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Self-compassion precedes confidence

It takes humility and courage to accurately assess where you are and commit to the next step.

If you feel intense anxiety getting out of your house, the idea of obtaining and committing to a job on a daily basis might seem beyond what’s possible for you.  If you feel intense anxiety sending an introductory text message to a potential romantic partner, the ongoing vulnerability required to sustain a long-term relationship might seem overwhelming.

Thinking about this, many individuals with anxiety disorders get so discouraged that they lose motivation to take the next step.

It’s important to see this as part of the pattern of anxiety’s game.

Anxiety (and his allies self-criticism and depression) will tell you:

“What you’re currently doing isn’t good enough. This shouldn’t be hard for you. You shouldn’t have to practice this. You’ll never get where you want to be.”

You need to be ready for this type of message and say back to it:

“Every time I identify, label, and allow an uncomfortable thought, feeling, or sensation, you get less power. What I’m practicing is a new process; it’s not about my outcome in any given moment. It’s okay that this is where I am and what I have to do. My fear circuitry has become conditioned by associations that don’t make rational sense. For whatever reason, other people’s fear circuitry has different associations than I have. The only way I’ll get to where I want to be is to gradually change these associations.”

If it’s difficult to muster the compassion, humility, and courage to set small, achievable goals on your way to overcoming your anxiety disorder, consider how you would teach a child how to read.

The child may really want to start reading a Harry Potter novel, but if he doesn’t know his letters, he can’t just jump into a text like that one. He also might not completely understand how identifying letters is the beginning of a more complex process of combining letters to make sounds, combining sounds to make words, combining words to make sentences, and combining sentences to make stories that convey ideas and make meaning. You know that.

So, you’re likely to be very patient with the child, encouraging him to start with the first step, continue to practice, reminding him that eventually he will be able to read.

You wouldn’t criticize the child if he isn’t making progress fast enough, because there is no pace that is right for everything, and you know that pressuring him to try to be someone he isn’t won’t help him read faster. If you saw him struggling, you’d make it “easier,” meaning that you’d break it into a smaller component. You wouldn’t make it easier because you don’t believe in him. You’d make it easier, because you understand that he has to master the smaller components before he can master the more complex process. Reading is also a skill to be mastered, meaning that having greater motivation will increase his skill-based acquisition. As a good teacher, you’d work to keep him motivated, because staying motivated is part of the process.

Can you see the comparison to overcoming an anxiety disorder?

Your anxiety disorder was created, intensified, and maintained by a cycle of fear, resistance, and avoidance of your thoughts, feelings, and sensations.

The skills you need to step out of this cycle are the opposite of what you’ve tried so far:

In the past, you have minimized, disregarded, and avoided your anxious thoughts, sensations, and feelings.

Now, you’ll be identifying, labeling, inviting, and even provoking more anxious thoughts, sensations, and feelings. This identifying and labeling process is like learning the alphabet of anxiety. Per the metaphor, you won’t be able to read — that is, do what you care about in the presence of anxiety with skill and grace — until you’ve practiced the basics over and over.

It’s important to do whatever it takes to stay motivated to take small steps. Self-compassion and humor are helpful strategies for staying motivated.


The attitude of active, willing acceptance

So, how do you relate effectively to your unanswerable, catastrophic thoughts? 

Your anxiety disorder will be cured when you overcome your anxiety sensitivity, or second fear. Anxiety treatment can’t and shouldn’t mean that you’ll never be anxious again. Becoming anxious is a normal, healthy adaptive reaction to doing challenging things with uncertain outcomes. I would never want to take the capacity to become anxious away from you. Instead, I want to teach you to respond to anxiety in a way that helps you rather than hurts you.  

When you feel anxious, here are your steps:

#1 – Label it as anxiety

#2 – Switch from content to process.

#3 – Do the opposite of avoidance: Get unfused from your thoughts. Open up to sensations.

#4 – Actively allow your anxiety. Make it worse. Ask for more of it.

There will be other posts going into detail on each of these points. For now, let’s discuss how to help yourself learn how active, willing acceptance.

There is a right way to self-monitor.  In order to practice the steps above, you’ll benefit from seeking out triggering situations and watching your experience. You want to observe the following aspects of your experience: 

1) What was the trigger? Was it internal or external? 

2) What sensations do you feel? 

3) What thoughts are you having? 

4) What is your reaction to the sensations and the thoughts? 

5) What types of avoidance do you want to engage in? 

6) Did you engage in avoidance/neutralization/compulsions?

7) If yes, what did you do? If no, why didn’t you?

Try to answer these questions as soon after (or during!) the episode as possible. Try to answer in as few words as possible, as if you are a scientist taking notes in a lab.


The relationship between dread and confidence

Responding effectively to anxiety is a challenging skill that develops experientially with time and practice.

Think of a challenging skill you’ve acquired in your life: riding a bike, learning to read, speaking a foreign language or learning a programming language, or playing a sport.

You didn’t have trust in your ability to execute those skills — that is, you didn’t have confidence — until you had many experiences of practicing and succeeding. If the skill was important to you, you likely had feelings of anticipatory anxiety prior to experiences that would test your ability because you didn’t know what would happen. That’s perfect! That’s exactly how anticipatory anxiety works! It’s not alerting you that you can’t do something. It’s alerting you that you don’t know yet how you’ll do.

For this reason, decreases in your anticipatory anxiety will be the last part of overcoming your anxiety disorder. For many people, the anticipatory anxiety is the worst part. They want it to go away now!

Anticipatory anxiety is a clever trickster that causes people to avoid, become demoralized, self-criticize, and waver in their decision-making. Do not be fooled! Your mind is actually working adaptively.

Like learning anything else, your body won’t give you the feelings of confidence until you’ve practiced the actions of confidence.

Thus, you have to face situational anxiety-provoking stimuli, while feeling unsure what will happen, in order to eventually have the confidence that nothing catastrophic will happen. You have to act as though you can face the thing you fear until your feelings match up with your experience and you feel as though you can do it too.

Making a decision about how you will act is one way to get relief from your dread. Setting small, achievable realistic goals and giving yourself credit for what you’ve achieved is the best way to build trust in yourself.

One barrier many people face as they are trying to take this approach is that they wish they had made more progress than they have. Let’s talk more about being humble and courageous about the process of learning to relate to anxiety more effectively.


Tricked into listening to dread

Let’s discuss what individuals with anxiety disorders often do instead of self-monitoring, identifying, labeling and allowing dread:

Listening to dread by avoiding

Because individuals with anxiety disorders characteristically avoid what they are thinking and feeling, they don’t recognize their dread as part of the pattern of anxiety. Rather it feels like information, as though whatever its saying is truth.

Feeling dread, you may think, “I’m so nervous right now. What if my anxiety just gets worse and worse? What if something bad is going to happen? Maybe I shouldn’t do it. Maybe I should do it some other time when I don’t feel like this. Maybe I don’t actually want to do this because I feel so bad when I think about it.”

Dread, when interpreted as information, triggers indecision and doubts; avoiding based on doubting thoughts causes more anxiety and more dread.

Listening to dread and becoming depressed

Dread can feel more like depression, and can hit you like a sudden lack of energy and motivation. If there are many thoughts, feelings, sensations, and situations that trigger your anxiety, you may feel a consistent and pervasive sense of dread that doesn’t feel like a passing feeling.

Similarly, if you always listen to what your dread says and avoid activities and people that are important to you, the feeling of dread can influence your mood. Depression is the intrusive, sticky mood state that tells you that you’re worthless, guilty, and that things will not get better.

Whereas anxiety typically speaks in uncertainties like, “What if something bad happens? What if I can’t do this?,” depression is more certain. Depression says, “Something bad will happen. I can’t do this.”

As dread becomes more and more associated with avoidance, depression is likely to join in, and make it harder and harder for you to do the things you fear.

Listening to dread and self-criticizing

Dread can also sound like a search for an explanation but actually inspire self-criticism. Feeling dread, you might think, “What’s wrong with me? Why do I always feel this way? Other people don’t feel like I do. I’m just a _(fill in the blank with your favorite bad name)__ for being like this.”

The cause of suffering here is that you did not recognize that your dread is a feeling. You didn’t choose and you can’t choose what you feel.

The beginning of this self-talk, “What’s wrong with me?” could potentially be helpful if your underlying attitude is curiosity, openness, and observation. With this stance, you can transition to, “Let me observe what’s happening, what I’m thinking and feeling.” In that moment, you could identify and label that you’re experiencing dread; remind yourself that it is a feeling, not a fact; and work to redirect your attention to what you wanted to do in that moment while still feeling the uncertainty. The labeling process cues you to turn this experience of anticipatory anxiety into an opportunity to practice relating to your anxiety effectively.

If, other hand, you listen to the self-criticism and get fused to the idea that there is something wrong with you and you will never get better, rather than being an opportunity to overcome your suffering, this experience is likely to increase your suffering.

Listening to dread and wavering in your decision making

Dread feeds on your ambivalence, which is your experience about wavering back and forth about what action you’ll take.

Some individuals with anxiety disorders wake up with a sense of dread that is very distressing to them. If the dread was talking, it would probably say, “What will I be triggered by today? Will I be able to handle it? Am I going to face my anxiety or avoid again?”

The cause of suffering here is the sense of uncertainty you have about how you will behave and the lack of trust you have in your ability to act the way you want to act. Just like relationships with others, the only way to develop trust with yourself is to act in a trustworthy way. You learn to trust yourself by following up on commitments that you make with yourself.

The more triggers you have, the more likely you are to feel dread about how you will respond.

But then again, the more triggers you have, the more opportunities you have to practice.


The role of anticipatory anxiety

As you learn to disarm anxiety, knowing its patterns is one of your best strategies.

One part of the pattern of suffering that anxious people experience is anticipatory anxiety, which is the feeling of dread about an upcoming thought, feeling, sensation, or situation that might bring about the feared situation.

Individuals with anxiety disorders typically have difficulty staying with the feeling long enough to recognize that it’s a feeling, not a fact or prediction. As I’ve discussed, the nature of your anxiety disorder is that your mind is experiencing your thoughts, feelings, memories, or sensations as unwanted and dangerous and is getting you away from them as soon as possible.

Whether or not you have a formal self-monitoring practice, identifying and labeling dread when its happening is a powerful step because it is the opposite of avoidance. Here’s a suggestion of what to say to yourself:

“What I’m experiencing right now is anticipatory anxiety. My dread is a feeling, not a fact or prediction. It’s an indication that I feel uncertain. The feeling of uncertainty does not mean something bad is about to happen. In fact, uncertain might indicate that something good is about to happen! This is just a feeling. I can allow dread to be present while I do what I want to do right now.”

If you’re wondering if some of this self-talk is reassurance, it is true that it might feel reassuring to think like this. We’ll talk more about this in another post, but for now, reassurance compulsions, like other neutralizers, are marked by your intent rather than the content of what you’re saying. So, if you use this type of self-talk repetitively to make your anxiety go down, you are using a self-assurance compulsion that is going to keep your anxiety going over time. If on the other hand, you use this type of self-talk to observe the process in your mind, remind yourself of the pattern, and redirect your attention so that you can refocus on what you care about, then you’re on your way to relating to your anxiety more effectively. In this case, the incidental experience of dread was an opportunity to catch the pattern in action and show yourself that you don’t have to play by anxiety’s rules.

After I explain what dread is and tell them to identify and label it, most of my clients say, “Ok. And, then what? How do I make it go away?”

My answer is, “Label it and then do nothing. You can’t make it go away.”

Anxiety treatment is just the worst, don’t you think!?!

Doing nothing to resist it or make it go away is powerful and intentional stance. Just like other parts of the anxious pattern, every time you label and actively accept what you’re experiencing, your mind is less likely to associate that experience as something to fear. The anticipatory anxiety may not dissipate in this moment, but you’re setting yourself up for success in future moments.


Frequent misunderstandings about exposure

Just do it.

Exposure has to be done the right way, meaning that the individual engaging in exposure has to have the right perspective. If you decide to “just do it,” it is true that the task will be achieved and for some people in some circumstances that in and of itself is important. However, just facing the fear does not mean that you are willing to experience the thoughts, sensations, and behavioral urges that accompany the fear. If you continue to resist against those thoughts, sensations, and urges, whatever task you are attempting will feel very burdensome. Fighting against the urge to avoid and trying to ignore feared sensations and catastrophic thoughts will be exhausting. 

The right attitude to embrace during exposure is one where catastrophic thoughts, uncomfortable sensations, and the urge to avoid are all expected and understood as part of the process. They are not signs and they don’t have meaning. When they arrive, you don’t fight to make sure they don’t get worse. Rather the attitude towards your thoughts, feelings, and sensations is something like, “Oh. It’s cool that you’re here. I was expecting you. I’m going to continue doing what I was doing.” 

I already expose myself to what I fear.

The issue here is experiential avoidance. In this case, you have been embracing “just do it” for some time and you wouldn’t consider completely avoiding because you care too much about the task. However, if you interpret anxious thoughts, sensations, and urges as dangerous, then you can be sure that you are using experiential avoidances to keep your anxiety at bay. Examples of experiential avoidances include worrying, safety behaviors, reassurances, and checking. 

Exposure isn’t curing my anxiety disorder.

If you are engaging in exposure, but not getting relief from your anxiety, assessing your attitude toward the exposure is important. Are you using the exposure to make the anxiety go away? Do you have the hope that if you practice exposure enough then you won’t feel anxious anymore? 

Exposure should be used to learn the attitude of acceptance. It is a lifestyle, not a technique. If exposure exercises are not changing your attitude toward anxiety, they are unlikely to help you get long-term relief from it.


Exposure is a lifestyle, not a technique

Cognitive behavioral therapy is known for its techniques, including self-monitoring, cognitive restructuring, exposure, and relaxation training. The original theory was that a skilled clinician can apply techniques to get her client to think differently and the consequence of thinking differently would be behavior change and provide relief from suffering.

From this perspective, although the clinician acknowledged the impact of the relationship, she was functioning a lot like a physical therapist. That is, the physical therapist knows more about the body than the client and can teach the client to manipulate her body through practice in ways that will provide relief. Similarly, a cognitive behavioral therapist knows more about the mind and its interactions with the body than the client, and the therapist can teach a client to practice thinking and behaving in ways that will provide them relief. For many interventions related to behavior change, this parallel continues to be accurate. 

Exposure, however, needs to be understood as a a way of being, not as a technique to apply. My post about exposure described what it is and how it relates to CBT. Willing exposure requires an attitude shift. It requires the person who has previously experienced his anxious thoughts, sensations, and urges as dangerous to practice thinking about his anxious thoughts, sensations, and urges as an opportunity. 

People often get relief when they first try exposure, because it’s so different than how they had previously interpreted those thoughts, sensations, and urges. However, if an individual starts using exposure as a technique that helps alleviate her anxiety, in the long-term she will not actually learn to embrace uncertainty. In the long-run, she will not get relief. 

Guided exposures give a client the chance to practice adopting the new attitude in the presence of the therapist. The therapist helps them practice gradually and points out where their thinking perpetuates their anxiety. Eventually the client learns to practice exposure alone. Indeed, exposure shifts from being a homework assignment done for therapy to an attitude towards one’s thoughts and feelings that is embraced on a daily basis.


What is exposure and how does it relate to CBT?

As explained in the spectrum of responses to anxiety post, the spectrum of responses to anxiety an individual could display ranges from avoidance to exposure. The belief of a person who avoids is that he or she is in danger. In contrast, the belief of a person who exposes herself to the anxiety on purpose is that the anxiety is an opportunity to learn.

Exposure is the willing act of putting oneself in psychological and physical situations that induce fear and anxiety. 

Willing exposure is challenging in the moment of anxiety, but in the long-term it decreases anxiety. 

One theory of why exposure works is habituation. This theory understands the fear response to be similar to other senses. For instance, if you were to enter a room that smelled distinctly, if you stayed there, after a little while, your sense of smell would adapt to the smell in the room and stop notifying you of the smell. If, one the other hand, you left the room and reentered repeatedly, you’d notice the smell anew each time. In the first situation you are habituating. In the second situation you are not. 

As it relates to anxiety, the theory is that you expose yourself to the fearful stimuli until your anxiety decreases and overtime you’d become less and less anxious when presented with the trigger. 

Another more recent theory is suggests that habituation isn’t as important as willingness to have the sensations, thoughts, and behavioral urges that accompany anxiety. The willingness is important because of the cognitive component of anxiety. Unlike your sense of smell, which habituates regardless of what you think about the smell, anxiety increases and decreases based on how you interpret the situation. That is, if while your heart is beating quickly or you have unwanted intrusions or you cross over a bridge, you think to yourself, “This really is dangerous” or something equivalent, your brain will pump more of the fear response through your body and you will feel more afraid.

Again, this is unlike your sense of smell in that even if you thought, “this really smells bad” you would still eventually stop noticing the smell. The way in which cognitive interpretation  influences the fear response is called anxiety sensitivity, or second fear. Anxiety sensitivity is responsible for anxiety disorders, not anxiety states themselves. 

Thus, exposure in and of itself is not sufficient for overcoming anxiety disorders. Exposure must be done the right way. Exposure is done the right way when the individual understands the point of exposure and she willingly exposes herself to the possibility of anxiety with the belief that experiencing anxiety will actually help her body learn that she is not in danger, over time. 

Frequently when an individual embodies this attitude he will not feel anxiety. This attitude effectively conveys to the mind that it is not in danger! However then individuals start trying to trick their minds into wanting the anxiety, when they truly prefer not to have it. This is a common experience in the process of therapy: individuals start exposing themselves and get quick relief. Then, if they still fear anxiety, it is likely to come back or pop up at different times. You cannot trick your own mind. The attitude of acceptance towards the thoughts, sensations, and behavioral urges that occur when the fear response is triggered must be authentic for long-term relief.


What is an anxiety disorder?

An anxiety state becomes an anxiety disorder when the individual adds an interpretation of danger and responds accordingly. Individual with anxiety disorders believe their catastrophic thoughts and attempt to problem solve or avoid their thoughts, feelings, and sensations.

Although there are other characteristics of each disorder, one way to think about the specific anxiety disorders is by understanding what the individual misinterprets as dangerous. 

Put simply, 

Panic disorder – Fear of sensations and avoidance of external or internal stimuli that may trigger those sensations

Generalized anxiety disorder – Fear of thoughts; hypersensitivity to uncertainty; problematic beliefs about the utility of worry

Obsessive compulsive disorder – Fear of thoughts; hypersensitivity to uncertainty, guilt, and disgust

Social anxiety disorder – Fear of sensations and thoughts; fear of positive evaluation and negative evaluation due to hypersensitivity to the possibility of rejection and perceived judgment

Sensitivity to anxious sensations occurs in all of the anxiety disorders. This trait is called anxiety sensitivity and it is a biological predisposition that runs in families and is passed down through social interactions. 

The fight-or-flight response is inherently neutral; it isn’t good or bad. It’s just happening. A performer who frames the way that his heart races before going on stage as excitement is experiencing his fight-or-flight response positively. He will not complain of having an anxiety problem nor will he experience the other problems that occur during the struggle against anxiety.

If you have anxiety sensitivity, you experience your fight-or-flight response as uncomfortable and potentially dangerous. You were likely born sensitive to being over-stimulated. You were likely socialized to fear and try to control your thoughts and sensations, because adults told you “calm down,” “don’t worry,” “don’t think like that,” and “you don’t need to feel like that.” In addition to telling you to control what you think and feel, you likely watched adults express worry when they felt uncertain and avoid when they felt anxious. 

Everyone with an anxiety disorder also focuses on the future too much. Having goals and plans is an important part of achieving your potential. If you have an anxiety disorder, you spend a lot of your time thinking and worrying about the future, in an effort to manage your intolerance of uncertainty, to the detriment of the present moment. 

Worry and unwanted intrusive thoughts can occur in all of the anxiety disorders. Hypersensitivity to uncomfortable feelings like uncertainty, guilt, disgust, rejection, disappointment, and shame are all common across the anxiety spectrum. Insurance companies may be concerned with the exact diagnostic criteria of a specific anxiety disorder. We believe it is more helpful for your long-term relief to have an underlying understanding of the patterns of thoughts and behaviors that all the anxiety disorders have in common and how you can respond differently, regardless of the content of the fear.


The spectrum of responses to anxiety

Your response to an anxiety state depends on your interpretation of the meaning of that state. The meaning that you could give an anxiety state ranges from danger on one side to opportunity on the other. 

People who believe “anxiety = danger” avoid internal and external situations that make them anxious. 

This is the primary misinterpretation that you are making if you have an anxiety disorder. It is true that the fear response (including sensations, thoughts, and an urge to problem solve or avoid) is triggered when there is a perceived threat, but the presence of the fear response does not equate to danger. 

What’s more, if, through learned behavior, you start believing that the fear response itself is dangerous, you will avoid more and more until your world is very small. For example, if you fear that your sensations will lead to a panic attack you will avoid anything internally or externally that might lead to a panic attack. Or, if you fear having certain thoughts, you will avoid internal or external situations that might trigger those thoughts or perform physical or mental compulsions to make the thoughts go away when they inevitably occur. In both cases, you are misinterpreting the fear response as equivalent to danger. The more you avoid your thoughts and feelings, the more often they will occur. 

People who believe “anxiety = uncomfortable, but not dangerous” pursue internal and external situations that could make them anxious and then attempt to do things to cope with the anxiety. 

Western society encourages us to think this way. It is a slightly better position than equating anxiety with danger, but the problem with this position is that the attitude still lacks acceptance of whatever thought or feeling is occurring. As long as you feel like you have to work to “manage” what you experience, you will risk getting burnt out by the effort of “staying in control.” For long-term wellbeing, it’s best to learn to open up to whatever thoughts or feelings occur without believing that those thoughts and feelings need to be managed. 

People who believe “anxiety = opportunity” purse internal and external situations that make them anxious on purpose, and then interpret the feeling as excitement. 

The most helpful attitude toward anxiety is one where it is interpreted as normal, healthy, and an indication that the person is engaging in something challenging and uncertain. 

Professional athletes, musicians, and performers all feel the same physiology as the anxious person when they are about to perform. They are able to channel their “anxiety” into high performance because they accept and get distance from their self-doubt and use the physical sensations to urge them towards behavior that is effective in that moment. 

Even the anxiety associated with an unwanted, intrusive thought occurring in OCD can be re-interpreted as an opportunity for curiosity towards your mind and how it functions. It can deepen your compassion for yourself and others.

This attitude, about any form of anxiety, is available to everyone and is learnable.