Anxiety and worry « The AI-Therapy Blog

Arguably no other notable figure in history was so fantastically wrong about nearly every important thing he had to say. – Todd Dufresne on Sigmund Freud in a 2004 LA Times Article

Freud was strange. On one hand, he’s the most famous therapist in history, and I have to admit I was excited to visit his former clinic on vacation in Vienna last year:

On the other hand, his theories are at best unsupported by evidence, sometimes completely ridiculous (I’m looking at you, penis envy), and at worst harmful.

Freud invented a form of psychological treatment called psychoanalysis. One of the cornerstones of psychoanalysis is that our personalities are strongly dependent on events in our early childhood. Obviously, this is true to some degree. We are all shaped by both our genetics and personal history, and childhood experiences can be influential. However, Freud and modern evidence-based psychology differ on how we should go about dealing with our past.

Dealing with the past is a controversial and complex topic. To begin with, there are different types of negative past events. For example, being bullied as a child is quite distinct from a difficult breakup. Therefore, the specific treatment will depend on the individual and their circumstances. I will not attempt a full literature review of this active research area, but I will make two general comments.

1. We can’t change the past, but we can change the way we think about the past.

It is important to acknowledge the negative events of our past, but unlike psychoanalysis, we must realise that they do not determine “who we are”. We are capable of living happy lives if we learn to think in a more rational, positive way. How can we accomplish this? If you’re a regular reader of my blog you will know what I’m about to say: cognitive behaviour therapy (CBT). CBT does NOT adhere to “just get over it” attitude. Rather, the goal of CBT treatment is to identify and target the unhelpful thinking patterns in the present that are maintaining the problem. Ultimately, the aim is to get to the point where these memories no longer upset us. In a sense, CBT therapy really isn’t about the past at all.

2. Dwelling too much on the past is not good for our mental health. However, if not the past, what should we be thinking about? When are we happiest?

“Live in the moment” is common advice, and in this case, it seems to be right! There is some interesting research that shows we are happiest when we are absorbed in what we’re doing, not letting our minds wander. CBT also has strategies to help people accomplish this! I try to do this as much as possible, while taking the occasional break to plan my future using my nerdy excel method.

These two points have something in common: the present. Since Freud’s time, it seems we’ve learned that living in the present is the key to dealing with the past.

Fjola Helgadottir, PhD, MClinPsych, is a clinical psychologist, a senior research clinician at the University of Oxford, and is a co-creator of AI-Therapy.com, an online CBT treatment program for overcoming social anxiety

“Fear of failure prevents us from making progress”
– Garry Kasparov, Oxford Union, 9th of November 2012

Last night I went to a debate at the Oxford Union on the subject “Is the current growth crisis a result of decades of technological stagnation in a risk-averse society?”. One of the speakers was Garry Kasparov, who is famous for political activism and for being one of the greatest chess players of all time. In a 2003 chess match he tied IBM’s Deep Junior (after loosing to Deep Blue in 1997), a machine capable of evaluating 3 million chess positions in 1 second. Given Kasparov’s amazing mind, I felt that it was worth listening to what he had to say.

It was a fascinating debate, and both sides made some excellent points. Garry was on the “Aye” side, and argued that today’s technological advances are slower and less impressive than those of previous generations. In particular, he talked about the great achievements of the cold war era in the 50s and 60s. He pointed out that many of today’s “modern” technologies (e.g. the internet) are a direct result of research performed during this time. He closed with a comment along the lines of “the iPhone 5 is nothing compared to Apollo 5”.

Fear of failure prevents people from taking risks, yet taking risks is necessary for progress

One of the topics that was discussed was the reasons why a society ceases to innovate. Garry offered an explanation quoted at the top of this blog – fear of failure prevents people from taking risks, yet taking risks is necessary for progress. This is undoubtedly true, as most breakthroughs are preceded by countless failures.

Garry was talking about societies as a whole, and the risk aversion of government funding bodies and large corporations. However, the same can be said about us as individuals, and I think it has consequences for mental health. For example, consider social anxiety. Risk aversion is one of the reasons that social anxiety doesn’t just go away without evidence based treatments. Social anxiety exaggerates the cost from being wrong, leading to risk aversion. However, treating social anxiety involves challenging your fears and stepping outside your comfort zone. It is worth mentioning that it is well established in psychology that we tend to overestimate risks and the negative consequences of failure.

Returning back to the original talk, Garry was making the point that if our societies are willing to undertake daring challenges, there can be wide ranging positive impacts outside of the original goals (he used the US space program of the 50’s as an example). I would argue that the same holds true for us as individuals. While the speakers were mainly concerned with economic growth, many of their arguments are applicable to psychological growth: overcoming our fear of failure can lead us to healthier and more fulfilling lives.

Parks and Recreation by Amy Poehler (a.k.a. Leslie Knope) is a hilarious show; it has me in tears every time. I’ve been told more than once that Leslie and I share some traits in common. I take this as a compliment, as her character is a great role model. In fact, sometimes I try to look at the world as if I was viewing it through Leslie’s eyes. Why? It makes boring and mundane situations much more lively. If she can have that much fun at a city council meeting, so can I!

Seeing the world through other people’s eyes is a common technique that is sometimes used in cognitive behavioural therapy (CBT). Obviously, that’s not all there is to CBT, but it can be a very beneficial exercise. Everyone knows someone (either fictional or real) who has a quirky way of seeing the world. They often have great stories to tell, and are generally content and happy people. Can we “borrow” their way of thinking? Would it have the potential to make us happier? Yes and yes.

The CBT tip of trying to “think like someone else” might sound a little strange, but it can be very beneficial. In fact, it can improve your mood considerably. I recently spent a day trying to think like Leslie Knope, and it was great. Who says you can’t have waffles with whipped cream for breakfast and lunch!

Here is your challenge (yes, you): Pick a person (e.g. a friend or a TV character) who has a great outlook on life. This should be someone who is relaxed and generally happy. Try “borrowing” their thinking style for a day. When you find yourself in a situation that would normally make you bored, angry, anxious, shy, etc., try to think like that other person. I would love to hear how it goes. Please send me an email (fjola@ai-therapy.com), use CBT tip in the subject line of the email, and have fun!

In anticipation of the upcoming “Mental Illness Awareness Week”, today I am going to discuss 5 devastating consequences of mental health problems. Unfortunately, the consequences are exacerbated by stigmas against those who suffer from mental illnesses, and stigmas against seeking treatment. I am hoping to show you that anxiety, depression, eating disorders, etc. are no less real than other “physical” problems, and deserve to be treated in a similar manner. (I put physical in quotes because, of course, mental and physical problems are deeply intertwined. However, that’s a topic for another blog).

There sometimes seems to be an underlying attitude that mental health problems are less serious than other disorders. This is an unhelpful and unsubstantiated viewpoint. Nobody asks cancer victims to “just toughen up”. However, this is often the sort of advice given to those with mental health issues. This is incredibly sad, given that we now have psychological therapies that are well grounded in scientific research. In particular, new psychological treatments go through rigorous, peer-reviewed testing, in a similar manner as new medical treatments.

Let’s consider the points below, and see what we can do to break the silence around mental health.

1) No-help: People who suffer from problems often do not admit to themselves or others that they need help

This is perhaps the biggest problem due to mental disorder stigmas. By seeking help one is admitting that they have a problem. Often people fear that if they are known to have a mental health issue, it will adversely impact their job or personal relationships. Therefore, seeking help can be very difficult. In fact, it has been estimated that two thirds of people with mental health problems never receive proper treatment. This leaves people alone, blaming themselves, and dealing with their problem in silence.

Taking the first step can be very difficult. This is especially true for social anxiety disorder (SAD), where a fear of being negatively evaluated by others is at the core of the problem.

Small steps are fine. Try talking to a trusted friend, family member or GP. Identify trustworthy people in your life and open up to them about your problems. Quite often, this person will already be aware (to some degree) of your mental health concerns. In fact, it may be the “elephant in the room” that everyone knows about, but no one dares speak of.

In time, after becoming more comfortable with speaking and thinking about your problem, you should aim to seek professional help. However, be careful to avoid:

2) Bad-help: Many people get inappropriate, non-evidence based remedies

It can take some people years to build up the courage to seek help for their mental health problem. Unfortunately, not all treatments are created equal. For example, a quick search on YouTube turns up many so called “cures” that have absolutely no scientific backing. When I say “no scientific backing”, that means, despite grand claims, that no one has ever checked to see if the treatment actually works. Mental disorder stigma makes it more difficult to force people to back up their claims. Also, it creates a market of people looking for “quick fixes”.

Non-evidence based treatments usually make problems worse. In some cases, they do nothing to help the situation, so the sufferer may resign them self to a life where nothing can be done about their problem. In other cases, the treatment itself can be actively harmful.

When seeking help for anxiety, depression, eating disorders, etc., make sure to find a trained psychology/psychiatrist/therapist who uses evidence-based techniques (such as CBT). A good therapist will take their practice seriously and have high professional standards. High quality online therapies that deliver CBT are another option, especially for those without easy access to well-trained professionals, or those who would prefer to stay anonymous when seeking help.

3) Suicide: As with physical illnesses, mental illnesses can be fatal

In the most tragic of cases, suicide can be a consequence of an untreated mental health problem. The stigma associated with having a mental illness can make a bad situation even worse – to a point where people see no other way out.

If you have ever thought about suicide, it is very important to seek help immediately. Check out this link to find someone in your country that you can speak to. Otherwise, go see a doctor and ask for a referral.

4) Alcoholism: Drinking to cope with problems

Many people abuse alcohol in an attempt to cope with their mental health problems. For example, people with chronic untreated social anxiety may deal with it by using alcohol and/or drugs to help them perform in social situations. Other people use alcohol or drugs as a temporary escape from depression. In all cases, this coping strategy is (A) dangerous and physically harmful, and (B) making recovery from the underlying problem more difficult.

5) Decrease quality of life: Happiness, health, relationships, etc

Almost by definition, mental health problems impact the happiness of those who suffer from them. People often have a low opinion of themselves, struggle in relationships, experience frequent stress, anger, and anxiety, etc. However, there are wider ranging impacts that should also be taken into consideration. For example, untreated mental health problems are associated with a shorter life span. Furthermore, one must also consider the impact on family members and loved ones.

Summary

The stigma associated with mental illnesses creates an environment where people are reluctant or unable to get the help they need. Untreated mental health problems have a range of follow-on effects, such as those discussed above.

I truly hope that in my life time things will change. I hope that mental disorder stigma will become history. The field of evidence-based clinical psychology is relatively young, so perhaps it is understandable that the world hasn’t caught on yet. However, we can all do our share. One way to start is for us to change our attitudes towards mental health. We need to speak about it more openly, and only advocate evidence-based treatments, as we would with any other illnesses.

Launch

Our July/August 2012 launch exceeded our expectations. We’ve had over 3500 visits so far, so thanks to everyone for checking us out and helping spread the word. We’re still actively promoting the site, so please contact us if you have any ideas about how we can reach more people. Any links, blog reviews, etc. would be great.

New free online social anxiety symptom assessment

Shortly after launch we added a free symptom test for social anxiety.

Blog

We will put out a new blog every week (give or take) on a wide range of topics. Some recent entries include:

Anger myths and facts – how to prevent future outbursts

How Excel can help you achieve goals

How to avoid the “Top 5 regrets of the dying”

The problem with self help books – they can make social anxiety worse!

Social phobia vs Spider phobia

Spider phobia (aka arachnophobia)

Future

We’ve got lots of exciting ideas in the works, so please keep an eye on the blog and come back soon!

Thank you for visiting! As always, we’d love to hear from you as our goal is to be constantly improving our site.

There’s definitely, definitely, definitely no logic to human behavior
-BjÖrk

I tend to agree with Björk (my fellow Icelander) — especially when it comes to “common sense” approaches to self help for improving anxiety or mood issues.

Despite having about 1000 trials supporting the efficacy of cognitive behaviour therapy (CBT) in the long term, the average Jane or Joe still has not heard about CBT. CBT has consistently outperformed medication when you look at long term benefits. What you learn through the CBT sticks with you for life! First, it addresses the root of the anxiety by determining what is keeping it going in everyday life. Next, it tackles the underlying cause using experiments and exercises. With CBT you develop strategies that you can use for the rest of your life.

One of the most common ways for individuals to deal with symptoms of anxiety and depression is to purchase self help programs (books, e-books, CD/MP3s audio series, etc.). The quality of these programs varies widely. There are some very good programs out there written by experienced and qualified professionals. Some of the best programs walk the client through the principles behind CBT.

Unfortunately, for every high-quality program, there are many more poor quality programs created by “self-help gurus”. Sometimes these gurus are well meaning people who have managed to cure their own problems, and would sincerely like to help others. Other times they are created by people simply looking for a quick buck. The problem is that some techniques for dealing with mental health issues are counter-intuitive, so without proper training, self-help authors can actually make problems worse. Let’s look at an example.

A typical title for self help books might be: Successful small talk: Learn to be open, interesting and intelligent. The purpose is to advise individuals on how to better manage their impressions on other people in social situations. If only human behavior was that simple! It would be great if we could sit down and read a book that would transform us into interesting and intelligent super-humans. Unfortunately, many of the recommended strategies (e.g. rehearse what you say in advance, make constant eye contact, etc.) can actually maintain anxiety in the long run. I mentioned these processes in my last blog, and referred to them as safety behaviors.

For social anxiety, people often believe that their safety behaviors help prevent negative evaluation in social situations. However, they actually might be preventing them from learning the truth. For example, assume that I deal with my social anxiety by only telling people about the positive aspects of my life (like many of us do on Facebook!). Perhaps I believe that this will stop them from judging me negatively. The problem is that if I never test this hypothesis, I am never comfortable being myself. What is wrong with this?

Firstly, it is unrealistic. People are people, and everyone has their ups and downs. By putting this extra pressure on myself to always look perfect, I might start avoiding social situations, reinforcing the anxiety. Social situations become extremely stressful.

Secondly, this type of safety behavior might make people judge me negatively. For example, people may feel resentful about my “perpetually success”, or suspect that I’m not telling the whole truth. Also, this maintains my social anxiety in the long run since I can never test if people approve of me for who I really am!

On the surface, common sense advice like “people don’t want to hear about your problems — focus on the positive” sounds great. However, as we’ve just seen this isn’t the case. Unfortunately, many self-help books are full of these sorts of recommendations.

There are some great self help books or programs out there. My advice is that if you do follow a self-help program make sure that it is (1) is created by a qualified professional with training in psychology/psychiatry, (2) uses CBT to tackle the core problems, and (3) does not promote behaviors that might end up making the problem worse.

Social phobia vs Spider phobia

In my last blog I talked about my personal “dislike” of spiders and other insects. In this blog we are going to look at the relationship between spider phobia and social phobia.

The major difference between specific phobias and social phobia is that people generally need to be around other people a lot the time. This is a bit similar to my unusual experience of moving from Iceland to Australia. I had to get used to being around spiders and other bugs all the time. After 6 years in the country, my fear of spiders had definitely decreased.

Social phobia and safety behaviours

With social phobia, you have to be around, and communicate with, other people on a daily basis. Therefore, the system that maintains social phobia is somewhat more complicated. People develop highly sophisticated mechanisms to prevent negative evaluation by other people. For example, imagine that I always wore pink socks while in Australia, and never got a serious spider bite. It’s possible that over time, I would begin to attribute my successful spider avoidance to the pink socks. This is known as a ‘safety signal’. As silly as this example sounds, we often learn ‘safety behaviours’ to help us deal with phobias and anxieties in day to day life.

The problem with safety signals is that I cannot always wear pink socks – can I? I would need to wear pink socks at all times to feel relaxed, and that could lead to some awkward social situations. I would feel anxious whenever I didn’t have access to pink socks. This is a little bit what happens with social anxiety – individuals have to be around and interact with other people on daily basis, so they develop ‘safety signals’ which prevent the feared social situation from happening.

Any behaviour can function as a safety signal. For example, both talking more and not talking can potentially function as safety behaviour to prevent the social fear of appearing boring, depending on the individual and the context. The distinction between adaptive coping behaviours and maladaptive safety behaviours is sometimes blurred, as the same behaviour can function as both. The category which the behaviour falls in depends on its intended purpose, the underlying belief, and the consequences from the situation.

Back to my example, wearing pink socks in itself isn’t that unhelpful (maybe a bit childish). However, it is only unhelpful if I think my socks have to be pink for them to protect me from a poisonous spider. If I believe in this “function” of the behaviour, I am preventing myself from learning that people rarely get bitten by poisonous spiders in Australia, regardless of the colour of their socks. Also, it makes me nervous to travel, given that one cannot have access to pink socks at all times. In social anxiety these behaviours have many detrimental effects such as increased self-focused attention and preventing dis-confirmation. In fact, these behaviours can even have the opposite effect, and can end up being the reason why someone would judge someone else negatively (once again, think of the sock example).

Common safety behaviours for social anxiety include:

carrying deodorant around at all times
always saying “yes” to other people’s requests
rehearsing what to say before entering a social situation
only telling other people about positive aspects of your life
laughing at inappropriate times
avoiding eye contact
saying little in group situations
re-reading emails many times before sending them

People may feel their safety behaviours are helping them, but they aren’t. On the contrary, several studies have reported the detrimental effect of such safety behaviours in social situations (Kim, 2005; McManus et al., 2008; Morgan & Raffle, 1999; Wells et al., 1995). Consequently, the current view is that safety behaviours can interfere with standard cognitive behaviour therapy techniques by inhibiting testing of hypotheses for socially anxious individuals.

In our online treatment for social anxiety (www.AI-Therapy.com) we explain these concepts in a lot more detail, and help people understand what their specific safety behaviours are. I hope you can see that social phobia is a much more complex issue than specific phobias, like spiders. You can now answer 10 questions, to see how you score on our free online social phobia symptoms test.

In an upcoming blog I will discuss the relationship between safety behaviours and one of my favourite topics – superstitious behaviours. My latest article on superstition was front page news in Iceland last week!