo-aroused. Working with their therapist or counsellor, they can then resource themselves with tools that they can use both in and out of the therapy room. Over time they may then be able to expand their window of tolerance where they can deal with and tolerate bigger challenges.
Polyvagal theory provides a more indepth tool for working with client trauma and anxiety, exploring how the nervous system responds to external stimuli varying from safety to danger. Similar to the Window of Tolerance it can be useful in clients gaining greater self awareness and understanding (and hopefully self-compassion and acceptance), and develop ways of self regulating. Useful resources include:
An Introduction to Polyvagal Theory. BTP Blog article with Tony Buckley, introducing Polyvagal Theory and how it can be used in counselling and psychotherapy.
Why Polyvagal Theory is Essential for All Therapists. BTP Blog article outlining five reasons why Polyvagal Theory benefits all therapists
Anchored: How to Befriend Your Nervous System Using Polyvagal Theory. (Deb Dana, 2022). Polyvagal expert, Deb Dana shares a down-to-earth presentation of Polyvagal Theory, bringing the science to life with practical, everyday ways to become more aware of your nervous system moment to moment, changing the way you respond to the day to day challenges of life.
Polyvagal Flip Chart: Understanding the Science of Safety. (Deb Dana, 2020). This flip chart offers therapists an easy, standardised way to support clients in understanding the role of the autonomic nervous system in their lives, making psycho-education an interactive experience.
Simple Polyvagal Deck. This illustrated deck of cards has been designed by a qualified and experienced counsellor and Creative Arts Therapist. These cards can be used to assist your clients in getting to know their nervous system and gain awareness in order to thrive.
Turn off Anxiety in Your Nervous System: 4 Ways to Turn on the Parasympathetic Response. Therapy In A Nutshell YouTube Video
Autonomic Nervous System Poster
This poster provides a thorough visual summary of the anatomy, function and phylogeny of the Autonomic Nervous System, based on the breakthrough research of Stephen Porges, PhD.
It visually explains Polyvagal Theory, and was developed and produced by John Chitty (RIP 2019). It is available through the Colorado School of Energy Studies in Boulder, Colorado, USA.
Limited supplies are also available through Brighton Therapy Partnership for £26.30 including UK postage and packaging (2nd class signed for delivery only). Please contact Laura on the BTP email address firstname.lastname@example.org to place your order.
Anxiety Book Recommendations
The following books provide greater insight and understanding into anxiety, along with practical tools for clients to implement.
Transforming the Living Legacy of Trauma. (Janina Fisher, 2021). This books provides step-by-step strategies that clients can use on their own or in collaboration with a therapist to transform traumatic experiences. It helps survivors to understand their symptoms and reactions as normal responses to abnormal events, and provides ways to work with the symptoms that intrude on their daily activities, preventing a life beyond trauma.
Anxiously Attached: Understanding and Working With Preoccupied Attachment. (Linda Cundy, 2017). Written for therapists, this book addresses the origins of anxious attachment, with the aim to increase understanding of preoccupied clients from an attachment perspective, to recognise the nature of their anxieties and resistances, and propose specific skills for therapeutic work.
But I Should Be Fine: How to gain relief from anxiety, overthinking and pesky self-doubt. (Zoe Clements, 2021). In this book, Zoe Clements shares her personal struggles and 16 years of professional experience to deliver a practical, psychobabble-free guide to relieving anxiety, overthinking and pesky self-doubt. Including aha! moments from the counselling room, this easy-to-follow guide provides essential techniques to help clients manage anxiety.
Anxiety – Deal with it!: What works, when and why. (Yvonne Bates, 2019). This self-help book helps you to understand what is causing your anxiety and know what to do about it, including learning how to avoid a lot of anxiety altogether by recognising the warning signs and dealing with them before the anxiety gets a hold of your body and mind. There are over 70 self-help exercises and techniques in the book to help build an arsenal of anxiety-busting weapons to use in different situations.
Unwinding Anxiety: Train Your Brain to Heal Your Mind. (Judson Brewer, 2021). Judson Brewer explains how to uproot anxiety at its source using brain-based techniques and small hacks accessible to anyone. Also available as an audiobook and has accompanying card deck (see tools and cards below).
Why Has Nobody Told Me This Before? (Dr Julie Smith, 2022). Drawing on years of experience as a clinical psychologist, Dr Julie Smith shares her toolkit and the skills we need to get through life’s ups and downs. Written in short, bite-sized entries, clients can turn straight to the section they need depending on the challenge they are facing. Also available as an audio book and Dr Julie Smith has a strong presence on TikToc (see below).
Anxiety: Meditations on the Anxious Mind. (The School of Life, 2020). This guide from the School of Life explores anxiety: why we feel it, how we experience it when it strikes and what we can do when we come under its influence. Across a series of essays that look at the subject from a number of angles, the tone is helpful, compassionate and in the best sense practical.
Under Pressure: Confronting the Epidemic of Stress and Anxiety in Girls. (Lisa Damour, 2019). Lisa’s second New York Times best seller is a celebrated, urgently needed guide to addressing the alarming increase in anxiety and stress in girls from elementary school through college.
Cards and Tools
“You can’t stop the waves, but you can learn to surf.”
The Unwinding Anxiety Card Deck: 60 Science-Based Strategies to Break Cycles of Worry and Fear. (Judson Brewer and Mitch Abblett, 2021). Based on Dr. Brewer’s New York Times best-selling book Unwinding Anxiety (see above), this card deck features 60 research-based practices to help work with clients to identify and overcome unhelpful anxiety responses, or habits, that prevent them from living life to the fullest.
Cards Against Anxiety: A Guidebook and Cards to Help You Stress Less. (Dr. Pooky Knightsmith, 2020). This pack of 25 cards and 128 page book uses long established CBT techniques and controlled breathing practices that will help users stress less and combat anxiety and depression. Designed for use on the go and around other people, there’s no need to find the perfect quiet spot to meditate in and it is discreet enough to be used on packed public transport or in an open public space without compromising your privacy.
The Cycle of Anxiety Game. Designed by a qualified Counsellor and Creative Arts Therapist, with over 8 years of experience in working with children, young people and adults. This game is designed to be used in a therapeutic setting and to facilitate psychoeducation through the use of True or False cards, to help normalise and offer an understanding of anxiety.
Calm Prompt Cards. (School of Life). 60 prompt cards designed to help you find perspective on life’s sorrows and regrets.Through ironic humour, consoling cultural references, and a small amount of pessimistic wisdom, they help to summon up our best and calmest selves.
Exercises to do with clients
Anchoring with NLP: Help clients to resource themselves when approaching edges of window of tolerance
Taking in the Good: Rich Hanson’s tool for addressing the fact that: “the brain is like Velcro for negative experiences, but Teflon for positive ones.”
“Tension is who you think you should be. Relaxation is who you are.”
Mindfulness has become popular in recent years, and is now taught in schools. Although it may not be appropriate for clients with extreme trauma who may need to approach it with caution, working with present moment awareness can be highly effective.
The BTP Blogpost Series on mindfulness and psychotherapy with Margaret Landale explores this over 5 posts:
The Present Moment Part 1: Empathy
The Present Moment Part 2: Compassion
The Present Moment Part 3: Mindfulness
The Present Moment Part 4: Challenges in Mindfulness
The Present Moment Part 5: Conclusions and References
“I know but one freedom and that is the freedom of the mind.”
Antoine de Saint-Exupery
Clear Fear App. App developed for teenage mental health charity stem4 by Dr Nihara Krause, Consultant Clinical Psychologist, using evidence-based CBT treatment to focus on learning to reduce the physical responses to threat by learning to breathe, relax and be mindful as well as changing thoughts and behaviours and releasing emotions.
Insight Timer. Highly popular and free app for helping with sleep, anxiety and stress with more than 100k guided meditations led by teachers from across the world.
Headspace App. Meditation app helping people to learn to manage feelings and thoughts with the lifelong skill of everyday mindfulness, any time of the day.
Calm App. Award winning app for Sleep, Meditation and Relaxation, with over 100 million downloads (includes specific Anxiety section and category)
iBreathe App. Simple yet powerful app to help guide you through deep breathing exercises. Whether you are struggling with stress, anxiety, insomnia, or are trying to meditate and relax, iBreathe provides an easy-to-use, beautifully designed user interface. Designed with simplicity in mind and also customisable with daily reminders.
Gratitude Daily Journal. App to support gratitude as part of daily routine using prompts and journaling reminders.
Instagram and TikTok
@dlcanxiety. Large Instagram Online Anxiety Community
Dr Julie Smith. Popular TikTok Channel – Dr Julie Smith – Psychologist and Author – 3.4M followers
@drjuliesmith Is your anxiety invisible to others? #anxiety #panicattack #panicattackhelp #anxietyattack #mentalhealth Inspired by @Share the Struggle ♬ overwhelmed by royal and the serpent
Being Well Podcast: Healing Your Attachment Wounds with Dr. Diane Poole Heller. Exploration identifying and healing attachment wounds
Powerful Daily Habits to Reduce Stress and Anxiety – Dr. Rangan Chatterjee / November 3, 2021. Episode including clips and tips from his previous guests and links through to the full episodes to explore more
Websites and Organisations
MIND: Mind provide advice and support to empower anyone experiencing a mental health problem. They also campaign to improve services, raise awareness and promote understanding. Including advice for self care for managing anxiety and panic attacks.
Anxiety UK: Established in the 1970s this charity offers an extensive range of support services designed to help people to control their anxiety rather than letting it control them. They also publish the Anxiety UK magazine.
Youtube Channels and Videos
Pooky Knightsmith Mental Health YouTube Channel. Pooky Knightsmith uploads videos every Tuesday and Friday about mental health. They draw on both her professional and personal experience and aim to educate and inspire. (14.7k subscribers).
Why We’re All So Anxious (School of Life). This video from the School of Life (with 7.5M subscribers) addresses the fact that “most of us are anxious pretty much all the time – but frequently imagine that other people aren’t. It’s time to admit the truth. Anxiety is just a basic fact about being human.”
Inside Out. (Link opens in YouTube). This Walt Disney animation provides an insightful view into our emotions and how to handle them. Watch the trailer:
As Good as it gets. (Link opens in YouTube). Classic Jack Nicholson film from 1997, depicting an obsessive-compulsive writer of romantic fiction who’s rude to everyone he meets, including his gay neighbor Simon (Greg Kinnear), but when he has to look after Simon’s dog, he begins to soften and, if still not completely over his problems, finds he can conduct a relationship with the only waitress (Helen Hunt) at the local diner who’ll serve him.
Girl Interrupted. (Link opens in YouTube). Released in 2000, this film is set in the changing world of the late 1960s. “Girl, Interrupted” is the searing true story of Susanna Kaysen (Winona Ryder), a young woman who finds herself at a renowned mental institution for troubled young women, where she must choose between the world of people who belong on the inside — like the seductive and dangerous Lisa (Angelina Jolie) — or the often difficult world of reality on the outside.
Ideas for getting more active and social
Park Run – free, weekly, community running events all around the world.
Daily Step Counter / Pedometer Apps – going for a daily walk and getting active
Meet up – connect with local groups for walking etc
Borrow My Doggy – connect with local dog owners to hangout with a canine friend
Volunteer in your local community – explore opportunities across the UK
Forest Bathing – Experience the benefits of the great outdoors
Support in Developing Habits
“The journey of a thousand miles begins with a single step.”
In many cases, we and our clients know what we could do to support ourselves in managing our anxiety. However, in our busy lives, actually putting breathing and mindfulness exercises etc into practice in our daily lives can be challenging.
Based around attaching micro activities to existing habits, for example doing 3 squats every time you boil the kettle for a cup of tea, the practice of Tiny Habits (pioneered by BJ Fogg) provides a practical way of getting started. The Tiny Habits website includes a free newsletter and free 5 day programme to get started.
Dr Rangan Chatterjee’s book: Feel Better In 5: Your Daily Plan to Feel Great for Life Paperback (2019) uses this approach, (Rangan studied with BJ Fogg), and provides suggestions for hands-on micro practices, lasting for 5 minutes, that can be used to incorporate positive practices into our lives.
Thank you to those who have already shared your recommendations! Do you have additional suggestions of resources that have helped you and your clients? Leave a comment or email us on email@example.com.
“There must be quite a few things that a hot bath won’t cure, but I don’t know many of them.”
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