The Anxiety Equation
In an earlier post I wrote about a very powerful and transformative therapy experience I had back in 2010. It was one of those therapy sessions where insight was enough to create change. Or at least I should say, the insight alone was enough to create some initial change, but it led me down a path that required a lot of work and practice. For the most part I have developed this belief in my own therapy practice that insight alone is usually not enough to create change. But what insight needs is practice. One must be able to take the insight gained and put it into some form of deliberate practice.
The equation I work from is: Insight + Deliberate Practice = Transformation.
Angela Duckworth in her wonderful book, Grit: The Power of Passion and Perseverance, writes the following words:
“Deliberate practice is a behavior, and flow is an experience.”
So for someone to work through and navigate their anxiety in a successful way, there has to be both of these things.
What is insight? Insight is simply the ability of a person to gain a deep understanding of one’s self, and hopefully other people. Insight can be achieved in many ways, but in the context of therapy it is often achieved through the use of a family genogram, or my use of the Pain Cycle and Peace Cycle in the Restoration Therapy model, or the reflection upon what is exchanged in session between a therapist and client as they work on issues.
What is deliberate practice? Deliberate practice is intentional and thoughtful repetition of a certain skill. In my practice I like to talk about deliberate practice as being those moments when someone intentionally experiments with the insight they have gained in therapy. For example, When I started gaining insight that I was fearful of “not being good enough”, I intentionally put myself in situations where I would have to engage that fear and work on things where if I failed, my identify was not dependent upon success in it…but this is for a later discussion on identity. In her book Grit, Duckworth says this about deliberate practice:
“Make it a habit. Figure out when and where you’re most comfortable doing deliberate practice. Once you’ve made your selection, do deliberate practice then and there every day. Why? Because routines are a godsend when it comes to doing something hard. A mountain of research studies show that when you have a habit of practicing at the same time and in the same place every day, you hardly have to think abut getting started. You just do.”
The 4 Steps of Restoration Therapy
One of the most important tools that I use in my work to help people with anxiety (and all issues for that matter), is the practice of the 4 Steps in the Pain Cycle and Peace Cycle in the Restoration Therapy model. In fact, the 4 Steps is a great example of combining both insight and practice. The four steps are created due to the insight of the client and therapist, and then that insight is put into the practice in the form of walking through some steps that can be said out loud verbally, as well as out loud in one’s own head.
For example, when a client first comes into my office to do work with me, I spend a fair amount of time helping them identify their four steps (insight), and we will continue to use that insight in the form of 4 steps as our foundational piece throughout therapy:
Step 1: Say what you feel… This step is part of the Pain Cycle and it’s identified by helping a person discover how they feel in certain situations such as conflict, distress, etc. I described in another post how I often feel below the surface when I become anxious. I often feel “not good enough, or not measuring up, or alone”. So in step 1, I too help someone identify their core underlying feelings.
Step 2: Say what you normally do… This step is also a part of the Pain Cycle and it’s identified by helping a person discover their coping behavior in situations such as conflict, distress, etc. I know that when I feel “not good enough, not measuring up, alone”, I tend to cope by becoming “anxious and often withdrawing from others”. From my experience this is often an easier step for people to identify. People seem to be much more aware of their behavior, then what the underlying feelings are that trigger it.
Step 3: Say your truth… This step is the beginning of the Peace Cycle and it’s one of the hardest to identify in my experience. Also, in my experience, working with Christians can be challenging when we get to this step, because many are quick to give a truth that feels cliche (i.e. a Christian answer that they feel they have to give to be a “good” Christian), and it often takes a lot of work to help someone identify a truth that resonates with them and their experience when they are emotionally regulated. In the Restoration Therapy model, truth can be identified from three different sources: a) self; b) others; c) God.
Let me pause here for a second to say something about these steps and why they are important. When a person is in their Pain Cycle they are emotionally dysregulated. That is to say, their emotional response is triggered by their underlying feeling in the Pain Cycle and they automatically respond to that feeling typically in an unhealthy way. In this moment they are reacting, rather than choosing to respond in a healthy way. In the Pain Cycle people are emotionally dysregulated, and the Peace Cycle is the beginning of emotional regulation. When a person identifies their truth and practices that, they are learning to emotionally regulate themselves and respond to themself and others in non-reactive ways.
Step 4: Say what you will do differently (and do it)…This step is also part of the Peace Cycle, and is the healthy response that one chooses when they are emotionally regulated and operating out of their truth. So for example, when I’m able to say to myself “I am good enough” and “I’m not alone”…or “I got this”, (Step 3) then I am able to respond by “being engaged” and “non-anxious” and “caring”, rather than becoming anxious and withdrawing from others.
My Pain and Peace Cycle typically looks something like this:
- I feel alone, not good enough, not measuring up…
- And when I feel this way, I tend to become anxious, I tend to withdraw, I tend to become passive-aggressive…
- But the truth is, I am good enough, I do measure up, I got this…
- Therefore, I am choosing to stay engaged, and be non-anxious, and be caring…
These 4 steps are something that I practice multiple times a day, even when I’m emotionally regulated. And I encourage clients I work with to make it into a habit, and to intentionally and deliberately walk through the 4 steps multiple times a day. Walk through the steps when they are emotionally dysregulated, and walk through them when they are emotionally regulated. I compare it to a fire drill, in that the more I practice it when I’m not in conflict, the more readily I will be able to put into action what I have been practicing.
In the quote at the beginning of the post, Duckworth talks about the difference between behavior and flow. Deliberate practice is the behavior that leads one into the flow experience. The way that I see this happen in my own life and the lives of my clients is this. A couple will deliberately practice their 4 steps multiple times a day, both in emotional regulation and dysregulation. In fact, I encourage couples to hand the 4 steps up in their closet on a large sticky, poster chart that I have drawn their Pain and Peace Cycle and 4 steps upon. And I ask this couple to intentionally set time aside to practice the steps. And what inevitably happens at some point, is conflict arises, the couple becomes emotionally dysregulated…and because they have been deliberately practicing, they are able to move into a flow experience with one another. It’s the fruition of all their hard work. This is what deliberate practice of the 4 steps looks like. In Grit, Duckworth quotes the swimmer and founder of Total Immersion, Terry Laughlin. He writes:
“Deliberate practice can feel wonderful. If you try, you can learn to embrace challenge rather than fear it. You can do all the things you’re supposed to do during deliberate practice – a clear goal, feedback, all of it- and still feel great while you’re doing it. It’s all about in-the-moment self-awareness without judgement. It’s about relieving yourself of the judgement that gets in the way of enjoying the challenge.” ~ Terry Laughlin
Though I find the 4 steps to make up the bulk and most significant portion of the tools that I help clients access when struggling with anxiety, I want to mention a few other that I have found to be absolutely instrumental in my own life around anxiety, and the lives of my client’s working through anxiety.
Tools and Exercises to Help With Anxiety
Simply Notice. Accentuate. Calm.
This is an exercise that I wrote about in a previous post in this series, but I want to highlight it again. One of the ways to help work through anxiety is to pay attention to it and what it does to your body, mind, etc. And the more you pay attention to it, you want to experiment with increasing and lowering the anxiety. Ultimately, the key is to help you not run from anxiety, but to put yourself into contact with it, and then allow yourself to be the one controlling the anxiety. For example, before I talk, I will allow myself to notice my anxiety come up. Then I will accentuate it by walking through my Pain Cycle, and then I will calm it by walking through my Peace Cycle. The exercise demonstrates to me that I am in control of my own emotional regulation. This exercise takes practice, but is well worth it.
I believe that breathing is completely undervalued in anxiety work. I know that sounds like a silly statement, but it’s true. Breathing is one of the last things that most people think of when they become anxious. Anxiety as I mentioned in the first post in this series often gives people the literal feeling of not breathing, as well as a more existential feeling of not breathing as they feel life is closing in around them. So one of the fastest ways to emotionally regulate and restore a sense of calm is to open up the airwaves and practice breathing from the diaphragm, rather than from shallow chest breathing. There are lot of places to go for this, but I recommend box breathing as a good place to start, and you can also check out a box breathing app.
I am a huge fan of meditation as I think it’s one of the best ways to teach someone to be more in control of their body and breathing, and in the process teach them how to better emotionally regulate themselves. I find that when it comes to meditation though, it can be very intimidating to a lot of people. Some are intimidated because they don’t know what they are supposed to do, or they feel like they can’t quiet their mind very long. And often, many shy away from meditation out of fear it will teach, or engage one in spiritual beliefs that are in opposition to them. So I highly recommend two apps that have transformed my life. I recommend Headspace because it’s super simple to use, and it’s a very beautiful app. And more importantly, I know it gets results for people. When people are also struggling with learning how to breathe correctly, this is where I send them. I also recommend Andrew Johnson’s app Don’t Panic. Johnson is a hypnotist by profession, and I find that he will very quickly put a person into a deep, calm, hypnotic state, all the while teaching you how to navigate your anxiety.
Walk Through Your Anxiety and Notice
I developed a flashcard exercise that gets people out of their chairs and moving, as well as out of their heads. I sit with a client initially and I have them write down on one flash card at a time all the things they are anxious about. Sometimes that will be 5 cards for a client, and other times it will be 25-30 cards. I will then have the client get up out of their chair and lay the flashcards on the floor throughout my office. Once they have finished doing that, then I have them walk through and around the flashcards, picking up one flashcard at a time. My goal is to have them get the anxieties out of their heads, and externalized onto cards. Then I want them to get familiar with the anxiety on the card, ask questions of it, see what it feels like to them, and what they notice when they walk by and through the cards. And when the client is left with one card, that will be the anxiety issue that we explore that day in session. I find this to be a good kinisthetic exercise that helps regulate some emotions. And I think it’s a super helpful exercise in teaching one to befriend their anxiety as they get acquainted with what is going on inside their head. And because of the externalizing of the anxieties onto flashcards, the anxiety feels less threatening to people.
What is bilateral stimulation you ask?
“Bilateral stimulation is stimuli (visual, auditory or tactile) which occur in a rhythmic left-right pattern. For example, visual bilateral stimulation could involve watching a hand or moving light alternating from left to right and back again. Auditory bilateral stimulation could involve listening to tones that alternate between the left and right sides of the head.”
Bilateral stimulation has found to be very effective in the treatment of anxiety, so that’s why I often recommend people to do EMDR, or ETT which I have trained for Level 1. I know that other activities like running have found to be helpful in the treatment of anxiety through bilateral stimulation as well. One thing that I have done in my office is put a ping pong table in it because I have noticed it helps calm the anxiety of my clients because of the rhythmic movement of the game.
Probably one of the most important things I have clients do in my first meeting with them, is to go over how they are taking care of themselves physically, emotionally, mentally, and spiritually. I find that one’s ability to care for themselves is often connected to their ability to emotionally regulate themselves and especially their anxiety. So I will often focus on making sure that clients are paying attention to taking care of their exercise, diet and sleep (physical). I will make sure they are paying attention to connecting with others like friends and spouses as well as tuning into their interior life (emotional). I will make sure they are paying attention to doing things that stimulate their intellect (mental). And finally, I will make sure they pay attention to doing things that help them connect spiritually to God, or their version of a higher power (spiritual). These are important categories to help reduce and manage anxiety.
Last, I think it’s so important when it comes to anxiety, that people are trying out little experiments. For example, if a kid is struggling with social anxiety, I might give them an experiment to just walk through the cafeteria and out, rather than trying to engage in conversation, and from there we can build. Or for someone like me who feared public speaking, I might give little speaking experiments (maybe beginning with ordering food in the drive through), and working my way up to giving a talk to a small group or something. One of the ways to work through anxiety is to continue to practice overcoming the barriers and gaining confidence in the process.
As you can see, there are lots of tools to help someone reduce, manage, and ultimately work through their anxiety. I think the most important tool is starting with the 4 steps in the Restoration Therapy model (i.e. the Pain Cycle and Peace Cycle) and then experiment with some secondary tools to aid in the process. If you utilize these tools and practice them deliberately, you will one day…hopefully soon…experience the transformation that you were hoping for when you gained your first insight on your anxiety.
Rhett Smith is a Licensed Marriage and Family Therapist in private practice in Plano, TX. He specializes in helping people struggling with anxiety find new opportunities for growth, as well as spending a majority of his week with couples as they navigate relational issues. He is the author of The Anxious Christian: Can God Use Your Anxiety for Good? and What It Means to Be a Man: God’s Design for Us in a World Full of Extremes. Rhett lives in McKinney, TX with his wife Heather and their two children. You can discover more about Rhett’s work through his writing and podcast at rhettsmith.com