It's funny...I have been writing in this blog for over two years on HO, oxytocin, and sometimes on my role as a special needs parent but I have not written much at all about mental health care despite my professional role as a clinical psychologist. I guess it didn't occur to me because mental health treatment was always thought to be my career job while Hope for HO was thought of as a forum for my role as a parent. For some reason, I recently saw a Facebook post from a very worried individual that reminded me that I might have some helpful info to share with those who are struggling with anxiety and stress.
I specialize in treating people with anxiety disorders and I have always enjoyed working with those who are anxious because I conceptualize anxiety as an "excess of caring"- therefore, anxious people are often the most earnest and caring people in the world. Think about it: if you didn't care about something or someone, you wouldn't feel anxious, right? We worry about the welfare of our loved ones because we care about them. We make our way quickly across the street when we see a car coming because we care about and prefer to avoid getting squished by an oncoming car. In other words, anxiety is a very normal and healthy response that signifies that we care about something.
So why does it feel so bad to be anxious if it's normal and signifies caring? I think the problem with anxiety arises when the worry or anxiety is not channeled to a constructive end because (1) you are worrying and struggling about something that is not within your control and/or (2) you are avoiding taking constructive steps to do something that is within your control and/or (3) you are taking steps to do something that is within your control but it doesn't agree with your set of values or is not effective.
According to the Serenity Prayer (a mantra used in 12-Step meetings):
"God, grant me the serenity to accept the things I cannot change, the courage to change the things that I can, and the wisdom to know the difference."
It's definitely the "wisdom to know the difference" that is the tricky part! So much time and energy is wasted trying to control what we can't control and so much agency is lost when we do not act on what is within our control. On the list of common things we try to control and wish we could control but can't: other people's behaviors, thoughts and feelings; the past; the future. Sometimes we are not even in control of our OWN behaviors (e,g.:accidents) or our OWN thoughts and feelings (e.g.:worries, other unhelpful thoughts).
Worrying about and trying to control things we can't control will only cause us to feel impotent and more anxious. In addition, anxious people struggle to have certainty in an uncertain world and this is also very distressing; in fact, the very act of insisting on having certainty (in an uncertain, inconsistent and imperfect world) is also another recipe for more anxiety and stress. What's really ironic to me is that many anxious people tend to have such a high intolerance of uncertainty that they end up making up the "end of the story" just to have a conclusion even if the conclusion is a terrible one! We've probably all done this and later realized that the apprehension and prediction we had about something in the unknown future ended up being so much worse that the actual outcome. In this situation, we used our energy to conjure up a terrible end of the story when we could have used that same energy on something else and perhaps saved ourselves a lot of mental anguish.
On the flip side, if our problems have concrete steps that can be taken but we do not take the steps to do something to address the problem, our problems will only be prolonged and exacerbated through this denial/avoidance.
What to do? There are several helpful psychotherapeutic approaches for handling distressing emotions such as anxiety including Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy (DBT) and Acceptance and Commitment Therapy (ACT). My personal favorite is Acceptance and Commitment Therapy (ACT). ACT is a therapy approach that combines the serenity of mindful acceptance with the practicality of behavioral activation and the wisdom of acting/living in accordance to one's values. Sometimes we are fortunate to have worrisome problems that are within our control to address. To address the problems within our control, we apply our available resources and follow through with an action plan. The problems not within our control are much harder to handle; in these cases, it is best to radically accept this fact and refocus our thoughts, feelings, and behaviors on something else that is within our control (valued commitments). Simply put, ACT can be broken down into this acronym: A= Accept (reality for what it is), C= Choose (to focus and live in accordance to one's values), T= Take action (on those valued commitments to live a meaningful life).
As mentioned above, even our own thoughts and feelings cannot always be controlled. In our frustration of not having control over our own thoughts and feelings (worrisome thoughts are good examples here), we end up judging ourselves, telling ourselves,"why can't I stop feeling and thinking this way", "snap out of it!" etc. Instead of struggling with our undesirable thoughts and feelings, we can accept that they are there and make space for them. It is important to note that acceptance DOES NOT mean approval. Acceptance means simply that you recognize reality for what it is, period. I accept that my son has very serious chronic medical conditions that may require our lifelong management. I don't like or approve of this fact... but I fully accept it.
ACT is often described with metaphors: if you are swimming in a lake with a bunch of beach balls and the beach balls are symbols of your undesirable thoughts, you can choose to use your energy to banish the balls from your view by trying to hold them down underwater (which requires a lot of effort) OR you can just leave them alone and let the balls float around you. Instead of focusing on the balls, you can choose to focus on other aspects of your lake experience (the sunshine, the temperature of the water, the company of friends, etc.). We may not be able to control the uncontrollable, but we CAN learn to have a more accepting attitude towards what is not within our control. This letting go is liberating because it frees us from the struggle to change the unchangeable and allows us to refocus our energies on our valued commitments. Refocusing on our values helps us live a life by design and not by default or at the whim of our passing emotions.
Ok, now that I've explained the theory, how would the ACT approach work when applied to a challenging situation common to a brain tumor survivor, for example? Let's take the example of a parent who worries (for good reason) about the health and welfare of her child who suffers from chronic medical conditions, including adrenal insufficiency. Adrenal insufficiency (AI) is a medical condition that requires a good degree of vigilance to manage since stress or illness can cause a life threatening situation (adrenal crisis) and lead to death if not handled with prompt and proper treatment. My son has AI so I understand the gravity of this disorder and I recognize that it is easy to worry about a person with AI...
What if he gets sick, has an adrenal crisis and dies?
What if he gets into a car accident and has an adrenal crisis?
What if he is without his Solu Cortef injection when he needs it?
What if he's alone and loses consciousness and can't call for help?
These kinds of worries probably cross the minds of the caregivers and of those who suffer from this condition. If we use the ACT approach, we would first accept what we cannot control: the fact that the person has AI, when an illness/stressful situation may strike, whether or not the ill person/others will be able to respond in a timely way to their illness, etc. We can then choose how we want to handle these facts based on our values: if we value having a certain active lifestyle with many activities, we can make choices to provide a life that supports these activities, even with the condition of AI. We would need to take action by ensuring that the needed medicines are available, key people are trained to deliver the medicine in case of an adrenal crisis, the person with AI has a medical alert tag worn at all times, the person with AI and others get trained in knowing the circumstances that would require stress dosing, etc. Even if all the boxes are checked and everything that is controllable is done, anxiety may still persist because life is full of uncertainties!
Different people with AI may choose to live differently with their condition, depending on their values. Person A who values safety/caution as #1 may choose to live a much more conservative life and perhaps choose to avoid activities that he considers too high risk for himself; person B with AI values adventurousness and may make very different choices. Person B may choose to take those risks because adventure, for her, contributes greatly to living a meaningful life. Person B knows the risks and feels the anxiety associated with these risks but still chooses to go on the adventure; in fact, person B may need to take her anxiety along on her adventure! There is no right or wrong lifestyle with AI, per se (provided that the AI person knows how to manage it and to stay alive). According to ACT, life is optimally lived when it is guided by one's values and not by one's default emotional reaction (often anxiety). The only exception to this rule of thumb is if safety happens to be one of the values that is held in high esteem. In this case, the person (like person A) who values safety is also living by his values by design.
When you are feeling anxious... breathe...ask yourself what is within your control and do something about those items and then remind yourself that you've done what you can that is within your control, let go of what is not within your control and focus on something else that can give you meaning in the moment. Here is a handout of the Worry Decision Tree that can help guide you to be more constructive with your worrying: https://www.getselfhelp.co.uk/docs/worrytree.pdf
If you are intrigued by the ACT approach and want to learn more about it, here is the website: https://contextualscience.org/act. Under the left side menu of ACT for the Public, you can find self- help resources, free audio exercises and free videos.
Thank you for taking the time to write this thoughtful post. As a 12-stepper and mom to a 13-year-old daughter with cranio, I can relate to much of what you’ve written. I am currently in the “choosing to accept but don’t like this” phase. I am trying to be kinder and gentler with myself, and my calmness is, oftentimes, contagious.
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